GW1-2022-08170_Well Construction - GW1_20220907

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
I
DAVID CAMP 1a warEKMONEs <{
FROM TO DESCRIPTION)I
Well Contractor Name
ft. ft. I
2136-A
NC Well Contractor Certification Number °,15;OU7 ER"CASING'for aiuld cased wells'OR'l iNER`if a' 8eabie '
CAMP'S WELL AND PUMP CO. FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 80 IL 6.125 In. SDR21 PVC
Company Name
p y SW22-0233 16 INNERiCASIN_G�URPTUBING eothermal elb3ed=too
2.Well Construction Permit#: FROM TO DIAMETER !l THICKNESS I MATERIAL
List all applicable well consmuction permits(i.e.UiC.County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): R. ft in
'17:i8CREEN-' �`.i�
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. In.
Geothermal(Heating/Cooling Supply) x[]Residential Water Supply(single) ft. ft.
IndustriaUCommercial []Residential Water Supply(shared) _,!S'J3ROUT
IITi ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft. BENTENITE POURED 14 BAGS
Monitoring CIRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
>19 SAND/GRAVEL'PACIC'if-o lkiible ..
Aquifer Storage and Recovery []Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology []Subsidence Control
Geothermal
(Closed Loop)
N r� []
r
Geothermal (Heating/Cooling Return) Other(explain under#21 Remarks FROM eb DESCRIPTION�(color,nbeacredsne s so,l frrock: a rain size,etc
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CLAY
4.Date Well(s)Completed: V J, Well ID# 81 ft. 605 ft- GRANITE ",i — £^` v.
5a.Well Location:
DANIEL WEGMAN rc. fc.
Facility/Owner Name Facility ID#(if applicable)
FREEWILL BAPTIST CHURCH RD.
Physical Address,City,and Zip ft. ft
RUTHERFORD 21 RE)vfnRxs}
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.Certification: I
35.38562 N -81.79744 W
6.Is(are)the weil(s)o Permanent or []Temporary Signa urc of Certified Well Contractor . Date
By signing this fain,l herebv certify that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: []Yes or ONo, with ISA NCAC 02C:0100 cr ISA NCAC 02C.0100_Well-Construction Standards and that a
/fthis is a repair,fill out known well construction information and explain the nature o(the copy of this record has been provided to the well owner.
repair under#21 remarks section or at the back of this faun. 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 I 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 ifdierent(example-3 a 200'and 2 t@1001 construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Resources,information Processing Unit,
lfwater 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 27699-1636
13a.Yield(gpm) Method of test: AIR 24c.For Water Suauly&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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016