GW1-2021-03158_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 DESCRIPTION
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NC-3556-A fL IL
ft. ft
NC Well Contractor Certification Number 15.OUTER CASING far multi-cased wells OR LINER if a licable
AAA Sweetwater Well & Pump, Inc. FROM 70 DLAbfeTER THICKNESS MATERIAL
fL ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
w List all applicable well consnuction permits(i.e.UIC,,County,State,Variance,etc.) -� I ft ' 0 fL 6 1/4 in' SDR-21 PVC
3.Well Use(check well use): R. ff. In.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural tcipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) Mesidential Water Supply(single) ft. ft
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
irrt anon FROM TO MATERIAL I EMPLACEMENT METHOD&•AMOUNT
Non-Water Supply Well: 0 % 20 fL Bentonite j Screened
Monitoring DRecovery ft. fL
Injection Well:
fL It.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK it applicable)
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL £MPLACE,AfENT METHOD
Aquifer Test DStormwater Drainage ft fL
Experimental Technology DSubsidence Control ft. fL
Geothermal(Closed Loop) ©ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Coolin Retum) 1710ther(explain under 921 Remarks) FROM fL fL TO DESCRIPTION J color,hardness,mivroctt type. rain size eta)
4.Date Well(s)Completed: Well iD# ft ft
5a.Well Location: fL ft.
ft.
.s.CGf/1 Wae lill
Facility/Owner Name Facility ID#(ifapplicable) fL fL
�D (J)tftf/x[`I / Iw✓� lQ1�t0� ft. fL
CCC ft ft UNII
P ysical Address,City,and Zip
21.REMARKS
�� 1?4Q�I,�-`fig 7 d J Grouted On:
County Parcel Identification No.(PiN) a.IYL
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: 1
(ifwcll field,one Iatilong is sufficient) 22.Certification'
N W
6.Is(are)the well(s)OPermanent or DTemporary gnature of C ified Well Contractor Date
Bt'signing this form,I herehr certifi,that the xvell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Dyes or MNo with 15A VCAC 01C.0100 or 15A NCAC 01CI.0100(fell Construction Standards and that a
if this is a repair,fill out knoxm well construction information and explain the nature of the copy of this record has been provided to the xrll owner.
repair under=21 remarks section or on the back 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-I i needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: =nee SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5-0 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of easing: 80 (ft.) Division of Water Resources,!Information Processing Unit,
If water level is above caring,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6 (in.) 246.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-
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WE L S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13s.Yield(gpm) Method of test: Timed 24c.For Water Supply&Injection Wells: in addition to sending the form
/ the address(es) above, also submit one copy of this form within 30 days
13h.Disinfection type: CCH Amount: I, /t7" completion of well construction to the!county health department of the cot
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Rc%ised 2-2
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