GW1--04728_Well Construction - GW1_20230724

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WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NC-3556-A
ft. ft. 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER ' THICKNESS lI MATERIAL
ft ft. in.
Company Name
^ i D)Sp) 16-I CASING
2.Well Construction Permit#: c`� �a_ I FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 4• ( ft S ft 6 1/4 in' SDR-21 PVC
3.Well Use(check well use): ft. _J ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public ft. ft. in.
Geothermal(Heating/Cooling Supply) 'Residential Water Supply(single) ft, ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 20 ft Bentonite Screened
Monitoring ID I-covery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge &Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery )21 Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test Ili tomttvater Drainage ft ft.
Experimental Technology DSu: idcnce Control ft. ft.
Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,gain size,etc.-)
Geothermal(Heating/Cooling Return) f iOther(exp in under#21 Remarks) ft. ft.
t- ft. ft. r i 1 �.i.--9
4.Date Well(s)Completed ��t �� Well ID# t�E�• , 1, r—-,..:
5a.Well Locatio : ft. ft.
,el Nyvieksb --- _ ft. ft. JUL 2 4 2023 .
Facility/Owner Name Facility ID#(if applicable) ft. ft. (9R$Gf9f+AeJ m rPr!'^ '!',iJ7 limy:
3 -9 ,Ihll Ca \1 . 1 19n 2� 0 I ft. DWOMG
ysical Address, and Zip ft. ft.
p
17 MCbto`,t ld.l} /l • I ��D0033) / �i/_ 21.REMARKS ts.ii
V County9tl \/vi,,'( Parcel identification No.o.(PIN),O�(J Grouted On:
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: •
55°� s' S .iv"N ' !•' set Si_ 1 tt w ( j /7"ie 3.-g- -a
6.Is(are)the well(s) Permanent or Temporary Signature of C iied Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or iNiNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under=21 remarks section or on the back of this form.
23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only 1 G W-,1l 1peeded. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: `J 'fry`, SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 0U5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 tr200'and 2- }@ltIo') construction to the following:
10.Static water level below top of casing: V O (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 Injection Wells: In addition to sending the form to the address in 24a
Drilled above,also submit one copy of this form withiri-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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 8 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
13b.Disinfection type: CCH Amount: i O 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