GW1-2022-01248_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
Well Contractor Name FROM fL ft.TO DFSCRIPTTON
NC-3556-A % ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased welts OR LINER if■ Reable
AAA Sweetwater Well& Pump, Inc. FROM TO DIAMETER TT11[K�IESS MATERIAL.
IL ft.
Company Name 16rI#ONKPCASiNG
a
2.Well Construction Permit#: �� /-00/S-78 FROM TO DLAMETER THICKNESS MATERIAL
List all applicable wril construction permits(i.e.U1C,County,State,Variance,etc.) fL fL 61/4 tea' SCR-21 PVC
3.Well Use(check well use): % ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE TTHCILNESS MATERIAL
Agricultural OMunicipaUPublic it. it. to
Geothermal(Heating/Cooling Supply) g<idential Water Supply(single) IL bL
industrial/Commercial Residential Water Supply(shared) ig GROUT
irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 iL 20 Bentonite Screened
Monitoring overy ft. fL
Injection Well: fL fL
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a liable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATF.RIAI. EMPLACEMENT METHOD
Aquifer Test Stormwatcr Drainage ft. IL
Experimental Technology siderice Control it. ft.
Geothermal(Closed Loop) �Trd 20.DRILLING LOG atueh additional sheets IT
Geothermal Heatin Coolie etum) Other( lain under 921 Remarks FROM TO DESCRIPTION color,h eoil/r«k ere
ft. %
4.Date Well(s)Completed: �0 1 Well ID# ft. ft
52.Wed Location: d ft. fL
6teh bl hz4a, - ft. ill. IAN 12 Zuzz
Fa/acility/OwnerNaamee Facility 1DO(ifapplicable) fL It.
L .Llrlyl (/LC� fL fL y.............
P ysical Address,City,a ip fL ft.
V7 tl
�&J,07 C' 973/��0�l070� 21.REMARKS
County Parcel Identification No.(PiN) Grouted On: -
Sb.Latitude and longitude in degrees/mmates/seeonds or decimal degrees:
(if well field one tat/long is sufficient) 22.Certification:
N w 2 a a
6.Is(are)the well(s)OPermanent or 131remporary gnature of C ified Well Contractor Date
B}+signing this form,/hereby certifi that the well(s)was(were)constructed in accordance
7.Is this a repay to an existing well: ®Yes or C§No• with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fdl out known well construction information and explain the nature of the copy ofthis record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well devils:
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- is needed indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
driilcd: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �S (ft.) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200')alai 2@1001 construction to the following:
/
10.Static water level below top of easing: o� (R.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in) 24b.For Infection Welts: In addition to sen/ding 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) Method of test:Timed 24e,For Water Simply&Injection 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: �Q completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of F_nvirontantal Quality-Division of Water Resources Revised 2-22-2016
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