GW1-2021-05984_Well Construction - GW1_20211008

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
e
DAVID CAMP
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER EASING formulN-Ca"sed wells'OR LINER%d e ]feeble
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft, 135 ft. 6.125 in. SDR21 PVC
Company Name 16:`INNER-CA
13329 SING QRTUBING•'`edtlieroial closedrloo { __ w,,u... _
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
W
ater Supply Well: _17OMCREE TOe DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. It. in.
Industrial/Commercial Residential Water Supply(shared)
Geothermal
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring -Recovery
Injection Well: ft. ft.
Aquifer Recharge QGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test _ 13Stormwater Drainage
_!Experimental Technology Subsidence Control
Geothermal(Closed Loop) !Tracer ,20aDR11tTsINGLUG.attach addifiooaLsbeets;d neces"sa` z
FROM TO DESCRIPTION color,hardness,sollfrock rein size etc.
Geothermal(Heating/Cooling Coolin Return Other(explain under#21 Remarks
— I / 0 ft. 135 ft• CLAY
4.Date Well(s)Completed: I J�t Well ID# 136 ft. 185 ft. GRANITE
ft. ft.
5a.Well Location:
TRINITY BARNES
Facility/Owner Name Facility ID#(if applicable) ft. it.
535 DESTINY CT. BESSEMER CITY ft. st.
Physical Address,City,and Zip
GASTON 21 REMARxs lone...i ce
DWR Section
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: �j
35.352710 N -81.255131 �, V.,- '� �! l�' 11,J ( `X r
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor V 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: DYes or E]No with 15A 1JCAC 01C.0100 or 15A IvCAC'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: 185 (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 l c@1001 construction to the following:
10.Static water level below top of casing: 20 (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:
(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) 10 Method of test: AIR 24c.For Water SUDDIV&Iniection 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.