GW1-2022-01266_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
WellConnactorName FROM TO DESCRIPTION
NC-3556-A fL R.
fL n
NC Well Contractor Certification Number 15.OUTER CMac—,
SING for mtdti med wells OR LIlVER I! Reabte
AAA Sweetwater Well & Pump, Inc. FROM M DtAMETEk MATTSRIAI.
n. IL in.
Company Name
O 16.111NER CASING eo
2.Well Construction Permit#: r•Ttx o TODIAMETERDiwerER TlIIctotess MATERIAL
List all applicable well construction permits(i.e.UiC,County,State,Variance,etc.) ^� fL 6 114 in- SDR-21 PVC
3.Well Use(check well use): fL ft. to
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TIIICI44ES.S I MATERIAL.
Agricultural OM cipaUPublic fL R In.
Geothermal(Heating/Cooling Supply) eside:ntial Water Supply(single) g g In,
IndustriaUCommercial Residential Water Supply(shared)
l8.GROAT
711rrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply W 0 fL 20 Bentonite Saeened
Monitoring 13Rccovciy ft. fL
Injection Well:
n n
Aquifer Recharge OGroundwate a iation 19.SAND/GRAVEL PACK 1'a e
Aquifer Storage and Recovery Barrier FROM To I MATERIAL I EMPLACEMENT METHOD
Aquifer Test ormwater Drainage fL fL
Experimental Techn OSu b' ence Control fL fL
Geothemta used Loop) Tracer 20.DRILLING LOG attach additional sheets V
ermal(Heatin Coolin Return) rJOther lain under#21 Remarks mom fL TO
To DESCRIPTION rnMr b soillrork etc
4.hate Wed(s)Completed: I Well iD# -� ft. fL
Sa. ell Location: D. M
fL 2
F ity/pruner ame Facility iD#(ifapplicable) ft. fL
K / _ [L fL jAN -
Physical Address,Ci Z' M
C/ IL ft.
/LL5^�� O 21.REARKS
County Parcel identification No.(PiN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one latflong is sufficient) 2L Certifi lion
• N W r�
6.Is(are)the well(s) ermaneut or Eftemporary ture of C tified Well Contractor Date
By signing this form.I herein,certify that thel ivell(s)was(were)constructed in accordance
7,is this a repair to an existing well: OYes or [NNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fdl out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
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 I GW is ed. 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: (ft.) 24a, For Ad Weds: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'andd 1@1001 construction to the following:
10.Static water level below top of calling: / / t/ (ft.) Division of Water Resources,Information Proeessbrg Unit,
1f water level is above casing,use"+" 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:S (an.) 24b.For Infection Weds: in additidirto Sending the form to the address in 24a
Drilled above,also submit one copy of this form within 90-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.Tined 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also subunit one copy of this form within 30 days of
13b.Disinfection type: CCH Amount 922= completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016