GW1-2022-06040_Well Construction - GW1_20220629

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP _ S 14:.Wi1iSERNESi-.. ( fa.,ia r? 1st tt Hwy l a i.4 try.: u<?{ t ?d`fis
FROM TO DESCRIPTION
WeIlContractorName ft. ft.
2136-A rc. ft.
NC Well Contractor Certification Number ads!OUTER,CASINW Whiidti4&id:4eils iUReL'INDR,:ifta`
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 82 fL 6.125 I°' SDR21 PVC
Company Name a634NNEKCASING'ORCT.UBING,"6&WoiiisiTelased=loo` _ ? R`=.• r .x s
2.Well Construction Permit#:791 FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well constntcrion permrits(i.e.UIC,Corral),State,Variance,etc.)
ft. I
' ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS A MATERIAL
Agricultural E3Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) iResidential Water Supply(single) ft. g, In.
IndustriaUCotmnercial 13Residential Water Supply(shared) 118-TGROUT"C `F_.z , ar* b s r.ui.--:"...i ,.i, yz},�.- • -
Irrigation •FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, HENTENITE POURED 14 BAGS _
Monitoring Recovery ft. ft.
Injection Well: rt. ft.
Aquifer Recharge []GroundwaterRemediation r"h19''SAND/GPAVEL'PACIC Niouoabler sx? 4 LNG; ", .- ,.-? sf^:ti, 371
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stomtwater Drainage
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer :ZO DRiLnIiINCriISOGi atteeti+additional sheets ILnecessa' ems, y. ..rr+ r•
FROM TO DESCRIPTION color,hardness sail rack qpe,grain size etc
Geothermal (Heating/Cooling g Return) nOther(explain under#21 Remarks a ft- 82 ft- CLAY
4.Date Well(s)Completed: rr _ ell ID# 83 ft' 505 tt' GRANITE
Ct. ft.
5a.Well Location:
CAROL STATON
Facility/Owner Name Facility IDN(if applicable)
1277 RIVER RIDGE WAY
rt. rt.
Physical Address,City,and Zip
CALDWELLZft4REMnRIes���
v..
County Parcel Identification No.(PIN) JVV Q7 L`•Ot7
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.91052 N -81.68800 Wl (Rx�tj
)
6.Is(are)the well(s) x Permanent or E3Temporary
Signature of Certified Well Contractor Date
By signing this Jotm:,I hereby cerqYy that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or %JNo wirh•15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Consinuction Standards and that a
Ifthis is a repair,fill oar known well coesir•trction information and explain the nature of the copy ojthis record has been provided to the well owner.
repair raider ff2l remarks section or on the back ojthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.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
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (10 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdier•ent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 120 (ft.) Division of Water Resources,Information Processing Unit,
' above casing,use"+"
1617 Mail Service Center,Raleigh,NC 27699-1617
Ijwater level is
I I.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
—p 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) 5 Method of test: AIR 24c.For Water Supply&Injection 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.
Four GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016