GW1-2022-08174_Well Construction - GW1_20220428

41�'
Print Fo fin
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
I ,
DAVID CAMP X'14.tWATERIZONESt,.¢: :
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2136-A ft. ft.
NC Well Contractor Certification Number rMSP OUTER,CASING�for ri ul6 LW-id*it fs URFI)1NEW,ifs 'Ucab1 / } ,
CAMP S WELL AND PUMP CO.
FROM TO DIAMETER THICKNESS MATERIAL
0 ft, 70 ft. 6.125 ' in. SDR21 PVC
Company Name ,16.11NNERIVASINGIOR`PUBINGf &tliCiihi relosed loo"P
2.Well Construction Permit#• SW21-0492 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e.U1C,County,State,Variance,etc) ft. ft, in.
3.Well Use(check well use): It. ft. in.
n
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public ft. ft. In
Geothermal(Heating/Cooling Supply) []Residential Water Supply(single)
Industrial/Commercial Residential Water Supply(shared) ;18sGROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well:
Aquifer Recharge []Groundwater Remediation
79:'SAND/GRAYELvPAGIC'ifa 'Ilcalile.r_„ ,�. ,.,i s 3 �i: .. ..�.< .t-'•'
Aquifer Storage and Recovery []Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage ft. I ft.
Experimental Technology []Subsidence Control
Geothermal(Closed Loop) []Tracer :20:%1)RILLING:TOG attiicdadillttoiiidsheetalfnerxsaa t47
FROM TO DESCRIPTION color,hardness sollfrock a rain size etc
Geothermal Hearin Coolin Return) Other(explain under#21 Remarks 0 k. 70 ft• CLAY
4.Date Well(s)Completed: Well ID# 71 ft 505 ft' GRANITE
ft. ft.
5a.Well Location:
BECKY BROWN
Facility/Owner Name Facility ID#(if applicable)
570 LAMBS GRILL RD. rt. rt. „'�f .
Physical Address,City,and Zip ft ft D
RUTHERFORD 4f21 tREMARkS,
Parcel Identification No.(PIN)
County �-•��M I ikiN
\r.,� n " T
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: '""' �•-
(if wcll field,one lat/long is sufficient) 22.Certification:
35.1929734 N -81.9594565 W 1-1)"
6.Is(are)the well(s)o% Permanent or []Temporary Signature of Certified well Contractor ! Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or QNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
/!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 tinder#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 505 (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@100) construction to.the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
ff,vater 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)
g 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
13b.Disinfection type: CHLORINE Amount: 2 CUPS completion of well construction to the county health department of the county
where constructed. I,
Form GW-1 North Carolina Department of Environmental Quality-Division Of Water Resources Revised 2-22-2016