GW1-2021-07401_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP =1a:wArERzbxEs N.f ...{ E
Well Contractor Name FROM TO DESCRIPTION
it. M
2136-A
NC Well Contractor Certification Number S.A.17ER',Ci1SIlKG.''formlifW.ea�seit�WeiIacOR—%MER'tf'a`'lic&ble
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 65 ft- 6.125 In' SDR21 PVC
Company Name FROM TO DIAMETER FARM WELL ;16•Ib1NE1x CASIxG OR§-[TBI'a Battier pal.cioseii+lob
2.Well Construction Permit#: THICKNESS MATERIAL
List all applicable well construction pennits(i.e.UIG County,State,Variance,etc.) ft. ft in.
3.Well Use(check well use): it. ft. In.
Water Supply Well: FROMSCAR TO DIAMETER SLOTSIZE L THICKNESS^I MATERiALr'
Agricultural OMunicipal/Public ft. ft. 4a,
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) %
Industrial/Commercial 13Residential Water Supply(shared) '18:GItO1f f a::3
litigation FROM TO MATERIAL ! I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 20 Ct. BENTENITE POURED 14 BAGS
_Monitoring ;Recovery ft
Injection Well:
ft. it.
_ Aquifer Recharge Groundwater Remediation
19L+SAND/GItAYEL PACK f an .,f
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwatcr Drainage
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer r20=DRiLLINGrLOC:attach add(tionahab¢etslitaec¢sse`
FROM TO DFSCRiPTION color,hardne soilfrock type,grain size etc.
Geothermal eatin Cooling Return) Other(explain under#21 Remarks o ft 65 ft CL y
4.Date Well(s)Completed: Well ID# 66 ft. 225 ft- GRANITE
ft. ft.
5a.Well Location:
ROBERT YARBORO
Facility/Owner Name Facility ID#(if applicable) ft. ft. et
p2
SELKIRK DR. LAWNDALE ft. ft. SU
Physical Address,City,and Zip ft. ft. > (Q
CLEVELAND 21`ItER3ARKS L1 ,, r-
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:
35.406705 N -81.531892 W
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6.Is(are)the wells)OPermanent or ©fTemporary signature o Certified Well Contractor Date
By signing this farm,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or JMNo with ISA NCAC 01C.0100 or ISA NC,4C 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 awrer.
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-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: 225 (ft-) 24s. For All Wells: Submit this form within 30 days of completion of well
For rnuitiple wells list all depths ifdi(ferent(example-3Q200'and 2Q1M 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 Inlection Wells: In addition to sending the form to the address in 24a
ROTARY above,also submit one copylof 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 276994636
13a.Yield(gpm) 60 Method of test: AIR 24c.For Water Supply&Injection"Wells: In addition to sending the form to
the addresses) above, also Isubmit 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
where constructed.
--•- +•+ + North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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