GW1-2022-08165_Well Construction - GW1_20220530

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WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information: y
Clint) Babbitt 14.WATER ZONES I
Well ContraclorName
r ;. FROM TO DESCRIPTION
NC-3556-A
NC Well Contractor Certification Number MAY 3 0 20 L� ft. ft.
15.98Sittt CASING le
AAA Sweetwater Well & Pump, Inc. uR� FR03f TO DAAf ER THIMNESS MATERIAL
Company Name [�i} � 16.INNER CASING OR TU ING(eotherma c set-loo v
2.Well Construction Permit# Q D FROM TO DIAMETER TIHCKNESS MATERIAL
List all applicable sell construction perm�(i.e.U1,County,State,Variance,etc.) ft. ft- 6 114 to SDR-21 PVC
3.Well Use(check well use): fL it. in.
Water Supply Nell: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS AIATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) F3<idential Water Supply(single) ft. ft is
industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft.
20 ft. Bentonite Screened
Monitoring Recovery tt. fL
Injection Well: fL ft.
AquiferRecharge /[03GroaterRemediation19.SAND/GRAVEL PACK(ifa iicable)
Aquifer Storage and Recovery arrier FROM TO MATERL1f. EMPI ACEMENTMETROD
Aquifer Test ter Drainage fLExperimental Technology ce Control fL R.
Geothermal(Closed Loop) 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock t c, min size,etc)
Geothermal(Hcating/Cooling Retum) Otlter(explain under 421 Remarks) ft fL
4.Date Well(s)Completed: v2 Wel ft. ft.
5a.Well Location: ft. ft.
ft ft.
Facility/Owner Name
acility/OwnerName Facility ID#(ifapplicable) ft ft.
I
ft. fI-
_✓/ Physical Address,City,and Zip fL fL
,,aA,6t)yX • 9 21.REMARKS
County Pared Identification No.(PIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one hit/long is sufficient) 22.Certification:
s`23'578 N 4SO02 02101 I-74• w ',
6.Is(are)the well(s) "anent or Temporary ( tgnature of C ified Well Contractor Date
By signing this form,I hereby cert fi,that the itvll(s)was(mere)constructed in accordance
7.Is this a repair to an existing well: QYes or Eaf�o with 15A NCAC 02C.0100 or 15A NCAC 02C.0200(yell Construction Standards and that a
If this is a repair,fill our known well construction information and explain the nature of the copy ofthis record has been provided to the x•ell oavrer.
repair under2l 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 I GW-I s n ded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: �X SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdierent(erantple-3 tr 00'and 2@1001 consttuction to the following:
10.Static water level below top of casing: � (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+'• 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) 1"5- 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 ofEnvironmental Quality-Division of Water Resources Revised 2-22-2016