GW1-2022-05111_Well Construction - GW1_20220527

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WELL CONSTRUCTION RECORD (GW-1) For hltemat Use Only:
1.Well Contractor Information:
Clint Babbitt 14.WATER ZONES
Well Cantractortiamc FROM TO DESCRIPTION
f[, ft. I j
NC-3556-A
ir. ft.
XC Well Contractor Certification Number is.OiLTER CASING for multi-cased wells OR LiNER if applicable)
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER I THICKNESS afATERL-U.
ft. ft. in.
Company Hume 16.INNER CASING OR TUBiN eothermal closed400 )
2.Well Construction Permit#•�n_ ` �J 11i 6US� FROM TO DIAMETER MATERIALList all applicable vrll construction pernnts(i.c.UIC',CaunO•,State,Iia•inm•c,etc•;1 V ft. �ft. '�?-/l in-
3 SDR-PI PVC
3.Well Use(check well use): ft. ft. in_
17.SCREEN'
�Yater Supply Well: FROM TO DIAMIETER SLOT SIZE THICKNESS MATERIAL.
rIndustrial/Commercial
Mural OMunicipal/Public fr. ft. in. I
rmal(Ileatin--/Cooling Supply) OResidential Water Supply(single) it. ft. In.
Residential Water Supply(shared) 18.GROUT
on 1,I1011 , TO MATERIAL EMPLACEMFENTMF.THOD&AMfO - "r '.
Non-Water Supply Well: 0 ft• 900 ft- Bentonite Bbrbeua f
Monitoring 13Rccovery ft. ft. �It(31 L
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable) I
V,Aquifer'fest
ifer Storage and Recovery Salinity Barrier FROMT TO NIATERIAL EMPLACEMENT METHOD
�StomiwaterDrainage
crimental Technology DSubsidencc Control ft. ft.
thermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessarythcnual(Heating/Cooling Return) Other(explain under#21 Remarks} FROM To DESCRIPTION(color.hardness soiUrock type, ra n size.etc.)
ft. ft. I
4.Date Well(s)Completed: 4 v Z) Well rD#
5a.Well Location: 1' 4-4k f4 fr.
Fact'tyiolvnerNa me Facility iD#(if applicable) ft. ft. i
� ft.
hv�uaI Address,City,and Zip ft. 1 ft.
County y�L V�-C— Parcel Identification No.(PIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one fatllong is sufficient) 22.Certification:
W
6.Is(are)the w•ell(S)E Permanent or Temporary tgnaiure Of ifie tiVell Contractor I Date
Br signing this lnrm,I hereby cerliJi•that the wells)it as(uerv)cons6ucird in accordance
7.is this a repair to an existing well: ❑Yes or �Io with JSd NG4C 02C.0100 or L5,INCAC 02C.0200 11e11 Construction.Stundmds and that it
If this is a repair..lill out known hell construction information and explain the nature of the copy of this record has beep;provided to the is-ell ou ner.
repair under=21 remarks section or on the hack oJ'this form.
23.Site diagram or additional well details:
3.For Geoprobe/DPT 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 is n eded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS DJ
osl
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
FTu nwhiple sells list all depths ifdijferent(erample-3•t 200'alul2C 100') construction to the following:
MAY 2 7 2022
10.Static water level below top of casing: x (ft.) Division of Water Resources,Information Processing Unit,
If xater 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 sending the form to the address in 24a
Drilled 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 27699-1636
13a.Yield(gpm) Bie�kt:Timed 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH : completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Emiromncntat Quality-Division of Water Resources Revised 2-22-2016