GW1-2022-05112_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.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC-3556-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if ap licable
AAA Sweetwater Well & Pump, Inc. FRONT TO DIANIETER THIU[iFSS MATERLAL
it It.
Company Name
16.INNER CASING OR TUBD'qlSg ermal dosed-loo
2.Well Construction Permit#: s ✓� FROM TO DIARIMR. MATERIAL
List all applicable rill construction permits(i.e.UiC,County,State,Variance,eta) 0
fL r�iTjt ` in SDR-11 PVC
3.Well Use(cheep well use): ILt u ItLI VVIVIL"
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICECNESS MATERIAL
r
Mural OMunicipal/Public ft. fL in.
rmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. tt in.
iaUCommercial Residential Water Supply(shared) 18.GROUT
on FRONT TO MATERIAL EDTPLACEAfENTMETHOI)&A6TOUNT
Non-Water Supply Well: p fL ft gentonite Somm¢d
Monitoring DRecovery ft
VIA P_
Injection Well:
fL ft.
Aquifer Recharge Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METilon
Aquifer Test [DStormwater Drainage I, ft.
Ex 'mental Technology ❑ISubsidence Control ft. ft.
eothennal(Closed Loop) ❑ITmcer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating(Cooling Return) Odier(explain under#21 Remarks) FRONT To DESCRIPTION color,hardy sail/racke, tam Stu,etc.)
ft ft
4.Date Well(s)Completed: - 1/Well ID# I I I A ft ft.
5 .Well Loca'on: I ft fL
fr. It.
acility/owner Name Facility ID#(if applicable) ft ft
�' 6 V (�Jh - fL fL
,sicpal(�Address,Ci ,and Zip Y .,� ,�U ft f,
J k
)\!III 21.REAfd KS
On
iun[y Parcel Identification No.(PIN) Grouted On: `
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certification: �1
N W tQ ;
6.Is(are)the w�ell(s),rmanent or Temporary ue of C ified Well Contractor Dat
� Ili,signing this fora,I herehr certifi,that the well(.$)was(mere)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ON. ivith 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
If this is a repair,fill out known ivell construction information and explain the nature of the copy ofthis 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-1 itpeeded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: j� i SUBMITTAL INSTRUCTIONS
9.Total well depth below land Surface: �� I (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wens list all depths ifdierent(example-3@200'an d 2@1001 construction to the following- DJ
10.Static water level below top of casing: Division of Water Resources,information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 2769-1 1 � rla)
Y " bL,
11.Borehole diameter. (in.) 246.For Injection Wells: In addition to sending the form t thy ess 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 276994636
Timed 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Meth d of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH A out: 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