GW1-2022-05110_Well Construction - GW1_20220527

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14..WATERZONES
Well Contractor Name FROM TO DESCRIPTION
NC-3556-A rt rt.
ft. f6
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER(if a licable
AAA Sweetwater Well & Pump, Inc. FR031 To DIAMETER THI.ESS MATERIAL
f4 h. in.
Company Name _
16.IMM R CASING
2.Well Construction Permit#: 4091 �d��� ' - FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction perntits(i.e.UIC,County,State,Variance,etc.) T T fL ail ft. 6 114 In' SDR-21 PVC
3.Well Use(check well use): ft. ft. is
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
:)Industrial/commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METFIOD&AaIOUNT
Non-Water Supply Well: 0 fL 20 ft, Bentonite Screened
Monitoring Recovery ft. ft
Injection Well:
ft. ft.
Aquifer Recharge /,E)GrouterRemediation
19.SAND/GRAVEL PACK if a licableAquifer Storage and Recoveryrrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test r Drainage ft. ft.
Experimental Technology Control ft. fi.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Rctum) Other(explain under#21 Remarks) FRodf fL To fL DESCRIPTION(color,hardness,solUrnck typc rain sfu,eta
4.Date Well(s)Completed: Well ID# ft. ft.
5a.Well Location: ft. ft.
_ ft. ft.
Facility Owner Name Facility ID#(ifapplicable) ft ft.
17 YY1avl U�o� �'�.o.� �-�er�rvr�,� Z�r�3b ft. it.
Physi�dress,City,and Zip ft. ft.
21.REMARKS
ounty Pastel identii cation No.(PIN) Grouted On: G
5b.Latitude and longitude in degrees/ngnutes/seconds or decimal degrees:
(ifwcll field,one Iat/long is sufficient) 22.Certifi tion: // e
N W Z a 2-
6.1s(are)the well(s) ermanent or Temporary signature of C ified Well Contractor I Date
��/ By signing this form,I hereby cert fv that the icell(s)was(1vere)constructed in accordance
7.Is this a repair to an existing well: OYes or 9115 with 15A NCAC 02C.0100 or 15A 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 ofthis record has been provided to the xell ouvter.
repair under'21 remarAs section or on the back of dds 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-1 is n�e*I*ate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �hf( /� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /19-S (ft.) 24a.For All Wells: Submit this form within 30 dayD jmpletion of well
For muhiple welts list all depths ifdii erent(Crumple-3@� /OOq construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Informa�ikj g srng`Uni,
Ijxnrer level is above casing,use"+" 1617 Mail Service Center,Raleigh)11�i.QA�76 4617U t'
11.Borehole diameter: 6 (in.) 24b.For Iniection Wells: In addition to 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
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WE LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016