GW1-2021-05997_Well Construction - GW1_20211008

SELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: i
`-
1.Well Contractor Information:
i
DAVID CAMP ,14.'WAT- Rr-NEs_
FROM TO DESCRIPTION
Well Contractor Name
ft. ft. I
2136-A
rt. rt.
NC Well Contractor Certification Number 15;OUTER CASING for:multi=cased wells sUR LINER` s`licable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 95 ft. 6.125! in' SDR21 PVC
Company Name 16.`NPM GASING OR TUBING`.. etitherinal closed too _::
2.Well Construction Permit#: 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): ft. ft. in.
Water Supply Well: FROME TOf DIAMETER SLOTSIZE THICKNESS I MATERIAL
Agricultural OMunicipal/Public ft. ft. In•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) pt. tt. in.
IndustriaVCommerciai DResidential Water Supply(shared)
Irrigation FROM TO 3 MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO tt. BENTENITE POURED 14 BAGS
Monitoring ;Recovery ft. ft.
Injection Well: ft. ft.
_ Aquifer Recharge OGroundwater Remediation
19-SAND%GRANWVPACK'if®"licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 20 DRILLU4G`L'OG:ittach ailditionil.eheet§':if.dece§sa" ' ;;
Geothermal(Heating/CoolingReturn .Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soufrock f rains etc
/ / 0 ft. 95 ft. CLAY
4.Date Well(s)Completed: l`0—1 • Well ID# 96 ft. 145 ft- GRANITE
ft. ft.
Sa.Well Location:
SHANE BAYNARD
Facility/Owner Name Facility ID#(if applicable) ft. ft.
At
423 PINEY MOUNTAIN RD.
Physical Address,City,and Zip ft. ft. in9 UI�It
RUTHERFORD :ir•REMARKS
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.Certificat�o
35.376694 -81.773587 ( `
N W
6.Is(are)the well(s)OPermanent or ®ITemporary 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 02C.0100 or/SA NCAC 02C.0200 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: 145 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 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 Injection 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) 50 Method of test: AIR 24c.For Water Sunoly&Infection 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: completion letion of well construction Rothe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016