GW1-2022-05261_Well Construction - GW1_20220527

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WELaL.CONSTRUCTION RECORD(GNV-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
FROM TO DESCRIM'ION
R'zllCon[nctor;`amc Tt, ft.
NC-3556 A
ft, ft.
\C�l'dl Contractor Certification Number 15.OUTER CASING far multi-cased wells OR LINER if a licable)
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER THIC(iVECS �fA7ERL0.I.
ft.
Company Name
16.INNER CASING OR TUBiN eotherntal clused-loop)
2.Well Construction Permit th W
1 O I 0C(02 FROM TO I DIAMETER a 1 NIATER1AL
List all applicable ist•11 con stmelion permits(i.e.U1C County,Stare,ibrianc•e,ate.) V ft. D ft- I ('i�1- 1 tin' 1 SDR-P1 PVC
3.Well Use(cheep well use): ft. ft. tin- -
I�ater Suppy<«'ell: 1�.SCREEN
FROM TO DIAMETER SLOTSIZE T1HCK\E,SS ' MATERL%I.
Agri ultural [3MunicipaUPublic ft. ft. in.
eothennal(Beating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&.1MO- T I
Non-Water Supply Well: 0 Tt 200 ft- Bentonite EbrbEvew {
Monitoring [3Rccovery ft. ft.
Injection Well:
fr. ft. .
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Barrier FROM To 'MATERLIL EMPLACEMENT NIETHOD
Aquifer Test 0,StomlwaterDrainage
Ex erimental Technology DSubsidence Control ft. , ft.
eothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary
FROM TO DESCRIPTION(color,hardness,soiUrockty e.gain size,etc.)
Gcothenrtal(11cating/Cooling Return)v Other(explain under-21 Remarks) ft. fi.
4.Date Well(s)Completed: ZO I We
rll ID# ft. ft
5a.Well Location: J CVet, yl l p ft. fr.
I\AtlJL7 t I�Q I j Q �GCK� 1 )A—-/� ft.
i
Faci t iOS ft
nerNamz Facility iD#(ifapplicable) ft. '
Wand�eying O�1� Q &S vll 2� ft. ft.
Physical Address,City,and Zip ft. ft.
✓���/ �rA^ 1„� /; 21.RE6fARKS
County l vp Y` F Parcel Identification No.(PIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/imtg is sufficient) 22.Certification:
N
6.Is(are)the well(s)QPermanent or Temporary simatureofC ifieaWellContractor I Dat
Br signing this form.I herehv eertiijv that the ivell/s/nas(were)conshucled in acemdance
7.is this a repair to an existing well, ®Yes or MVo vilh 1 ti t VC4C 02C.0100 or 15.4 NC,1C 02C.0200 t ell Construction.Standard.and that a
If this is a repair, ll out known well consouctinn information and explain the nature of the copy;f this record has beet;provided to the well oxner.
repair tinder=21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
S.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 ned. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
uJ
9.Total well depth below land surface: J � (ft.) 24a. For All Wells: Submit this form within 30 days of completion of—,,.Jell
Far muhiple wells list all deptics if different(example-3 t 200'and 2C100') construction to the following: ®J
10.Static water level below top of casing: x (ft.) Division of Water Resources,Information Processing Unit,
If water level is above caving,use" 1617 Mail Service Center,Raleigh,NC 27699-1617 �Y 022
11.Borehole diameter: 6 (in.) 24b.For Injection Wells,. In addition to sending the form to due ad cis in 27
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,cue.)
i
Division of%A ater Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Service Center,Raleigh,NC 27699-1636
Timed 24c.FDr.Wate�Supply&Injection Wells: in addition to sending the fomt to
13a.Yield(gpm) bietho o test: PP g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH to t: completion of well construction to the county health department of the county
where consituctcd.
Foam GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Reused 2-22-2016