GW1-2021-05280_Well Construction - GW1_20210601

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP �., wa 14.WATER ZONES
4.+ FROM TO DESCRIPTION
Well Contractor Name
ft, ft.
2136-A J�N 2021 ft. it.
NC Well Contractor Certification Number 15.OUTER CASING for multitased wells OR LINER if a 'feeble
CAMP'S WELL AND PUMP C(����Irr31ion��,'t���e�sJ uniZ FROM t
DIAMETER THICKNESS MATERIAL
^�BSI:>7O 0 ft. ft- 6.125 rn' SDR21 PVC
Company Name
FARM WELL 16.INNER CASING OR TUNING eutbermal -closed-lob
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fL ft. in.
3.Well Use(check well use): ft. tt, in.
Water Supply Well: 17:SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agricultural []Municipal/Public ft• ft. in.
Geothermal(Heating/Cooling Supply) E311csidential Water Supply(single) ft. ft.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL BENTENITE POURED 14 BAGS
Monitoring EIRecovery ft. fL
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 It. fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal eating/Cooling Return) Other(ex lain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
Q 2 I 0 ft 105 tt. CLAY',
4.Date Well(s)Completed: Well ID# 106 rL 285 ft, GRANITE
ft. ft.
5a.Well Location:
HERMAN HERSHBURGER it. it.
Facility/Owner Name Facility III#(ifapplicable) fL ft.
2982 HOLLIS RD. iL rt.
Physical Address,City,and Zip ft. ft.
RUTHERFORD 21.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:
35.361875 N -81.699866 W
6.Is(are)the well(s)oPermanent or Temporary 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: []Yes or E)No 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:
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: 285 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing: 80 (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 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:
(Le.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) 3 Method of test: AIR 24c.For Water Supply& Iniection Wells: In addition to sending the form to
CHLORINE 2 cups the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 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