GW1-2021-02613_Well Construction - GW1_20210811

wE L,CONSTRUCTION RECORD(GW-11
For Internal Use Only:
1.Well Contractor Information: 777777777777-.
2=;
DAVID CAMP 14WATERSZQNES DESCRIPTION
FROM TO
Well Contractor Name
2136-A It. tt.
NC Well Contractor Certification Number 15i;0UTER�CASING`.forttntil Was" TERIAL
ed wells .OR'LINER; a `liceble
FROM TO DIAMETER THICKNESS MA
CAMP'S WELL AND PUMP CO. 0 ft. 85 ft- 6.125 lo. SD PVC
Company Name 16iiINNER CASING"OR TUBTNIG eotheruel€clo8ed'loo"
EHW21-01872 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:
rt. ft. in.
List all applicable well construction permits(i.e.UIC,County,State,Yariance,etc.) tL tt• in.
`SCREEN
3.Well Use(check well use):
17 . . '
Water Supply Well: FROM TO :a
.DIAMETER SLOTSIZE THICIQVFSS MATERIAL
_ Agricultural QMunicipaVPublic
tt.
rn.
_ Geothermal(Heating/Cooling Supply) Residential Water Supply(single) tt ft `
Residential Water Supply(shared) 18:GROUT OD
IndustriaUCommercial FROM TO MATERIAL EMPLACEMENT METH &AMOUNT
_ Irri ation 0 ft. 20 ft, BENTENITE POURED 14 BAGS
Non-Water Supply Well: R.
Recovery tL
Monitoring - tt.
Injection Well:
A TO MATER Aquifer Recharge Groundwater Remediation 19.S FROM AND/GRAVEL•PACK•if a ill`vcabl IAL e ` EMPLACEMENT METHOD
Aquifer Storage and Recovery Salinity Barrier ft.
ft.
Aquifer Test oStormwater Drainage
Experimental Technology oSubsidence Control
ft. ft•
Tracer 20 DRIf L'U4QLUG`attecti e8ditional sheetstf necessa
Geothermal(Closed Loop) � FROM TO DESCRIPTION color hardness soiUrock rein size,etc.
Geothermal eatin Coolin Return Other(explain under#21 Remarks 0 ft. 65 ft- CLAY
I 66 tt• 125 ft' GRANITE
4.Date Well(s)Completed: Well ID#
ft. ft.
Sa.Well Location: tt. t�•
WILLIE JACK CHILDERS
Facility/Owner Name Facility 1D#(if applicable)
ft. ft.
FLAY RD. CHERRYVILLE rc• tL r��e '
Physical Address,City,and Zip 21:REMARl{S `
t ��t
GAST-ON � ) n C 6 � K
Parcel Identification No.(PIN)
County
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:`
(if well field,one lat/long is sufficient) G��'� '�!\
35.474097 -81.462206 W
N r""' Date
Signature of Certified Well Contactor
6.Is(are)the well(s) Permanent or oTemporary By signing this form I hereby certify that the rvell(s)ivas(were)constructed in accordance
Oyes or No with 15A NCAC 02C.0100 or 1 SA/vCAC 02C.02Q0 P1e11 Constnrction Standards and that a
7.Is this a repair to an existingwell: copy of this record has been provided to the well owner.
If Ibis is a repair,fill out known well construction information and explain the nature of the 23.Site diagram or additional well details:
repair under#21 remarks section or on the back of this form.
You may use the back of this page to provide additional well site details or we
ll
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells SUBMITTAL INSTRUCTIONS
drilled:
25
(It-) 24a. For All Wells: Submit this form within 30 days of completion of well
9.Total well depth below land surface: ction to the followings
For multiple wells list all depths ifdifferent(example-3@200'and 2@1001 constru 20 (ft.) Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 1617 Mail Service Center,Raleigh,NC 27699-1617
Ifwater level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in well
30 days of completion of
above, also submit one copy of this form within
ROTARY construction to the following:
12.Well construction method:
Injection Control Program,
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resources,Underground
1636 Mail Service Center,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
AIR 24c.For Water Suably&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) 15 Method of test: the address es) above, also' submit!one copy of this form within 30 days of
CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
North Carolina Department of Envi
Revised 2-22-2016
ronmental Quality-Division of Water Resources