GW1-2022-03421_Well Construction - GW1_20220318

Pr .,
XELL.CONSTRUCTION RECORD (GW-1) For Internal Use Only:
.Well Contractor Information:
DAVID CAMP 01414WAmEItsZONEstYr2
✓ell Contractor Name FROM TO DESCRIPTION I
ft. ft.
2136-A
ft. ft. I
IC Well Contractor Certification Number -- .
�"1'SY,OU'IIER"CASING forsmul'tlkii`s'e"8[welle;OR$LINER,Ifta lic`htile
AMPS WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 1 120 ft. 6.125 in' SDR21 PVC
ompany Name ,. _.,.• »<
169582 �46ANNEWCASINTW ORITUBING;�eothermel elo e$,lbo r• "r ':3 s`+;
.Well Construction Permit#' FROM TO DIAMETER THICKNESS MATERIAL
ist all applicable well constn(etion permits(i.e.UIC,Comity,State,Variance,etc.) ft. ft. in,
Well Use(check well use): ft. ft. in,
Vater Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public R. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. in.
�Industrial/Commercial QResidential Water Supply(shared) a 48 GROUTT"
Irri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
ton-Water Supply Well: 0 ft- 25 ft. BENTENITE 30 BAGS
Monitoring Recovery ft. ft.
ejection Well:
' ft. ft.
f Aquifer Recharge 13Groundwatcr Remediation
,]9`:gANO/GRAVEL'YPAC a° 18' liable
MAquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I EMPLACEMENT METHOD
Aquifer Test ❑Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
MGeothermal(Closed Loop) Tracer c20 vDRILUINGiLOGt a'ttaehTaddltlonel'ih eWi f;Tecesak"
Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soll/rock type,gnin size,etc.
0 ft. 120 ft- CLAY AND SAND
Date Well(s)Completed:2-19-2022 Well ID#
a.Well Location:
721 ft- 505 ft- SLATE ROCK
3ERALD MCCOMBS ft. rt. IVE
xcility/Owner Name Facility ID#(ifapplicable)
n2911 WOODS DRIVE ft. ft.
MAK
brsical Address,City,and Zip ft. ft.
OOORESBORO NC 28114 CA 10AEMARIC3 ::.: t ._,r r �..:H,:x
ounty Parcel Identification No.(PIN)
b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f%-cll field,one lat/long is sufficient) 22.Ce�fication:
15.196906 Iv` 81-753243 W l
3-2-2022
As(are)the well(s)o% Permanent or Temporary Signature of Certified Well CO tar Date
By signing this form,I herebv certify that the well(s)'was(were)constructed in accordance
Is this a repair to an existing well:_ rlYes or M% No with 15A NCAC 02C.0100 or ISA NCAC 02C.0100 Well Constn"ction Standards and that a
'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.
pair under#21 remarks section or on the back ofthis form.
23.Site diagram or additional well details:
.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
instruction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
tilled: SUBMITTAL INSTRUCTIONS
Total well depth below land surface: 505 00 24a. For All Wells: Submit this form within 30 days of completion of well
7r multiple wells list all depths ifdierent(example-Sea 200'and 2@1001 construction to the following:
0.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
'water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
2.Well construction method: AIR construction to the following:
.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
OR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3a.Yield(gpm) Method of test: AIR 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy',of this form within 30 days of
3b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
where constructed.
i
rut GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016