GW1-2022-01261_Well Construction - GW1_20220112

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 1 14.WATER ZONES
/ WelI Contractor Name FROM TO DESCRIPTION.
fL tL
NC-3556-Aft. ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a ticable
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER rDICRNESS MATERIAL
1L ft.
in.
Company Name
1 I �' 16.It1iAi$It CASING
2.Well Construction Permit#: („� -1 FROM To DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. C',Countv,State,VaPiaA,etc.) ft- -�fG• ft. 6 114 in' SDR-21 PVC
3.Well Use(check well use): % ft. tn.
SCREEN17.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) Jrtesidential Water Supply(single) ft. ft. to
IndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
hTi ation FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft, Bentonite Screened
Monitoring 011ecovery fL ft.
Injection Well:
R. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERUL I EMPLACEMENT METHOD
Aquifer Test [:)Stormwater Drainage fL fL
Experimental Technology Subsidence Control fL fL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/CoolingReturn) Other(explain under#21 Remarks FROM To DESCRIPTION lcolor,hardness,eo(Urosk size,etc.
FL ft.
4.Date Well(s)Completed: d Well iD#! Lh ft. ft.
Sa.Well Location: I'll ft ft ? -
�'. 2c- fL IL
F dity/Owner Name Facility M#(ifapplicable) ft. ft• if h:i' r.^('n
ft. ft.
� r QUA i
t_ tL ft.
P sicai Ad s,City,and Zip
21.REMARKS
ounty Parcel identification No.(FIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat)long is sufficient) 22.Certiflcaattiien:
N W
6.Is(are)the well(s) Permanent or Temporary ( r azure of C ified Well Contractor Dace
By signing this Jorm,I hereby certifi-that Uhe well(s)was(were)constructed in accordance
7,is this a repair to an existing well: ©Yes or E]No with 15A VCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information a explain the nature of the copy ofthis record has been provided to the well owner.
repair under e11 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geopro"PT 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-I is needgd/hldicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ; /�- SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: V=7 (ft.) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1,g000) construction to the following:
10.Static water level below top of casing: I r1 y (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Ma©Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6 On-) 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) Method of test Timed 24c.For Water Supply&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 Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Deparanent of Environmental Quality-Division of Water Resources !i Revised 2-22-201f---.`„,
I