GW1-2022-07545_Well Construction - GW1_20220815

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. ----"WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
I.Well Contractor Information:
DAVID CAMP 14;�wATEit--ZONES F-
- r: r
FROM TO ,.'DESCRIPTION
Well Contractor Name
2136-A rc• ft.
NC Well Contractor Certification Number 15'OUTER_EASING-for,iiiulti dosed wells`sUR IitHER;if a''""Uebble
FROM TO DIAMETER THICKNESS MATERIAL
CAMP'S WELL AND PUMP CO. 0 tc. 105 ft- 6.125 ! In SDR21 PVC
1'b:INNERFCA'SING,ORk2 fIBING"` �tbermarclosed]oo
Company Name 2.Well Construction Permit#: DIAMETER THICKNESS MATERIAL
EH-21847 FROM TO
[t. tL in.
List all applicable well construction permits(Le.U1C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): H, r.>,`tom sP
17t SGsREENF
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
T
[3MunicipaUPublic fa R. In
Agricultural in
Geothermal(Heating/Cooling Supply) x)Residential Water Supply(single) fa tt r r
Residential Water Supply(shared) lti^GROUT ,,;
IndustriaUColnmercial FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
L71 ation 0 ft- 20 ft, BENTENITE POURED 14 BAGS
Non-Water Supply Well: ft ft.
Monitoring Recovery
Injection Well:
Aquifer Recharge QGroundwaterRemediation ,19 SANDIGRAT�+�ypA
EMPLACEMENT METHOD
Aquifer Storage and Recovery Salinity Barrier
FROM TO MATERIAL
ft. ft.
Aquifer Test 13Stormwater Drainage
Subsidence Control
Experimental Technology
Tracer =20:°DRILLING LUG;ittacW_-Iddid6iiii alieeta it necesii"a s -
Geothermal(Closed Loop) Q FROM TO DESCRIPTION color.hardness solUrock a rain size etc.
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks)J0 ft. 105 ft- CLAY
WeIIID# 106 ft' 585 ft' GRANITE
4.Date Well(s)Completed: / �5a.Well Location:
CHRISTOPHER DUPREE ft fc. 2Q2
Facility/Owner Name Facility ID#(if applicable)
ft. ft. t. Ura
CHRISTOPHER RD.,TRYON
Physical Address,City,and Zip
:'E1i`REtvIA1tK3
POLK
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22 _ cation:
(if well field,one lat/long is sufficient)
35.22540 N -82.22187 W
Signature of Ccrti6ed Well Contractor
Date '
6.Is(are)the well(s)M% Permanent or Temporary By signing this form,1 herebv certify that the well(s)was(were)constructed in accordance
with I5A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Consmhction Standards and that a
7.Is this a repair to an existing well: Yes or %MNo copy ojthis record has been provided to the well owner.
1f this is a repair,fill out known well contraction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back ojthis form.
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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
9.Total well depth below land surface: 585 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdderent(example-3Q200'and 2Q1001 construction to the following:
60 (ft) Division of Water'Resources,Information Processing Unit,
Ill.Static water level below top of casing: 1617 Mail service Center,Raleigh,NC 27699-1617
if water level is above casing,use"+"
11.Borehole diameter: 6 (in) 24b.For tniection 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,
1636 Mail Ser
FOR WATER SUPPLY WELLS ONLY: AIR
Center,Raleigh,NC 27699-1636
Method of test: AIR 24c.For Water Suauly&1In1ectio1 Wells: In addition to sending the form to
10 M
13a.Yield(gpm) the address(es) above, also submit one copy of.this form within 30 days of
CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Fnrm GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources
Revised 2-22-2016