GW1-2021-08113_Well Construction - GW1_20211105

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1/1V1iIContractor Information:
1
DAVID CAMP 14.WATER420NES
FROM TO DESCRDPTION
Well Contractor Name f. ft,
2136-A
ft.
NC Well Contractor Certification Number 15::OUTER,CASING.for"multi etised,wells'tIRrLINER:` s."ticetite
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
Company Name
0 ft. 58 ft. 6.125 In- SDP21 PVC
r
16'.INNER;CA SING'.tSR=I UBING "eother"mAI closedl`oo
2.Well Construction Permit#: SW20-0563 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits r.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): rt. n. In.
Water Supply Well: 17•SCREEN.
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. !in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) ,--O[J`F ' . �q�,.;
hTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring 13Recovery
Injection Well: ft. ft.
_ Aquifer Recharge Groundwater Remediation
:19aSATJD/GRA�'EL:PiACIC f.a"iicab7e.� �-� `' "-'
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.SDRIIs7 ING LOG afta'eh additional sheet6jif necessa`.' {
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks 5 FROM T DESCRIPTION color,hardness,soiUrock rains etc.
2 0 ft. 58 ft. CLAY
4.Date Well(s)Completed: !)J Well ID# 59 ft' 605 ft' GRANITE
5a.Well Location:
NATHANIEL EAVES
Facility/Owner Name Facility ID# if a licable ft. ft.
288 RICHARDSON CK. ft. ft.
Physical Address,City,and Zip ft. ft. N Q y - 5 2021
RUTHERFORD 2I ItEMARI{S` t. . r .'
County Parcel Identification No.(PIN) of
f'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.252923 N -81.891971 W t
���c� ..ter /�•- �S'-mil
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: E]Yes or ONo with 15A NCAC 01C.0100 or 15A NCAC 01C.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-3Q200'and 1Q100� construction to the following: '
10.Static water level below top of casing: 100 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 off 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) 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 coup health department of the county
13b.Disinfection type: Amount: P h' P
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016