GW1-2023-01923_Well Construction - GW1_20230222

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SELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
•i.Well Contractor information:
Clint J Babbitt MMATER ZONES
FROM, I TO DESCRIPTION
Well Contractor Name
NC-3556-A ° n
NC Well Contractor Certification Number M! CASING
AAA Sweetwater Well& Pump, Inc. UNM
11- To ° TIDCP0 MATERIAL
Company Name 16.INNER CASING OR TUBING eotbermal closed-loo
2.Well Construction Permit#:, V -V W FROM. TO DLAMETERo. TIBCiGYESS MATER4IL
Gist all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft iL B 1/4 in. SDR-21 PVC
R iG fa
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SL07 SIZE TBICICVEss MATERIAL
Agricultural [3Municipal/Public R. ft.
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) it, % la
Industrial/Commercial Residential Water Supply(shared) I8.GROUT
hTi tiOR FROM I TO MATERIAL E6IPLACEMM METHOD dr AMOUNT
Non-Water Supply Well: 0 ft 20 ft- Bentonite Stxeened
Monitoring Recovery it. ft.
Injection Well: ft. ft.
Aquifer Recharge-- undwater Remediation 19.SANDIGRAVEL PACK if a Reable _
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATER4IL EMPLACEMENT WHIM)
Aquifer Test [3Stotmwater Drainage ft. fa
Experimental ology Subsidence Control n ft
Geoth al(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if recce
FROM TO DESCRIPTION eolor'bardnen,soiVraek etc.
eothermal(Heating/Cooling Return Other explain ender#21 Remarks) ft. ft
'
L►�IdcAq(bWe ,, it 1
4.Irate Well(s)Completed: t7 a�Well ID#
ff. it.
5a.Well Location:
117a
1�-� ✓orskkityr, - it R. _ ..... ._
Facility/ Nam J#(ifepplicable) tt
S �S �p 1 l• J-f� �T1 f P�, N it. FEB 2 d
�G1t ft. ft.
Physical Address,City,and Zip
E1/°Yr/rd� - `
�
� 9 Sig l'� -- Grouted On: a wv r
Counn ty Parcel identification No.(PIN)
5b.Latitude and-longitude in degrees/minutWsecends or decimal degrees:
(ifwell fteld,one tat/long is sufficient) 2L Certification:
N W - /�
'Signature of C Wed Well Contractor Date
6.Is(are)the well(s),3Permanent or [3Temporary
By signing this form,I hereby cerdfi,that the wells)was(were)constructed in accordance
7.IS this a repair to an existing well: QYes or No with 15A NCAC 02C.0100 or 15A NCAC 02C.0206*ell Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy ojthis record has been provided to the well owner.
repair under#21 remarks section or an the back of this form. 21 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 1 GW 1 is ne ed. Indicate TOTAL NUMBER of wells
construction details. You may also attach additional pages if necessary.
drilled: f� i SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: / (ill 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdijjerent(example-3@200 and 2@100) construction to the following:
I
10.Static water level below top of casing: I�)-o (ft.) Division of Water Resources,Information Processing Unit,
If uuter level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (�•) 24b.For Iniecdon Wells: In addition to segding the fog to the address in 24a
Drilled above,also submit one copy of this form withm'30-days'of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground nd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm)&y Method of test-Timed 24c.For Water SDDDIy&Infection Wells-. In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: CCH Amount C�d completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2016