GW1-2022-01259_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 DESCRIPITON
ft. ft.
NC-3556-A
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NC W cll Contractor Certification Number 15.OUTER CASING for mold-cased wells)OR IANER if 6k
AAA Sweetwater Well& Pump, Inc. FROM TO DLow"IR TTIICItNESS MATERIAL
fa.
Company Name 1 16i8H4RCASING R.
2.Well Construction Permit#: 1 I � � ' —1 /� FROM TO DIAMETER THICKNESS TIATERiAL
List all applicable tsrll construction permits e.1 C, ouno�.State,Variance,ctc.J ft- 28 it- 6 1/4 1a SDR-21 PVC
3.Well Use(check well use): iL ft. in. �
17.SCREEN
Water Supply Well: FROM TO DIAMETER SL[rt SIZE I TIIICILNESS MATERIAL
Agricultural QMunicipaMblic ft. It. is
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in,
Industrial/Commercial Residential Water Supply(shared) 18,GROUT
irri ation FROM TO M.ATERUI. F.MPI_ACf.MENT METHOD&AMOUNT
Non-Water Supply Well: 0 it. 20 it- Sentonite Screened
Monitoring Recovery JIL ft.
Injection Well: ft, ft.
Aquifer Recharge /Subsidence
r Remediation
19.SAND/GRAT'EL PACK if applicable)
Aquifer Storage and Recoveryer FROM To MATERIAL F.MPLACEMMMETHOD
Aquifer Test Drainage ti IL
,Experimental TechnologyontrolGeothermal(Closed Loop) 20.DRILLING LOG attachadditionlsheetsifnecessaGeothermal(Hcatin Caolir Retuin and =2]Rem ) FROM To nEseRlenoN tcolor, soiYr«k she eta)
fG fL
4.Date Well(s)Completed:J24'1 Well iD# I S I ft. it I
�4c-o LCQ_ J 2 h.
Well Location: ` 6�u (%W ft.
JAN 202?
a1 Ic
Facilityi0wnerName Facility ID#(ifapplicable) i<• ft.
ft. ft.
Physical Address-CAy.and Zip fL ft. '
✓ ` -1 1 LL-Lb'l I O8 21.REMARKS
County Parcel identification No.(PiN) Grouted On:
laze ha Mj PanT-1
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcii field,one fat/long is sufficient) 22.Certification:
Lellz'A, a a
6.ls(are)the wells) PernTantot or []Temporary tgnattue of C ified Well Conaactor I AF
at
By signing this form,/herein'certtfi•that the»rll(s)was(were)constructed In accordance
7.iS this a repair to an existing well: []Yes or FhNo with 15A VC.4C 01C.0100 or 15A NCAC 02C.0200 FFW1 Construction Standards and that a
If this is a repair,.il)out Anown well construction information and explain the nature of the copy of this record has been provided in the-Atli owner.
repair under=21 remarks section or on the lack of this(orm.
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 rsrll site decizib car
construction,only I MIX
Indicate TOTAL NUMBER of wells construction details. You trey also anach addi Y.aez _
drilled: �_J I I $U 1M1 Ai.INSTRUCTIONS
9.Total well depth below land surface: t!/S (ft-) 24a.For All Wells: Submit this form within 30 days of c*mp wr- _.
For multiple wells lit all depths ifdinirent letample-3@200'anal @10') Construction to the following:
10.Static water level below top of rasing: I �(ft) Division of Water Resources,Information Processing t*iL
rf x,tter level is above casing,use--" 1617 Mail Service Center,Raleigh,NC 27699-161'
11.Borehole diameter: 6 (in.) M.For Infection Wells: In addition to,somding the foam tr tac s'� a
Drilled above,also submit one copy of this form'within 3e days of :at ;:f °ct
12.Well contraction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Iopeedw C P,so
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.RakigkL%C:"a41 Cft
Method of test:Timed 24c.For Water Suaaty&Infection Welts, ! wi—:--, ==� me 'u=— a•
13a.Yield(gpm) the address(es) above, also submit one ccp,� a-- 5:,rr a-m^ 31
13b.Disinfection type: CCH Amount: completion of well construction to the cases.+ -�» a br
where corutnucto:d.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
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