GW1-2021-04783_Well Construction - GW1_20210527

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
2136-A It. ft. p
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
CAMP'S WELL AND PUMP CO. FROM�ftgO
o DIAMETER THICKNESS MATERIAL
0 ft. 6.125 in' SDR21 PVC
Company Name C G
WZO-0566 16.INNER CASING OR TUBING j eothermal closed-loop) _
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc.) ft. It. in.
3.Well Use(check well use): fL ft. in.
11 SCREEN
Water Su Well:
Supply FROM TO DIAMETER SLOT SIZE TRICIINESs MATERIAL
Agricultural 13Municipah?ublic ft. R, in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft. in.
IndustriaUCommercial 13RLsidential Water Supply(shared) 18.GROUT
[Experimental
lOn FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
ater Supply Well: 0 fL 20 fL BENTENITE POURED 14 BAGS
toring DI Recovery fL ft.
n Well: ft. ft.
er Recharge Groundwater Remediation
19.SAND/GRAVEL PACK Cif applicable)
er Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
er Test DStormwater Drainage ft. ft
Technology Subsidence Control ft. fLermal(Closed Loop) �ITracer 20.DRILLING LOG(attach additional sheets if necessaFROM TO DESCRIPTION color,hardness,soil/rock e, 'sin si etc.ermal(Heating/Cooling Return) r3Other(explain under#21 Remarks)
0 ft. 90 ft* CLAY
4.Date Well(s)Completed: Well ID# 91 H 505 It* GRANITE
ft. ft.
5a.Well Location:
RICHARD MCBRAYER ft. e.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
1554 COOPERS GAP RD. e. ft. :L)
ft. ft.
Physical Address,City,and Zip
RUTHERFORD zl:REMARKS 1,"
County Parcel Identification No.(PIN) r YL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: U V v„
(if well field,one lat/long is sufficient) 22.Certification:
35.3811 N -82.027 W D��
513
6.Is(are)the well(s)oPermanent or []Temporary Signature ofCertified Well Contracto Date
By signing this form,I hereby certify that the ivell(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 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#11 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.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: 505 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 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) 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
13b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
where constructed.
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Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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