GW1-2022-01262_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 DESCRIPTION
ft. /t.
NC-3556-A
tz n
NC Well Contractor Certification Number 15.OUTER CASING for maltFased wetbs'OR LINER ble
AAA Sweetwater Well& Pump, Inc. FROM TO DIAMETER il T1ICKNESS MATERIAL
ft, ft. Ira
Company Name
yy--�� Q� 7� 16. CASING
2.Well Construction Permit#: 11 V 1 ✓ C� V FROM To Dl Uterett TInClKNM 1 MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) a n IL 6 1/4 to J SDR-21 PVC
3.Well Use(check well use): fL tL to
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE TtIC[4NFSS MATERIAL.
Agricultural []MunicipaUPublic & % in
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. R is
IndustriaUComnimial Residential Water Supply(shared) 18.GROUT
_11nipation FROM TO MATERIAL i EMPL.ACEMENT METHOD @ AMOUNT
Non-Water Supply Well: 0 It- 20 ft. Bentonite Screened
Monitoring Reco % iL
Injection Well:
rr. It.
Aquifer Recharge dwater Remediation
19.SAND/GRAVEL PACK.If liable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage I ft
Experimental Technology Subsidence Control ft. a.
Gcotfientral(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if
Geothermal Hearin Cooli Return) Other lain under#21 Remarks FROM TO DESCRIPTION eelor,h sollhock etc.
EA. fL
4.Date Well(s)Completed: �-31 -a ) Well M# M,((,h it. h `
spa,Well Location; � L '
ft. ft 2
✓`, 12l#'h15 �YD(j'11G�1r� T -- _ rt. n.
Facility/Owner Name Facility ID#(ifapplicable) ft ft.
a:
ft. ft.
Physical Address,City,and l0p ft n'
�ktidiwsn _ J o_-/1 V 21.REMARKS
County Parcel Identification No.(PiN) Grouted On: a
5b.Latitude and longitude in degrees/ndnutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 2L Certification:
N W 10
Z�AK&
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6.Is(are)the well(s) ertnanent or Temporary 'tare of ified well Contractor i Date
By signing this form.I herebv certify that the wuu(sl was(were)constituted in accordance
7.is this a repair to an existing well: Oyes or MPO with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the cagy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
S.For GeoprobeMPT 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 feeded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /a t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3`-'S (fL) 24a.For All WeOs: Submit this form within 30 days of completion of well
For multiple wells list all depths if di ferent(example-3@200 and 2@1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If%titer levet is above casing,use"+" 1617 Mail Service Center,Ralelgh,NC 27699-1617
I I.Borehole diameter: 6 (in.) 24b.For lnjection Wells: In additid to sending the form to the address in 24a
Dr above,also submit one copy of this form within 30-days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276"-1636
13a.Yield(gpm) Method of test.Timed 24c For Water SDDgly&Injection Weds: in addition to sending the fmin to
/`7 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH Amount ! completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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