GW1-2022-05340_Well Construction - GW1_20220530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt tl" N 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC-3556-A
MAY 3 fL f[.
NC Well Contractor Certification Number '
O,i�i��rpyR(�U S.OUTER CASING Cor multi cased wells OR LIAER ifa livable)
AAA Sweetwater Well & PuMA.&gt> FRONT To UL1NfETER THICKNESS MATERIAL
WJQiSOG ft.
Company Name �y/i/ �y/�Z��t3' //IJtJ FRONTtFEi2 CASING2.Well Construction Permit#• FROM TO DIANTETER TTIICKVESS bATERIAL
List all applicable cell construction permits n.e.=Cate,Variance,etc.) .� fL fL s 1/4 i"' SDR-21 PVC
3.Well Use(checkwelluse): It. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE I THICKNESS I MATERIAL
Agricultural �M icipaUPublic ft. it in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) tt, ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FRONT I TO 11TATERIAI, ENIPLACENIENT MF,TIIOD&A610 UNT
Non-Water Supply Well: 0 ft- 20 fL Bentonite Screened
Monitoring ORecovery ft. It.
Injection Well:
IL ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK ifa livable
Aquifer Storage and Recovery Salinity Barrier FRONT To I MATERIAL I ENIPLACEMENT NTETHOD
Aquifer Test QlStotmwater Drainage ft ft.
Experimental Technology OSubsidcnce Control ft. fL
Geothermal(Closed Loop) ❑)Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks) FRONT To DESCRIPTION(color,hardness,soilinck*Tic grain size,etc)
rL FL
4.Date Well(s)Completed: a� t)- Well ID# TL ft.
q�5well L cation: ft. IT.�- ft. ft.
ility/Owner Name Fac 'y ID#(ifapplicable) ft. ft.
II n fL ft.
Physi al Address,City,an Zip l•� It. It.
ccbJ))���bb/�Dp ov) /!%y �+J 1 �37 21.REMARKS
County P:u�csel Identification No.(PIN) Grouted On: �a-
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long Ls sufficient) 22.Certification:
N W ( , � a
6.Is(are)the well(s)�ermanent or Temporary 5 gnature of� fed Weit Contractor Date
�� By signing this form,I hereby verb,that the well(s)was(sere)constructed in accordance
7.Is this a repair to an existing well: E)Yes or 1�"" 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 oflhe copy ofthis record has been provided to the well owner.
repair under lr21 remarks section or an the back ofThis 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 needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ' JA-- J ` SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: IQ�S 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all deprhis if ili erent(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: ')b ID A) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniection 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) O 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
136.Disinfection type: CCH Amount: completion of well construction to the county health department of the county
where constructed.
Forth GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016