GW1--04804_Well Construction - GW1_20230721

1 I Print Fora
WELL CONSTRUCTION RECORD(GW-I) For internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES I
FROM I TO DESCRIPTION I
Well Contractor Name ft. ft.
NC-3556-A 1
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
AAA Sweetwater Well & Pump, Inc. FROM I TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Name 16,INNER CASING OR TUBINt ((geothermal closed-loopy'
FROM TO DIA'!E:TER TiilLKNESS MATERIAL
2.Well Construction Permit#: �I I D 1��S �
List all applicable well construction permits(i.e.UIC.County.State,Variance,etc.) Ef ft• Aoft. . I in' SDR7-11 PVC C y
3.Well Use(check well use): it ft. in.
17.SCREEN
Water Supply Well: FROM TO I DIAMETER SLOT SIZE THICKNESS I MATERIAL.
III Agri• Itural Oltfunicipal/Public ft. ft. I in. I
n 'eothennal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. I in.
i
Industrial/Commercial OResidential Water Supply(shared) 18,GROUT I
Irrigation FROM 1 TO I MATF.RLAr. i F.SIPI.ACEMEIYT)1F.THOD&AdfO T
Non-Water Supply Well: ,,g' ft. Iota) ft' Bentonite
•Monitoring Recovery ft. LJL/ ft. ,4 iPPI ReC i X :3
—)
Injection Well: 1
ft. ft.
■Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
j11AquiferStorage and Recovery DSalinity BarrierFROM TO MATERIAL. EMPLACEMENT METHOD
in Aquifer Test .Stommater Drainage fr. ft.
II Ex crimental Technology DSubsidcncc Control ft. ft. i
F. 'eo1hermal(Closed Loop) OTracer 29.1)RILLING LOG(attach additional sheets if necessary)
ii Geothermal(Heating/Cooling Return) QOther(explain under=21 Remarks) FROM I TO DESCRIPTION(color,hardness soiUrud type,grain size.etc.)
ft. I ft.
4.Date Well(s)Completed: (PI 22) Well iD# ft. ft. R�, �yyyy'�p
5a.Well Location: ft. ft. '�k,
n 01 I vet rt. ft. .1111 pp i9
FacilityiOwnerNam \r Facility(DO(ifapplicable) tt ft. l GO2J
3� 9 4 V 6 . AtivAtl, j$1' ft. ft. ligto iciiern t�r.V. 1
Unit
Physical Address.City,and Zip ft. ft. "^tide l
/ UnCt&k1^„ t a1.53t�, _ 21.REMARKS vounty I/�� Parcel identification No.(PiN) Grouted On: 41 I al Z' j
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
Orwell field,one lat/long is sufficient) 22.Certification:
i
N W ieI& A3
y a eat or Tem Oiary ignatureofC (fiedWellCon Date
6,Is(are)the A ell(s)Egerm np
Bt'signing this Joan.1 hereby eert ,that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or Eio with 15d NCAC(12C.0100 or/54 NCAC 02C.0200 Well Construction Standards and that a
1f this is a repair,fill out known well construction information and explain the nature of the copy of obis record has been provided to the well owner,
repair under v21 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 pace to provide additional well site details or well
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 e taloa (-L, 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diiffrrent(example-30(200•and 2@100'l construction to the following:
i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1/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
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.c.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) bfetho o 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 to t: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016