GW1-2022-07552_Well Construction - GW1_20220815

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAV I D CAMP I4 WATER ZONES.
Well Contractor Name FROM TO DESCRIPTION
2136-A
rt. ft.
NC Well Contractor Certification Number A5 iUUTER CASING'fii malti4iiiied,NJR:L OINER if a"'ll ca6le
CAMP'S WELL AND PUMP CO. FROM TOI DIAMETER THICKNESS I MATERIAL
0 fi 85 fL 1 6.125 in' SOR21 PVC
Company Name
.SW22-�305 �:16�INNER�CASING OR`TUBING° eotliermel closed=too •: ^•-:� -s_-
2.Well Construction Permit#: FROM TO I DIAMETER THICKNESS MATERIAL
List all applicable well constntction permits(i.e.VIC,County,State,Variance,etc.) ft• ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: .17:SCREEN:•'
FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
Agricultural []Municipal/Public fL ft. in,
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) tt IL
Industrial/Commercial Residential Water Supply(shared) 'Lilt'GROUa'.K
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- PO ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft. .
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation _
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) QTracer 30:'1)RiLI ING I OG'��ts'i3h'iidditlonalstiet tri.iLn"'eee3sa r, ;Y,, ,s xn.}
FROM TO DESCRIPTION color,hardness soll/rock a rain size etc.
Geothermal(Heating/CoolingReturn �t Other(explain under#21 Remarks) 0 rt. 85 ft- CLAY
4.Date Well(s)Completed: Well ID# 86 fir 305 fi' GRANITE
ft. ft.
Sa.Well Location:
STEVE METZ rt. rt.
Facility/Owner Name Facility ID#(if applicable) tt. ft. ,�"' ', s t•
HUDLOW RD. ft. ft.
Physical Address,City,and Zip ft. ft. �)(� 1 •s
RUTHERFORD 21=REMARKS '
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/miuutes/seconds or decimal degrees: "
(if welI field,one[at/long is sufficient) 22.Certification:
35.43923 N -81.92937 W l
6.Is(are)the well(s)oX Permanent or Temporary Signature of Certified Well Contractor I Date
By signing this form,/her•ebv cerlify that the well(s)was(were)constructed in accordance
7.1s this a repair to an existing well: Yes or QNo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consintction Standards and that a
/f this is a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair tinder#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: 305 (ft-) 24a. For All Wells: Submit',this form within 30 days of completion of well
For multiple wells list all depths ifdijjer•ent(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 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
i
13a.Yield(gpm) 4 Method of test: AIR 24c.For Water Supply&Injection 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.
Fomi GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016