GW1-2022-04865_Well Construction - GW1_20220520

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP M4."WATEWZONEW ,P-P- 0f Fits...`i,.�r_x�s',W S AP,� $s
Well Contractor Name FROM ft. ft.TO DESCRIPTION I
2136-A
rt. ft.
NC Well Contractor Certification Number (1B.'MUTER+GASINCs2 for mtildrease$;wtll9 s'OR�I INER"if it' llcable s"`� �_�.!�'�"}
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 83 ft. 6.125 In. SDR21 PVC
Company Name AlCiINNEWCASING`UR-TUBING," eofheriniil'elb"sed lhhi" i f ?;.k t Azxt zs�'`5
2.Well Construction Permit#: SW22-0064 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pehnhfts f.e.U1C,Comity,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft. ft. in.
'0SCREENr x3..au:#rho .,...,`_sf*iz ;:c' ss7� vah}shyj
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) ft. ft. In.
lndustrial/Commercial Residential Water Supply(shared) A8.GROUT..'W,'?
Irrigation FROM TO MATERIAL r.EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. BENTENITE POURED 14 BAGS
Monitoring Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge ©Groundwater Rcmediation
19r;SAND/GRAVEL!PACK"ifa"lic5ble
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. ft.
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20-.=-DRIL T, 0VOGi attach:eililltiohel(sheefi'Ifiuecess =r t k F
Geothermal(Heating/CoolingFROM TO DESCRIPTION(color,hardness solFroek type,grain size etc.
Return) Other(explain under#21 Remarks) 0 ft. 83 ft. CLAY
4.Date Well(s)Completed: � `"`�}} Well ID# 64 ft 365 ff GRANITE
Sa.Well Location:
BRAD&ALLISON SHAMLIN ft. ft. l� Qz 1 �.Di
Name Facility ID#(if applicable) 'I'
LEE CAMP RD. rt. rt. MAY 2 ILIL
Physical Address,City,and Zip ft ft r
RUTHERFORD
.21::REMARLCS:T_,''1c.a..,,..4,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 22.Certification:
35.42025 N -82.03972 W
6.Is(are)the well(s)OPermanent or Temporary Signature of Certified Well Contrac r Date
By signing this font,1 herebv certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or INo with 15A NCAC 02C.0100 or ISA NCAC 01C.0200 Well Construction Standards and that a
/f this is a repair,ft/1 out known hve/l couutnuction information and explain the nature of the copy of this 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-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: 365 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifeli ferent(example-3(a1200'and 21@1001 construction to the following:
10.Static water level below top of casing:40. (ft.) Division of Water Resources,Information Processing Unit,
lfivater 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) 20 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
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