GW1-2021-06958_Well Construction - GW1_20210505

f
WELL CONSTRUCTION RECORD (GA-1) For Intemal Use Only:
1.Well Contractor Information:
DAVID CAMP �, �,�?� 14:R'ATER`•ZQNEs . _- ,;;a
F ,,,,� v FROM TO DESCRIPTION
Well Contractor Name .,,,� ' ft. ft.
2136-A
NC Well Contractor Certification Number =
�� 1)ie1t <.15:-OUTER:CASLNG W'mul8�casedwells OR LINER`" a'Rcatile -
CAMP'S WELL& PUMP CO. S"'ql S�t FROM TO DIAMETER THICKNESS MATERIAL
` 0 ft. 95 ft. 6.125' In. SDR21 PVC
Company Name WtASING.OR TUBWG eotherinal closed=l'oo _
SW20-0417 FROM TO I DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM I TO DIAMETER SLOT SIZE *THICKNESS L.MATERIA
Agricultural E)Municipal/Public tt. ft.
Geothermal(Heating/cooling Supply) oResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) l8i=GROUT f-: _ r
Irrigation FROM TO MATERIAL. . EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 tt• BENTENITE POURED 14 BAGS
Monitoring JoRecovery
I
0 Injection Well:
Aquifer Recharge Groundwater RemediationAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT
q A uifer Test 13Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [ITracer 20`ssDRILL'Il!iGiLOG-°attech.iidditi"nal slieeta:af necessa"
FROM TO DESCRIPTION(color,hardness so
iUrockk rain size,etc.
Geothermal(Heating/Cooling/'�I Return) Other(explain under#21 Remarks tt. 95 tt. CLAY
4.Date Well(s)Completed: `J Well ID# 96 tt 305 rt GRANITE
ft. ft.
5a.Well Location:
GRANT GIAUGUE
tY ID#Facility ifapplicable)
tt. it.
Facility/Owner Name (�
288 WALKER RD NEBO, NC 28761
ft. ft.
Physical Address,City,and Zip
MCDOWELL :2rREntARlcs .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iattlong is sufficient) 22.Certification:
35.591418 N -81.855338 W 1 41- 1E=�
v�k �-JAA�LA
Signature of Certified Well ontractor Date
6.Is(are)the well(s) Permanent or Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JMNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction 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 this 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-I is needed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 305 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
6 in. 24b.For Iniection Wells• Inaddition to sending the form to the address in 24a
11.Borehole diameter: ( )
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) 4 Method of test: AIR 24c.For Water Supply&Iojection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE Amount 2CUPS completion of well constructioni to the county health department of the county
13b.Disinfection type: where constructed.
Fnrm(iW-1
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
'' .