GW1-2021-06659_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP a � nia{WATER`ZONES = ,«
t FROM TO DESCRIPTION
Well Contractor Name O� �Z ft. ft.
C� �
2136-A � ��A
ft. tt
NC Well Contractor Certification Number `jJ� E�\On y
CAMP'S WELL AND PUMP \It�0I 3�L FROMuTE12I TOnvG`rnr I DIAMETERe11B i0;�KNESS MATERIAL
0 ft. 1 50 ft- 6.125 in SDR21 PVC
Company Name
SW21-0086 `,16.�T MMGASING:ORTUBING eottieemal,closedfloo :. , __.'.' ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(l.e.UIC,County;State,Variance,etc.) ft. ft, in.
3.Well Use(check well use): ft. n• in.
Water Supply Well: FROME TO DIAMETER I SLOT SIZE p THICKNESS I MATERIAL
Agricultural E]MunicipaWublic tt. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. In.
Industrial/Commercial 13Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
:19aSAN61GRAV,EVPACIs; rw Bcable�- f
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) 13Tracer =-20.DRILXING LOG':.aHacti adaitiooafshcets if:netiessa c,:
Geothermal eating/Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION(color,hardy soiUrack rain size etc.
Q�} 0 ft. 50 ft. CLAY
4.Date Well(s)Completed: -/ Well ID# 51 ft• 465 ft* GRANITE
5a.Well Location: ft. n.
JASON ROWELL
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
251 SYCAMORE DR. ft. ft.
Physical Address,City,and Zip ft. ft.
MCDOWELL Zi xEMARIts F=
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.773706 N -81.959407 W `
6.Is(are)the well(s)oPermanent or [3Temporary Signature of Certified Well Contractor Date
By signing this fonn,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 13Yes or EJNo 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#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-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: 485 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter: 6 (in.) 24b.For Inlecdon Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Y 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: AIR 24c.For Water Supply&Iniection 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 county health department of the county
13b.Disinfection type: Amount: p tY P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016