GW1-2022-05844_Well Construction - GW1_20220601

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
tt. ft.
NC Well Contractor Certification Number ISO R'CASING;`fortmuld;cased welts iOR75iNElt',iL•a"'11¢ib e
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS 1 MATERIAL
0 ft- 102 ft• 6.125 1" 1 SDR21 PVC
Company Name 16:<INNERSG'pSING!URT,,UBINGY eotherniiil:elosed=too`
2.Well Construction Permit#: SW21-0314 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well canstrrction permits(i.e.UIC,County.State,Variance,etc) rt. rt. in.
3.Well Use(check well use): ft. ft. in.
173CREENN -..ri t?r.=_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft. in.
IndustriaVCommercial 13Residential Water Supply(shared) 4i18:(GROUTk, ?t'd*n
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19:SANI)1GRAVEL'tF1GK ifs livable.f�.<.. _
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20-DRiLLING LO.G eft¢b:edilltioiiiil sheets'if.necessa'. �b� , z,,:, y.
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM To DESCRIPTION rotor,hardness solUrock a grain size etc
0 rt. 102 ft- CLAY
4.Date Well(s)Completed: J K— Well ID# 103 it- 505 ft, GRANITE
ft. ft.
Sa.Well Location:
DYLAN&VICTORIA BOWEN rl.9P . 171
Facility/Owner Name Facility ID#(if applicable)
139 GREEN LEAF DR. rt. rt. ". .
Physical Address,City,and Zip unit
MCDOWELL21:7xE117A1tiCs ;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.62719 N -81.90077 W t
t� 5
6.Is(are)the well(s)�% Permanent or Temporary Signature of Certified well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or %JNo with 1 SA NCAC 01C.0100 or 15A NCAC.02C.0100 Well Construction Standards and that a
/f this is a repair;fill out known well construction infor•nration and explain the nature of the copy of this record has been provided to the well owner.
repair trader#21 remarks section or on the back of thisfonn.
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 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: 505 (ft-) 24a.'For All Wells: Submit this form within 30 days of completion of well
For rnrr/tiple wells list all depths if different(example-3 r@200'and 2©1001 Construction to the following:
10.Static hater level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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) Method of test: AIR 24c.For Water Supply&Iniection 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.
Fomi GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016