GW1-2022-01260_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
Well Contractor Name FROM TO DFSCRIMON I'
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NC-3556-A
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NC.We1I Contractor Certification Number 15.OUTER CASING for molDtased welh OR LINER if cable
AAA Sweetwater Well& Pump, Inc. FROM TO DIAMIEM i TMCICNESS MATFRML
IL f. Ire.,
Company Naa
16.FMXFflCASING
2.Well Construction Permit# (X bu!r FROM To DL+METER Tafcrn MATEWAL
List all applicable well construction permits(i.e.UIC,,Counn,,State,Variance,etc.) ( ft• fL 6 1/4 ta-` SDR-21 PVC
J.Well Use(check well use): 11L n• to �
Water Sappfy Well: 17.SCREEN
FROM TO DIAMETER SIATF SIZE 71HCICNFSS MATERIAL i
Agricultural OMunicipaMblic iG R• In.
Geothermal(Heating/Cooling Supply) ®Residential Water Supply(single) fL R. io
industrial/Commercial 0Residential Water Supply(shared)
1&GROUT i
Irri ation FRONt To MATERIAL i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 it 20 ft• Bentonde Scfeened
Monitoring Recov fL fL
Injection Well:
fL fL
Aquifer Recharge undwater Remediation
19,SAND/GRAVEL PACK if a 'cable
Aquifer Storage and Recovery Salinity Barrier FRoM To MATERIAL EMPLACEatEV I METHOD
Aquifer Test �Stormwaterlhainage fL tL
Experimental Technology Subsidence Control >z fL
Geothermal(Closed Loop) [Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Hcatin Cuolin Return) Other(ex lain under#21 Remarks) FROM fL fL To DFSCRIMON Icoler,hudoess,wivrecY lytit,grals slim,etc.)
'
4.Date W ell(s)Completed: b al WeR ID# `//� _ ft• fL i
a.Wen Location: C V( fL It.
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by
Facility/OwnerNarne Facility tD#(ifapplicable) fL fL
fL fLalaldrILd
Physical Address,City.and Zip
`'1 , �S�/Q<' 21.REMARKS
Couni�v— Parcel identification No.(PiN() Grouted On: ► Ell (xhN
5b.Latitude and longitude in ttegrees/minutes/seconds or decimal degrees:
(if)vcll field,one(at/long is sufficient) 22.Certification:
W v air a •
6.Is(are)the well(s)64Ytrmanent or Temporary tore of5pliffied Weil Contractor Dail
By signing this form•l herein,certifj that thel wrllis)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or MS. with 15A.VC.4C 02C.0100 or 1 SA NCAC 01C.0200 Well Construction Standards and that a
If this is a repair..rll out known well construction n formation and explain the nature of the copy ofthis record has been provided to the well owner.
repair under=21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wens having the same You may use the back of this page to protide additional well site deti!s;T-:-r::
consituction,only I GWA1 jspgpded. Indicate TOTAL NUMBER of weds construction details. You may also ate adibound pwmm w Asa=
drilled: /"//� r SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: >D (it.) 24a,For All Wells: Submit this form Within 30 days o corapionk-r c
Far mudiple wells list ail depths ifrhfjerew(example-3Ca200'and 22@11001 construction to the fallowing:
10.Static water level below top of casing: !U 0 (ft.) Division of Water Resources,information Proccu arg L ass.
If water level is above casing,use'•-" 1617 Mail Service Centers Raleigh,NC 27699-161-
11.Borehole diameter: 6 (in) 24b.For Inlectiou Wells: in addition to sending the f xmi ac ttic. -
Drilled above,also submit one copy of this form within 30 days of -r-7
12.Well construction method-ethmethod-
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injeclaw Caartas Prawr
FOR WATER SUPPLY =WELLS ONLY: 1636 Mail Service Center.Raleigh.NC" 1414
f`
13m.Yield(gpm) !P S Method of test: Timed 24c.For Water Supply&Injection Wells.- l:bi&tr_m =r >--
the address(es) above, also submit one cola of=m ;r wm-
13b.Disinfection type: CCH Amount: completion of well construction to the i-ocm-ti rsr=u n tat
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources :•'sic._ = R