GW1-2021-01808_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: d
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
fL fL
2136-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER da 'Rcable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER TrncKNESS MATERIAL
p fL 60 ft. 6.125: in- SDR21 PVC
Company Name r� -
S v V�/t�2O-�G59 16:INNER CASING OR TUBING eotnerma4closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) fL fL in.
3.Well Use(check well use): ft. fL in.
17.SCREEN
Water Supply Well:
PP Y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
'Agricultural [3MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery fa ft.
Injection Well: fL ft.
Aquifer Recharge 13Groundwater Remediation
19.SAND/GRAVEL PACK.(if a livable '
11-%Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage fit. ft.
Experimental Technology Subsidence Control ft. fL
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size etc.
p fL 60 fit. CLAY
4.Date Well(s)Completed: Well ID# 61 ft. 505 ft, GRANITE
fit. fit.
5a.Well Location:
JIM SAUTER ft. ft.
Facility/Owner Name Facility ID#(if applicable) fL fit.
2189 GRANDVIEW PEAKS DR. fL ft.
Physical Address,City,and Zip fL fit. N
MCDOWELL 21.REMARKS ++ n rnnci _ t1431
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:
N - � ) . � D81 W
6.Is(are)the well(s)MPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or 1@No 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. I
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-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: 505 (ft•) 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@100D construction to the following:
10.Static water level below top of casing: 65 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 24b.For Iniection 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) 4 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
13b.Disinfection type: CHLORINE Amount: 2 cups completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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