GW1-2021-03102_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
Well ContnelorName FROM TO DESCRIPTION
NC-3556-A ft. ft.
fr. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)OR LINER if applicable)
AAA Sweetwater Well & Pump, Inc. FRO]f TO DIAMETER TRICKNES.S M.ATERFAI.
f4 i ft. in
Company Name
q 16.INNER CASING OR TUBiN thermal closed-loop)
2.Well Construction Permit h: ! I Do lQD.5 FROM TO DIAMETER s MATERIAL
List all applicable nxll consnveeliem permits(i.e.UIC.Coun(y.State,Variance,Vc.) � ft. i3_0 ft. ,yj y I 1n• SDR-41 PVC
ft. I ft. Vn
3.Well Use(check well use):
Water Supply Well: 17.SCREFN
FROM TO J DIAMETER SLOT SIZE i THICKNESS SIATERIAI.
Agri rural [DNlunicipaUPublic tr. it.
eothennal(HeatinglCooling Supply) Residential Water Supply(single) ft. ft. I 1n.
Industrial/Commercial Residential Water Supply(shared)
18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&ASIO T i
Non-Water Supply Well: 0 n. rt. Bentonite 00umew
[)Monitoring ®Recovery ft. j ft. �1t L At !
Injection Well: i._--
!t. ft.
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0SaIWty Barrier FROM TO MATERIAL EMPLACEMENT NfETHOD
Aquifer Test OStomtwater Drainage
IL
ft.
Ex intental Technology DSubsidencc Control t<• j ft. J
eothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary
FROM TO DESCRIPTION{color,hardness,soihrock type, rain size,etc.)
Geothermal(Hcating/Cooling Return) Other(explain under-21 Remarks) rc i ft.
4.Date Well(s)Completed: ' Well t tL ft.
ft. ft.
So.Well LocaIII
:
(,viar ft i ft.
FacilityiOwnerName - n&D#(ifapplicable) ft.pro A.1U 11 M D. ft. UfZit
/phc*Couv
sical Address.City,and Zip F ft. ft. �utl`''Btt00 r'e
Yoil0 /�,t21.RE1tARK5") tl 1AGrouted On:Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Iifwell field.Line fat/long is sufficient) 22.Certi6gation:
6.Is(are)the well(s)2plermanent or Temporary Signature of C ified Well Contractor Date
Br signing this lnrni, I herehr certifi,that the mulls)ads(tcere)cnnshvcied in accordance
7.Is this a repair to an existing well: 0yes or �O it ah 15A.NCAC 02C.0100 ar 1 V4 NC'AC 02C.0200 n:11 Construction.Standards and that a
I(this is a repair.fill out knonn,cell enmso uction in/oi mation and c%plain the riulwr of the copy of thic record has been provided to the iieli owner,
repair under=21 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 page to provide additional well site details or well
construction,only I is needed. Intricate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Frir multiple u�c1Ls list all depths il'dijlerent(example-3(aUW'a1ki2@l00) construction to the following:
i
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
it a aver level is above casing.use' " 1617 Mail 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
pe Well curvy.cable, 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,Ralctigh,NC 27699-1636
13a.Yield(gpm) meth 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 m t: completion of well construction to the county health department of the county
where constructed.
Form GW I North Carolina Department of En%ironniental Quality-Division of Water Resources Revised 2-22-2016