GW1-2021-01579_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAV I D CAMP la.WATER ZONES =
Well Contractor Name FROM TO DESCRIPTION
ft. ft
2136-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased=wells OR LINER ifa licable
CAM P'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 35 nt 6.125 ISDR21 JPVC
A 16.INNER CASING OR TUBING(geothermal closed46o W20-o44
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): (L ft in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) InResidential Water Supply(single) It. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '18.GROUT
❑hri ation ❑Wells>100,000GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft BENTENITE POURED 14 BAGS
❑Monitoring ❑Recovery ft ft
Injection Well:
IL ft.
❑Aquifer Recharge ❑Groundwater Remediation
l-49.!(SAND/GR`e1VY,LVAGK if,a licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control f. ft
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock rain size,etc.)
0 ft 35 ft CLAY
4.Date Well(s)Completed: �- -,?-I Well ID# 36 ft 225 ft GRANITE
5a.Well Location: ft ft
ROBIN JEFFERY ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
2816 DALE SUMMEY RD., RUTHERFORDTON ft ft
Physical Address,City,and Zip ft ft. 1A A k X 9 2
021
RUTHERFORD 21.REMARKS
Information Processing
County Panel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one]at/long is sufficient) 22.Certification:
35.236067 N -81.919728 W au
6.Is(are)the well(s): nPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only I GW-i is needed. Indicate TOTAL NUMBER of wells (add'Se a Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 225 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2Q100')
f40 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (t.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROTAR fp�/
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(Le.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR CCPCUA
13a.Yield(gym) 50 Method of test:AI
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: CHLORINE Amount: 2 CUPS
c
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018