GW1-2021-05247_Well Construction - GW1_20210503

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVI D CAMP 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d a tieahle
CAMPS WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 rt 125 ft- 6.125 in' SDR21 PVC
Company Name S V V�/t/
9-0470 16.INNER CASING OR TUBING eothermal c1osed46o
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County.State, Variance,etc) ft. ft. m.
3.Well Use(check well use): ft. fL
Water Supply Well: 47.SCREEN
FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
Agricultural E]Municipalftblic ft. ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL ft. in;
Industrial/Commercial 13Residcntial Water Supply(shared) 18.GROUT
IITI 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: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL FACIC"Ifs 'livable)"-
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3 Stormwater Drainage ft. ft.
Experimental Technology OSubsidence Control ft. ft. k
Geothermal(Closed Loop) 0TraceT 20.DRILLING LOG attach additionalsheets if necessary)
Geothermal eating/Cooling Return Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type rain size,etc.)
0 ft. 125 fL CLAY
4.Date Well(s)Completed: / Well ID# 126 fL 405 ft* GRANITE
5a.Well Location: ft. ft.
HUNTER JENSEN/AMY FERRISS ft. ft.
Facility/Owner Name Facility 1D#(ifapplicable) ft. ft. 1 Q, W•
ELLIOT ROAD ft. ft. A" q
Physical Address,City,and Zip ft. ft. MAY X 31021
RUTHERFORD 21.REMARKS
3 1- Unit
County Parcel Identification No.(PIN)
I�I�rl;• �1�i�ro>a s r�0
I Y vvv i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.449880 -82.041434 4
N W MQ
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: 13Yes or E)No with 15A NCAC 02C.0100 or I5A 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: 405 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100� 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
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 ofjthis form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 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
CHLORINE 2 CUPS
13b.Disinfection type: Amount: completion of well construction to the 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