GW1-2022-06193_Well Construction - GW1_20220620

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP -M W. ATERoZONES� sr'
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2136-A ft. IL
NC Well Contractor Certification Number 15'OUT ER'CASING,`for-mplli=udsedlweils'iO%L- R`(if
CAM P'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 115 ft- 6.125 1n SDR21 PVC
Company Name r 5�16:,INNER<CASING.'UR:TUBING "enthei u alrpliiyi6d liio Y, `.�'..,s >< =f
2.Well Construction Permit#: EH-22457 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(1.e.VIC,County,State,Ydriance,etc.) ft. tL in.
3.Well Use(check well use): it. ft. in.
FRM.'SCREEN'. .r_
Water Supply Well: FROM TO DIAMETER y SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Mlmicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) [!]Residential Water Supply(single) ft. ft. in.
❑lndustriallCommercial ❑Residential Water Supply(shared) ii18 GROUT:.' . -_. w
❑hri 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: .
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation .dl-l"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothemral(Closed Loop) ❑Tracer 20 ULLINGLOGi attach,iidilitiou'411'stieets>if,necess'a .{ .:"r<.i, .li .. t.ra
FROM TO DESCRIPTION color,hardness sail/rock rain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft' 115 ft. CLAY
4.Date Well(s)Completed: 6 1 �z� Well ID# 116 ft• 390 ft GRANITE
5a.Well Location: ft. ft. a
JOHN MOORE
Facility/Owner Name Facility ID#(ifapplicable) ft. ft. 20
GREEN RIVER COVE RD. it. ft• InU:;:� lr
Physical Address,City,and Zip ft. ft i i bOG
POLK
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:
35.31891 N W-82.22830
6.1s(are)the well(s): [!]Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,l hereby certify that the wells)ivas(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or InNo ISA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,full out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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 construction info
construction,only I GW-1 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: 390 (ff) Submit this GW-1 within 30 days of well completion per the following:
For mnhiple wells list all depths ifdierent(erample:3@200'and 2 r@i 1001
24a. For All Wells: Original form to Division of Water Resources (DWR),
if Static water level below top of casing: 60 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
Ijw•ater level is above casing,use"+"
11.Borehole diameter: 6 (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 Su 1 and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environments ea th epartment of a county where insta e
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 100 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