GW1-2022-10198_Well Construction - GW1_20221111

Print,Form..
M.T.[:OWS BE� For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
FROM TO DESCRIPTION
WellComractorNamc fL fL
NC-3556-A
fL R
NC Well Contractor Certification Number IS.OUTER CASING for maltitased wells OR LINER a Inbk
AAA Sweetwater Well & Pump, Inc. FROM TO °,AMETEK THICKNESS MATERIAL
R. IL
Company Name
I1 1&-JNP R CASING
2.Well Construction Permit#: I O n D SJ`-. FROM �TIO DIAMETER THICKNESS MATERIAL
_.. ! la
ff List all applicable well construction periniis(i.e.iJIC,Counry,State,Yuriance,etc,) rf' n' fL 6 1/4 iO' SDR-21 PVC
3.Well Use(check well use): ft. fL
Water Supply Well: ROM SCREEN
TO DIAMETER SIATSIrE THICIC4M MATERIAL
Agricultural [3muriicipal/Ptiblic fL fL lit.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) fL n iIL
Industrial/Commercial 'nitResiderttial Water Supply(shared) I&GROUT
hri ation FROM I TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 fL Bentonite Screened
Monitoring 13
Re"' tt fG
Injection Well- 010, fL ft.
Aquifer Rftharge Groundwater Remediation
19.BAND/GRAVEL PACK(if applicable
Aquifer Storage and Recovery Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test ]Stormwatcr Drainage ft. n'
Experimental Ter: ogy Subsidence Control ft. ft.
osed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessa
Goo al(Heating/Coolin Return) Other(explain under#21 Remarks FROM To DFSCRIPr1oN cobr,Lsrda toillrotk KG
ft ft.
4.Date Well(s)Completed: Well III# fL %
n ft.
5 .Well Location: /� j
l-por l fflh, bL2— _ tL EL
Facility/Owner Name U Facility,1D#(ifopplicable) R ft
/Phys'eat Address,City,and Zip (� ^ fL ft. i401'R118bon Pmcmillir
21.REme
M1tARIGS�
County Parcel Identification No.(PIN) Grouted
r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one Iittlongissufficient) 21Cei�flcation:
N W �, 1 U
6.Is(are)the weil(s)IJPermanent or Temporary ignatttre of C 'fled Well Contractor Date
s.� By signing this form,I hereby rertr%4 that the well(s)was(were)constructed In accordance
7.Is this a repair to an existing well: ]Yes or t/rryo with 15A NCAC 02C.0100 or 15A NCAC 02G.0200 Well Construction Standards and that a
If this is a repair,fill out known well constructionm inforation and explain the nature ojthe copy ojthis record has been provided to the xr!l owner.
repair under 421 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 WW �S exdp - ed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drillexl: T/�_ �j SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 0 v (ft•) 24m. For All Wells t Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3®200'and 1®1001 construction to the following:
10.Static water level below top of casing: &O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" -]2 hv,%.) 1617 Mail Service Center,Raleigh,NC 37699-1617
11.Borehole diameter: 6 (in.) 24b.For Infection Wells: In addititm 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
i 12.Well construction method: construction to the following:
(i.e.anger,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
13a.Yield(gpm) � Method of test:Timed 24c.For Water SoDDty&infection IWeils: to addition to sending the form to
the address(es)'above,also subunit one copy-of this fodin within 30 days of
13b.Disinfection type: CCH Amount: ? OIL- completion of well construction to tie county health department of the county
where constructed.
I
Form GINA North Carotins Department of Environmental Quality-Division of Water Resources i` Revised 2-22-2016
I