GW1-2021-02565_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information:
F
DAVID CAMP 14 WATER>2ANEs .
Well Contractor Name FROM TO DESCRIPTION
ft. it.
2136-A
NC Well Contractor Certification Number ;15 OUTER CkSING-fdr:fi6111 esed wells'OR`-LINER"
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 78 ft, 6.125, in' SDR21 PVC
Company Name ooC
SW20-�J V V 16 INNER CASING OR TUBING.; eothermiil closed
2.Well Construction Permit#• 1I V vV FROM TO DIAMETER THICKNESS MATERIAL
List all applicable ivell construction permits(i.e.UIC,County,State,Yariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROME TO DIAMETER SLOTSIZE r THICKNESS MATERIAL,
Agricultural 13Municipal/Public
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) Ig GROUT -
_ Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
_ Monitoring _ !Recovery fa ft.
Injection Well:
ft. ft.
Aquifer Recharge QGroundwater Remediation
19tSAN1)/GRAYEI;--PACK f a 'jicable s:
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
_Aquifer Test OStormwater Drainage
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer a20 DRILLING-•LOG;alttaib i:dditi6i a]=ihiits3d•neceise`
FROM TO DESCRIPTION color hardness softock,type, reins etc.
Geothermal(Heating/CoolingReturn) ^7 .Other(explain under#21 Remarks 0 ft. 78 ft- CLAY!
4.Date Well(s)Completed: �` Well ID# 79 ft. 585 ft* GRANITE
ft. ft.
59.Well Location:
TYLER RITTLE
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Facility/Owner Name Facility ID#(if applicable)
PINEY MOUNTAIN CHURCH RD. ft. ft.
Physical Address,City,and Zip
RUTHERFORD 21`REm1ARItS-
Dn't1
County Parcel Identification No.(PIN) In
1ni0`�,3 $eC{lOn
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification-
35.385871 -81.806108
6.Is(are)the well(s)oPermanent or [3Temporary 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 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
#'this is a repair,fill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the well owner.-
repair under#11 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: 585 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3®200'and 2@1001 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,;R:alelgh,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.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 2 Method of test: AIR 24c.For Water Supply&Injection 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 constructionl to the coup health department of the county
13b.Disinfection type: Amount: P county P n'
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources es Revised 2-22-2016