GW1-2022-08169_Well Construction - GW1_20220530

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt _ 14.WATER ZONES
Wel l Contractor Name r FROM TO DESCRIPTION
4s ft f.
NC-3556-A '' ff. ft.
NC Well Contractor Certification Number O 2oq�
L LL 15.OUTER CASING Car multi cased wells OR LINER if a licable
AAA Sweetwater Well & Pump, Ifs`( FROM TO UI►METER ft ft. in. IA TRICKNESS MATERL
Company Name �IQ s
��/,� 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: iCQ I I na '8 oG FRONT To DIAMETER THIc1CNEss MATERIAL
List all applicable irell construction permits(i.e.UIC,County,State,Variance,etc.) 4- rt r- 6 1/4 in. SDR-21 PVC
3.Well Use(check well use): tt ft in.
Water Supply Well: 17.SCREEN
FROM TO I DL l%fETER SLOTSIZE TIIICIC M I MATERIAL
Agricultural OMu icipal/Public ft. tt in.
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. rt I in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation FRONT TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Screened
Monitoring ORec cry ft. ft.
Injection Well:
ft. fL
Aquifer Recharge witr dwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL I ENIPLACEME-NT METTIOD
Aquifer Test OStormwater Drainage ft. fL
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
FRONT
TO DESCRIPTION(color,hardness,nil/rack type,grain size,elcl
Geothermal(Heating/Cooling Return) Other(explain under N21 Remarks) ft. ft.
4.Date Well(s)Completed: 1 V Well UN ft. fL A
5. WeHLocation: ��Y) ft. ft
t;;
k I 'P.'-. ft. It.
Facility/Owner Name Facility lDr(ifapplicable) fL ft
'®r
La au I I P l'o—wW,- - ft ft. YV
Ph sical Address,City,and Zip ) ft ft
✓ �/1�1 p!a ( IJn 21.REMARKS
County �Parcel hddeenitificationNo.(PIN)Y� Grouted On: s ja al as
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one fat/long is sufficient) ` ' 22.Ce
/ on:
3 a a-
6.ls(are)the well(s)[3fermanent or Temporary nature of C ified Well Contractor Date
By signing this form,I herebP eery that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well- OYes or,QAo with 15A NCAC 02C.0100 or 15A A'CAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out knoau well construction it fortnation and explain the nature of the copy ofthis record has been provided to the well oamer.
repair under=21 remarks section or on the back ofthis 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 1 G})V-J As needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary, a
drilled: j�j /•/'C SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ,9 v v (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple ivelb list all depths if different(example-3@200'an!2@I00) construction to the following:
10.Static water level below top of casing: 4- (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.) 24h.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 276994636
13a.Yield(gpm) o . 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
13b.Disinfection type: CCH Amount completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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