GW1-2022-08947_Well Construction - GW1_20220919

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID CAMP _ 4 WATERZONES va
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2136-A
NC Well Contractor Certification Number 15 UUTER'CilSQ7Cs;ror=intiltl casedlwells?OR!LlNERs0£8"liealile 3 ..`
CAMP'S WELL AND PUMP CO. FROM T I DIAMETER THICKNESS MATERIAL
0 ft• 65 ft- 6.1251 in. SDR21 PVC
Company Name r� ';1G:-INNERtGASING'URTUBINGs
2.Well Construction Permit#• SW21-0537 FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well contraction permits(i.e.UIC,County,State.Variance•etc.) ft. ft. in.
3.Well Use(check well use): fit fit in
17iSCREEN ;;, s+
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public ft. fit, in.
Geothermal(Heating/Cooling Supply) EiResidential Water Supply(single) g• tt, In.
IndustriaUCommercial []Residential Water Supply(shared) 18.YGROUT ::F:= i t•
Irrigation FROM TOS I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non=Water Supply Well: 0 rt. 20 fit. BENTENITE POURED 14 BAGS
Monitoring Recovery
Injection Well: ft.
Aquifer Recharge ❑Groundwater Rcmcdiation -
`19,tSAND/GRAYEtiiEACIG;
Aquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test \ QStormwater Drainage fit. fir.
Experimental Technology ! Subsidence Control tt. fit.
Geothermal(Closed Loop) QTracer 120 DRIliLING`LOG•sttacb addltioriel`slieet6itf necessa` .zw .ry <_.:,., J .:a'
FROM TO DESCRIPTION color,hardness soli/rock type,grain size etc
Geothermal eatin Coolin Return Other(explain under#21 Remarks) 0 ft. 85 ft. CLAY 1
4.Date Well(s)Completed: ` Well ID# 66 fi US ft' GRANITE
Sa.Well Location:
j )�4 .9d E.4 I
HARVEY CAPPS rt. fir.
Facility/Owner Name Facility ID#(if applicable) rt. rt. — _
ISLAND FORD RD. ft. tr. r -.-
Physical Address,City,and Zip ft. tt. 1
RUTHERFORD 21#:REMARKS;:
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:
35.21721 N -81.81165 W
6 "I
'6.Is(are)ttie w6ll(s)o Permanent or 'ElTemporary Signature ofCcrtified 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: Yes or %JNo with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Constntction Standards and that a
lfthis is a repair,fill ota known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair ender#21 remarks section or'an 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.
I
drilled: SUBMITTAL INSTRUCTIONS
185
9.Total well depth below land surface:-.— (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,/jerent(example-3©200'and 2 a)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,Raleigh,NC 27699-1617
i
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 ofl 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