GW1-2022-10132_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 CUntYAetOr Name
FROM I TO DESCRIPTION i
NC-3556-A
fL ft. I
\C Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
AAA Sweetwater Well & Pump, Inc. FROM To DIAMETER TTIICICNFIGS MATERIAL
f6 ft. in.
Contpany Name
„ ' 16,INNER CASING OR TUBiA thermal closed loo
2.Well Construction Permit#:—ltrf/1�►--ti 1=) 111 FROM TO DIAMETER MATERIAL
List all applicable well cnnstnicuon perm is(i.e.VIC,County.State,i'ariance,err./ fit• ft, 1 f �' $DR�' 'PVC
3.Well Use(check well use): fL ft. In.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER[ SLOT SIZE THICKNEss MATERIAL
ZAgri [rural �Afunicipal/PtLblic ft. ft. in.
eolhermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial OResidentia[Water Supply(shared) 19.GROUT
Irri ration FROM i TO MATERIAL. ;F.MPI.ACFMF.NT METHOD&AMOLAT
Nan-Wa[er"Su 1
PP y Well: 0 R ft, Bentonite 0ameve11t
Monitoring Recovery ft. fr. 4('i i
Injection Well: "�
Aquifer Recharge 00roundwater Remediation R. to
19.SAND/GRAVE!-PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO M
MATERIAL EMPLACEMENT ETHOD
Aquifer Test OStormwater Drainage rt. R.
Ex erimental Technology Subsidence Control ft. It,
eothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets it necessary
FROM TO DESCRIPTION(color,bards sot/rock type, rain size,etc.
Geothermal(HLating!Coolin Return) rjOther(explain under=21 Remarks) tr.
4.Date Wells)Completed: !7� Well iD# ft, ft, D
5a.Well Location: ft. ft.
FaciiityiOwnerName Facility ID#(ifapplicable)_ ft. [t. Qn Prxtl>.W4 V11l
ft. ft.
J5 �p��" �nal�e�lan�Rc9SI2o I L�
J Phvsical Address,City,and Zip tL tt
i
21.REMARKS
yi Gro
ounty Parcel Identification No.(PiN) uted On: '5--5 —
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
lit'fiell field,one laViong is sufticicnt) 22.Certin tion:
6.Is(are)the well(s)Vermanent or Temporary Signature of C ificd Well Contractor Hate
Br signing this fmwnr.I hereby certifi,that the well(s)it as(were)constiucted in accordance
7.1s this a repair to an existing well: Yes or �io with ISd NCAC 02C.0100 or I14 A'CAC 01C.0200 Well Constniction Standards and that a
!(this k a repair,fill uut known well consnwctinn information and explain(he nautre of the copy of this record has been provided ro the well ottiier.
repair under=11 remarks section or on the hack of this form.
23.Site diagram or additional well details;
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to pro-tide additional well site details or we]I
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: 2
2 (�� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J `-' ([t.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ff ili 'erent(example-3@200'and 2@110001 construction to the following:
10.Static water level below top of casing: X (fL) Division of Water Resources,information Processing Unit,
If ivater 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
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:Tlfned 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 o t: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Cvolina Department of krivironinugal Quality-Division of Water Rcseurces Revised 2-22-2016
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