GW1-2021-06680_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP
Well Contractor Name ve FROM TO DESCRIPTION
� oti� ft. ft.
2136-A �C Q v �� rt ft
NC Well Contractor Certification Number ���r°xv3 15r'.`OUTER:EASING#for,rudlH?ea"sed wells'OR:LTIV R ifg"""livable
CAMP'S WELL AND PUMP CO. 3++T` %i+'of\ FROM TO DIAMETER THICKNESS MATERIAL
o ft. 70 rt. 6.125 in' SDR21 PVC
Company Name
W21-0126 --�6-nvNER'.cnsINcoR:Tus�cr eoftiei7ital cloBed>loo
2.Well Construction Permit#: FROM I TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Count};State,Variance,etc.) it. ft. in.
3.Well Use(check well use): tt tt in
17 SCREEN fs ;: . 3
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) E)Residential Water Supply(single) tt. tt. in.
Industrial/Commercial DResidential Water Supply(shared)
_ Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
:)Aquifer Recharge Groundwater Remediation
�19:�SAND/GRAREli'PACK fa "_licab7e '-
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Heating/Cooling Coolin Return Other(explain under#21 Remarks)) itiona sheets da
Geothermal(Closed Loop) OTracer 20'DRtiLIIVG LOG:.attaeb add
FROM TO DESCRICf10N(color,
hardness,
dnness soil/rocka rain si etc.
0 ft. 70 ft. CLAY
4.Date Well(s)Completed: Well ID#
71 ft 305 ft' GRANITE
tt. ft.
5a.Well Location:
STEVE GARRISON
Facility/Owner Name Facility ID#(if applicable)
HARVEY LOGAN RD.
Physical Address,City,and Zip
RUTHERFORD :21_REMARIf5 , h
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.Certification:
35.386442 N -81.771914 W
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Wel ontractor Date
By signing this form,I hereby certify that the well(s)was(w✓)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
#*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:
S.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: 305 (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:60 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Servi i ce Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: Inladdition 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
13s.Yield(gpm) 10 Method of test: AIR 24c.For Water Supply&I ie&lon 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 corn letion of well constructi n to the,county health department of the county
13b.Disinfection type: Amount: p
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016