GW1-2023-01922_Well Construction - GW1_20230222

WELL CONSTRUCTION RECORD(GW-I) For Internal Use ODIy: Print Four
1.Well Contractor Information:
Clint J Babbitt ia.WATER ZONES j
Well Contractor Name FROM TO I DESCRIPTION
NC-3556-A
ft. ft. 'I
NC Well Contractor Certification Number
15.OUTER CASING for multi-cased weds OR LINER if applicable)
t
AAA Sweetwater Well& Pump, Inc. FROM I TO DLAMETER ITHICV-NLCS I MATERIAL
ft rt. ln. i
Company Name
1 I �� 16.INNER CASING OR TUBi\ thermal closed-loo
2.Well Construction Permit#: \�4r FROM TO I DIAMETER VATERLAL
List all applicable uvil construction permits fi.e.UIC,Coimry,Stare,Variance,etc/ 0R• Z�fL g j iO SDR-11 PVC
3.Well Use.(check well use): fL fL is �-
Water Supply Well: 17.SCREEN
FROM I To DUMETER SLOT SIZE THICILNESS MATERi.AL
Agri ItttraI OMunicipal/Public fL ft. it
eothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. n to
industrial/Commercial OResidential Water Supply(shared)
18.GROLfT
IIrigatiolt FROM TO MfATFR1A1. I FMPt.ACEMTENTMF,THOD&AMID T
Non-Water Supply Well: 0 ft. R• Bentonite 11911t( f
Monitoring Recovery fa Its
Injection Well: 4 L
tr. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM I To I n1ATERIAL EMP[ACEME�7T 11fErfiOD
JEX
ifer Test OStormwaterDrainage n• tL
erimental Technology Subsidence Control ft.thetnral(Closed Ltwp) Tracer 20.DRILL]NG LOG(attach additional sheets if necessarythermal(Heating/CoolingRetum) Other(explain under=2l Remarks) oM To DESCWPITONtcotor,taraness.eoiurockt. e. me eec.t
% fL
4.Date Well(s)Completed: I 1 1 111 d�V'—Well W# fL fL
Sa.Well Location: ' 1 D �'g�' fL fL
fL
Facility;OwnerName Facility ID#fiifcable) % ft.
3 ft. fL _
R 2
7J C / � �
i
ZAVV
Phy-'cal Address,Ci�ip tL f4 iR�ivP.frfsFb:C3•D Pry�3u��)F,3 t;R:i I
✓ 21.REMARKS : n i
County Parcel Identification No.(PAIN)-(ICJ Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlung is sufficient) 22.Certirt ation:
R e/ a-
6.Is(are)the well(s)Vermanent or Temporary ignature of Ctfiified Well Contractor Date
i
Br signing this form.I hereby certi i,that the wellfsl stas(were)constructed in accordance
7.Is this a repair to an existing well: OYes or M<o with 15d-VC.4C 02C.0100 or I s4 NCAC 02C.0200 IWeJl Construction Standards and that a
If(his is a repair•fill out knmva well construction information and explain the nature of"the copy al'rhis record has been provided to the%wil owvter.
repair under=21 remarks section or on the hack ol'this form.
23.Site diagram or Additional well details:
S.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 1 GW�'s needed. Indicate TOTAL NUMBER of welts construction detail's. You may also attach additional pages if necessary.
drilled: `� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (tt.) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depdu if different(example-3@200 and 2@1`00`3 construction to the following:
10.Static water level below top of casing: X 00 Division or Water Resources,Info t I adon Processing Unit,
If tinter level is above easing,use' 1617 Mail Service Center,Raleigh;NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Wefts: 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
construction to the Following:
(i.e. ry,e.auger,rota cubic,direct push,etc.)
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY., 1636 Mail Service Center,Raleigh,NC 27699-1636
Timed
13a.Yield(gpm) Methe o test: 24ts For Water Supply&Injection Wells: in addition to sending the form to
the address(es) above, also submit one copy'of this form within 30 days of
113b.Disinfection type: CCH t: 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