GW1-2021-02642_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: j
DAVID CAMP mLfWATER>ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number 15.OIJTER CASING(for mpitiised�tvells ,UR LINER a Ifceble r
CAMP'S WELL AND PUMP CO. FROM TO DLAMETER THICKNESS MATERIAL
Company Name
0 ft- 62 ft. 6126 In. SDR21 PVC
q
S�tA�VV2O-0�772 16;tNNER:GASING;OR=Trls _0 ottiei;nal>clogellsloo
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS I MATERLAL
List all applicable well construction permits ri.e.UIC.County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use):
Water Supply Well: 17SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. !in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. it. in.
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO N MATERIAL EMPLACEMENT METHOD&AMOUNT
1"Geothermal
on-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
jection Well:
Aquifer Recharge QGroundwater Remediation
19=SAND/GRAVEL PACK rf a lab! i ..
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage R. ft.Experimental Technology Subsidence Control ft. ft.Geothermal(Closed Loop) _Tracer 20t^DRILLIN.G1 OG.attiik-"didonal ihee- if,ne(Heating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIM ION color,hardness sell/rock type,grains etc.
0 ft. 62 ft- CLAY
4.Date Well(s)Completed: Well ID# 63 ft. 565 ft, GRANITE
Sa.Well Location:
ft. ft.
RAYMOND GORECKI/POWELL GROUP
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
1225 MTN.VISTA DR. LOT#343 ft. ft.
Physical Address,City,and Zip
ft. ft. O�
MCDOWELL zr.REMnxxs ,
County Parcel Identification No.(PIN) Ge_3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: �g
(ifwell field,one lat/long is sufficient) 22.Certification:
35.557209 N -81.882035 W
6.Is(are)the well(s)oPermaneut or OTemporary Signature of 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: 13Yes or E)No with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards 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-I 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: 565 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: 100 (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
t
13a.Yield(gpm) 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 z Cuas completion of well construction fo the coup health department of the county
13b.Disinfection type: Amount: p tY P h'
where constructed.
r
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016