GW1-2022-10118_Well Construction - GW1_20221110

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
WelI ContraclorNamc FROM TO DESCRIPTION f �
NC-3556-A ft. (t.
ft. ft.
NC lL'elI Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a icable
AAA Sweetwater Well & Pump, Inc. FROM I TO DIAMETER 1.TTHCRNESS MiAI KIAL
% ft.
Company Nanic
// 16.INNER CASING OR TLBiN thermal closed-lot
2.Well Construction Permit#: 1 n ( oo t.P30 17�.
TO DIAMETERMATERIAL
List all applicable»ell construction permits(i.e.U1C,,County,State,Mariance,etc.) 0It. �1 ' it• SDR41 PVC
3.Well Use(check well use): ft. ft. is
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERi.AL
Agri Itural OMunicipal/Public ft. ft. in
thermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. tit.
Industrial/Commercial OResidentiat Water Supply(shared) 18.GROUT
Im ation FROM TO MATERIAL EMPLACEMENT METHOD&AMO' T
Non-Water Supply Well: 0 it Y00 fL Bentonite �bf6tg3etlf
Monitoring 13Recovcry ft. ft.
Injection Well:
Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [)Salinity Barrier FROM To MATERIAL EMPLACE,'NENT NWIT(OD
Aquifer Test DStormwater Drainage ft. ft.
Ex erimental Technology Subsidence Control ft. fL
eothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary
Gcothennal(Hcating/Coolin RCLUM) Other(explain under=21Remarks) FROM To DESCRIP17ONeo►or,hardd solUrocka setc.)
([. f4
4.Date Well(s)Completed: �i Well iD# ft. It.
Sa.Well Location: i Ul? ft ft
�QYY 1 L1 mnP_I h" iYP, �,D �/ ft rt. Fuji
Facility/OwnerNa z Facility iD#(ifapplicable) ft, ft. j
21 V.(vet p� ¢ll �� ft. (L
Physical Address,City,and Zip ft. ft. n Procuiev U '
21.REMARKS ±
1/ County Parcel Identification No.(PiN) GTO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field.one fatllong is sufficient) 22.Certifi ation:
W :a-
6.Is(are)the well(s)&rPermanent or QTemporary ignalure of C ified Well Codirector Date k
Br signing this Jmm.I herebi rerfi i,that the uel/(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or [Bo with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
((this is it repair..Qll out known cell constuction information and explain the nature of the Copt•ojthis record has been provided to the deli 0h7ler.
repair under=21 remarks section or on the hack of this(orm.
23.Site diagram or additional well details:
8.For Geeprobe/DPT or Closed-Loop Geothermal Wells having tine same You may use the back of this page to provide additional well site details or well
construction,only t GW�needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
GQ �9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple sells list all depths i(diQerenr(example-3@200'and 2@100') construction to the following:
10.Static water level below top ofeasing: X 00 Division of Water Resources,Information Processing Unit,
If water level is abate casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Iniecdon Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Drilled above,also submit one copy of this form within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Meth o test:Tlf(tBd 24c.For Water Supply&Infection 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 t: completion of well construction to the county health department of the county
where constructed.
Font GW-1 North Carolina Department ofEmiromnental Quality-Division of Water Resources Revised 2-22-2016