GW1-2021-01659_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES `
FROM TO DESCRIPTION
Well Contractor Name
9 ft. ft.
2136-A PQ� o�sg��9 tL ft.
NC Well Contractor Certification Number Qi �O
CAMP'S WELL& PUMP CO. 1��0� 30�1�Sg FRO OUTER C SD>NG ttrm 61AMETERtnlsed ti OTIHCKNESS a PMATERIAL
o SDRZ
Company Name
EH2O-04588 VC
16.livNER CASING ORTIIHING 'eatnermal;closed-Ion .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) fL ft. in.
3.Well Use(check well use): FL ft. in.
Water Supply Well: 11 SCREEN..
PP Y FROM TO DLIMETER SLOT SIZE TLHCKNESS MATERIAL.
Agricultural E)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) ORcsidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18:GROUT
1rri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL BENTENITE POURED 14 BAGS
Monitoring D1 Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
19i SAND/GRAVEL'PACK(if applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets'if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness;soil/rock type,grain size etc.
0 ft. 55 ft. CLAY
4.Date Well(s)Completed: Well ID# 56 fL 185 ft, GRANITE
ft. ft.
5a.Well Location:
RONNIE GUNTER JR. it. it.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3043 FISH POND RD. CHERRYVILLE, NC ft. ft.
Physical Address,City,and Zip fL ft.
GASTON 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification.
35.430289 N -81.396183 W
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified well Conhactor 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: [3Yes or EJNo with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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: 185 (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� construction to the following:
10.Static water level below top of casing: 30 (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 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:
(Le.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) 40 Method of test: AIR 24c.For Water Supply&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 , county P
where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016