GW1-2021-00250_Well Construction - GW1_20211213

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.2136-A
e. rL
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 THtc.N,& MATERIAL
0 ft• 140 ft 6.125 1 ' I SRD21 PVC
Company Name
S W21-0336 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLAT SIZE THICKNESS MATERIAL
NAgricultural DMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) ft. M in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
hTiRation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery - _ ft ft. -
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ❑ISalinity 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 if necessary)
FROM TO DESCRIPTION color,hardness,wit rock e, rain size,etc.)
Geothermal(Heating/Cooling Coolin Return) Other(explain under#21 Remarks)
0 ft. 140 ft CLAY
4.Date Well(s)Completed: 11 /�=�AVell ID# 141 ft. 505 ft. GRANITE
5a.Well Location: ft. ft.
ROBBIE GANTT k' ft 4
Facility/Owner Name Facility ID#(if applicable)
r,
3552 WHITESIDES RD. rt. ft. 1 -�
Physical Address,City,and Zip ft. fL r.f' r,
RUTHERFORD 21.REMARKS
County Parcel Identification No.(PIN) •c� '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
1I- '.� ;' ��' ttrrlt
(if well field,one hit/long is sufficient) 22.Certification:
35.419011 N -81.859483 W
6.Is(are)the well(s)oX Permanent or DTemporary Signature of Certified Well 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 02C.0200 Well Construction Standards and that a
Ifthis 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-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: 505 00 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'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 27699-1636
13a.Yield(gpm) 1 ip .,_ 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
CHLORINE 2 CUPS completion of well construction to the county health department of the county
136.Disinfection type: Amount: P tY P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016