GW1-2021-04486_Well Construction - GW1_20210429

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
DAV I D CAMP001
14: VATER'ZONES ht<
Well Contractor Name FROM TO DESCRIPTION r~
ft. ft.
2136-A 910-1
NC Well Contractor
flcation Number
CAMPS WELLrAND PUMP CO. PQ�o�QtOcl
cs(�� FR MUTERCTo formDIAME ERe� THICKNESS a EMATERIAL
Company Name ;0(� O 0 ft. 70 ft. 6.125 i° SDR21 PVC
FARM WELL�� 1b:INNER.cnsuv ox?TUBING, eothermal.clused5loo . _
2.Well Construction Permit#: FROM I TO I DUMEER I THICKNESS I 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: 17SCREEN;
Im FROM TO I DIAMETER I SLOTSIZE I THICKNESS MATERIAL
PAgricultural E)Municipal/Public ft. ft. I I in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD V&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Aquifer Recharge E3Groundwater Remediation ft. ft.
19:SAND/GRAVEL`PACK=da' iiCable
Aquifer Storage and Recovery OSalinity Barrier FROM To I MATERIAL EMPLACEMENT METROD
Aquifer Test OStormwater Drainage ft. ft. .
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer ;'20 DRII I ING L'OGi attach.additionalsheefs_if neei?sse
Geothermal (Heating/Cooling Return Otber(explain under#21 Remarks FROM TO DESCRIMON color,hardness soiUrock type,grain size,etc.
.Lr� 0 ft. 70 ft. CLAY
4.Date Well(s)Completed: Well ID# 71 ft. 605 ft-
GRANITE
Sa.Well Location:
ft. ft.
EDDIE HOLLAND ft. ft.
Facility/Owner Name Facility iD#(ifapplicable) ft. ft.
LOW BRIDGE ROAD ft. ft.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21 xEMARKs
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.Certification:
35.309425 N -81.803241 W
f -'-19-02�
6.Is(are)the well(s)OPermanent or OTemporary Signature of Certified Well Contract'r 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 E)No with I SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a.
Ifthis is a repair,fill out known well construction information and explain floe 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-1 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: 605 (fti) 24a. For All Wells: Submit ithis form within 30 days of completion of well
For multiple wells list all depths if different(example-3©200'and 2@100) construction to the following: 1
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing.use"+" 1617 Mail Servo Ice 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: F
.e.auger,rota construction to the following: ,.
('t g 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
u
13a.Yield(gpm) 2 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
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 Oualitv-Division of Water Rem Iimxc RP i—A l_77_In i F