GW1-2021-01328_Well Construction - GW1_20210329

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
n. n.
2136-A
n. B.
NC Well Contractir Cemfication Number 15.OUTER CASING for multi-cooed wells OR LINER ifs Bnblit
CAMP'S WELL AND PUMP CO. F DM TO DIAMETER THICKNESS MATERIAL
0 11 H 6.125 ISDR21 IPVC
Company Name 16.INNER CASING OR TUBING eotla anal closed-too
2.Well Construction Permit#: EH-20882 FROM TO DIAMETER f111C'KNESSI MATERIAL
Lai all applicable well construction permits li.e UIC.County.State, Variance,etc.) fI. ft. in.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN
FROM I To DIAMETER I SLOT SIZE I THICKNESS MATERIAL
❑Agnicultural ❑Municipal/Public R, n, in.
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) n H in,
[ Industrial/Commercial []Residential Water Supply(shared) IS-GROUT
❑lni alien ❑Wells> 100,000 GPD FROM TO MATERIAL EMPLACEMENT MErHOD&AMOUNT
Non-Water Supply Well: 0 f' 20 f` BENTENITE POURED 14 BAGS
❑Monitoring ❑Recovery
Injection Well:
H. R.
❑Aquifer Recharge OGmundwaler Remediation
19.SAND/GRAVEL PACK if We
❑Aquifer Storage and Recovery ❑Salinity Barer FROM '1'0 MATERIAL. EMPLACEMENT METHOD
ElAquifer lest ❑Stormwater Drainage h ft.
❑Experimental Technology ❑Subsidence Control n. H-
ElGeothermal(ClosedLoop) OTracer 20.DRILLING LOG Ouffiach additional sheets if neciam
OGeothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hnrdnew,mlVrock rain sine,etc.)
0 H 140 fL CLAY
4.Date Well(s)Completed:J5 Well ID# 141 H 505 D- GRANITE
Sa.Well Location: n D.
CORY GREENE a n.
FacihIv Owner Name Facility Fos(1fapplicablc) ft. ft. -
POORS FORD ROAD ft. ft.
Physical Address,City,and Z.p f` ft'
POLK 21.REMARKS , �..•:
many Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell Field,one Im/long is sut➢ciem) 22.Certification:
6.ls(are)the well(s): OPermanent or 1-l7'emporary signature ol'CeniFied Well Contractor Date
Ili signing novLarm./herein,(erom,that the we04)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or MIND 154 NCAC 02C.0100 or 15A NCAC 02C.0200 Hell Construction Standards and that a cop,,
Ifthis is a repair,fill out known well construction information and erplain the nature of the pl thia record has been provided to the nrll owner.
repair under#21 remarks section or on the back of this form
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (ft.) Submit this G W-1 within 30 days of well completion per the following:
For mu0iyle wr]/s list all depths i)'di/jerent lesample-3(aJ200'and 2(-100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10-Static water level below top of casing: 70 (R•) Information Processing Unit, 1617 MSC,Raleigh,NC 27699-1617
!hater lrcel i.r above casing,use"-
11.Borehole diameter: 6 (in.) 241E. For Injection Wells: Copy to DWR, Underground Injection Control UUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: RO I-T•ARY
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(ie.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
AIR Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 4 Method of test:
13b.Disinfection type: CHLORINE Amount: 2 CUPS
Form GW-i North Carolina Department of Environmental Quality-Division of Water Resources Re,,scd 6-6-2018