GW1-2021-03331_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
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1.Well Contractor Information:
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DAVI D CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2136-A
fL rL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)0R LAYER rf a' licable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER TWCKNESS MATERIAL
o ft, ft. 1 6.125 in' SDR21 PVC
Company Name r�
S WGO-� 27 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State. Variance.etc.) fL ft. DIAMETER
3.Well Use(check well use): ft. ft. in.
11 SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. fL in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:
fL fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK rf a licable
Aquifer Storage and Recovery [2Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage
ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG_attach additional sheets if necessary)
Geothermal(Heating/CoolingQReturn) FROM TO DESCRIPTION(color,hardness,soil/rock rains etc.Other(explain under#21 Remarks) 0 ft- 4 5 ft- CLAY i
4.Date Well(s)Completed: <J'13-tZ 1 Well ID# / ft. 285 ft, GRANITE
5a.Well Location: tP ft. ft.
DOUG & LYNN RUPP ft. fL ?•�.A�#�,
Facility/Owner Name Facility 1D#(if applicable) ft. ft.
573 LAKEVIEW TRAIL ft. ft. 9
Physical Address,City,and Zip ft. ft
MCDOWELL 21.REMARKS
County Parcel Identification No.(PIN) �^
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.5616 N -81.9029 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: E)Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 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 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-1 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: 285 (ft-) 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@1001 construction to the following:
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 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 f Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 90 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: z cups completion of well construction Ito;the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resou Ies Revised 2-22-2016