GW1-2022-04848_Well Construction - GW1_20220520

G WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number r]5OUTER'CASING.`f6r;'riruld ctised�wells'URiL`INER+1fe"`doable, x. ,Est;.,!"
CAMP'S WELL AND PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 ft. 1 50 ft. 6.125 in' SOR21 PVC
Company Name t eotheimel'clo'sed-loo""
.16.INNER'CASING�OR=T;[3BING�. .�:
2.Well Construction Permit# EW21-07348 FROM TO DIAMETER THICKNESS MATERIAL v
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: �1�:;SG'REEN'�.:a°__ _ n.�`iif•.i� 'r'�=sas�' S.t:;F!]?�._ z_f_.."U`A .�. �.�a
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural []Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft, ft.
IndustriallCominercial Residential Water Supply(shared)
Irri ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) []Tracer 20s.DRiLIING'IV;OG`a tt"a'e h.aildltidaalsheetsiftnecessa ;t
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness sofOrock ram size,etc.
/ J y_-• 0 ft. 50 ft. CLAY
—
4.Date Well(s)Completed:'1�— "t" ��]Nell ID# 51 f• 505 ft, GRANITE
ft. ft.
Sa.Well Location:
MICHAEL WAYNE MCNEELY
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ALF HOOVER RD.
Physical Address,City,and Zip ft. ft. KT0i
LINCOLNIz1s;REMARfcs;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latlong is sufficient) 22.Certification:
35.50651 N -81.33898 W
6.Is(are)the well(s)a% Permanent or []Temporary Signature ofCcrtified Well Contractor Date
By signing this farm,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or X[]No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constnhcrion Standards and that a
If this is a repair,fill out known well construction information and erplain tine nature of the copy of this record has been provided to the well owner.
repair under#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW4 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: AIR 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016