GW1-2021-08114_Well Construction - GW1_20211105

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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
rt. rL
NC Well Contractor Certification Number 15.OUTER CASING for T!DLId esed wells OR LINER R e livable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 1 123 It- 6.125 in' SRD21 PVC
Company Name
SW20-0554 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM I 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): P
ft. ft. in.
Water Supply Well: IZ SCREEN
PP Y FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft. ta.
Industrial/Conimercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ii' 20 BENTENITE POURED 14 BAGS
Monitoring EIRecovery ft. ft.
Injection Well: ft, ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks) FROM To DESCRIPTION color,tardn eolVrocktype, rein size,eta
0 If• 123 it- CLAY
4.Date Well fs)Completed: 1 V-z6-.2- Well ID# 124 ff• 285 It' GRANITE
ft. ft. 1,
5a.Well Location: i
DAVID CLARK rt. rt 4
Facility/Owner Name Facility lD#(ifapplicable) ft. ft. NOV - 52021
NEW COVENANT WAY e. fa
it. It.
Physical Address,City,and Zip
RUTHERFORD 21.REMARKs I "'".•..,:I�� 1 '
County Parcel Identification No.(PIN) ..e•
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer ea loon::L /35.373937 N -81.727585 WL`/ )G�/t l�f 16)-27
-Zf
6.Is(are)the well(s)oX Permanent or ❑ITemporary Signature of Certified Well Contractor 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: QYes or XONo with 15A NCAC 02C.0100 or 15A NCAC 02C.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 an 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 details. You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 285 (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: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 t(in.) 24b.For Injection 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 Suunly&Ini'ction 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. t
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
i