GW1-2022-07478_Well Construction - GW1_20220810

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WELL CONSTRUCTION RECORD(GA-11 For Internal Use Only:
1.Well Contractor Information:
f
RZONES
DAVID CAMP - ;-ld wATE ��
FROM TO DESCRIPTION
Well Contractor Name fL ft.
2136-A
NC Well Contractor Certification Number ,,15 OUTEWCASIN. for:muldeeased,wellswOR?LINER`!fie"lirsbk
FROM TO DIAMETER' THICKNESS MATERIAL
CAMP'S WELL AND PUMP CO.
U ft. 85 ft, 6A25 in. SOR21 PVC
Company Name
' '_, �. "ti€rmal'.el'osed
,16:'INNER-CASINGQR't'1'OBING� eot
N/A; FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. g, an
List all applicable well consnmction permits(i.e.UIG County,State,Variance,etc.)
ft. ft. in.
3.Well Use(check well use):
s's17sSGREEN .,... ;y
rAgricultural
Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
QMunicipal/Public ft. ft. In.
hermal(Heating/Cooling Supply) BResidential Water Supply(single) {t Ct. In.
strial/Commercial 13Residential Water Supply(shared)
FROM TO MATERIAL•. EMPLACEMENT METHOD&AMOUNT
ation 0 ft. Y0 ft* BENTENITE POURED 14 BAGS
Non-Water Supply Well:
Monitoring ;Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge OGroundwater Remediation
.1"'"NDI RAVELTACK if:a"'Ildilile
Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test QStormwater Drainage ft• ft.
Experimental Technology 0 Subsidence Control ft. R
Geothermal(Closed Loop) Tracer 20 DRILI3ING7LOG_attncti addldooelriiheete iLiiecesse 3s
FROM TO DESCRIPTION color,hardness solFrock a 1n size ere.
Geothermal Hearin Coolin�f Return) Other(explain under#21 Remarks 0 fL 85 ft. CLAY
4.Date Well(s)Completed: Well ID# 66 ft• 355 ft. GRANITE
5a.Well Location:
ANN MINTON «. rc
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
146 RIVER BREEZE DR.
Physical Address,City,and Zip ♦ 3t
BURKE _
County ParcelldentificationNo.(PIN)
It n�+�'r''�i enYtt,i 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
76911 `
35.73682 N -81. w
Signature of Certified Well Contractor Date
6.Is(are)the well(s)Ex Permanent or Temporary..
By signing this form,I hereby certify that the wells)was(were)constricted in accordance
7.Is this a repair to an existing well: ©Yes or %�No with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
!'this is a repair fill am known well consnvction information and explain the nature of the copy ojthis record has been provided to the well owner.
repair tinder#11 remarks section or on the back ojthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 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: 355 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdiffer•ent(example-3 n 200'and 2@1001 construction to the following:
0' Static water level below top of casing:
60 (ft.) Division of Water Resources,Information Processing Unit,
Ijrmter 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
AIR 24c.For Water Suaaly&Iniection Wells: In addition to sending the form to
13a.Yield(gpm) 50 Method of test: the address(es) above, also submit one copy of this form within 30 days of
CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016