GW1-2022-07551_Well Construction - GW1_20220815

i
l
WELL CONSTRUCTION RECORD GW-1InPr t r
For ternal Use Only:
1.Well Contractor Information:
DAVID CAMP _
Well Contractor Name I''lAWA11ER8ZUNES �:'
FROM TO DESCRIPTION
2136-A fit. ft.
NC Well Contractor Certification Number ft. n,
CAMP'S WELL AND PUMP CO. t s;OvrERicnsBVG"forfmulfl=cas"awell3 UR3LINpRi ifa Ilcatile ;FROM TO DIAMETER THICKNESS MATERIAL :
Company Name 0 ft. 58 It. 6.125 in.
W22-0032 sDR21 PVC
2.Well Construction Permit#: �18?iIlY1NERtCASINGiURLTUBING""
FROM eothcrmatcloied=loo'..?1X��.�'��'-•�' ;"hr� ;
List all applicable well consavction penults f•e.—1,,County,State,Variance,etc. ft. TO DIAMETER THICKNESS MATERIAL
� fit. to.
3.Well Use(check well use): fL ft
la.
[Ge
Supply Well:
FROM TO
cultural E3Municipal/Pubiie DIAMETER SLOT SIZE THICKNESS MATERIAL
thermal(Heating/Cooling supply) QResidential Water supply n' n. In.
g PP Y) pp y(single)
strial/Commercial ft n in.
Residential Water Supply(shared) ,, ,�
tion kti.,GROUTu .;,
ater Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
itoring 0 fit. Y0 fit• BENTENITE POURED 14 BAGS
Recovery n•on Well: H.
fer Recharge QGroundWater Remediationfit• ft.
fer Storage and Recovery QSalinity Barrier �K=1t`iaFROMTERIALer Test [3Stormwater Drainage ft. EMPLACEMENT METHOD
ftimental"Technology QSubsidence Control
ft.
ermal(Closed Loop) Tracer120. LOermal eatin Coolin Retum) Other ex lain under#21 Remarks oM TO
DESCRIPTION color hardness solUrock a rain size etc.
0 fit. 58 ft- CLAY
4.Date Well(s)Completed: / �, .. ;-� 11 eC
— Well1D# 59 ft. 665 n•
Sa.Well Location: GRANITEft. ft.
LAMAR BURCH rt• n• Y '� Q22
Facility/Owner Name Facility ID#(if applicable) ft. ft.
1550 COOPERS GAP RD.
rt• rr. ..r.r ;�
Physical Address,City,and Zip ft. ft.
RUTHERFORD F21.REtrlaizresxr' 3� w r'1 U x R,"y 1
ri"�-..3Iht1:,n,.'< t.., F SS:f a_t� ,j,.;Y)S ,f,•
County Parcel Identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
35.38475 N -82.02840 22•Certification:
�
6.Is(are)the well(s)OPermanent or 13Temporary Signature ofCertificd Welt Contractor
Date
7.Is this a repair to an existing well: Yes or M)No By signing this form,1 herebv cer16 that the wells)was(were)constructed in accordance
Ifthis is a repair,fill out known well consa•rrction irforntation and explain the nature ofthe with 1S4 copy of this rc ord NC 2C.b 0 n prov or NCAC the well 200 Well Construction Standards and that a
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-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: 665 (ft.)For m 24a. For All Wells: Submit this form within 30 days Of completion of well
multiple wells list al/depthsifdiffer ant(example-3Q200 id 2Ql0
'a0�
construction to the following:
10.Static water level below top of casing:
Ywater level is above casing,use-+- (ft.) Division of Water Resources,Information Processing Unit,
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
12.Well construction method: ROTARY above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: AIR 24c.For Water Supply&Infection Wells: In addition to sending the form to
Amount: 2 CUPS
13b.Disinfection type:
CHLORINE the address(es) above, also submit one' copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016