GW1-2022-10181_Well Construction - GW1_20221110

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&ELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: R ECEI�
Clint J Babbitt � 14.WATER ZONES I.
Well Contractor Name FROM TO DESCRIPTION .. _..__._._
NOV 2012
NC-3556-A 1 0 ft. ft. �
Inl0►+halion Pr I. %
NC Well Contractor Certification Number ( .- Unp 1S.OUTER CASING for malti-nsed wells'OR LINER a llnble
AAA Sweetwater Well & Pump, I-nC. m""'erER I retcxNEss "'"'ERf"t
00
iZ ft in.
Company Name
ZI 5 W FROM
iRRCASING
2.Well Construction Permit#: — TO DIAMETER la T�CIGNFSS MATERIAL
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Lis[all applicable cell constnictian permits"(r.e.UIC,Caiin7y,State,Ya'r�iihce,"etc.) rt. 3�j fL g 1/4 SDR-21 PVC
3.Well Use(check well use): & ft
Water SupplyWell: 17.SCREEN
FROM TO DIAMETER SIATSIZE THICICWM 1fATERW
Agricultdral [3MunicipaltPublic it, fL is
Geotberna](Heating/CooHng Supply) Residential Water Supply(single) ft. iL is
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
lrri orlon FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 % 20 fL Bentonite Screened
Monitoring Recov % fL
Injection Well:
t4 fL
Aquifer Recharge undwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test [)Stormwater Drainage fL fL
Experimental Technology Subsidence Control fL tL
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Hearin Coon Return) Other(explain under#21 Remarks FROM To DESCRIPTION eolor,huda wmtock ere
tt rL
4.Date Well(s)Completed:� WeU ID#
ft,
fL iL
Sa.Well Location:
Facility/Owner Name Facility ID#(if applicable) fL ft
Physical A ,•,dity,and Zip t , % ft.
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`�� �Q 21.ItEMARKST,
county Parcel Identification No.(PIN) GrOUted Ofl:
5b.Latitude and longitude in degrees/minates/seconds or decimal degrees:
(if Well field,one lat/IOKg is'Sufficient) 2L Certilication:
N W , O(
6.Ware)the well(s)WA Permanent or Temporary rgnature of C 'fied well Contractor Date
TTTTTT"'''' By signing this form,I hereby certifi'that the tvell(s)was(were)eonstnwietl in accordance
7.Is this a repair to an existing well: ❑Yes or No with 15A NCAC 02C.0100 or 15A NCAC 02C X200 Well Construction Standards and that a
If this is a repair,fill out known well construction informationAxplain the nature of the copy of this record has been provided to the ivell owner.
repair under h21 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 G yl�c nceded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: / f� SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: eJ (ft.) 24a. For All Wells l Submit this form within 30 days of complexion of well
For multiple wells list all depths if different(example-3@200'and 2@1tr001 construction to the following:
10.Static water level below top of casing: I V 0 (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.) 24b.For Iniecdon Wells: In addict cifi-to scxtding the form to the address in 24a
Drilled above,also submit one copy of this form withiii-30-days'of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push;ere:)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) y Method of test:Timed 24c.For Water Supply&Injection!Wells: In addition to sending the form to
the addr&s(es) above, also submit oue copy of this form within 30 days of
13b.D(sinfection type: eCH Amount: i) completion of well construction to the county health department of the county
where constructed.
0
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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