GW1-2022-04852_Well Construction - GW1_20220520

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14:iWATERZONES J;" ?` ?t.�. J� _ . 4 :7b!t' i ':. rf _a•u`
Well Contractor Name FROM TO DESCRIPTION
+ft
ft.
2136-A
ft.
NC Well Contractor Certification Number _ys:'OUTERa;CpSING:t6r._iaulfl cased wells OR1I31NER.iR.a`licabte ti z :.'..r
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 60 ft- 1 6.125 1" SDR21 PVC
Company Name
SW21-0439 E 46�INNERKCASING.OR:TUBINGe eoftie idil lo'sed-lot +
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constuction permits ri.e.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17 SCREEN.::"y r , �^sv -•`.�...},'�.PF� i ;",2`.z... = tit-. C`'n. > fi;..-s. .,1 zat•S
FROM TO 4 DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) x[]Residential Water Supply(single) ft. ft. In.
Industrial/Commercial []Residential Water Supply(shared)Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTE141TE POURED 14 BAGS
Monitoring []Recovery
Injection Well:
ft. ft.
Aquifer Recharge []Groundwater Remediation
A9 SAND/GR VTVPAC&if`s"`Ilcable U „t`<x 4`.., •:j g .. .,t:. X#. FsYts :.'<
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology []Subsidence Control ft. ft.
Geothermal(Closed Loop) []Tracer20:;I)R1IL'ING;LUG iittiich:addlHunaltsheetsiifnecessa`:' ) ;s _ €r,. i.
Geothermal(HeatinglCooling Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soilfrock type,grain size etc.
ry 0 ft. 60 ft. CLAY
4.Date Well(s)Completed: —�.Z`/.a Well ID# 61 ft. 590 ft. GRANITE
5a.Well Location: ft. ft.
BARRY&TRACY BLACK/POWELL ft. ft.
Facility/Owner Namc Facility ID#(if applicable) ft. ft. t 9
73 STONETHROW DR.
Physical Address,City,and Zip
$URKE M C_ [)P)l 1>P_I I '-.21?REMARKS;: .>, v._3 x.:e ;t_ t�;^ ii•t .($(v?.!v "�t i 3},I.{%t k:s
County Parcel Identification No.(PIN)
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.55095 N -81.89638 W
(1)�171�
6.Is(are)the well(s)M% Permanent or []Temporary Signature of Certifrcd Well Contractor I Date
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or %[]No with 15A NCAC 02C.0100 or/SA NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this fonn.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 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: 590 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(erample-3@200'and 2@100 construction to the following:
10.Static water level below top of casing: 60 (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: constmction 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
Farm GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016