GW1-2021-03236_Well Construction - GW1_20210628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14°a_WATER7,oNES 7 c,
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
rt. rt.
NC Well Contractor Certification Number ,16:(OUTEX'G1SING_'for�mulH `sed walls"=.OR2INER if a 'llcabls ,
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER i THICKNESS MATERIAL
0 ft. 130 ft 6125 in i SDR21 PVC
Company Name 16:1NNERCASING OR T,UBIN.G 'es;tfiei"al:c ose`dtlo
2.Well Construction Permit#: 732 A
FROM To DIAMETER I I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.l
E
3.Well Use(check well use): ft. ft. f In.
Water Supply Well: 1 :;SCREEN_ q
FROM TO f Y DIAMETER SLOT SIZE .I THICKNESS I MATERIAL ~
Agricultural E)Municipal/Public ft. ft. I rnl
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. I in.
Industrial/Commercial DResidential Water Supply(shared) lg„GROUT,ckr , r __ fi
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
]_9-SAND/GRAYEL:EACK if=a'"HcaBle - a' • ,
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer '20 liREL-1 ING LOG:ai ieti�addltlonat alive"ts if.riece3sa
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soiltrock type,grain size etc.
0 ft. 130 ft- CLAY i
4.Date Well(s)Completed: OX2_z Well ID# 131 ft- 305 it- GRANITE j
5a.Well Location: ft. ft.
POWELL GROUP
Facility/Owner Name Facility 1D#(if applicable)
ft. ft.
ROCKY FALLS LN.
Physical Address,City,and Zip ft. tt.
CALDWELL 2 REMARK r`,0_ �siLt u(It:
County Parcel Identification No.(PIN) DW R Section
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient)
22.Certification: !i
35.913879 -81.674089
N W
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified We 1 Contractor Date
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: E)Yes or MNo with 15A NCAC 01C.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#11 remarks section or on the back of this•form.
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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-1 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: 305 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100� I
60 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addiltion to sending the form to the address in 24a
12.Well construction method:
ROTARY above,also submit one copy of this form within 30 days of completion of well
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(i.e.auger,rotary,cable,direct push,etc.) construction to the following: I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service]Center„Raleigh,NC 276994636
13a.Yield(gpm) 12 Method of test: AIR 24c.For Water SuDDIy&Infeltion Wellls: 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: CHROLINE Amount: 2 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 Resoun es Revised 2-22-2016