GW1-2021-03250_Well Construction - GW1_20210628

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i 9 i
DAVID CAMP 14.WATERZONES
FROM TO DESCRIPTION I
Well Contractor Name ft. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number 15:O,UTER CASING for";muldi'8 edeivella
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft, 30 ft, 6.125, in' SDR21 PVC
Company Name 16 iINNER CASING OR:TUBIlY �othergrilrclosell`140
2.Well Construction Permit#: RE20-0355 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits O.e.UIC,County,State,Variance,etc.) it. ft. in.
3.Well Use(check well use): ft. ft. In.
Water Supply Well: DFROM
TO S DIAMETERµ SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft.
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) ft. In• i
Industrial/Commercial Residential Water Supply(shared)Irri ation TO MATERIAL d EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 PO ft. BENTENITE I POURED 14 BAGS
!Monitoring :Recovery ft. ft.
Injection Well:
ft. it.
Aquifer Recharge OGroundwater Remediation v.
19:eSANDIGR'AYEI.•P`ACK If a`7iciible - .,.�,`,..�u. ",`�;-��� '�.�g t�.�'��'�:.�.-
Aquifer Storage and Recovery ©ISalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology 13Subsidence Control ft. ft.
1
Geothermal(Closed Loop) Tracer 20 DRIISI:IhTGT OG,iittscfi aditidonal aheete-if necessa
Geothermal eatin Coolin Return Other(explain under#21 Remarks FROM TO DESCRIPTION color hardness soiVrock rain a etc.
0 ft. 30 ft. CLAYI
4.Date Well(s)Completed: r Well ID# 31 ft. 105 ft, GRANITE 1
5a.Well Location:
RANDELL BOCK
Facility/Owner Name Facility ID#(if applicable) ft. ft.
CHICKADEE AVE.
Physical Address,City,and Zip
RUTHERFORD Z1:REMARKS'
County Parcel Identification No.(PIN) 4
� o
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaVlong is sufficient) 22.Cert' adon:
35.425219 N —82.169568 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
7.Is this a repair to an existing well: DYes or ONo with 15A NCAC 01C.0100 or 15A NC.4C 02C.0100 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 oflhis 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 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: 105 M-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,jferent(example-3@200'and 1 aC31001 construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servicell Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition tc 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 SuDDIV&,Iniel don Wells: In addition to sending the form to
the address(es) above, also submit one I copy of this form within 30 days of
CHLORINE 2 CUPS completion of well constructions to the county health department of the county
13b.Disinfection type: Amount: P ty' p ty
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources) Revised 2-22-2016