GW1-2022-01263_Well Construction - GW1_20220112

Print Form
WELL CONSTRUCTION RECORD (GW-1) Fur Internal Use Only:
1.Well Contractor information:
Clint J Babbitt 14.WATER ZONES
eROM To DESCRIPTION
Well Contractor Name
NC-3556-A
NC Well Contractor Certification Number 15. R CASING
Nor MCI-- Cobh)
AAA Sweetwater Well & Pump, Inc. FROM 70 I DIAMETER THICKNESS AtATERLA[.
ft ft. 1 in.
NameCompany NaK
16.INNER CASING OR TUBING eotherma closed-ltro
2.Well Construction Permit#:-_` 0t la T FROM TO DLa 1tF.TER THICIC�ESS MATERIAL
List all applicable null cant action permits(ee (;C.Cnunnt rare.Yoriance,etc) ft. j fL 6 114 in• SDR-21 PVC
3.Well Use(check well Ise): IL it.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
Agneultnral [DN4unicipal/Public ft. ft. in. !
i
Geothermal(Heating/Cowling Supply) residential Water Supply(single) ft. fL in. !
Industrial/Commercial Residential Water Supply(shared) 18.GROAT
01nigation FROM. i TO NIATERIA112 FM PLACF.II ENT METHOD&AM1fOt N'r
Icon-Water Supph Well: 0 f6 20 ft, Bentonite j Screened
Monitoring pRecovery i ft. ft.
Injection Well'
ft. i ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery OSalinity Barrier FRONt To MATERIAL EMPLACEMENT NIETROD
Aquifer Test OStormwater Drainage FL ft.
Experimental Technology OSubsidence Control ft. tL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets If necessary
Geothermal(Heating/Cooling Return) Other(explain under-21 Remarks) FROM TO IIESCRIP7TON(color.h■rdnesa solUrock e, rain size.etc.)
ft. ft.
4.Date Wells)Co m leted: Well iD# L A. ft.
h ` ft. ft.
5a,Well Location`.
Fir. rLJAN 12
tacilityRhvnerName�— Facility ID#(ifapplicable) ft ft. `
AurzAr'AI&r fti fL tr
J Physical Ad ss,City,and Zip fL ft. tf
G Qj`n C�I Lf 5-1 '1 21.REMARKS
oumv 7 J IParccl Identification No.(PIN)
1 Grouted On: ��
Sb.Latitude and longitude in degrees/minutes/smonds or decimal degrees:
(ifwcll field,one iat/long is sufficient) 22.Certification'
N W + --21
i
6.Is(are)the well(s)*ermanent or OTemporary Signature of C ified Well Contractor I Date
He signing this lorni,1 herehr cert/ that(he)tell(s)xas(tcere)constructed in accordance
7,is this a repair to an existing well• 0Yes or O with 15A,VC4C 02C.0100 ar/fq:k2'4C 0:C.0200 TfiW Construction Siandords and that a
Ifdtis is a repair.fill out known tcell construction in/ormation an explain the nature of the copy of this record has been provided to the xr/1 oxner.
repair under=21 remarks section or on the back of this form.
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- i Ned. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: too �_(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fr,rmultiple t,-e11s list all depths ildt�9erent(grumple-3@200'arul2Clt3)I'TI') construction to the following:
10.Static water level below top of easing: S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,we"-" 1617 Mail 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 276"-1636
13s.Yield(gpm) 2— Method of test:Timed 24c.For Water Supply&infection Wells: In addition to sending the form to
n 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 GWA North Carolina Department of Ertairotnnental Quality-Division of Water Resources Revised 2-22-2016