GW1-2022-06805_Well Construction - GW1_20220715

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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DAVID CAMP
FROM TO DESCRIPTION
Well Contractor Name
2136-A ft. ft.
NC Well Contractor Certification Number
DIAMETER'CAMP'S WELL AND PUMP CO.' TO FROM THICKNESS MATERIAL
0 in.ft.
6.125 1' 1 SDR21 PVC
Company Name _T40INNEWCASING�OROIJB 111111111 116,-,_-Wiltdbiedri �
EHW21-07535 2.Well Construction Permit#: FROM TO DIAMETER, THICKNESS MATERIAL List all applicable well construction permits(i.e.&7C,Comity,State,Variance,etc.) ft. ft.
.
3.Well Use(check well use): ft ft. in.
w.. . ... ........
Water Supply Well: FROM I To I DIAMETER SLOTSIZE I THICKNESS MATERIAL
Agricultural [3MunicipaL/Publio rut. tt. in!
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) ft. f, ini
Industrial/Commercial 13Residential Water Supply(shared) t1l,8 ROU
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft* BENTENIITE POURED 14BAGS
71 Monitoring -ORecovery
Injection Well: ft. ft.
Aquifer Recharge [3Groundwatcr Remediation MWS AND/GRAVEL9P,9CK3 iVWbli&1iI
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stonnwater Drainage ft.
Eiperimental Technology 0 Subsidence Control
Geothermal(Closed Loop) [3Tracer ftOYDRILIV
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
Retu
0 ft- CLAY
4.Date Well(s)Completed: Well ID# it 405 ft. GRANITE
ft. ft.
52.Well Location: —
DEVON&AMETHYST HANNAH ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
BRYANT COOPER LN.
ft. ft. ME 15 zon
Physical Address,City,and Zip
LINCOLN .11�_,'RE KARXS%W­!rN'—Ai'_A6
DMI�11A
County Parcel Identification No.(PIN) - - =
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lattlong is sufficient) 22.Certification:
35.423985 N -81.220824 W
6.Is(are)the well(s)opermanent or [3Temporary Signature ofCcrtified Well Contracto(/! Date
By signing this form,I hereb.v certify that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing vy _well: Yes_ or
_- N with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
_ - _ L El Ythis is a repair,fill out known well construction informathindnd explain the nature of the copy of this Fecord has been provided-to the well owner.repair wider#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS!,
405 i
9.Total well depth below land surface: (ft-) 24a. For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths ifd6ftrent(erample-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use 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 Coulter,Raleigh,NC 27699-1636
1 1
13a.Yield(gpm) 10 Method of test- AIR 24c.For Water SunnIv&Iniectioii Wells: In addition to sending the form to
— the address(es) above, also subdiit I 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.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.-22-2016