GW1-2021-06679_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP (`A �44 MATER-ZONES
Well Contractor Name O FROM TO DESCRIPTION
O� � ��, ft. ft.
2136-A (�`, re�5�ng ft. ft
CAMP'S WELLCertrANron Number V�01 I
D PUMP CO. ��c�'3Q�rjR�9 ,,or NC Well Contractor 151 Mi1TERC OING formDIAMETEReIIs iOTHICKRESS;e "IlcMATE
0 ft. 90 ft, 6.125 in. SOR21 PVC
Company Name 16 INNERs,CASIIJGOIi�TUBTI!Ntii,. etrth'ermal closed=loo
2.Well Construction Permit#: SW20-0468 FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
fiSCREE ,
Water Supply Well: 17 N.�FROM TO t. DIAMETER x SLOT Si22z THICKNESS MATERIAL
Agricultural OMunicipaVPublic ft. ft. in.
:)Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commereial 131kesidential Water Supply(shared) ..1g GROU ry '
Itrl ation FROM TO MATERIAL V EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- PO ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
[Experimental
ifer Recharge QGroundwater RemediationT9.'Sifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ifer Test 13Stormwater Drainage Technology Subsidence Control ft. ft.
thermal(Closed Loop) Tracer :20,?DRQ L1NG.BOIr attach•additional stieete If ne¢essathermal(Heating/CoolingReturn Other(explain under#21 Remarks FROM T9 DESCRIPTION color,hardness soft/rock rein ai etc.
0 ft. 90 ft. CLAY
4.Date Well(s)Completed:..,/ Well ID# 91 ft. 445 ft GRANITE
59.Well Location:
THOMAS FOSTER
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
4209 PEARIDGE RD. ft. ft.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 2I::REMARKS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification:
35.423407 N -81.869016 W
Div` i L",01
6.Is(are)the well(s)oPermanent or OTemporary 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: [3Yes or MNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 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:
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-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: 445 (M) 24a. For All Wells: Submit this 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: 20 (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: Ins 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
1
13a.Yield(gpm) 3 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
CHLORINE 2 CUPS completion letton of well construction to the coon health department of the coon
13b.Disinfection type: Amount: P county P h'
where constricted.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016