GW1-2021-05279_Well Construction - GW1_20210601

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
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DAVID CAMP 1� "°a J 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
fL fL
2136-A pN ft. ft.
NC Well Contractor Certification Number �Ii Urllz 15.OUTER CASING for multi-cased wells OR LINER if a licable
CAMP'S WELL AND PUMP CO. �nScr►ra,ion PC0>;eSS FROM TO DIAMETER T�CIaVESS MATERIAL
Itn�_C�ort!OIl
a p ft. gp ft. 1 6.125 j in' SDR21 PVC
Company Name
W21-0155 16.INNER CASING OR TUBING eetnermal closed-loop)
_
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. fL in.
17.SCREEN
Water Supply Well:'
FROM TO DIAMETER SLOT SIZE THICIC#;FM MATERIAL
Agricultural [3Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) fL ft, in.
industrial/Commercial Residential Water Supply(shared)Pp Y( 18.GROUT
Itri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p fL PO ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge E]Groundwater Remediation
19.SAND/GRAVEL PACK If applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) F30ther(explain under#21 Remarks) FROM TO DESCRH'TION color,hardness,soil/rock type,grain size,etc.
/� ) 'f p fL gp ft. CLAY
4.Date Well(s)Completed: . -) 21 Well ID# 91 ft. 165 ft' GRANITE
5a.Well Location: fL ft.
HENRY MILLER ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1608 WALLS CHURCH RD. ELLENBORO 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'
35.367360 N -81.754197 W
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified We11 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: DYes or E)No with 15A NCAC 01C.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#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 I 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: 165 (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:40 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service'PCenter,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) 5 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 Ito the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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