GW1-2021-03098_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: f
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES )
FROM TO DESCRIPTION
Well Contractor Name
ft
NG-3556-A tt•
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NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a liu
AAA Sweetwater Well & Pump, Inc. �� TO DIAMETER rlHcxNEcs MATERIAL
It. ft. in.
Company Name
`�/S _ 1 16.INNER CASING OR TUBING(geothermal cl oo
2.Well Construction Permit q: D V '' �Y �1,/ FROM TO DL4METER THICFLNICIGYFSS MATERIAL
List all applicable well construction permits 0.e.UiC,County,State,Variance,etc.) fL _h fL 6 1/4 'rro SDR-21 PVC
3.Well Use(check well use): R rt rn
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [:)MU icipal/Public ft. fL
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft in.
IndustriaUCommercial Residential Water Supply(shared) 18.GROUT
Irrl ation FROM TO MATERIAL EMPI.ACEMF.NT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 rt Bentonite Screened
Monitoring ecovery fL ft
Injection We11:
FL fL
Aquifer Recharge AO
r Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery er FRoil TO MATERIAL U.MPLACEMENTMETROD
Aquifer Test Drainage ft fL
Experimental Technology ontrol It. ft.
Geothermal(Closed Loop) 20.DRILLINGLOG attach additional sheets ifnecessGeothermal(Heating/Cooling Return) in u der#21 Remarks) FROM TO DFscRIrrloN color,hardness soivrock etc.)
ft. fL
4.Date W ell(s)Completed: (�- Well im fL fL
ft ft.
5a.Well Location:
�,
V d )F'1 ft. rL
Facility/OwnerNa a Facility ID#(ifapplicable) ft ft.
`;125 IGi-�' �►7 �Y1-� �IVV110 ZQ7 fL fL pCessin Unit
Physical Address,City,and Zip ft ft. %NR S'eC'Ql)n
TND (a— A 21.REMARKS
County Parcel identification No.(PIN) Grouted
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Certification: J
. N W
6.Is(are)the well(s) ermanent or DTemporary nature of C ified Well Contractor Date
By signing this form,i hereby certifi,that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: ❑Yes or To with ISA NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill our known well constvelion information and explain the nature of the copy of this record has been provided to the well owner.
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 I GW-I is ngedpd. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: (1-i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: W� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 1 e D (ft.) Division of Water Resources,Information Processing Unit,
If water 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
Drilled 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
k
Timed 24c.For Water Supply&Injection Wells: In addition to sendin the form to
13a.Yield(gpm) Method of test. g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH Amount: cQ-Se2m 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