GW1-2022-05262_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
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OILL_ER if a licable)
AAA Sweetwater Well & Pump, Inc. FROM TO ll1AME17R THIESS DfATERLIL
Company Name
j� I0.-ttC1CL"[t'CASrNG'
2.Well Construction Permit#: Q L�J FROM To DIAMETER k6S AL
List all applicable well constructionpennits(i.e.UIC,County,State,irariance,etc.) >% fL S fL 6 1/4 tn- SDR-21 PVC
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunici al/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. fL in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FRO?t TO MATERM. Eb1PLACE\PENT METHOD&A1tOUNT
Non-Water Supply Well: 0 ft- 20 fL Bentonite Screened
Monitoring DRec ry ft. tL
injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if a licable
Aquifer Storage and Recove Salinity Barrier FztoM To MATERIAL EMPLACEDIENT DIETIIOD
Aquifer Test DStormwater Drainage fL fL
Experimental nology Subsidence Control ft. ft.
Geoth al(Closed Loop) DTracer 20.DRILLING LOG attach additional'sheets if necessary)
FROM TO DESCRIPTION(color,hardness,suillrock t e,^rain sin,etc.)
othetmal(Hcating/Cooling Return) not
(explain under 421 cmarks) ft. ft.
4.Date Nell(s)Completed: ct w Well 1. ft. ft.
Sa.Well Location:
fL ft.
/ �✓ _. _ ft. ft.
Facilit/Owner Name Facility rD#(ifapplicable) fL ft.
1 . �` �r ft. fL
�Irysical Address,City,arA Zip fL ft.
21.REMARKS /
County Parcel Identification No.(PIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W �
6.Is(are)the well(s)g7 yrermanent or Temporary ure of C ified Well Contractor 1 Date
7r By signing this farm,I hereby cerlifi,that the u-ell(s)teas(irere)constructed in accordance
7.Is this a repair to an existing well: []Yes or allo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
if this is a repair,fill our knona well construction information and explain the nature of the copy ofthis record has been provided to the[tell ouvter.
repair under=21 remarks section or on the back ofthis 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 1 GlN-1 is needded� Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: xe SUBMITTAL INSTRUCTIONS DJ
9.Total well depth below land surface: ( U/� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(erantple-3@200'and 2@100D construction to the following: h (,R r2(`3 j
p� �A11 27 )
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Prdcessing Unit,
lfi ater level is above casing,use"*" U 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Drilled above,also submit one copy of this form within 30-days'of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / 0 Method of test: Tinted 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 &P completion of well construction to the county health department of the county
where constructed.
Form GWA North Carolina Department of Etniromnental Quality-Division of Water Resources Revised 2-22-2016