GW1-2022-06828_Well Construction - GW1_20220715

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP
Well Contractor Name FROM TO DESCRIPTION
2136-A
NC Well Contractor Certification Number 911 S-.-,'O-U TIME RICAS EKG#6 ORMINE
T5 I THICKNESS MATERIAL
CAMP'S WELL AND PUMP CO. iqmrg
0 t- 1 57 ft- 1 6.125! In, SOR21 PVC
Company Name
V-16'.�INMRICASINGIOR,T BINGU66t liclbdiid-'1666W,�,Vtk',-3k
2.Well Construction Permit#: SW22-0124 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): tt. it. In.
MVSCREEM�� '4kifM 1�
Water Supply Well: FROM TO DIAMETER :1 SLOT SIZE THICKNESS MATERIAL
:)Agricultural []Municipal/Public ft. ft. In.
_JGeothermal(Heating/Cooling Supply) IMResidential Water Supply(single) —ft. ft. I;
—Ihidustrial/Commercial [3Residential Water Supply(.shared) kiftYGROUW,
IrriRation FROM I TO MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 20 BENTENITE POURED 14BAGS
Monitoring 13Recovery
Injection Well:.
Aquifer Recharge []Groundwater Remediation
579SANDIGICkYEL,MAC
Non-Water
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stonnwater Drainage ft. ft.
Experimenf6l Technology []Subsidence Control
Geothermal(Closed Loop) []Tracer A1y0DRI1ffl1NG!E0G,,'W(6
FROM TO DESCRIPTION(color,hardness,sollfrock We,grain stm,etc.)
'Geothermal(HeatinglCooling Return) MO(her(explain under#21 Remarks) 0 ft. 57 ft- CLAY!,
4.Date Well(s)Completed: Well ID# 58 ft. 125 ft, GRANITE
5a.Well Location: ft.
Ft
PITTS, RONALD&BOBBY ft. ft.
2022
Facility/Owncr Name Facility lD#(ifapplicable) ft. ft.
790 MOONLIGHT PASS
Physical Address,City,and Zip ft. ft.
M4�'T-%A' T 10 1 P R 0 C E S S l,,,'G L i\l I
-meaewnl_
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latilong is sufficient) 22.Certification:
35.46046 N -81.96800 W
Signature of Certified Well Contractor Date
6.ls(are)the well(s)oPermanent or []Temporary
By signing this forin.I herekv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or EINo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consiniction Standards and that a
If this is a epair,fill out known well construction information and arplain the nature of the copy ofthis record has been provided to the well omier.
repair under#21 remarks section or on the back of this forin. 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 pige to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may alsoi ,attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 125 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlfferent(araniple-3@200 and 2@100) construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Reso I roes,Information Processing Unit,
Ifivater level is above casing,use 1617 Muff Servicel Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition I 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 Servic I e Center,Raleigh,NC 276994636
13a.Yield(gpm) 40 Method of test: AIR 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also subniit one copy of this form within 30 days of
136.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
where constructed. I I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resou rces Revised 2-22-2016