GW1-2022-01247_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
I.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
Well Contractor Namc FROM TO DESCRIPTION
ft. ft.
NC-3556-A
h. h.
NC well Contractor Ceritiwtion Number 15.OUTER CASING for multi-cased wells OR LINER if a Hcable
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER THICKNESS MATERIAL
f4 ft. in.
i
Company Name 16.O ' n 1FR5M ER CASING OR TUBEA therm 1al closed
Z.Well Construction Permit ft: l� FROAf TO DIAMETER MATERIAL �
List all applicable ur11 construction permits 0 e.U1C County,State.iWiunce,etc) � f4 it. �1 la SCR;1 PVC
3.Well Use(check well use): tZ ft. is
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
9Agri Itural OMunicipaUPublic (t. ft. in.
1
eothetmai(Heating/Cooling Supply) 011esidential Water Supply(single) ft. I f4 In. i
industrial/Commercial OResidential Water Supply(Shared) 18.GROUT
hTl alton FROM TO MATERIAL. 1 F.MPI.ACE4IENT MF.Ttf011 B AMO` 'r
Non-Water Supply Well: 0 f4 OC ft Bentonite 0abetiew
Monitoring Recovery ft I ft. // L
Injection Weli:
f4 ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a Ncabte
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT MET1tOD
Aquifer Test oStormwater Drainage ft. ft.
Ex erimental Technology Subsidence Control ft. I It.
euthermal(Closed Loup) Tracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Hcating/Coolino Rctum) Other(explain under=21 Remarks) FROM To DESCwrrtoN odor,hardness,wi0rock ty a nie ettt ere.)
�l'?�a� ft. ft. 1
4.Date Well(s)Completed: Well IDLE(�I / % ft.
i
Sa. Yell Location: h. f4
f4 f4 t ,
FacilityiOwnerName ility iD#(Wf pplica le) ft.
ft.
Physical Address.City,and Zip t4 ft.
lt�.,�,_ / _ 97a -7�}/�0�� 2f.REMARKS Ibt': 1 1
L O,/ /�, Grouted On:
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f if well field.one Iat/long in sufficient) 2L Certifl anon:
• Y W �/ 4&
6.Is(are)the well(s)VIrmanent or OTemporan' tgnature of Crfiified Well Contractor Date
Br signing this firm.1 herehr c•ertifi•that the Delfts)ryas(were)constructed in uccordance
7.is this a repair to an existing well: Oyes or [g o with 15A:VC9C 01C.t1100 or I5A A'--CAC 01C.6200 D'e11 Construction Standcnas and that a
if this is a repair.fill out knuivn well constuction information and explain the nature of the• copy of this record has been provided to the is 0u7ter.
repair under=11 remarks section or on the hack ofthis/arm.
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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: o�(� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: C� ��" (ft-) 249.For All Wells: Submit this form,within 30 days of completion of well
Fin multiple uellc list all depths ifdiflerent(example-3@2110'and 2@100') construction to the following:
10.Static water level below top of casing: X (fL) Division of Water Resources,Information Processing Un14
If tinter level is above casing.use" 1617 Mall Service Center,Raleigh,NC 276"-1617
11.Borehole diameter:6 (in.) 24b.For Injection 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) Methi—I
test:Timed 24c.For Water Suuuiv&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 • completion of well constttiction to the county health department of the county
where constructed.
Form Gw-I North Carolina Department of Environmental Quality-Division of water Resources j Revised 2-22-2016