GW1-2021-06678_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: kk
1.Well Contractor Information: gg
DAV I D CAMP �07 ^s' is vvATER zONES. ;: . 3
FROM TO DESCRIPTION
Well Contractor Name
� tio11 ft. ft.
2136-A �C ft. ft
NC Well Contractor Certification Number �C jrJB�gtI�� 15 OUTERGASING fdr multi ce'sed wells UR:LIPi1GR "'livable,„^a `
CAMP'S WELL AND PUMP CO. r`u�'SIT I�5e���On FROM tt• TO ft. DIAMETER THICKNESS MATERIAL
0 70 6.125 SDR21 PVC
Company Name Y
W21-0126 =-t6'1NNER.CASING;OR TUBDVG3 eofhe€tiial,closedld'o
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS I MATERIAL t
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: FROM I TO DIAMETER SLOT SIZE THLCKNESS MATERIAL
_ Agricultural E3MunicipaVPublic ft. tt. in,
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft.
Industrial/Commercial Residential Water Supply(shared) 18°GROtJI"' ,
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. PO ft. BENTENITE POURED 14 BAGS
Monitoring r3Recovery
Injection Well: ft. ft.
_Aquifer Recharge OGroundwater Remediation _
x-19 SAND/GRAVF,I;PACK. f-a'"Hcab7e
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL J EMPLACEMENT METHOD
_Aquifer Test OStormwater Drainage ft. ft.
Experimental Technology 13Subsidence Control ft, ft.
Geothermal(Closed Loop) Tracer 201)RILLING I OG.attach'eddifioneP"she_efs if;necessa .,
FROM TO DESCRIPTION color,hardness soiVrock type,gre(n size,etc.
Geothermal(Heating/CoolingReturn ' Other(explain under#21 Rern!±s2i 0 ft. 70 ft. CLAY
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4.Date Well(s)Completed: —M Well ID# 71 ft. $05 tt. GRANITE
5a.Well Location:
STEVE GARRISON
Facility/Owner Name Facility 1D#(if applicable)
HARVEY LOGAN RD.
tt.
Physical Address,City,and Zip ft.
RUTHERFORD -2I'R>MARxs
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certific-ationl:n
35.386442 N -81.771914 W ��
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Wet ontractor Date
By signing this form,i hereby cerilfy that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: E]Yes or E]No 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: 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-3Q200'and 1Q100') 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 Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: I,I 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
13s.Yield(gpm) 10 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 2 CUPS completion of well constructii n'to the county health department of the county
where constructed.
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016