GW1-2021-02294_Well Construction - GW1_20210722

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
It. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER d a licable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 100 ft- 6.125 in' I SOR21 PVC
Company Name
SW20-0558 76.INNER CASING OR 2'[JBINC eothermal closes-loo . _
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): fL fL in.
SCREEN17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13MunicipaVPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. It. ;n•
Industrial/Commercial DResidential Water Supply(shared) 18•GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 % 20 ft• BENTENITE POURED 14 BAGS
D Monitoring DJ Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if ii"licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. fL
Experimental Technology [3 Subsidence Control fL ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrock a rain s' etc.
0 ft. 100 ft. CLAY.
4.Date Well(s)Completed: E_ 21 WeII II}# 101 ft. 505 ft* GRANITE
ft. ft.
Sa.Well Location:
VERONICA RISORTO
Facility/Owner Name Facility ID#(ifapplicable) L I L 2 2
125 SHOOTING STAR LANE re ft. ljttit
Physical Address,City,and Zip ft. ft. Irl orl'�:3f, �'
Y tY. P r' SeTinn
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::
35.429097 N -82.147507 W U �4 �
6.Is(are)the well(s)opermanent or 13Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify That the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well• OYes or E)No with 15A NCAC 02C.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 ofthe copy ofthis record has been provided to the well owner.
repair under#11 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 1 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 (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 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.
246.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:
(Le.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) 6 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 coup health department of the county
136.Disinfection type: Amount: P E county eP
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource's Revised 2-22-2016