GW1-2021-03237_Well Construction - GW1_20210628

E 1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2136-A
rt. rt.
NC Well Contractor Certification Number Wit aUTERCINGft mlqeasedw Ucible t
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft 75 ft, 6125 in. SDR21 PVC
Company Name
16:7NNER=`CASING.OR'TU1s1NG`", `eotit& i1i'8 id=lflo
2.Well Construction Permit#: 693 FROM To DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits fl.e.UIC,County,State,Variance,etc.) ft. ft. I I , In.'I
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .'17 "..,t,�,.
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public ft. It. �xnl
Geothermal(Heating/Cooling Supply) MResidential Water Supply(single) ft. ft. Iio!i
Industrial/Commercial OResidential Water Supply(shared)
hxi ation FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- Y0 ft. BENTENITE POURED 14 BAGS
Monitoring . Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation `` //RAUAACK Ua"
Aquifer Storage and Recovery ©ISSllnity Barrier FROM TO MATERIAL i EMPLACEMENT METHOD
ft.
Aquifer Test 13Stormwater Drainage ft. J
F
I Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer x20.�DRII:I:IN.GLOCy;attaclisaddihosal-"atiee
FROM TO DESCRIMON color,hardness soilfrock type,grains etc.
Geothermal eatin Coolin Return Other(explain under#21 Remarks)] 0 ft. 75 ft. CLAY
4.Date Well(s)Completed: z' Well ID# 76 ft' 285 ft* GRANITE
% ft.
5a.Well Location:
JOE MORRIS
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ROUND MOUNTAIN PKWY tc rt. 20
Physical Address,City,and Zip ft. ft. t
CALDWELL ,,21iREMARICS,.
County Parcel Identification No.(PIN) 1�fOIm R SB ,O
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.894785 N -81.639131 W24'4,/1;X C A,I
t
6.Is(are)the well(s)OPermanent or [Temporary Signature of Certified Well Contractor I 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 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 weU;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
9.Total well depth below land surface: 285 (fh) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) 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 Serviced Center,iRaleigh,NC 27699-1617
� I
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition t I sending the form to the address in 24a
ROTARY above, also submit one copy of Ithis 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!C nter,'I Leigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: AIR 24c.For Water SUDDIV&Injection Wells: In addition to sending the form to
the address(es) above, also submit one(copy of this form within 30 days of
CHLORINE 2 cups completion of well construction to the coup health department of the county
13b.Disinfection type: Amount: P h' p
where constructed,
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources III Revised 2-22-2016