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GW1-2022-04865_Well Construction - GW1_20220520
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: DAVID CAMP M4."WATEWZONEW ,P-P- 0f Fits...`i,.�r_x�s',W S AP,� $s Well Contractor Name FROM ft. ft.TO DESCRIPTION I 2136-A rt. ft. NC Well Contractor Certification Number (1B.'MUTER+GASINCs2 for mtildrease$;wtll9 s'OR�I INER"if it' llcable s"`� �_�.!�'�"} CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL 0 ft. 83 ft. 6.125 In. SDR21 PVC Company Name AlCiINNEWCASING`UR-TUBING," eofheriniil'elb"sed lhhi" i f ?;.k t Azxt zs�'`5 2.Well Construction Permit#: SW22-0064 FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction pehnhfts f.e.U1C,Comity,State,Variance,etc.) ft. ft. In. 3.Well Use(check well use): ft. ft. in. '0SCREENr x3..au:#rho .,...,`_sf*iz ;:c' ss7� vah}shyj Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL Agricultural []Municipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. In. lndustrial/Commercial Residential Water Supply(shared) A8.GROUT..'W,'? Irrigation FROM TO MATERIAL r.EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS Monitoring Recovery ft. ft. Injection Well: ft. ft. Aquifer Recharge ©Groundwater Rcmediation 19r;SAND/GRAVEL!PACK"ifa"lic5ble Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Aquifer Test []Stormwater Drainage ft. ft. Experimental Technology Subsidence Control Geothermal(Closed Loop) Tracer 20-.=-DRIL T, 0VOGi attach:eililltiohel(sheefi'Ifiuecess =r t k F Geothermal(Heating/CoolingFROM TO DESCRIPTION(color,hardness solFroek type,grain size etc. Return) Other(explain under#21 Remarks) 0 ft. 83 ft. CLAY 4.Date Well(s)Completed: � `"`�}} Well ID# 64 ft 365 ff GRANITE Sa.Well Location: BRAD&ALLISON SHAMLIN ft. ft. l� Qz 1 �.Di Name Facility ID#(if applicable) 'I' LEE CAMP RD. rt. rt. MAY 2 ILIL Physical Address,City,and Zip ft ft r RUTHERFORD .21::REMARLCS:T_,''1c.a..,,..4, County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwcll field,one lat/long is sufficient) 22.Certification: 35.42025 N -82.03972 W 6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contrac r Date By signing this font,1 herebv certify that the well(s)was(were)constructed in accordance 7.Is this a repair to an existing well: QYes or INo with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a /f this is a repair,ft/1 out known hve/l couutnuction information and explain the nature of the copy of this record has been provided to the well owner. repair under#11 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: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifeli ferent(example-3(a1200'and 21@1001 construction to the following: 10.Static water level below top of casing:40. (ft.) Division of Water Resources,Information Processing Unit, lfivater 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) 20 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 13b.Disinfection type: CHLORINE Amount: 2 CUPS 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