GW1-2022-01265_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 TO DESCRIPTION I
rl. ft.
NC-3556-A
M
NC Well Contractor Certification Number 15.OUTER CASING for multi-cued wells OR LINER if Malficable
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER T®cKNess MATERIAL
fL ft. in.
Company Name Q�
(J 16 PAiGItCAS1NG
2.Well Construction Permit#: 11. �+ L FROM To DIA ILTER I TMCIcvFss MATewwL
List all applicable well construction permits(i.e.U1C,County State,Variance,etc.) -� f6 f6 6 1/4 la SDR-21 PVC
3.Well Use(check well use): R % io
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT'SIZE TMCILNM MATERIAL
Agricultural OMunicipal/Public & ft. In.
Geothermal(Heating/Cooling Supply) &esidential Water Supply(single) ft. ft. In.
IndustriaUCommercial Residential Water Supply(shared) Ia.GROUT
71irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 H- Bentonite Sovened
Monitoring Recovery ft. &
Injection Well:
ft. ft.
Aquifer Recharge OGro ater Remediation
19.SANDiGRAVEL PACK ff applicable)
Aquifer Storage and Recovery alinity,Barrier FROM TO MATERIAL EMPLACEAMW 1% TIroD
Aquifer Test [3Stormwater Drainage ft. ft.
Experimental Techn Subsidence Control R- ft.
Geoth osed Loop) Tracer 20.DRILLING LOG attach additional sheets if neeessa
ermal(Heatin oolin Return) 1730thcr lain under#21 Remarks) FROM To ft.
color,hardness,soahaek etc
R. rt.
4.Date Well(s)Completed: i2) Well ID# _ It, %
5a.Well Location: n
Acdity/Owner Name Facility ID#(ifapplicable) & & �.
-V ._ �12��s'3 iL it.
.�hysical Address,City.and Zip fL tL
i , '15 A 21.REMARKS
�I t Grouted On: .5 a
County Parcel identification No.(PIN) -
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one[attlong is sufficient) 22.Certification: Ll
N W
6.Is(are)the well(s) ermanent or Temporary &ture 0172rilified well Contractor Date
By signing this form.1 herebv certifi�that the well(s)was(were)constructed in accordance
7.Is this a repair loan existing well- QYes or ioNe with ISA NCAC 02C.0100 or i5A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been proiided to the well owner.
repair under 021 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 I GW-(,ii nep¢Fd. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: -T SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft•) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: d Do (ft.) 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 Injection Wells: In addition to saa*.wg the form to the address in 24a
Drilled above,also submit one copy of this form withiin 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) t/ Method of test•Timed 24c.For Water Supply&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: completion of well construction to the county health department of the county
where constructed.
Form GW-1 Nonb Caminta Department of Environmental Quality-Division of Water Resources Rc%ised 2-22-2016