GW1-2022-05108_Well Construction - GW1_20220527

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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 FROST TO DESCRIPTION
fL fL
NC-3556-A
f4 fL
INC Well Contractor Certification Number 15.OUTER CASING for mul6-eased wells OR LINER if a licable
AAA Sweetwater Well & Pump, Inc. FRONT ro DIAMETER THICKNESS AIATEI2LAL
ft. ft.
Company Name � 16.ITOM CASING Leo tlli
2.Well Construction Permit#:J�II 1a / / t/ ✓`� FROST TO DIAMETER THICKNESS MATERIAL
pp pQ ry, ) � ft. fL 6114 in SDR-21 PVC
List all applicable well construction rnti ts�e.U C,Caun Slate,Variance,etc.
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICILN-ESS MATERIAL
AgriculIUral
�Municipal/Public R. fL in.
Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. fL to.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
0In1 atlon FRONT TO MATERIAL EMPLACESIENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 fL Bentonite Screened
Monitoring DRecovery ft. fL
Injection Well:
fL ft.
j` -": rRecharge [DGroundwaterRemediation —
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery ❑ISalinity Barrier FRONT TO MATERIAL ENIPLACEAlENTMETHOD
Aquifer Test QlStonmvater Drainage fL fL
Experimental Technology DSubsidence Control fL fL
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Retum) Other(explain under#21 Remarks) FROST To DESCRIPTION(color,hardness,soillriicktypc,"rain size.eta)
fL fL
4.Date Well(s)Completed: Z Well ID# fL fL
5a.Well Location: fL fL
— fL ft.
acilit wnerName Facility ID F(if applicable) ft ft.
ravw di
Ph y'cal Address,City,Ind Zip C� fL ft.
21.REMARKS
JaeV / J Grouted On: AP
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certir Ition:
N W /
6.Is(are)the wells) ermanent or Temporary ( ' nattue oC C ified Well Contractor Dale
By signing this form,I hereby certh,that the well ft)was(were)constructed in accordance
7.IS this a repair to an existing well: [3Yes or-EINo with 15,4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known hell construction it fornmlion and explain the nature of the copy ofthis record has been provided to the well ou,ner.
repair under 41 remarks section or on the back of[his 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 wel 'te etails or well
construction,only 1 W 1' eded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if ry.
drilled: / SUBMITTAL INSTRUCTIONS {{
rn
9.Total well depth below land surface: Z(Q (ft.) 24a. For All Wells: Submit this form within 30 II yAdf a"�ompletio f well
For multiple welhslisi all depths ifdierent(example-3@200'and 2@100D construction to the following•
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 6 (in.) 24b.For Iniection Wells: In addition to seq_ding the form to the address in 24a
Drilled above,also submit one copy of this form within-30 days'of completion of well
]2.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 27699-1636
.Timed 24c.For Water Su Dlv&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test. P g
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
--constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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