GW1-2022-08171_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP ia7wnTERbzoNEs :
Well Contractor Name PROM TO DESC I RIPTION
ft. fL
2136-A
NC Well Contractor Certification Number _1Y5 OUTERrCASING for multi ce`sedaweUs ORftINER'"ita ltceliie
CAMPS WELL AND PUMP FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 125 ft- 1 6.125 In• SDR21 PVC
Company Name
SWZZ-000Z `36 1NNERTASING=OR';Ti1BING.' eothecmalildied=too , €
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): it. tt. in.
Water Supply Well: ii17^'.SGREEN:?��F<s,.?.�,�Ts�r_��:'�
PROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural DMunicipal/Public it. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. ft. in.
i IndustriaUCommercial []Residential Water Supply shared
:. PP Y(shared) $sGROUf" ?
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• BENTENITE 20 BAGS
i Monitoring Recovery
Injection Well:
ft. tt.
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control
Geothermal(Closed Loop) OTracer 20:DRIL'LING LOG:attech>ed lIIIbn 6ior:; z
FROM I TO DESCRIPTION color,hardness soiProck type,grain size etc.
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks)
0 ft. 125 ft- CLAY AND SAND
4.Date Well(s)Completed:44-22 Well ID# 126 ft• 265 ft• GRANITE
Sa.Well Location:
HUNTER HAYNES
Facility/Owner Name Facility lD#(if applicable) ft. ft.
SHERIFF HUSKY DRIVE rt. «.
APR I
Physical Address,City,and Zip ft. ft. -
RUTHERFORD
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.Cert ed o
35.3015 N -81.9119 W 1
4-7-2022
6.Is(are)the well(s)oPermanent or DTemporary Si of Certified Well Contr for Date
By signing this form,I hereby tfy that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes. or EJNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
Ifthis is a repair.fill out known well construction infornration and explain the nature ofthe 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 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: 285 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifelifferent(example-3Qa 100'and 2@100) construction to the following:
10.Static water level below top of casing: 30 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
13a.Yield(gpm) 4 Method of test, AIR 24c.For Water SunDly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
P
13b.Disinfection type:
CHLORINE Amount: 1-1/2 CUPS 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