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HomeMy WebLinkAboutGW1-2021-00192_Well Construction - GW1_20210505 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: g -� DAVID CAMP r 1+1:�WATE11�-ZUNES• s -r' ..r.;, Well Contractor Name '° ' FROM TO DESCRIPTION 2021 ft. it. 2136-A NC Well Contractor Certification Number l FROM TO sed=.wellsORLINER', ;a''"Ilcable .., 15.OUTEItCAS1NG(for<multica CAMP'S WELL AND PUMP CO. 1;'"`lt"1tJcy oIi DIAMETER TmCKNEss MATERIAL' U ft. 6 ft. 6.125 In. SDR21 PVC Company Name SW20-0056 .,><6.INNER,CASINGOh'TUBING;"eother;gsilcloseil=l"`b 2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL List all applicable well construction permits fl.e.UIC,County,State, Variance,etc.) ft. ft. in. 3.Well Use(check well use): tt ft. in. Water Supply Well: FROM RF I TO r fiI DIAMETER I SLOT SIZE LLTIIICKNESS MATERIAL Agricultural OMunicipal/Public ft. ft. in. Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft Industrial/Commercial DResidential Water Supply(shared) :" i _75 Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 ft- Y0 ft. BENTENITE POURED 14 BAGS Monitoring DRecovery ft. ft. IAquifer ection Well: ft. ft. quifer Recharge Groundwater Remediation quifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD Test OStormwater Drainage . .xperimental Technology Subsidence Controleothermal(Closed Loop) Tracereothermal eatin Coolin Return) .Otirer ex lain under#21 Remarks FROM TO DESCRIPTION color hardness soil/rock t e rains etc .)Other ft. o ft- CLAY 4.Date Well(s)Completed:4-6-2021 Well ID# ft. 705 ft- GRANITE 59.Well Location: ft. ft. DAVID KEMENSKI ft. ft. Facility/Owner Name Facility ID#(if applicable) ft. ft. INSPIRATION RIDGE DR. ft. ft. Physical Address,City,and Zip ft. ft. RUTHERFORD zl:REMARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees: (if well field,one lat/long is sufficient) 22.Cer Cation: 35.484459 N -81.823262 W 6.Is(are)the well(s)oPermanent or ©ITemporary Signature of Certified Well Contractor 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: OYes or E)No with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a If 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 thisform. 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-I 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: 705 i(fL) 24a. For All Wells: Submit this form''within 30 days of completion of well For multiple wells list all depths if different(example-3@200'and 2@I00� construction to the following: I 10.Static water level below top of casing: (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 Injection Wells: In aiddition to sending the form to the address in 24a _t above,also submit one copy of this form within 30 days of completion of well 12.Well construction method:r[3rtI7 w 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) 10 Method of test' AIR 24c.For Water Supply&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 to the coup health department of the county 13b.Disinfection type: Amount: P county P h' where constructed. Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1.Well Contractor Information: DAVID CAMP 14iWATERZONES Well Contractor Name FROM TO DESCRIPTION % 2136-A 20 61 17L ft. NC Well Contractor Certification Number 15.OUTER CASING(for Tuiti-cased wells)F!ILI R ifapMble), THIM S FROM TO DIAMETER R I MATERIAL CAMP'S WELL AND PUMP CO. Company Name in. I SDR21 PVC S 16.INNER CASING OR TUBING-igeother,a]closed400 tr p) 2.,Well Construction Permit#: W20-0098 0 95 6.125,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): fL ft. in. 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SUN THICKNESS MATERIAL Agricultural 13M[unicipal/Public ft. ft. i n. 7)Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. i I n. 3Industrial/Commercial DResidential Water Supply(shared) A8.GkOuT. -,IhTigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0 % 20 BENTEN I ITE POURED 14BAGS Znitoring [3Recovery & Injection Well: ft. ft. Aquifer Recharge OGroundwater Remediation Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD i Aquifer Test OStormwater Drainage ft. ft. Experimental Technology OSubsidence Control ft. ft- Geothermal(Closed Loop) [3Tracer 20.DRILLING LOG(attach additional sheets ifnecessary) FROM TO DESCRIPTION(color,hardness�seiltmck type, rain size,etc.) Geothermal(Hearin Cooling Return) E]Other(explain under#21 Remarks) 0 ft. 95 % CLAY! 4.Date Well(s)Completed: Well]D# 96 & 305 n* GRANITE 5a.Well Location: ft. ft. ROBERT BUSBEE ft. ft. Facility/Owner Name Facility ID#(ifapplicable) ft ft. WHITESTONE CIRCLE LOT 98 HEARTHSTONE Physical Address,City,and Zip RUTHERFORD 21.REMARKS County Parcel Identification No.(PIN) 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: (ifwell field,one lattlong is sufficient) 22.Certificatio 35.4507 N -81.9615 W i J_/—A 7 Zj 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 7.Is this a repair to an existing well: [)Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a ffthis 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,only I GW-I 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: 305 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdifferent(example-3@200'and 2@1003 construction to the following: 10.Static water level below top of casing: 50 (ft) Division of Water Res"urces,Information Processing Unit, Ifwater 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) 5 Method of test: AIR 24c.For Water Supply&Iniection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of 13b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county where constructed. Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016