GW1--00406_Well Construction - GW1_20240116

IPrint Forrr
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES I i I
Well Contractor atrtc FROM 1 TO DESCRIPTION I I
NC-3556-A ft. ft.
ft. ft.
NC Well Contractor Cenititntion Number 15.OUTER CASING([or multi-rued crels)OR LINER(if applicable) i
AAA Sweetwater Well & Pump, inc. FROM TO DIAMETER I THICKNESS f MATERIAL
ft. ft. in.! I
Company Name
O 16.INNER CASING OR TUBIN(otitertual closed400p)
DFROM TO DL-vEfER i T ICK ans MATERIAL
2.Well Construction Permit#: �
f11
List all applicable mil construction permits(Lc WCC,Cou�;State.Variance,etc.) ft. c2�ft. in.I SDR--11 PVC i
3.Well Use(check well use): ft ft. is I x '
Water Supply Well: 17.SCREEN I E
FROM TO t DIAMETER SLOT SIZE t THICKNESS ` MATERIAL
Agri Rural Ditiunicipal/Public ft. ft. I in. 1
eothermal(Heating/Cooling Supply) E3Residential Water Supply(single) It. R. la i
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT I i(
Irrigation FROM TO I NIATERIAt. I ,�EMPLACEMENT METHOD&A\I0•• T I
Non-Water Supply Well: ..g' IL D ft. Bentonite
Monitoring ORecovery ft fr. A 01 p.eL 1 )
Injection Well: -...—
Aquifer Recharge - DGroundwater Remediation [` `
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Bather FROM 1 TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage tt, ft.
Es erimental Technology DSubsidencc Control ft. ft.
'eolhenmal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 1 TO DESCRIPTION(color.hardness,soilrock type,yarn size.etc.)
Geothermal(Heating/Cooling Return) nOthcr(explain under 21 Remarks) ft. ft.
Well iD�i ()l i 4k. . t. ` �E C' E `�7)
4.Date Well(s)Completed: 1 !.� L.� ft f `1s
5a.Well Location: La 4 3 ft. ft.
u ll�S*]yid CAii ft. ft. JAN 2624
FacthtyiOunerName r' a/ccilily iD;(it-applicable) ft. ft. I lrlivZr iG^..± rn i�fx",��o;r2 Ci,.N.
Sg`Vt / I,f/^1 V1It1l, 2 _7 ft. CtI15iCj O3
/ Phnsical Address,City,and Zip ft ft. i t
✓ 'R� (�J"�T '^ g,a,03�aazattotto 21.REMARKS
Minute ' I Parcel ldentititatien\u.(PIN) Grouted On: C —)3 -.93
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/lung is sufficient) 22.Certifi ation:
N W t_
6.Is(are)the weU(s)Iermanent or ['Temporarye 9-20-23
wture of c ified Well Con or Date
Br signing thin.fisrnt.I hereby eertifi'that the wells)nuts(were)constructed Jr.accordance
7.Is this a repair to an existing well: ❑Yes or EKo with ISA VCAC 02C.0100 or ISA MAC 02C:f 2W Well Construction Standards and that a
if this is a repair..fill out known well runsauction infointation and esplain the nature of the copy of this record has been provided to the well owner.
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 the same -- -You may use the back of this page to provide-additional well site details or well
• construction,only I GW is needed Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if neecsary.
drilled: t�7� SUBMITTAL INSTRUCTIONS
2
9.Total well depth below land surface: v (1 .. 2w —I.-, 24a. For Ali Wells: Submit this form:within 30 days of completion of well
For multiple nails list all deprlcs if different(movie-3@200'and 2@iOli) construction to the following: I
10.Static water level below top of casing: X (ft.) Division of Water Resources,Information Processing Unit,
If mutter level is abase casing.use---• 1617 Mail Service Center,;Raleigh,NC 27699-1617
II.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addition rot'sending the loan 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:
ii.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,iRaleigh,NC 27699-1636
Timed
13a.Yield(gpm) Meth o test: 24c.For Water Sootily&Injection Wells: in addition to sending the form to
the address(es) above, also submit one Ictipy of this form within 30 days of
13b.Disinfection type: CCH t: completion of well construction to the county health department of the county
where constructed.
Forts GW-1 North Carolina Depatuncut of Environmental Quality-Division of Warm-Resources Revised 2-22-2016