GW1-2021-07058_Well Construction - GW1_20211129

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"'CONSTRUCTION RECORD GW-1 For Internal Use Only:
1 Well Contractor Information:
DAVID CAMP M4:1`WATERIZONES'
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
NC Well Contractor Certification Number VOUTEWCAS ING f foi m 1N cased w1 "OR7:INER�If s' lice 46r; i<'i
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 fl' 60 ft- 6.1M In SDR21 PVC
Company Name
SW21-0188 �16JNNER2CASING>OILTUBINCs” eothermal closed=ilia
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft• tt• i°•
3.Well Use(check well use): R. ft. tu.
171SCREEN`:as..<. , z. K r�£ .s;;rs h zk eta
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural []MunicipaUPublic ft. R. In.
Geothermal(Heating/Cooling Supply) EIResidential Water Supply(single) tt. ft. I In.
IndustriaUCommercial Residential Water Supply(shared)
`Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft• BENTENITE POURED 14 BAGS
Monitoring -- !Recovery
Injection Well:
tt. tt.
:),Aquifer Recharge ElGroundwater Remediation
�19�$AND/G12•AY,EI�PAGK.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology 0Subsidence Control
Geothermal(Closed Loop) Tracer 20�DRIL^I ING LOG attach eddltioire4atieetatif necesgr'`.�.zFb �t �arWN- _
a
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness sallfroek rain sl ate.
0 ft. 60 ft. CLAY
4.Date Well(s)Completed: Well ID# 61 ft
( v ~K • 205 ft. GRANITE
K 5a.Well Location: ft. ft. - -
DALE PETERSON ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. NOVt
MALLARD RD. ft. ft. �V
r,-•�,.,.t,�
Physical Address,City,and Zip ft. tf. I I%'�:� JC..•!i'.il
RUTHERFORd 214REMi1RKS;
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:
35.433423 N -82.73129 W 2
6.Is(are)the weU(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerlyy that the)wills)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or MNo with 15A NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis 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-I 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: 205 (ft-) 24a. For All Wells: Submit Fthis form within 30 days of completion of well
For multiple wells list all depths ifdtfferent(example-3Qa 100'and 2 100) construction to the following:
10.Static water level below top of casing: 60 (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 Infection Wells: In laddition 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) 30 Method of test: AIR 24c.For Water Supply&Infection 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016