GW1-2021-07059_Well Construction - GW1_20211129

RECORD(GW-1) iFor Internal Use Only:
actor Information:
DAVID CAMP 14.WATER ZONES
ell Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A -
e. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER If a livable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
p It. 83 ft. 6125 In 1 SDR21 PVC
Company Name
SW2�—�224 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits ri.e.UIC,Comity,State,Variance,etc.) ft. tt. in.
3.Well Use(check well use): R. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT i
hri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well: _
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK B applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets it necessary)
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM To DESCRIPTION color,hardness soll/rock type,praln size,etc.
p ft. 83 ft. CLAY
4.Date Well(s)Completed: (' Well ID# 84 f'' 345 ft' GRANITE
5a.Well Location: ft. ft.
PAUL WILLIS
Facility/Owner Name Facility ID# ifaP livable)
CLARK RD. ft. ft. NOV
'
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) r' t'"'1 !,r,""r,
`rw�nw UiJli
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) 22.Cer' cation:
35.413076 N -82.095337 W , t,
�- -21
6.Is(are)the well(s)OX Permanent or DTemporary Signature of Certified Well Contrric[or Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or X)No with 15A NCAC 01C.0100 or 15A NCAC 01C.0100 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 1121 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-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: 345 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@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 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 276994636
13a.Yield(gpm) 12 Method of test: AIR24c For Water Suably&IniecHim Wells: In addition to sending the form to
the address(es) above, also Isubmit 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. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016