GW1-2022-10174_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: Print Fom
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION j
NC-3556-A
ft. ft.
NC Well Contractor Cenifiution Number
15.OUTER CASING far multi-cased wells OR LINER if applicable)
AAA Sweetwater Well & Pump, Inc. FROM I TO DIAMETER I THICKNLS.4 M.ATERLAL
fL ft. to
Conspany Natne
'A)! n O�� 16.INNER CASING OR TUBI\ thermal closed-loop)
2.Well Construction Permit 4:tJ�f V FROM To DIAMETER MATERIAL
Lin all applicable well conenvctinn permits Ii.e.U�Counq%State,Rrriance,cre.i � fL Q C)rL �1 in. $DR-�1 PVC
3.Well Use(check well use): ft. fL is
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNL4S MATERIAL
Agri Itural OMunicipaMblic ft. ft. in.
euthemal(Heating/Cooling Supply) DResidential Water Supply(single) fL iL In.
Industrial/Commercial 011esidential Water Supply shared
pp y(shared) 18,GROUT �
Irrl atlon FROM TO B14TF.RIA1. EMPLACEMENT METHOD&AMO T I
Non-Water Supply Well: 0 fL 200 fL BentoniteA7e01f
Monitoring DRecovery fL fL
Injection Well: L
ft. fL
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To •fATEAIAL E]IPLACEMENT METHOD
il
Aquifer Test OStormwater Drainage rL iL
Ex erimental Technology OSubsidencc Control fL tt.
euthermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Gcothcrmal(Hcatin Cooling Return) Other(explain under 21 Remarks) FROM TO oESetuPflONtcolor,budn eoiurockty raie size,dc.l
fL fL j
4.Date Well(s)Completed: I Well iD# rL fL
59.Well Location:
�tdJ/aY! �1129�V� °j�IGI IZA �d�1 rL ft.
Aftelin
j
FacilityiOwnerName FB ji!"'O.-ablef fL ft. N
7�TalI�nI-{��v( 1�i� �P �'IIJrl� rt. una
Phy�ie I Address,City.an ip �'� fL fL rye
J9/_ 21.REMARKS I
County OQ Pared Identification No,(PIN) Grouted On: J D a J a a-
j
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lifwell field.one lat/long is sufficient) 22.Certiff ation:
W 2 a Z
6.Is(are)the well(s)GRIPermanent or OTemporary 1gnature of C ied Weil Contractor Date
Br signing this form.I hereby certifi•that the welks)was(were)constructed in accordance
7.Is this a repair to an existing well: Oyes or [Bo with 15d NC.4C 02C.01110 or 15.4.VC,4C 02C,0200 He11 Construction Standad•and that a
If this is u repair,fill out known it-ell consnvctinn in formalion and explain the natae of the copy aJ this record has been provided to the well oxrrer.
repair under=21 remarks section or on the hack of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same You may use the back of this page to provide additional well site details or well
construction,only 1 G I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /� ��I SUBMITTALINSTRUCTIONS
9.Total well depth below land surface: (�F�l/ ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Fro multiple iveiic list all deptkc if dijjei-ent(example-36200'and 2@/00'1 construction to the following:
10.Static water level below top of easing: X (ft.) Division of Water Resources,information Processing Unit.
1/aater level is above casing,use•, ' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address 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 27699-1636
13a.Yield(gpm) Meth o test: Timed 24c.For Water Supply&infectlon 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: CCU t: completion of well construction to the county health department of the county
where constructed.
Forrn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016