GW1-2021-03251_Well Construction - GW1_20210628

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
DAV I D CAMP 14.WATER ZONES a I
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
NC Well Contractor Certification Number
15.OUTER CASING for:multi-cas'ed,wells (JR LINER'if a "ticable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 65 ft. 6.125 in' SDR21 PVC
Company Name
S`^,r�G —0002 16.1NNER,CASING ORT.MING:"eothermal,closed-too _. .. . .. ;_
2.Well Construction Permit#• V V FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIG County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public ft. ft. i .
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft• ,I•
Industrial/Commercial 13Residential Water Supply(shared) &GROUT
Irrigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. BENTENITE POURED 14 BAGS
Monitoring ®Recovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.5AND/GRAVEL PACK"if a "licable
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
J Aquifer Test OStormwater Drainage
ft. ft.
Experimental Technology [(Subsidence Control ft. ft
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additibnal`sheets`if necessary)
Geothermal eating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiUrock type, rain size,etc.)
0 ft. 65 ft. CLAY
4.Date Well(s)Completed:6" Well ID# 66 ft' 405 ft* GRANITE
5a.Well Location: ft. ft. 11++
ROBERT OWENSBY fa
Facility/Owner Name Facility lD#(ifapplicable) ft ft.
WILLIAMS RD. ft. fr. ,Ulu
atilt
Physical Address,City,and Zip
RUTHERFORD 21.RENIARKS O
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: f I
(if well field,one lat(long is sufficient) 22.Certification:
35.439046 N -82.082927 W
- ,
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: OYes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Iflhis 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 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: 405 (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@1001 construction to the following:
10.Static water level below top of casing: 70 (ft.) Division of Water Resoui ces,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 Infection 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
i
13a.Yield(gpm) 2 Method of test: AIR24c.For Water SUDDly&Inieetion 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: z CUPS completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resourcl s Revised 2-22-2016