GW1-2022-06052_Well Construction - GW1_20220629

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1'.Well Contractor Information:
DAVID CAMP 14.WATERZONES`
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2136-A
It. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 102 ft. 6.125 Rn' I SDR21 PVC
Company Name
EH-23259 16.INNERCASINGORTUBING eothcrmalvlosed-loa
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): I' ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) %Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o ft 20 ft. BENTENITE POURED 14 BAGS
Monitoring QRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge [3Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) ®Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock type,grain size etc.)
/ 'J / 0 ft. 102 11- CLAY
4.Date Well(s)Completed: `� ' / ,,OVWel1ID# 103 ft. 605 ft. GRANITE
5a.Well Location:
HEATHER PETTIT EL ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. J U N
5346 HOWARD GAP RD. iL ft.
Physical Address,City,and Zip Otrt ':, -
POLK 21.REMARKs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
35.23878 N -82.30113 W .
6.Is(are)the well(s)o% Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis 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: 605 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdier•ent(erample-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 60 (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
13a.Yield(gpm) 1 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
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