GW1-2021-08097_Well Construction - GW1_20211105

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: k
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2136-A
rt. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER f a licable
CAMP'S WELL AND PUMP CO. FROM To DIAII�TER THICKNESS MATERIAL
0 ft. 85 it- 6.125 In. SDR21 PVC
Company Name
E H-22405 16.INNER CASING OR TUBING eothermal closed-loo
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): I
ft. ft.17.
Water Supply Well: FROM SCREENTO I DIAMETER SLOT SIZE I THICKNESS IMATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO rt. BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft-
Injection Well: it. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness,sui0rock type,grain size,etc
( 0 ft. 85 % CLAY
4.Date Well(s)Completed: �y �/ Well 1D# 86 ft. 225 fL GRANITE
Sa.Well Location: ft. ft.
'�
LIZZIE HUDGINS/ROBIN WILLIAMS ft. ft. �'.1 t•, „l
Facility/Owner Name Facility ID#(if applicable) B. ft. Nov _ '
72 FOX MOUNTAIN RD.
Physical Address,City,and Zip
ft. ft. ` t
POLK 21.REMARKS r,,,`9 ! t i
County Parcel Identification No.(PIN) `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certification:
35.256229 N -82.183239 W
/Da44 14)t`I 41
6.Is(are)the well(s)oX Permanent or ❑ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certi�y that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: 'Dyes or X)No with 15A NCAC 02C.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 native 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:
S.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 constriction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 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: 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) 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
CHLORINE 2CUPS 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