GW1-2021-03249_Well Construction - GW1_20210628

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: �T
1.Well Contractor Information:
DAVID CAMP 14.WATER:ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.-
2136-A
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR.LINERi if a"livable`;-.
CAMPS WELL AND PUMP CO. FROM TO' DIAMETER THICKNESS MATERIAL
0 ft. 60 ft. 6.125 in." SDR21 .... PVC
Company Name
SW20-0536 16 INNER CASINGOWTUBING'pother closed-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): ft. ft. in.
Water Supply Well: FROMREE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. ft. iIn.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) tt. ft. rI•l
Industrial/Commercial 13Residential Water Supply(shared)
18 GROUT
Irrigation FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
Non-Water Supply Well: 0 ft PO ft. BENTENITE POURED 14 BAGS
Monitoring DRecovery, ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19 SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) [3Tracer 30:DRILLING LOG-attach additionalsheet's if,necess
Geothermal(Heating/Cooling Return .Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness soiUrock c' rain si etc.
0 ft. gp ft. CLAY
4.Date Well(s)Completed: ` Well ID# 61 tt 505 tt' GRANITE
ft. ft.
5a:Well Location: C.
SCOTT HOPPER
Facility/Owner.Name Facility ID#(if applicable)
JOE BOSTIC RD. ft. ft. ro�essillg
Physical Address,City,and Zip ft. ft. `11 &qR SBC110
RUTHERFORD 21 REMARKS .
County Parcel Identification No.(PIN)
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5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.399317 N -81.818041 W
6.Is(are)the well(s)okermanent 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: E)Yes or MNo 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 additional well details:
You may use the back of this page to provide additional well site details or well
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same d
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 �isi form (within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing:40 (ft.) Division of Water Res)urces,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center, leigh,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 is 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) 7 Method of test: p`IR 24c.For Water Suppiv&Iniectil n 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: z 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