GW1-2022-10130_Well Construction - GW1_20221110

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WELL CONSTRUCTION RECORD(GW-1) For hiternal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES {
Well Contractor Name FROM TO DESCRIPTION I
NC-3556-A it. fL
ft. fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if an ilcable
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER�clowed400p)
MATERIAL.
fL ft.
Company Nanac
16.INNER CASING OR ITM t
2.Well Construction Permit#: IN l/� e / FROM I TO DIAMETER MATERIAL
List all applicable urHconstruclionpen iu(i.e.UIC,Cbunl) State,iariance,etc./ 0 1" gMfL 'g j ' In- SDR-11 PVC
3.Well Use(check well use): tt vv iG to
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agri IturaI [)MunicipaMblic ft. ft. in. I
eothemtal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROAT
_11nigation FROM TO MATERIAL. I I FMPI.ACF.AIENT METHOD&AhIO T �n
W
Non-Water Supply Well: 0 ft- 200 ft, Bentonite I' fillabetellif
Monitoring Recovery ft. ft. `rn C
Injection Well:
R. ft.
Aquifer Recharge Groundwater Remediation I9.SAND/GRAVEL PACK if a Hcable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT ATETHOD
Aquifer Test oStormwater Drainage fL ft.
Ex erimental Technology OSubsidencc Control ft. ft.
eothetmal(Closed Loop) DTracer 20.DRILLING LOG attach additional sheets if necessary
Geothermal(Heatin.Coolin Return) Other(explain under=2l Remarks) FROM fL To DESCRIPTION color,harda soillmck g in she,etc.
fL
4.Date Well(s)Completed: a a Well iD# ft. IL i
Sa.Well Location:
to iL
ed,x1±-rh410,Ln irb
-� AI Pet e,�tf-I'�'a ft R.wnerName r Facility ID#tifaMlicable) IL ft. 1
14 I —T mm V 1P�
A ryt rt. ft.
Physical Address,City, p ft. fte jJOW4"on roCs"NV
UM
�r[�trb0 �F3tfi� acTz:(� 21.REMARKS !
County I Parcel Identification No.(PIN) Grouted On: -2,-Sj2 {
5b.Latitude and longitude in degrees/minutesAeconds or decimal degrees:
(ifwcll field.one[at/long is sufficient) 22.Certii( ation:
f
N W6& 0
A
tgnatureofC afie Well Contractor Date
6.Is(are)the well(s)�ermanent or []Temporaryi
Br.signing this Jost.I herehr cert fi•that the iirll(sb was(were)constructed in accordance
7.is this a repair to an existing well: ❑Yes or [B o with I5A YC4C 02C.0100 or 154.NCAC 01C.0200 Well Construction Standards and that a
I(this is u repair..rill out known tc ell construction it formalion and explain the nature of the copy of this record has been provided to the xr11 oxver.
repair under=21 remarks section or on the hack of this(orm.
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 needed(.?Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: 1/ YZD SUBMITTAL iNSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells: Submit this form within 30 days of completion of well
Frrr multiple wells list all depths if different(example-3@200'and 1@1`0001 construction to the following:
10.Static water level below top of casing: X (ft.) Division of Water Resources,information Processing Unit,
If aarer level is above casing.use"-- 1617 Mail Service Center,(Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection 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,clef
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Met o test: Timed 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.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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