GW1-2021-08039_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: _T
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
FROM 7 TO I DESCRIPTION
Well Contractor Name
ft. ft.
2136-A
rt. Irt.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER a Ileable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 ft. 95 ft 6.125 In' I SDR21 PVC
Company Name
16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: N/A FROM TO DIAMETER THICKNESS MATERLII
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
27.
Water Supply Well: FROM E TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural DMunicipallPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single)
lndustriaVCommercial DResidential Water Supply(shared)
18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
IDjection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness soil/rack a rain a etc.
Geothermal astir Coolin Return) Other(explain under#21 Remarks
0 ft. 95 it- CLAY
4.Date Well(s)Completed: It 't Well ID# 96 ft. 385 ft. GRANITE (` -
rt. rt.
5a.Well Location:
KEITH BAKER
Facility/Owner Name Facility ID#(if applicable) ft. ft.
144 RIVER BREEZE DR. MORGANTON, NC
ft. rt.
Physical Address,City,and Zip ft. ft.
BURKE 21.REMARKS
County Parcel Identification No.(PIN) '►. -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient) 22.Certification:
35.736788 N -81.769585 N, 2- S_'2/
6.Is(are)the well(s)OX Permanent or Temporary Signature eoof Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or X)No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Slandods and that a
Ifthis 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: 385 (ft•) 24a. For All Wells: Submit'Ithis form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (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 Iniection Wells: Iwaddition 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) 40 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
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