GW1-2022-05344_Well Construction - GW1_20220530

\ Print Form
«'ELL CONSTRUCTION RECORD(GW-1) For Intemal Use Only:
1.Well Contractor Information: E
Clint J Babbitt 14.-WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
NC-3556-A fL IL
Inf0fBiEAion Pr"�t;+.,ing LIM fL ft.
NC Well Contractor Certification Number D-VQ/BOG 15.OUTER CASING for multi-cased wells)OR LINER if applicable)
AAA Sweetwater Well & Pump, Inc. FROM TO DLANIETER THICKNESS MATERIAL
IL ft. in.
Company Name I i
16.$7=* ASING VG eat er m ca us n
2.Well Construction Permit# 1 V o I FROM TO DIAM1IETER 1111CKNFSS MATERIAL
List all applicable it-ell construction permits(i.e.UIC,County,Slate,T ariance,etc.) -r fL ft- 6 1/4 tp' SDR-21 PVC
3.Well Use(check well use): fL ft. in.
17.SCREEN
Water Supply Well:
FRO31 TO DIAMETER SLAT SIZE THICKNESS \MATERIAL
Agricultural [)Municipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft. ft. in.
Industrial/Commercial r�Residenti t Water Supply(shared) 18.GROUT
Irri ation 'wLy FROM TO MATERIAL EMPLACEMENT ME 17HOD&AMOUNT
Non-Water Supply Well: 0 % 20 fL Bentonite Screened
Monitoring DRecovery fL fL
Injection Well:
fL ft.
Aquifer Recharge 13Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery []Salinity Barrier FROM TO MATERIAL EMPLACEMENT IIMETIIOD
Aquifer Test [Stormwater Drainage fL fL
Experimental Technology [Subsidence Control fL ft.
Geothermal(Closed Loop) [ITracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soturack a rain size etG
it. fL
4.Date Well(s)Completed: Well ID# fL fL
5 . VeIl Location: fL ft.
5V'V
CL ft.
Facility me rNa Facility ID#(rcable)• f4 ft.
jil Idel
fL ft.
�]�hysical ddress, ity,and Zip ft. ft.
/I)Q► (� —7 9a Ad- 21.REMARKS
County / Parcel Identification No.(PIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one fat/long is sufficient) 22.CertirUicitti0n:
N W1 � 3
6.Is(are)the well(s)'q Permanent or Temporary gnature of C ied Well Contractor Date
By signing this form,I hereby cent fi,that the rvell(s)was(mere)constructed in accordance
7.Is this a repair to an existing well: []Yes or @No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 MMell Construction Standards and that a
If this is a repair.fill out known hell construction information and explain the nature of the copy ofthis record has been provided to the well oxvter.
repair under°2l remarks section or on the back of this 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 well site details or well
construction,only I GW- s eded. Indicate TOTAL NUMBER of wells construction details. You may also anach additional pages if necessary.
i
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below 1 nd surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierew(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: v (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 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 ofWater Resources,Underground Injection Control Program,
FOR WATER SUPPLY. LS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 'Off Method of test: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
136.Disinfection type: CCH Amount: 42completion of well construction to the county health department of the county
61 Where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016