GW1-2021-03159_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 Contractor Name FROM To I DESCRIPTION
NC-3556-A It. rL
2 ft.
NC Well Contractor Certification Number
15.OUTER CASING Jfor multi-cased well's OR LINER if a lie
AAA Sweetwater Well & Pump, Inc. FRDM TU DIAMETER THtcKNesc cablhATERIAL
tt ft. in'.
Company Name
�) 16.INNER CASING OR TUBn,G eothei-mal closed-loont
2.Well Construction Permit#• p(I I o I DOS FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) •}' I ft. fL 6 1/4 t�• SDR-21 PVC
1 in
3.Well Use(check well use): 5O IL (pQ ft. 1 C
Water Supply Well: 17.SCREEN J
FROM TO DIAMETER SLOT SIZE THICKNFSS MATERIAL
OAgricultural DMunicipal/Public ft. fL in.
Geothermal(Heating/Cooling Supply) [;Wsidential Water Supply(single) ft. 1L in.
Industrial/Commercial 011esidential Water Supply(shared) 18.GROUT
Tt-rigation FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft* Bentonite Screened
Monitoring DRec ery ft. ft.
Injection Well: fL iL
Aquifer Recharge /inRgRetum)
undwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Renity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Testmwater Drainage fL ft•
Experimental Technolosidence Control fL fL
Geothermal(Closed Loer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(HeatinglCer(explain under#21 Remarks) FROM TO DESCRIPTION color.hardrin wittroek rain du.etc.)
PrL fL
4.Date Well(s)Comp ted: t Well ID# fL ft.
5a.Well Location: I fL fL
11Fa�cility/O2wner Name ���/'► 1�1/Facility ID#(if applicable) fL ft. J 4ZIt
lY��) �• i k�vr 1 LC(1 fL fL
t D
Physical Address,City,and Zip n ft. �;y
21.REMARKS
?25: ��11_0 W
✓ �v 1 (J Parcel Identification�N-o-.(�PINN)) Grouted On: U.-9
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
N W 60- ��
6.Is(are)the we0(s)[*-ermanent or OTemporary nature of C tfied Well Contractor Date
Bt'signing t is fmaq I hereby cert •(hat the awll(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ffJ1V0 with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the wr11 ouver.
repair under`21 remarks section or on the back of this form.
23.Site diagram or additional well detaDs:
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 GW-I is necdcA Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: N I/' 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 ifdifferew(example-3@200'and 1@1001 construction to the following:
10.Static water level below top of casing: / V (ft.) Division of Water Resources;Information Processing Unit,
If outer level is above casing,use 1617 Marl 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
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
i
13s.Yield(gpm) 0 Method of test: Timed 24c. For Water Supply&Infection 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: the
of well construction to the!county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016