GW1-2022-06041_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD (GW�
For Internal Use Only:
1.Well Contractor Information: v Tti r s :
iv14:,WA'PER'ZONES :_.. a to rax _. r
DAVID CAMP FROM TO DESCRIPTION
Well Contractor Name
it. ft.
2136-A tt tt
1t15i{OUTER?,CASING'foriiriiiltl-ca's'edeivClls(URsIi1NER"iffs liea6le r'+' a
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
CAMP'S WELL AND PUMP CO- 0 it. 82 ft. 6.125 in SDR21 PVC
tE16,INNE1WCASING ITUBINGI cot giiIjaTclosed loo r '>:y pet •.:r -
CompanyName 170672 FROM TO DIAMETER THICKNESS MATERL.L
2.Well Construction Permit#:
ft. ft. In.
List all applicable well consnttction permits(i.e.UIC,County,State,Variance,etc.) ft ft to
3.Well Use(check well use): ,w,
FROM TO DIAMETER SLOT SIZE THICKNESS
Water Supply MATERIAL
1 Well: in.
Agricultural �Municipal/Publ is ft. ft.
tt In
Geothermal(Heating/Cooling Supply) x�Residential Water Supply(single) it yt _V
Residenrial Water Supply(shared) 1KiJGAQ T.,fir-rxr. t r,t,,�uf{ <a r
Industrial/Cornmercial FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Irri ation - - 0 ft. 20 H- BENTENITE POURED 14 BAGS
Non-Water Supply Well: ft.
Monitoring
ft.
Recovery
Injection Well:
tt. ft.
Aquifer Storage and Recovery
❑Groundwater Remediation ,19 SANDIG1ZAVEL PACK'"if a lieiible ..i c� PL t . •'. 4 i x ii"4
Aquifer Recharge MATERIAL EMPLACEMENT METHOD
Salinity Barrier FROM TO� t3' tt, ft,
Aquifer Test []Stormwater Drainage
ft. tt.
Experimental Technology Subsidence Control ,
a110 BDR1L'LING,L'OGi ef(echtadtlltiouelfeheetarif necessa
Geothermal(Closed Loop) E3Traccr FROM TO DESCRIPTION color,hardness soillrock type,grain size etc.
Other ex lain under#21 Remarks) ft. S2 ft, CLAY
Geothermal(Hearin Ccolin Return) o
2wel1ID# 83 tt. 405 ft. GRANITE
4.Date Well(s)Completed: c
Sa.Well Location:
JASON DONAHOE ft. rt.
Facility/Owner Name Facility IDN(if applicable)
[t. ft.
6577 WARD GAP RD. rt.
ft. Irn�„<t .�� r✓rc�:ya r l!na:
. 3
Physical Address,City,and Zip
Zla•RENIARKS: .t_�...
CLEVELAND
Parcel Identification No.(PIN) •
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35.56427 N 81.60182 Nt
Signature of Certified Well Contractor
Date
6.Is(are)the well(s)opermanent or OTIomporary
By signing this jor•m.I hereby cer•lifY that the well(s)was(were)comstrtncled in accordance
with 15A NCAC 02C.0100 ar ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Yes or %INo copy of this record has been provided to the well owner.
Ijthis is'a repair,fill out known ivell construction information and explain the nature ojthe 23.Site diagram or additional well details:
repair under 021 remarks section or on the back of this jonn.
You may use the back of this page to provide additional well site details or we
ll
construction,only T or GW-1 is needed. Indicate TOTAL osed-Loop Geothermal NUMBER of wells
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTION
drilled: S
drilled:
Total well depth below land surface: 405 (ft.) 24a, For All Wells: Submit this form within 30 days of completion of well
9.
For multiple wells list all depths ijdierent(example-3 r@200'and 2@100) construction to the following:
60 (ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mall Service Center,Raleigh,NC 27699-1617
If ivater level is above casing,use-"
(in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
11.Borehole diameter: 6 above,also submit one copy of this form within 30 days of completion of well
12.Well construction method:
ROTARY construction to the following:
(i.e.auger,rotary,cable,direct push;etc.) Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 276994636
FOR WATER SUPPLY WELLS ONLY:
6 Method of test: AIR 24c.For Water Suaaly&Infection Wells: In addition to sending the form to
13a.Yield(gpm) the addresses) above, also submit one copy of this form within 30 days of
CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Revised 2-22-2016
North Carolina Department of Environmental Quality-Division of Water Resources
Form GW-1