GW1--04802_Well Construction - GW1_20230721

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
FROM TO DESCRIPTION.
Well Contractor Name ft it
NC-3556-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if appjlicable)
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER, i THICKNESS I MATERIAL
/ ft. ft. in.!
16- CASING
Company Name f / _
2.Well Construction Permit#: V"' GAiV-r /T/ FROM TO / DIAMETER THICKNESS MATERIAL
List all applicable rill construction permits(i.e.U/C,County,State,Variance,etc.) 711 ft. ,- ft 6 1/4 ,in' SDR-21 PVC
3.Well Use(check well use): ft ft. in.
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Publie ft. ft. in. .
Geothermal.(Hcating/Cooling Supply) ( Residcntial Water Supply(single) ft. ft. in.
Industrial/Commercial QIReReesidential Water Supply(shared) 38,GROUT
irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Bentonite Screened
Monitoring DRecov ft. ft.
Injection Well: ft. ft.
Aquifer Recharge Do undwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery alinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test Stormwater Drainage ft ft.
Experimental Technology DSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soiUrock rive grain size,etc.)
H. fL
4.Date Well(s)Completed:211 S12 3°Well ID# ft ft IN � i
VED
5a.Well Location: ft. ft.
S)rtS i 2 1,i 1 i' it ft. 1 f11 N 11 9• t1 202
Faciliitty�//Owner Name ,,t- Facility
IDy#(if
aap�pliiccablleee) ,�j;ti„ C am.,
Li t.l..t e r ty1.�11 4— S.,e i i Ito n �271 r it fL f� j}tr(snifla°'ie Lie
P sic/al A esss,,,City,an Zip (� R G t--1 ft. ft. •v
i/t�t�rf %YO0�J 1/i DUC) 21.REMARKS f- PI
� , `
'ounty Parcel Identification No.(PiN) Grouted On: " ( 0 e ct/ 3
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if welt field,one las/long is sufficient) ) 22.Certification:c f� I
3 *?.).?) i Ll te.. 9.t N R D C)3 5 1 13- IP It W ��/ ' /,�GG '% `1/-�/2
6.Is(are)the well(s) ermanent or []Temporary tore of c ified Well Contractor Date
By signing this form,I hereby cert(r that The well(s)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.0200 Well Construction Standards and that a
If this is a repair,fill out brown 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 hack 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 1 GW-1 is n Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: t 3 to S (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@200'and 2@100) construction to the following:
10.Static water level below top of casing: /Ci (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Matt Service Center,Raleigh,NC 27699-1617
1
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 within-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) (p 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 151w 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