GW1-2022-06790_Well Construction - GW1_20220715

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
a
DAVI CAMP _ �afa:�wnmERizoNEs:��>��dio-u`�,�,1.tt��:e��>s.�vr• �?A"-•�.d�.�:•"x7r kr,tr,._,:�%� 'f+&r.�.
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2136-A
I.
NC Well Contractor Certification Number l5 U.U.1 ERtt4ASING?fo`r.m'ulti5c6sedtwells;ORILINER ifia`'Ucelilb R '% "f4
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
ft. 138 ft. 6.125 In. SDR21 PVC
Company Name ., „ e s
16INNERtI'ASINCrOR;'DUBING! eotiiei'inaliclos'edloo'- - 5,�„i.� .
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction perntits i7a.e.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
$?17r3CREENSI" ' _ ck fi�rj3 mrxs51 °tif dK �"a":r�u g fiS 'r
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XBResidential Water Supply(single) % ft. !in.
IndustriaUCommercial Residential Water Supply(shared) 18$GROIJQf � r:n ', 3� k. ..vs? � ?xBxs
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft' BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stomrwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) 13Tracer 920 yDRIMING)DOGi rttfae1►a$illtiohel'iitieetsiifinecesaa xa r f� t'49 :s d;
FROM TO DESCRIPTION Color,hardness salUrock e, rains etc.
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks) FROM
ft. 138 ff• CLAY
4.Date Well(s)Completed: '� Well ID# 139 ft• 245 fl• GRANITE
5a.Well Location:
AMERICA'S HOME PLACE
Facility/Owner Name Facility ID#(if applicable) ft. ft.
HWY 181 TO 4299 GWALTNEY RD. JUL 1 2022
Physical Address,City,and Zip
t, t a igF u �: ;t�t^b7#rf of F Crilz7 k5.e' ?
B U RKE
� inn= ;3r�• ! �,r1�r,�C��SI !�J\ll'
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:
36.78730 N -81.81347 `,Ir _
6.Is(are)the well(s)oX Permanent or 13Temporary
Signature of iC. ell Contractor Date
L y signing this form,1 herebv certify that the.well(s)was(were)conslnicted in accordance_
7.Is this a repair to an existing well: Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Constniction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided'to the well owner.
repair under#21 remarks section or on the back of dais 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: 245 (ff•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd different(example-3©200'and 2©1001 construction to the following: I
10.Static water level below top of casing:60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,arse"+" 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) 20 Method of test: AIR 24c.For Water Supply&Injection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016