GW1-2021-05328_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP t. 14.WATER ZONES
Well Contractor Name .� FROM TO DESCRIPTION
y ft. ft.
2136-A
R. ft.
NC Well Contractor Certification Number ry t, 15.OUTER CASING for multi cased wells OR LINER if a livable
CAMP'S WELL AND PUMP CO. tr ^ rrO�eSJInJ v OM TO DIAMETER TRICKNESS MATERIAL
�j;1 - 0 ft• 95 fL 6.125 1°' SRD21 PVC
Company Name p
16.INNER CASING OR TUBING eother al closed-loop)
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. 1n.
3.Well Use(check well use): ft. fL in.
17.Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) X❑IResidential Water Supply(single) fL ft. in
Industrial/Commercial ❑IResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:
tt. f4
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifs livable
Aquifer Storage and Recovery ❑ISalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. it.
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
I-IFROM TO DESCRIPTION(color,hardness,wil/rnck e, rain s' etc.)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks)
/ 0 ft• 95 ft CLAY
//
4.Date Well(s)Completed: !y�/ Well ID# 96 ft• 505 ft• GRANITE
N Sa.Well Location: ft. ft "
WM. COLT HERRON ft. ft
Facility/Owner Name. Facility lD#(ifapplicable) ft. ft.
5789 RICH RD. ft. ft.
Physical Address,City,and Zip ft. ft.
MGWW*Et-L (J Lk-y-l 21.REMARKS
County lJ (\ 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:
35.646769 N -81.779070 W
2LP-4
6.Is(are)the well(s)OX Permanent or DTemporary 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: Dyes or QNo with ISA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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 G W-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 ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 60 (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) 1.5 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