GW1-2022-06194_Well Construction - GW1_20220620

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1:,: ::;=Prilt,Formr,
1.Well Contractor Information:
DAVID CAMP
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
ft. rt.
NC Well Contractor Certification Number J15 OUTER'-CA31NGt ton.iiiW cased ells tORiLINER l ti"'Ubatile r,,,., z ,: ,>,,
CAMP'S WELL AND PUMP CO. FROM TOI DIAMETER I THICKNESS I MATERIAL
Company Name
0 ft, 102 it' 6.125 in, SDR21 PVC
SW21-0807 =i16::INNEREA$1NG.'OR:TU131Nc; eottiiririel:closed=ldo s t>: wY
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnrction permits(i.e.UIC,Coun)4 State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): et. ft. in.
1fi.3CREENu.,tr,.,_. ?(?,.s5'k_?. :;:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL s
Agricultural E3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft. In.
Industrial/Commercial Residential Water Supply(shared) VGROIIT 'I?r
IITi ati0n FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it- 20 ft. BENTENITE POURED 14 BAGS
Monitoring 13Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery 1{Salini Barrier h]9.,SAND/GRA3!EIstEACK MA.."II'bable t.: ��,. E
{�J tY FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer e20DRILLIIVG3LOG;attac}i edillttooelalieefs?itaecesss: .�wy' <" .K
Geothermal (Heating/Cooling Return) MOthcr(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness solurock type,grain size,etc.
0 ft. 102 it- CLAY
4.Date Well(s)Completed: -r 2 ) -'t 2Well ID# 103 ft 305 ft GRANITE
5a.Well Location:
BRIAN WALKER ft. ft. ► 2022
Facility/Owner Name Facility ID#(if applicable) ft. ft..
1802 TATTERTOWN RD. ft. it. ;lam �^
Physical Address,City,and Zip ft. ft.
MCDOWELL 21'REMAIPMi'.. s. '-if .X'T-5-,,,W;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.61488 -81.90084
6.Is(are)the well(s)OX Permanent or E3Temporary 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: E3Yes or JqNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Constnrction Standards and that a
Ifthis is a repair fill out known well construction information and erplain the nahae ofthe copy ofthis record has been provided to lite well owner.
repair under#21 remarks section or on the back of this 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 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: 305 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,(jerent(ewrnple-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
If ivater 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: 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) 4 Method of test: AIR 24c.For Water Supply&Inlection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016