GW1-2021-02623_Well Construction - GW1_20211110

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L CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1 7
DAVID CAMP 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft, ft.
2136-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
CAMPS WELL AND PUMP CO. FROM TO DIAMETER THICIaVESS MATERIAL.
0 ft• 35 fL 1 6.125 In' I SDR21 PVC
Company Name
SW20-0432 16.INNER CASING OR TUBING eothermal closed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits fi.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.
Water Supply Well: FROME TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural OMunicipaVPublic ft. ft. in•
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft.R io•
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Itri ation - FROM I TO MATERIAL -EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 40 ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK R applicable)
Aquifer Storage and Recovery OlSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage B• ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets it necessary)
Geothermal(Heating/CoolingReturn Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness,aoi0rock ins etc.
Q L 0 ft 35 IY CLAY
4.Date Well(s)Completed: 1 -1` d-(Well ID# 36 ft 365 ft' GRANITE
ft. ft.
5a.Well Location:
RODGER PARKER ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. I N Fo
HWY 226 CASAR, NC ft. ft. NO
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.REMARKS DWRSEOM
County Parcel Identification No.(PIN) 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: i
35.505012 N -81.716446 W
6.Is(are)the well(s)0Permanent or ❑(Temporary 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: OYes 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 on the back of this form. 23.Site diagram or additionalwell 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: 385 (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: 100 (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 Infection 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
i
13a.Yield(gpm) 40 Method of test: AIR 24c.For Water Supply&Infection 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016