GW1-2022-05342_Well Construction - GW1_20220530

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r WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt As WATER ZONES
Well Contractor Name OAI TO DESCRIPTION
NC-3556-A `� 1V rL ft.
ft. ft.
NC Well Contractor Certification Number � y 3 0 2022 15.OUTER CASING for multi-cased wells OR LINER if a livable
AAA Sweetwater Well & Pump, In H FROM TO .1,011ER 1 THICKNESS 1fATE.
CompanyNamc L"'Ja���r(vyQ 16. CAS[NG
2.Well Construction Permit#: I I f7� I�f +W � FROM TO DLA51ETER THICKNESS MATERIAL
List all applicable wrell construction permits(i.e.UIC,County,State,Variance,elc.) .t- ( fL fL 6 1/4 i°' SDR-21 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DMATETER SLOT SIZE THICKNESS MATERIAL
Agricultural [DMunicipaUPublic ft. fL in.
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Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft. fL in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO AfATERTAL EMPLACEMENT METHOD&AAIOUNT
Non-Water Supply Well: 0 fL 20 ft, Bentonite Screened
Monitoring [DReco ry ft. ft.
Injection Well:
ft. R.
Aquifer Recharge roundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Stortnwater Drainage ft. ft.Test D
Experimental Technology ubsidence Control ft. ft.
Geothermal(Closed Loop) ❑ITrac 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Remm) Other(explain under#21 Remarks) FROM ft. To DESCRIPTION(color,hardums,soi0rock e, in size,etc.)
I fr.
4.Date Well(s)Completed:121 Wet[W# ft. ft.
Lft. ft.
Sa.Well Location: �q / 'c],
1"I V IC 1/1 l�l.C/ -r-6 0/ ft It.
'Facility/Owner Name Facility ID#(ifapplicabhe) ft, ft.
r�fri, y„s 1, , ft. ft.
Physt alAddressss,/Cittyy..alnkZip ft. ft.
ry� f e t yn) 21.REMARKS
County Parcel
b tJ /Paar'celIdentificat`ioonnNo.(PIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one farthing is sufficient) 22.Certification:
6.Is(are)the well(s) ermanent or OTemporary tgoature of Cy ified Well Contractor Date
By signing this form,I hereby certify that the wrl/(s)was(mere)constructed in accordance
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7.Is this a repair to an existing well- ❑Yes or)ONo with 15A 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 copy ofthis 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 Geoprobe/DPT or Closed-Loop Geothermal Welts having the same You may use the back of this page to provide additional well site details or well
construction,only I G1,-1 is n eded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �a0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@1001 construction to the following:
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10.Static water level below top of casing: C2 (ft.) Division of Water Resources,Information Processing Unit,
If venter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection 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) 01-` Method of test:Timed 24c.For Water Supply&Injection 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 Amount: completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016