GW1-2022-01258_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt t4.WATER ZONES
FROM TO DESCRIMOr
Well Contractor Name
NC-3556-A ft.
ft.
i
ft- n l
NC Well Contractor Certification Number 15.OUTER CASING for multi-coed dells OR LINER if a cable
AAA Sweetwater Well& Pump, Inc. FROM TO DI.AIt[ETER rnlaaFss MATERIAL
fl. ft. la.
Company Namc 16.IB011£11 CASING
2.Well Construction Permit#: l 9 FROM I To DLAMLTER IMCKNFSS MATERIAL
List all applicable well construction permts(i.e.UIC•,Counnt State,irariance.ctc.i ft. ft 6 114 In- SDR-21 PVC
J.Well Use(check well use fti ft. in
r
Water Sup*Well: 17.SCREEN
p FROM TO DIAMETER SLUT SIZE THICKNESS MATERIAL
Agricultural MunicipaUPubhc ft. R. hL
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fL n is
Industrial/Commercial esidential Water Supply(shared)
pp y 18.GROUT
_11irigation FROM TO MATERIAL F.MPt.ACF.MF\T METHOD&AMOU%T
Non-Water Supply Well: 0 ft 20 ft Bentonite Screened
Monitoring 13Rccov ft. fL
Injection Well:
ft. f[.
Aquifer Recharge undwater Remediation
19.SAND/GRAVEL PACK lif applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL I ORMACEMLNT MI;HOD
AquifcrTest E3StormwaterDrainage rc ft
Experimental Technology OSubsidence Control ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG falls It addidoaal streets If necena
Geothermal(Hcatin Cooli Return) Other(explain under=21 Remarks) FROM To DESCRIP77ON(color. wtUtseh ,Qe ere.)
rr. fn
4.Date Wel(s)Completed. I We'll FD# . fr
5a.Weil Location: �(C kj�CoCP iS-}-
I-o HD • JAN 12
^�
Facility/Owner Name Facility ID#(ifaMlicWc) fL ft.
li ical Address,Cit4od,Zip (� p ft w
r 1��a`7 3�' 2L REMAPKS
County N� Parcel identification No.(PiN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 2L Certification:
N W a a-7 121
tgnatum of C tified Well Contractor Date
6.Is(are)the well(s)MPermanent or Temporary i
Br signing thin form,I herein,cerufi•that the iiellls)was(were)caasnucted in accordance
7.Is this a repair to an existing well: QYes or No with/SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,.ill out knuwn well construction information and explain the nature of the copy of this record has been provided to the welt owner.
repair under=21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Geoprebe/I/PT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site dads x
constmction,only 1 GW-i is Qe�lp�d Indicate TOTAL NUMBER of wells construction details. You may also attach addiocica pores°w
drilled: �,J /T} SUBMITTAL Q7MUCTIONS,
9.Total well depth below land surface: O� (R 1 24a.For All Wells: Submit this font within 30 days of zoczipieticr _.
For multiple wells list all depths it difrerent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: -D 00 Division of Water Resources,Information Proccub g t aft-
it water level is above casing,use'•-'• 1617 Mail Service Center,'1Raleigh.NC 27699461-
11.Borehole diameter: 6 (in.) 24b.For Infection Welts: in additiob to sending the farm to roc z --
Drilled above,also Submit one copy of this form within 30 da)s of•s=c�rtrr�r =o�
12.Well construction method: construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Resourcim Underground 1ejectiaa Cattaaas!*rramr
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center.!Rakigk NC
13a.Yield(gpm) rQ 4 en OL"ethod of test:Timed 24c.For Water Supply&Injection Wells: 11 addjc�<T 1 madmia ze 1= u
the address(es) above, also submit one;corN of Sac- a=w '%I
136.Dlsinfectlon type: CCH Amount: completion of well construction to the corm^. .- t rt t1r. _.. .-
where ctmstructod.
Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resource t=—"tee-= =