GW1-2022-06192_Well Construction - GW1_20220620

W LL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAV I D CAMP '�,:14i WATER%ZONES 4111
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2136-A
NC Well Contractor Certification Number
15OU1'ERSCASING;for.;mulh=cased
CAM P'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS I MATERIAL
0 ft- 100 ft' 6.125 1n SDR21 JPVC
Company Name
EH-22967 '16:.INNERtCASING'ORTUBING("------mahelosed;lois
2.Well Construction Permit# FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stare,Variance,etc.) ft. ft. in.
ft ft in
3.Well Use(check well use): _
47 SCREEN
Water Supply Well: FROM I TO.k DIAMETER SLOT SIZE THICKNESS+ MATERIAL
❑Agricultural ❑Municipal/Public fL tt. in.
[]Geothermal(Heating/Cooling Supply) dResidential Water Supply(single) ft. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) ti�,!S GIWXJTi>'.ti nsF, , r - ::..,9,E .w 1`3.,,,z, , 6?:` ;• ;,w.;F . :.,'.
❑hTi ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft- BENTENITE POURED 14 BAGS
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
:d9dSAND/GRAVEL PACK,if a'ileeblc r t
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. tt.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 1207 DRILLiNG`tiOGi attach iiilillHooal sheets ifnecessa":". ki _.`P, .ti }. 4 r
❑Geothermal(Heating(Cooling Return) ❑Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness soil/rock type,grain size eta
0 ft• 100 ft• CLAY
4.Date Well(s)Completed: 0 l6-Izl)- Well ID# 101 ft- 305 ft• GRANITE
5a.Well Location:
WM O'DONNELL ft. ft.
Facility/Owner Name Facility ID#(if applicable) D• ft.
GREEN RIVER COVE RD. ft ft
Physical Address,City,and Zip Linji
POLK '.21:�REMARKS�==. .�:..,. � ,} 4� :a.. c� I...�_ �•"5.:;
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:
35.31669 N -82.22754 W
6.1s(are)the well(s): C)Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constricted in accordance)Phil
7.Is this a repair to an existing well: ❑Yes or ONO 15A NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
Ijthis is a repair,fill out known well construction information and explain the nature ojthe of this record has been provided to the well owner.
repair render#21 remarks section or on the back ojthis fora. 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 construction info
constriction,only i GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft*) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ijdjoer ent(arample-3@200'and 2 r@i 100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 60 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijtirarer•level is above casing,use"+"
11.Borehole diameter: (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12,Well construction method: ROTARY 24c.For Water Supgly and Open-Loop Geothermal.Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) coun57-environmental health department of the county where installs
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 50 Method of test:AI R
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type. CHLORINE Amount: 2 CUPS
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018