GW1-2021-08112_Well Construction - GW1_20211105

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_WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
t
DAVID CAMP 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
2136-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for mtild-cased'wells OR LINER a livable
CAMP'S WELL AND PUMP CO. FROM To DIAMETER TLLLCKNESS MATERIAL
0 ft. 90 ft. 6.125i in SDR21 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: i FROM To I DIAMETER THICKNESS MATERIAL
List all applicable well construction permits rue.UIC,County,State,Yariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft.
17.
Water Supply Well: FROME TO DIAMETER SLOTSIZE THICKNESS MATERIAL.
Agricultural [Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) XOResidential Water Supply(single) rL ft. in•
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test [Stormwater Drainage
Experimental Technology [)Subsidence Control
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROMI TO DESCRIPTION color,hardness soiltrock type,grairt size,etc
0 ft. 90 fL CLAY
4.Date Well(s)Completed: V/3_Z Well ID# 91 ft. 125 ft, GRANITE
5a.Well Location:
JOEL& NECIA SCRUGGS fc. rt
Facility/Owner Name Facility ID#(if applicable)
185 CLARK RD. rt. ft.
Physical Address,City,and Zip ft. ft. i+"_ ,r;. `j;; �J t„l'+I
RUTHERFORD 21.RENIARKS
u.
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.Certi on:
35.415778 N -82.063396 W
.6.Is(are)the well(s)OX Permanent or Temporary Si re of Certified Well Contrac 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 X[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 ojthis 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: 25 (ft) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Qa 200'and 2@100) construction to the following:
10.Static water level below top of casing:40 (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:
(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 276994636
13a.Yield(gpm) 50 Method of test: AIR 24c.For Water Supply&Infection 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 Quality-Division of Water Resources Revised 2-22-2016
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