GW1-2022-07752_Well Construction - GW1_20220819

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP
FROM - TO DESCRIPTION
Well Contractor Name
2136-A
NC Well Contractor Certification Number 75.UUTER'CASING,ff6,WuIfi:Jjj id*61W,OWLINERF if:a`"livable t'b'-4'ss::?s ,
CAMP'S WELL AND PUMP CO. FROM I TO DIAMETER THICKNESS MATERIAL
0 ft. 75 ft. 6.125 In, SDR21 PVC
Company Name 13197 ; NEWC O1fNG.OR:'1uB1NGE t eothermel'closed�lo"o �.�•`;�c x"'-
FROM
2.Well Construction Permit#: TER THICKNESS MATERIAL
List all applicable well consm,clion permits(1*.e.U1C,County,State,Variance,etc.) in.
ft. tL I
3.Well Use(check well use): in. u.
Water Supply Well:
PP Y FROM TO I DIAMETER SLOTSIZE I THICKNESS MATERIAL
Agriculttual QMunicipaUPublic tt. ft. in.
Geothermal(Heating/Cooling Supply) EX Residential Water Supply(single) fI. fL In.
Industrial/Commercial [311esidential Water Supply(shared) ,,18:GROUT >'. :
Irrigation ----_ _FR_OM TO MATERIAL ry EMPLACEMENT METHOD&AMOUNT+
Non-Water Supply Well: 0 ft. 20 ft• BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation
il9.SAND/GRAVEL;P.ACK- f-a"linable . J.n: ...
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage fa ft.
Experimental Technology [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ,20 DRILtiIIYMUD attach addltiouel sheetstif+uecessa ' x t .: '
FROM TO DESCRIPTION color,hardness sailfrock -type, rein size etc.
Geothermal(Heating/CoolingRetum) Other(explain under#21 Remarks 0 ft. 75 ft• CLAY
4.Date Well(s)Completed: hs Well ID# 76 rt• 405 rt' GRANITE
Ct, ft.
5a.Well Location:
ASHLEY JOHNSON rc. rt. F E
Facility/Owner Name Facility ID#(if applicable)
227 LORAY FARM RD., DALLAS NC n rt• A.Ut, 1 -
Physical Address,City,and Zip ft. ft I{t)Liv:tC.l �f^ x; Pa Ursa
GASTON 3 . y
2]'RE1VIiARKSf.� s t°,1..'_ •r�,,,A�# �q:.,,�13`r v r,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) 22.Certification:
35.34921 -81.22568 �•-
6.Ware)the Well(s)MX Permanent or Temporary Signature of Ccrtifncd Wc;lf Contractor VDate
By signing this form,l herebv certify•,that the well(s)was(were)consimcled in accordance
7.Is this a repair to an existing well: Yes or %)No with 15A NCAC 01C.0100 or ISA NCAC 01C.0100 Well Consrnicrion Standards and that a
lfthis is a repair,fill out known well consa-uclion information and erplain the nature of the copy of this record has been provided to the well owner.
repair tinder#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-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: 405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 ii 200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (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 ofithis form within 30 days of completion of well
12.Well construction method: constriction 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) 7 Method of test: AIR 24c.For Water SuaDiv&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type:
CHLORINE Amount: completion letion of well construction' to the county health department of the county
where constructed.
Foot GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016