GW1-2021-03099_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES l
Wei I Contractor Name FROM TO DESCRIPTION
NC-3556-A fL IL
ft fL
NC Well Contractor Certification Number 15.OUTER CASING for multicased wells OR LINER If Ileable
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER TTIICIGNESS a MATERIAL.
ft. ft. in.
Company Name
f �f��]'� JJ�� 16.INNER-CASING OR TUBING eathermal closed-too
2.Well Construction Permit#: �I F'L_2z^V V3 FRUM To DIAMETER THICKNESS MATERIAL
List all applicable Hell construction permits(i.e.UIC,County,State,Variance,etc) j. ft. l' fL 6 1/4 ra SDR-21 PVC
3.Well Use(check well use): JpQ fL D n (.p'lq I°-
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT'SIZE T IICKNFSS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) �$esidential Water Supply(single) ft. fL la.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft- Bentonite Screened
Monitoring DRecovery ft. ft.
Injection Well:
fL fL
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK H a licalile
Aquifer Storage and Recovery OSalinity Barrier FROM I To I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage fL rL
Experimental Technology QlSubsidence Control fL I ft.
Geothermal(Closed Loop) QlTrdcer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Hcating/Cooling Return) 1710ther explain under 421 Remarks) f opt To DESCRIPTION(color,bards Uro soick a grala siuta,e
tt. fL
4.Date Well(s)Completed: Well ID# ft. fL J5acility/Owner
We➢Location• q�,, fL FL
1-Y 4" fL r 1 Name Facility rD7(if applicable) ft. ft.
ft. IL aflon Proces-
JtSlng'J""dniab? " inform.
ysi I Address,Ci ,and Zip ft fL
,// 9� 21.REMARKS
County Parcel Identification No.(PIN) •LJ Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 21 Certification:
N WI�I'�I
6.Is(are)the we➢(s) ermanent or OTemporary tgnature of C ifi(d Well'Corffictor Date
Br signing this form,I hereby certify that the xel/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ImNo with 15A NCAC 02C.0100 or 1 SA NCAC 0'X.0200'Well Construction Standards and that a
If this is a repair,fill out known sell construction information and explain the nature of the copy of this record has been provided to the weli ox,rer.
repair under=21 remarks.section or on the lack gl'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: h)01At SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 'l (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths if different(example-3@200'avid 2@1001 construction to the following:
10.Static water level below top of casing: �© (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing.use" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In additidn 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
13a.Yield(gpm) Timed Method of test: 24a For Water Supply&[niectiori 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: CCH Amount: 02P 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