GW1-2021-04616_Well Construction - GW1_20210510

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: 0:�
DAVID CAMP '
14.WATER ZONES.
Well Contractor Name Vj AT I ft FROM TO DESCRIPTION
ft
2136-A �S,n. U1 1
IfiS�llratl.n i'e..
1-e1 ' O ft. rt
NC Well Contractor Certification Number Dt yi1�Ji c'OI1 15.OUTER CASING for multi cased wells OR LINER if a licable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 rt 140 rt 16.125 in. ISDR21 JPVC
W21-0007 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) fL ft in.
3.Well Use(check well use): IL ft in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt ft. in,
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑lrri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt 20 ft BENTENITE POURED 14 BAGS
❑Monitoring ❑Recovery ft ft
Injection Well:
ft ft.
❑Aquifer Recharge ❑Groundwater Remediation
`19.'SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑�quiferTest ❑StormwaterDrainage ft tt
❑Experimental Technology ❑Subsidence Control tt tt
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.
/ - 0 ft 40 ft CLAY
4.Date Well(s)Completed: G�k Well ID# 41 rt 305 ft- GRANITE
5a.Well Location: ft ft
BRIAN SYLVIA ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
747 MOSS RD. ft. fL
Physical Address,City,and Zip ft ft.
RUTHERFORD 21.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.Certification: t
35.391185 N -82.034804 W
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 with
7.Is this a repair to an existing well: ❑Yes or (tNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).,You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 305 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@I00')
f65 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (t•) Information Processing Unit,161,7 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: 6 (in,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(lUQ
ROTARY Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: ROTARY For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gym) 3 Method of test:AI f`
13b.Disinfection type: CHLORINE Amount: 2 CUPS
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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