GW1-2021-03103_Well Construction - GW1_20210625

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NYELL CONSTRUCTION RECORD fGW-1) For internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTIOI 11` r
NC-3556-A ft. ft. n,(
ft. ft.
\C Well Contractor Certification Number 15.OUTER CASING for matQcased wells OR LINER if applicable)
AAA Sweetwater Well & Pump, Inc. FROM rt TO DIAMETER THICKNESS MATERIAL
Company Name
�� � FROM
CASING C
2.Well Construction Permit#!: FROM ro DIAMETER THtCKxEss MATERIAL
List all applicable ivell construction permits(i.e,U1C,Counn.State,Variance,etc.) a ( rt rt i)1/4 in SDR-21 PVC
3.Well Use(check well use): It It. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS I NATEIMAL
Agricultural OMunicipaUPublic ft. ft. In.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft it in
industrial/Commercial OResidential Water Supply(shared) 18.GROUT
lrri ation FROM TO MATERIAL. EMI'LACENIENT METHOD,&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Screened
Monitoring Recovery ft ft.
Injection Well: ft tL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a iicable
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL I EMPLACEMENT METHOD
Aquifer Test oStOnTwaler Drainage ft ft.
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG tattsch additional sheets if necessary)
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM ft ft aaw,To DESCRIPTION I+atar,hxr sotltr«k s' etc-)
4.Date Well(s)Completed:� � Well FD# _ ft. It.
5a.Well Location: i . ft ft.
ft. �U
1cilitylm
merNae Facility ID#(if applicable) �— ft. ft O�BCygp�
Mia BAiG1h t.Yt_ �t �r�l ft. ft. ��tCl'l c a t•ti `'>F"-tt
ysical Address,City,and Zip I ft ft.
21.REMARKS
County Parcel identification No.(PIN) 'tJ Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: L
(if well field,one fat/lung is sufficient) 22.Certif' tion:
6.Is(are)the well(s)�ermanent or Temporary f store of C ified Well Contractor Date
By,signing this form,1 hereby cerrh,that the i ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or I:)t`o with 15A NCAC 02C.0100 or 15A NCAC 02C:0200 hell Construction Standards and that a
ff 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 omier,
repair under=2l 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-l.ys needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / 11 SUBMITTAL INSTRUCTIONS
9,Total well depth below land surface: 2('P 5 {ft-) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple welts list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: o (ft.) Division of Water Resources,Information Processing Unit,
if warer 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,rosary,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)- Method of test: Timed 24c.For Water Supply&Injection!Wells: In addition to sending the form
the address(es) above, also submit one copy of this form within 30 days
13b.Disinfection type: CGH Amount, completion of well construction to the county health department of the coc
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-2: