GW1-2022-01241_Well Construction - GW1_20220112

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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 DESCRIMON
ft. ft.
NC-3556-A
ft. fr.
NC Well Conuuctm Cenification Number 15.OUTER CASING for multi-eased welt OR LINER if a abk
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER THICK\ESS MATERIAL
ft. fE. in.
Cumpan}'Name /�q�t'� 16 i�0CASING OR-WHIM.qKV0,1*1
2.Well Construction Permit#: ,VD Q I-cxo 72 FROM I TO I DIAMETER TWCWWAS MATERIAL i
List all applicable tsrll construction permits(i.e.U1C',Counn'.State,Variance,etc.) ft. i-0 ft, 6 1/4 In. SDR-21 PVC f
J.Well Use(check well use): R fr. in
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOT SIZE THICIC ESS MATERIAL
Agricultural E]MunicipabPublic ft. R In. I
Geothermal(Heating/Cooling Supply) liaResidential Water Supply(single) fL ft. In.
i .
Industrial/CommercialResidential Water Supply(shared) 18.GROUT I
Irti ation FROM TO MATERIAL F.MPI_ACEMENT METHOD&AMOC.NT
Non-Water Supply Well: 0 it• 20 it, Bentonite Screened
Monitoring Recovuy fL ft.
Injection Well:
ft. ft.
Aquifer Recharge undwater Remediation 19,SAND/GRAVEL PACK if a cable
Aquifer Storage and Recovery Salinity Barrier FR0. To MATERIAL EMPLACEMENT ZIETHOD
Aquifer Test [JStomtwater Drainage ft. fL
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) OTTacer 20.DRILLING LOG mach sddidonal sheets if necessary)
FROM TO DTSCRIMON 4colorb willmli dace tic.) !
Geothermal(HcatinglCoolin ettu/m) Othcr(explain under#21 Remarks) rr It. t
4.Date Well(s)Completed: d Well ID# is ft. JAN
5n.Well Location- R ft.
v��Y rt rr r,
LFaccidli_ Owner Name Facility lD#(dapplicable)
ASS CI!avus
f h sicaI Address,City.and Zip
/ t!I Ir 1� 9���f✓7 W t��G.G..CJ 21.REMARY.S
County Parcel identification No.(PIN) CafOU fin'
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwdl field,one lat/long is sufficient) 22 Certifi lion:
., N W dY
6.Is(am)the well(s)E2 'ermanent or QTemporary Ignature of C ifi Well C nor ( Date
Br signing this form,/herein certify that the,well(.$)was(were)constructed in accordance
7.is this a repair to an existing well: Yes or ONO with 15A NC4C 02C.0100 or IS.A NCAC 02C.026Y)11'ell Construction Standards and that a
((this is a repair,ill out known well construction information and explain the nature ofthe copy ofthis record has been provided to the will owner.
repair under=21 remarks section or on the hack of this(om.
13.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 detli'.s or ,c"
construction,only I�W�t�needed Indicate TOTAL NUMBER of wells construction details. You may also attach addioonal==a
d SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (D•) 24m.For All Wells: Submit this form within 30 days of c,,xnP '
For multiple welts list all depths iftlii ferent(example-3C100'and 1Cla 100'f construction to the following:
10.Static water level below top of casing: No (ft.) Division of Water Resourees,�Information Processing Las.
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-161-
11.Borehole diameter: B in
( ) 24b.For Infection Wells: in addition to send aing the fi�ae�c-_�"'w . .
Drilled above,also submit one copy of this form witbin 30 drA
12.Well construction method: > Y tv
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground in CAMEr i pmpr
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rakigh.NC Z=d"44,+
d
I3a.Yield(gptn) Method of test:Time 24c.For Water Supply&laiection R'elh: lz sddcT --V. =a-- °::
the address(es) above, also submit one cop — a
13b.Disinfection type; CCH Amount: completion of well construction to the cotsz. br
where conswctcd.
I
Form GW-1 North Carolina Department of Emiromnental Quality-Division of Water Resources �-