GW1-2021-01018_Well Construction - GW1_20210426

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
fL I 11.
2136-A
It. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER d a lica6le
CAMP'S WELL& PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 ft. 55 ft- 6.125 in, SDR21 PVC
Company Name 16.INNER CASING OR TUBING 'eotherulal'closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State, Variance,etc.) ft ft. DIAMETER
3.Well Use(check well use): ft. ft. m.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) fL ft. in.
Industrial/Commercial Residential Water Supply(shared) iS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
,Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVES PACK if a licable '•' `>r
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test C)Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. %
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional:sheets if necessary)
Geothermal eating/Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness soil/rockrain si etc.
0 ft. 55 ft- CLAY
4.Date Well(s)Completed: #-1�1 Well ID# 56 ft. 445 ft- GRANITE
ft. ft.
5a.Well Location:
ALLEN ANNAS ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft, ft.
5991 BUZZ LOWAN ST. CONNELLY SPRINGS ft. ft.
Physical Address,City,and Zip ft. ft. 0 Z021
BURKE 21.REMARKS cessing Unit
County Parcel Identification No.(PIN) EMIR Seefien
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcll field,one lat/long is sufficient) 22.CertifiC lion:
35.651661 N -81.512977 W � Z�l- r
6.Is(are)the well(s)oPermanent or Temporary
Signature of Certified Well Contractor a�w
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 EJNo 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 I 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: 4115 00 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 1@I00� construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 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 Services Center,'Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: AIR 24c.For Water Supply&Infection 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 I county P tY
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016