GW1-2021-01580_Well Construction - GW1_20210309

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14zWATER-•ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2136-A ft. fL
NC Well Contractor Certification Number 15:OUTER,CASING for multi-cased well§ OR LINER:if a `livable
CAM P'S WELL AND PUMP C O. FROM TO I 'DIAMETER I THICKNESS MATERIAL
Company Name
0 ft 70 it- 16.125 in SDR21 1PVC
-
W20-0506 -16:�INNER=6ASING-OR':TUBING' eotliermehclosed•hio'
2.Well Construction Permit#• FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits ri.e.UIC,County,State,Variance,etc.) ft ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROME TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft, in.
❑Industrial/Commercial ❑Residential Water Supply(shared) iB GROUT,-
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft. BENTENITE POURED 14 BAGS
ElMonitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
19s=SAND/GRAVEti PACK,.if a"'livable _•-
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERL 1 EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
[]Geothermal(Closed Loop) ❑Tracer 207DRILLING LOG attach-additional'sheets•irneces"sar
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness soil/rock rain size etc.
0 rt. 70 it. CLAY
4.Date Well(s)Completed: —J I Well ID# 71 ff 605 fL GRANITE
5a.Well Location:
ROGER LIAMG ft. rt.
Facility/Owner Name Facility ID#(if applicable) ft. ft
RECEIVED
174 CREEKSIDE CIRCLE rt. rt.
Physical Address,City,and Zip
RUTHERFORD 21'i+REMARKS informatinn
County Parcel Identification No.(PIN) DWR Section
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat(long is sufficient) 22.Certific tion:
35.405875 N -81 .992324 W
i
6.Is(are)the well(s): OPermanent 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 L'JNo 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known welt construction information and explain the nature of the of this record has been provided to th6 veil omier.- -- ---
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'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 605 (ff) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100�
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 75 (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+•'
24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 6 (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROTARY 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.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(gpm) 2 Method of test•A I R
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: CHLORINE Amount: 2 CUPS
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018