GW1--04697_Well Construction - GW1_20230724

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: /
1.Well Contractor Information: t I
Clint J Babbitt 14.:WATER ZONES �j/3 2
Well Contractor Name FROM TO DESCRIPTION
NC-3556-A " �`
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(if op livable)
MA Sweetwater Well & Pump, Inc. FROM TO DIAMETER THICKNESS g MATERIAL
ft. ft. In.
Company Name
a 1 C ) 113E b I 1 -INtMBfFCASING
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable stall construction permits(i.e.UKC,County,State,Variance.etc.) 4.- I ft. q I ft, 6 1/4 in• SDR-21 PVC
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R. ft. In.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 fL 20 ft: Bentonite Screened
Monitoring DRecovery ft. ft.
Injection Well:
It. ft.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery EiSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStornwater Drainage ft: ft.
Experimental Technology OSubsidcncc Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soiurocktype,gnte btu etas
/ rt. ft.
i
4.Date Well(s)Completed: 1. 2 " ' Well ID# ft. ft.
5a.Well Location: I-01kt Lb L ft: ft.
V.r i9Itin 666/ibi yid i\lei5civi PciAk i 4_,D) - - ft. ft.
Facility/Owner Name
� !,! e'/t��i/ D Facility 113#(if applicable)� / ft. ft. ' 7 q Li'
t, t Vt N i
;)i2 L U/l�Y4 ��Crrau C-I . IU,Els v' ft. JUL 4 2023
!�
Physical Address,City,and Zip y1, ,, ft. rt.
Y 0� n �lie 3A to (1 l�/f Y ' v 21.REMARKS _ [e-mail] ipn ?rrt- . t x
/ . -,e,!r.;(.i ce
County Parcel Identification No.(PIN) Grouted On:- __-- rj t�' �� ',•m'.t,
5b,Latitude and longitude in degrees/minutes/seconds or decimal degrees: - - '�' { _
(if well field,one lat/long is sufficient) 22.Certification:
•
N W ( � tp,,,-93
6.Is are the wells Permanent or Tem o ature ofC ified Well Contractor Date
Is(are) () Q Py
,�( By signing this form,I hereby certifj'that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or No with 15A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information nil explain the nature of the copy of this record has been provided to the well ouster.
repair under'21 remarks section or on the back of 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-1,is ed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: N (� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: /S5 (tt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: IQ 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 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 withid 30-days'of completion of well
construction to the following:
(i.e.auger,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) I I Method of test:Timed 24c.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
I3b.Disinfection type: CCH Amount: 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