GW1-2022-08230_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14evVAT1sR°7rbIVEs'
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2136-A
t
NC Well Contractor Certification Number i 15 OU It'C 4SING fdmu ti @ iV8 iOR
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 75 ft. 6.125 In. SDR21 PVC
Company P Y Name
SW21-0199 FROM�
2.Well Construction Permit#' 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): ft. tt. In.
Water Supply Well: FROM
._ S
PP Y FROM TO DIAMETER' SLOTSIZB THICKNESS MATERIAL
Agricultural 0Municipal/Pablic ft. n. in.
Geothermal(Heating/Cooling Supply) oResidential Water Supply(single) tt. «. in•
Industrial/Commercial Residential Water Supply(shared)
hri atlOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. Y0 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery
Injection Well: rt. ft.
Aquifer Recharge E3Groundwater Remediation ,
d.>9:4AMIGRA+YEL PAf`IC$If?B ltoagl8. .:..w n
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
_ Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 0."1112YiI3TNG')LO:G a(taeff:adtlltion`.'iilsaheets f:oecesse <:-
FROM TO DESCRIPTION color,hardness sollfrock rain size,etc
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks
0 ft. 75 ft. GRANITE
4.Date Well(s)Completed: 2 _ Well ID# 76 tt' 565 ft' CLAY
5a.Well Location:
KEN SEPTOR
Facility/Owner Name Facility ID#(if applicable)
COAL PIT MTN. DR. I5-Y
Physical Address,City,and Zip ft. it. AP R 18 202?
MCDOWELL 21,:R1;1G1Al2ICS .: r:.
CountyParcel Identification No.(PIN)
{{
•'rr�;,k�ii�li`ti'J E i ;1'v���y.:v:71 !`rI
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one laUlong is sufficient) 22.Certification:
35.567156 N -81.908908 W, 'n
6.Is(are)the well(s)oPermanent or ©ITemporary Signature of Certified Well Contracfbr Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [Dyes or E)No wills 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature of the copy of this 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 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: 565 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths jdi Brent(example-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) 30 Method of test: AIR 24c.For Water Sunuly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
CHLORINE 2 CUPS completion of well construction toy the county health department of the county
13b.Disinfection type: Amount: where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016