GW1-2022-01250_Well Construction - GW1_20220112

WELL CONSTRUCTION RECORD (GW-l)
1. \Nell f'orit r actor Information:
For Internal Use Only:
Print Porn'
GW12022.
Cl.i.›.44abbitt
NC-3556-A
Co-Id:Et:1
AAA Sweetwater Well & Pump, Inc.
Nxr,.
2. Well Construction Permit 1 DI -Doti 46
f.e.: off ippf11 : imn Li(• ,
3. Well Use (check well use):
l'cater Supply Well:
,:ioiri •uftunit
iconierond (1 leatnie,Cohog Supply)
lndustriaLCommercial
l'ii-ivation
Non -Water Supply Well:
NIonitorinu
0:Municipal/Public
OResidemial Water Supply (sin-,zie)
EiResidential Water Sul (shared)
injection Well:
Aquifer Ret:barge
Ago ifer Storage. anti RCCOVCry
0.Aqui1er .Jet
DE \ noriincrital Technology
ieothermal (Closed Loop)
Cicotlicrmal leating Cooling Return)
airoundy. ate'. Remcdiation
OSalinity Barrier
OStomiwater Drainage
DT....
DOther (explain under =21 Reinarks)
4. Date Well(s) Completed: -:41-)-C1--
f Well 110
";Well Location:
-Ctit161(A/ (Aki')rte i /a61 (1,4f}"I'141-?
Faeilit) 1D. !if arph0le)
.'.2cility th\ na . -me
.-Sda,Maid-g'r (117/1:t7r4a21--9 M.11 tA.A4.1
--..,
1
ritillA114-6 91106/1-0 P 3ti'Zff
r.„,.:. lik.„„fiL,,,, N,,. tP1N;
titj. and 13p
5h. Latitude and longitude in degrees/minute/seconds or decimal degrees:
17!' Ci I A.TIC i0:1!1:•
. ,
6. is(are) the r.ell(s)
ermanent or lTeniporary
7. Is this a repair to an existing vseli: ON'es or
fill 'eta %Art., ii tic flf,/: Mitt; ,httiltttl titl'i t
:order 2i emark.: on the back Brit
S. For Geoprobe/OPT or Closed -Loop Geothermal Wells havina the same
constniction. only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
2
9. Total Well depth below land surface:
o.:/iree depth: riittimolt 311210. <ma rij UM')
111. Static ater level helm.% top °leasing: (ft.)
ir lei:2i 1.8 ilhOle
11. Borehole diameter: 6 (in.)
12. Well construction method: Drilled
augcr. rotary. cab(e, dtrect push, dz.)
1
3 za)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type: CCH
Metho
to
est: Timed
t
14. HATER ZONES
10011 ) 10
DESCRIP1 11 IN
ft. •
it.
ft.
ft.
15. OUTER CASING (for multi -cased v.ell) OR LINER (if applicable)
FFION1 10 1)11711E1ER 1 HICKNESS 11-111:11111.
ft. ft. in.1
16. INNER CASING OR TURIN eotherinal closed-1°,1.1T,"
FROM To [11 ‘Att.-1-14/ , ftfug-Nin), '1 'I((
". ZOO IL et* soR-pi I PVC
ft. , • (
17. SCREEN
I tRoAt To ; 111.1111.1 ER st.OT SELF: THICKNESS ) NIATEHI 11.
ft. ft. in. I ;
ft. ; ft. , in.
18. GRCR
FR( t11 ), I Elft%t f pi :1M1.VI 11111101, &ANH) rt,
0 ft' 20( Bentonite lifectevel* X
ft. ft. p.f
ft. ft.
S ANDIGRAVEI. PACK fit -applicable)
IRON) Ti) Nf sTEHI.st.
11. ft.
i 1AIPIACtIMFV1 NiETIMD
f1.
ft. :
20. DRILLING LOG (attach additional shells if necessar0
111(11,1 10 ntsCRIPTION (color. bardnes). soil ruck t?.pe.u,ruin )11e. etc.)
ft.
ft.
ft.
ft.
ft.
'
'
,
i 'r rs- •-,
....'
ft. i
ft.
2
24.1/1?
ft. 1
ft.
ifTfr A ' '
:
, , r. :. :
' • '
)
' '
. • .. :
ft.
ft.
ATIIREM ARKS
2i ra ••
22. Certification:
Sin,aure C Comraciol
/
111•1 fai • f :I v. Li. dim
110: 1.5.1 .\-C C 1,2C Mbier t/r 12•4 if )!.:Pttiett tit :ittd !het! et
:t.tpt* et! :hit rt"t/ttei ht, been pro: ;Cid f 11,0 eh'
23. Site diagram or additional well details:
You may use the hack of this page to min ide additional uel) site Mails or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells- Submit this form within 30 days of completion et. well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service (enter, Raleigh, NC 27699-1617
24h. For Iniection Wens: In addition to sending the form to the address in 24a
above. also submit one copy of this form within 30 days of completion of ueil
construction to the 6)11ov:fig.!:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center. Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the tom; to
the address(c) above. also submit one copy of this tom'/ iihn 30 days 10
completion of well construction to the county health department of die comny
;here constructed.
ono (i1V-1 North Calolina Deparrocm of En,. uomn:ntal Quality - pis islon of V. Resoun:6:,
0/77 2-22-2016