GW1-2021-06980_Well Construction - GW1_20210505

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