GW1-2021-02232_Well Construction - GW1_20210722

1
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: F
1.Well Contractor Information: f
I
DAVID CAMP 14 WATER ZONES
FROM TO DESCRIPTION .
Well Contractor Name j
ft, ft.
2136-A i
ft. ft.
NC Well Contractor Certification Number 15 OUTER CASING(for multi cased wells ORLINER'if s licabte
CAMP'S WELL AND PUMP CO. FROM To DIAMETER TrncxivEss MATERUll
0 ft- 1 142 ft- 1 6.1251 in' SDR21 PVC
Company Name
13416 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): fa tt. in.
17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. ia.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. tt. in.
Industrial/Commercial DResidential Water Supply(shared) 'I&GROUT.
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery
Injection Well: ft. ft.
Aquifer Recharge [1 Groundwater Remediation
19.SAND/GRAVEL PACK(if a `licabte
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. It.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20 DRILLING LOG attach additional sheets if necessary),
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soiltrock typc rain size,etc.)
/ qQ 0 ft 142 ft- CLAY;
4.Date Well(s)Completed: wit.-/—4� Well ID# 143 ft 365 ft GRANITE
fL ft.
5a.Well Location:
CMH HOMES
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft.
1017 WESTBROOKE CT. BESSEMER CITY
Physical Address,City,and Zip fL tt.
GASTON 21.REMARKS' P-rocesbi
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:
35.332469 N -81.324799 W a"
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor, Date
By signing this form,I hereby certify'that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 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: 385 (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@100) 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 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: r
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 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 2 CUPS completion letion of well construction Ito the coup health department of the
13b.Disinfection type: Amount: P i county P county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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