GW1-2022-07826_Well Construction - GW1_20220822

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
DAVIV CAMP
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I
2136-A
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NC Well Contractor Certification Number i�13rUUTER7CISIIVC Is fo""P�miilU=¢ edw ""OR I3iNERt if,a Iieatill 76r ti,.>�v
CAMPS WELL AND PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 fi- 140 ft- 6.1251 in. SDR21 PVC
Company Name .._16I1VNERfG�ASIING�QRWLUBIN�' thermal(elo`$eilabo' -
2.Well Construction Permit# SW21-0198 FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,Comi)4 State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): ft. R. in.
s,'�17:'S!?REENii��'
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural E]Mumicipal/Public ft. ft. in,
Geothermal(Heating/Cooling Supply) 1DResidential Water Supply(single) ft, g, in,
hldustriaVm Comercial Residential Water Supply(shared) GIYOiJIIS ' jX"t `1 'a
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
_ Non-Water Supply Welh _ 0 ft. 20 rL BENTENITE-_ POURED 14 BAGS
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
F19i,;SAND/.GPA,VZVYAGK ifWp]I pble z
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. rt.
Geothermal(Closed Loop) Tracer 4 20;?DRIIiL11VG4LOG,attacheddtilouatsheets:"lr,nece3ea:'. n?_ s"�c,:3 •y�
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM To DESCRIPTION color,hardnena solitrock type,grain st etc
0 ft. 140 ft. CLAY
4.Date Well(s)Completed: '7'—/r—,UWell ID# 141 ft 505 M GRANITE
5a.Well Location:
FOSTER 8 KENDALL KNOWLES rt. ft. j' I-�
Facility/Owner Name Facility ID#(if applicable) ft. ft. Q I r
335 JAMES VIEW RD, MARION
Physical Address,City,and Zip
MCDOWELL V21 REMAA"9 N�'_. 4� 5 .��•{ r� a yz .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.Certification:
35.707086 N -82.0144935 ?
41
6.Is(are)the weH(s)o% Permanent or Temporary Signature of Certified Well Contractor Date
- - _ _
By signing this form,I herebJcertijy that the well(i)was(were)constructed is accor once
7.Is this a repair to an existing well: Yes or %)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ojthe copy ojthis record has been provided to the well owner.
repair under#21 remarks section or on the back ojthis jorm.
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-I 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: 505 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierenl(example-3(Qa 200'and 2Qn 100) construction to the following:
10.Static water level below top of casing: 50 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service,Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
ROTARY above, also submit one copy of4his 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
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13a.Yield(gpm) 2 Method of test: AIR 24c.For Water Supply&Iniection 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: z 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