GW1--04806_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 I I
FROM I TO DESCRIPTION
WclI Contractor Name ft. I ft.
NC-3556-A
ft. I ft, I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap livable)
AAA Sweetwater Well & Pump, Inc. FROM I TO DIAMETER i THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TURIN eothermal closed-loop)
2.Well Construction Permit 14: IA)I d I D°T23~ FROM TO -_ DLMMErER tHILKSE15S MATERIAL
List all applicable lie permits(i.e.U/C,County,State.Variance,etc./ ,erft- 1 H. 1 in* SDR-� F PVC A/
.-....--.\\)
3.Well Use(check well use): ft ft. ,n /1C_
Water Supply Well: FR17.OMSCREEN 70 I DIAMETER SLOT SIZE 1 THICKNESS 1i,iTERIAI.
111 Agri- Itural DMunicipal/Public ft. ft. in.
e reothennal(HeatingiCooling Supply) DResidential Water Supply(single) ft. ft. to
1
a,industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM I TO I MATERIAL i EMPLACEMENT METHOD&AMO 7 T
Non-Water Supply Well: ..0' ft. 1 2D0ft. Bentonite
'Monitoring DRecovcry ft. ft. l ill
Injection Well: ft. ft. tL L-�-
in Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier FROM TO MATERIAL i EMPLACEMENT METHOD
Aquifer Test DStommwater Drainage ft. ft.
Ex erimental Technology DSubsidcncc Control ft. ft.
eothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO DESCRIPTION(color.hardness,soiUruck type.Brain site.etc.) I
Geothermal(Heating/Cooling Return) DOther(explain under=2I Remarks) ft. ft.
�4.Date Well(s)Completed:5iii I I/2i3
ft. ft,Well ID# RECEIVED
J!
5a.Well
tt n(,''vj ft. ft. �
Facility/OwnerName h9� Facility lDrF(ifapplicable) ft. ft. JUL 2 1 21�A�3
u.fr 4j I 2 �. ft. ft. infoon4ierfproc
Physical ddress,City,and Zip ft. 1 ft. r++
1 Vl ;jrn,lat_ 9.7 a >,-73y3au 21.REMARKS
'ounryAN)Identification No. N) Grouted On: iu123
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/lung is sufficient) 22.Certification:
N W S
tg
ry Tem or nature of C rifled Well Contractor Date
6.IS(are)the w•ell(s)OPermanent or p a -
By signing this Jot'm.I hereby certifi•that the mdl(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or �NO with 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Construction StandariL and that a
If this is a repair,fill out known well construction information and explain the nature of the cape al this record has been provided to the+re11 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 I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: /� ��v/� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: v (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths if different(example-3n200'and 2@100') construction to the following:
10.Static water level below top of casing: X (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.) 2413.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
(gp ) Timed 24e.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield m 1lietho o test:
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH o 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