GW1-2021-03100_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: /
1.Well Contractor Information: TC11
Clint J Babbitt 14.WATER ZONES Zlv"
Well Contractor Name FROM TO DESCRIPTION
ft
NC-3556-A ft. ft. J ,G
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased;wells OR LINER if a ticable
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER THICIGVKSS MATERIAL
rL rt. in.
Company Name
�T p•�� / 16.hr�CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: O oZ C7 00 7 FROM TOI DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 1,I f6 fL 6 1/4 i"' SDR-21 PVC
3.Well Use(check well use): ft• ft. in.
Supply Well: 17.SCREEN
Water Su
PP FROM TO DIAMETER SLOT SI7.E THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. fL in,
industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft* Bentoniie Screened
Monitoring Recovery ft. ft
Injection Weft: ft ft.
Aquifer Recharge Xrainagc
Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery r FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test fL fL
Experimental Technology ontrol tt. ft.
Geothermal(Closed Loop) 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOthcr(explain under#21 Remarks) FROM ft. To DESCRIPTION(color,hardness,soiUmck a rain sin,etc.)
;;••�� emar IL
4.Date Well(s)Completed: V Well ID# h• fL
Sa.Well Location: ft. ft
_ ft. tL IM
All K11 wkt B,I I
ft iL
Facility/Owner Name Facility iD#(ifapplicable)
to 12 00, �-}`�i iCl I rV)e�✓ ? j�(� a ft. rooessing ri
/h sicaI Address,City,and f^Zip^ ft, ft. Dktk4R 5sCY1n
2t.REMARKS
D
✓/ I MUM,Y L!!i I �"/ ('�%— f/ i
County Parcel identification No.(PiN) Grouted On: rj f o': .IjZ (�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwelt field,one Iatllong is sufficient) 22.Certification:
N W
6.Is(are)the w•ell(s)�,f.�.��,tEPermanent or Temporary nature of C ified Well Contractor Dace
/` By signing this form,I herehr certify that the well(s)tvas(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ONO with 15A NC9C 02C.0100 or 15A NCAC 02C.0200 Well Constntction Standards and that o
If this Ls a repair,fill out kmn%w ivell construction information and explain the nature of the copy of this record has been provided to they well ouvter.
repair under=11 remarks section or on the hack of this form.
23.Site diagram or additional well details:
S,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 js pefded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
G
9.Total well depth below land surface: 242. For All Wells: Submit this form within 30 days of completion of well
For multiple welts 14st all depths ifdierent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: <9 (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 Inlection Wefts: 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
Timed 24c.For Water Supply&iniectiow Wells: In addition to sending the form to
13a.Yield(gpm) Method of test. Pe Y g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH Amount: I O 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