GW1-2021-02548_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: j
DAVID CAMP 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. fL
2136-A
ft. ft.
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NC Well Contractor Certification Number .15.OUTER CASING'for multi-cased wells OR LINER if a 7icable
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THIctwFss MATERIAL
0 ft. 1 25 n' 6.125 ln' 1 SDR21 PVC
Company Name
16.INNER cAslNc OR TUBING" eothermal e�osea-loo
RE W 19-0447 , ..
2.Well COOStrUCtlOn 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 ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATER '
17.SCREEN
MATERIAL_
Agricultural OMunicipal/Public fL ft. in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring ORecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK'if applicable)
Aquifer Storage and Recovery E3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) F3 Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
7 l 0 ft. 25 ft, CLAY
4.Date Well(s)Completed: �` / Well ID# 26 ft. 505 ft* GRANITE
ft. ft.
5a.Well Location:
HOLLY GREENE ft. rr. _
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
3142 NEW HOUSE RD. fL ft. mA
Physical Address,City,and Zip ft. ft. ire. ' fi ry_ nrra^S11'i�. U110
RUTHERFORD 21.REMARKS . i'
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:
35.3410 N -81.7486 W f-)"
6.Is(are)the well(s)OPermanent or Temporary 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• E3Yes or E)No with 15A NCAC 01C.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 ofthis 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 1 GW-1 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 2@100� construction to the following:
10.Static water level below top of casing: 80 (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 oflthis 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) 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
13b.Disinfection type: CHLORINE Amount: 1 CUP 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