GW1-2021-07433_Well Construction - GW1_20210921

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. IL
2136-A
rt. rL
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a livable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER THICKNESS MATERIAL
0 ft. 70 ft. 6.125 rn' 1 SRD21 PVC
Company Name
REW21-0032 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. % in.
3.Well Use(check well use): ft. ft. I in.
7
Water Supply Well: 1FR.SCREENO TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public ft. ft. in.,
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) fL ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT i
lrri ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a 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 DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology DSubsidence Control ft. fL
Geothermal(Closed Loop) ❑ITracer 20.DRILLING LOG attach additional sheets if necessary)
RGeothermal(Heating/Cooling Return) FlOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type rain size,etc.
q 0 ft. 70 fL CLAY
4.Date Well(s)Completed: L _2_ z1 Well ID# 71 ft. 605 rL GRANITE
5a.Well Location: fL tt.
CHRIS NORRINGTON ft. & tl
Facility/Owner Name Facility 1D#(if applicable) ft. ft
GARDEN LANE, LAKE LURE ft. ft.
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 ladlong is sufficient) 22.Certification:
35.442182 N -82.220789 W
6.Is(are)the well(s)�IX Permanent or ❑ITemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the rvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or )No with I5A 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-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 (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 2@100) construction to the following:
10.Static water level below top of casing:260 (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: 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 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 of well construction to the county health department of the count
13b.Disinfection type: Amount: P I tY P Y
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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