GW1-2022-10129_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
Well Contractor Name FROM TO DFSCRWIION!
NC-3556-A ft. fL
& fL
NC Well Contractor Certification Number 1S.OUTER CASING for?E�Fcased wo OR LINER f liabh
AAA Sweetwater Well & Pump, Inc. FROM CO
DIAMETER TIDCtL�IESS MATERIAL
rL rL in:
Company Name !� / T(�[�
(.I I'U(J T 7 9 16. IEli CASING
1.Well Construction Permit#: FROM TO DIAMETER THIC'ILNESS MATERIAL
List all applicable well construction permus(i.e.UIC,County,State,Variance,etc.) fL fL 6 1/4 SDR-21 PVC
3.Well Use(check well use): fL ft. id
Water Supply Well: 17.FROM TO
TO DIAMETER stOr SIZE Tt O(NES5 I MATERIAL
Agricultural [3Municipal/Public ft. M in.
Geothermal(Heating/Cooling Supply) ENG'idential Water Supply(single) fL fL In.
Industrial/Commercial bResidentiat Water Supply(shared) I&GROUT
Irrigation FROM TO MATERIAL : EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 IL 20 fL Bentonite Screened
Monitoring Recov ft ft.
Injection Well:
ft ft.
Aquifer Recharge umdwater Remediation
19.SAND/GRAVEL PACK a Hable
Aquifer Storage and Recovery Saty Barrier FROM TO MATERIAL EMI LACEMM METHOD
Aquifer Test /oStormwater Drainage fL fL
Experimental Technology Subsidence Control fL ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if
Geothermal(Heating/Cooling Return) r3Other(explain under#21 Remarks) FROM TO DESCRIMON color,hirdness,soW—k etc.
% ft.
4.Date Well(s)Completed: Well ID# f4 fL
Snell Location:
fr. ft. '
Facility/OwnnerName F .I.tty/ (if licable) R' D'
o.� 1'/p fL r� �� rxa
�hysi al Address,City.and Zip (�(� It. ft.
/w✓1/ /SW 21.REMARKS
County Parcel Identification No.(PIN) Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/long is sufficient) 2L Certification:
• N W
6.Is(are)the well(s)1314rmanent or Temporary qg ature of C ified Well Contractor I Date
By signing this form,1 hereby certfi+that the,w'11(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or EK. with ISA NCAC 02C.0100 or 15A NCAC 01C.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 of this 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:
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-I 'tc nPe¢ 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: (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3 d200'and 2@1001 construction to the following:
i
10.Static water level below top of casing: t (ft.) Division of Water Resources,Information Prdeessing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: 6 (in.) 24b.For Iniectlon Wells: In additi(R fo sending the form to the address in 24a
Drilled above,also submit one copy of this form withiri 90-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
13s.Yield(gpm)_�_Method of test:Timed 24c.For Water Sug&&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 Amount: completion of well construction to the;county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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