GW1-2021-03101_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 t Cf
Well Contractor Name FROM TO DESCRIPTION
NC-3556-A rL ft. d
fL ff.
NC Well Contractor Certification Number f
15.OUTER CASING for multi-cased wells)OR LINER if a livable
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER THICKNESS I MATERIAL
ft ft. ilL
Company Name
16. CAST.
2.Well Construction Permit#• G—�v _oo u FROM TO DIAMETER THICKNESS MATERIAL
List all applicable uvll construction permits(i.e,UIC,County State,Pariance,etc.) t rt.
fL 6 1/4 in. SDR-21 PVC
3.Well Use(check well use): fr. fL is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOTSIZE THTCFCNESS MATERIAL
Agricultural �M nicipaUPublic fr. fr in.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irr't anon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Screened
Monitoring Recove ft. ft.
Injection Well: ft. fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Re cove Salinity Barrier FROM To TfATERLIL t tiPl ACEMEN'r METHOD
Aquifer Test OStonnwater Drainage ft. fL
Experimental ology Subsidence Control ft. ft.
Gent al(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
FROM TO DESCRIPTION color,hardn soillmk e, rain size,etc.)
geothermal(Heating/Cooling Retum) E30ther(explain under#21 Remarks) ft. fL
4.Date Well(s)Completed: 'r� Well TD# ft. ft.
ft. fL5 WeR Location: �Ah
[/ty" n. ft.
Facility/OwnerN me Facility M#(ifapplicable) ft fL J
1 1 T
t-)reep /YJ +V)• . V W t lL 1L1.� 21 / fL It. ! i Unit
lillysical Address,City,and Zip ft. ft. infol t i
� 21.REMARKS
County Parcel identification No.(PIN) Grouted On: 5-C . ; �2`. 2J 6.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latllong is sufficient) 22.Certification:
N W
6.Is(are)the well(s)Qt(ermanent or DTemporary naua/ems/of Cytified Well Contractor Date
� Be 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 L No with 15A NCAC 02C.0100 or 15A XCAC'02C.0200 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 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 gie same You may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: N� / SUBMITTAL INSTRUCTIONS
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 deptls if dierew(example-3@200'and 2@10,0/11 construction to the following:
10.Static water level below top of casing: u Q (ft.) Division of Water Resources,Information Processing Unit,
1f uuter 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
13a.Yield(gpm) l Method of test: Timed 24c.For Water Supply&Infection 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: arotm completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Emiro mental Quality-Division of Water Resources Revised 2-22-2016