GW1-2021-06770_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14wATERzoNEs s-.
FROM TO DESCRIPTION
Well Contractor Name rut. ft.
2136-A rut. ft.
NC Well Contractor Certification Number
�IS;OU.'I'E$ECASING CormulH=ea"sed-Wells AR-IrsINE1t
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 45 fi' 6.125 in' SDP21 PVC
Company Name u
FARM WELL 1R_ca 6.,INNE SING.oxTUB7NG! e otheemalclp8ed'loo
2.Well Construction Permit#: FROM TO DIAMETER ! THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft.
3.Well Use(check well use): ft. ft.
Water Supply Well: FROMCE TO a DIAMETER SLOT SIZE Y THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft• ft. in.
%dustriaUCommercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BEN TENITE POURED 14 BAGS
Monitoring ORecovery ft. ft.
Injection Weil:
:)Aquifer Recharge Groundwater Remediation
=194SA'ND/GRAUEL-PACK fd'"`Iicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage ft. ft. '
Experimental Technology OSubsidence Control ft. ft.
_ Geothermal(Closed Loop) Tracer 20 DRII LING LOG`attach addtionalstieeta,if necessa ?_ _
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRrPTION color,hardness soil/rock type,grains etc.
0 ft- 45 ft. CLAY
4.Date Well(s)Completed: ` _ Well ID# 46 ft' 165 ft, GRANITE
5a.Well Location: ft. ft.
RONNIE HAWKINS ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft.
MCKINNEY MILL RD. fc. rut.
Physical Address,City,and Zip ft. ft. ,i3 Processing
RUTHERFORD 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.Certi tion.
35.348310 N -81.720537 W
-�
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contractor Date
By sl�vninv 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 E)No with 15A NCAC 02C.0100'or ISA kAC 01C.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 o(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: 185 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diaerent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing:20 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
il.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: j
(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) 15 Method of test: AIR 24c.For Water Sunoly&Iniec'tion 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 completion of well construction to the county health department of the county
13b.Disinfection type: Amount: P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources R&ised 2-22-2016