GW1--04807_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
FROM i TO DESCRIPTION I
Well Contractor Name
It. ft.
NC-3556-A 1
ft. I ft.
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 , THICKNESS MATERIAL
ft. 1 ft. in.
Company Name
y�� 1 16.INNER CASING OR TURIN eutbermal closed-It 5
2.Well Construction Permit II: 11 FROM TO DIs METER ,iIIsLi MATERIAL
List all applicable well construction permits(i.e.U/C,Cwrnry•,Stare,Variance,etc;) ft. j ft. X in' 'SDR-1 i PVC X
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: FROM ` TO I DIAMETER SLOT SIZE I THICKNESS I MATERIAL.
III:Agri'ultural DMunicipal/Public ft. ft. in. I i ,
r eothennal(Heating/Cooling Supply) DIResidential Water Supply(single) ft. ft. In. I , I
•',Industrial/Commercial DResidential Water Supply(shared) 18.GROUT I
Irrigation FROM I TO MATERIAL. F.MPLACEMENT METHOD&•tMO' T 1
Non-Water Supply Well: fa' ft. 1 Qt�`tp ft' Bentonite1,2-)
al MonitoringRecovery ft. ((��JJ ft. [��t jill�e V G i /t
Injection Well: 1
fr. ft.
Aquifer Recharge 0Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Et Salinity Barrier FROM I TO MATERIAL. EMPLACEMENT METHOD
Aquifer Test V DStotmwater Drainage ft. ft.
ExtcrimentalTechnology QDSubsidenccControl ft. ft.
'euthermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM I TO DESCRIPTION(color.hardness,soil/rock type,grain silt.etc.)
Geothermal(Hcating,-Cooling cluuml) DOther(explain under=21 Remarks) ft. ft.
4.Date Well(s)Completed:5' 6 Well iD#J ft. ft.
5a.Well Location: Ol U V e ft. 1 ft.
i Ft ClyTvlJ St, L1-I a , ft. ft. F cE 6 VED
aciltry%Owne Name Facility ID#(if applicable) ft. ft.
22 2t Rv 4 molt" j 4 )( ft. ft. JUL ? 12023
P 'sical Address,City,and Zip �J, (�fyy�]�/� ft. ft. I
Cc q�a»s��:J�7 wl.w' REMARKS
Grouted On: b I 0 j 2,
Ink"macil ��Te
G t Its„
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one lat/lung is sufficient) 22.Certifi ation:
1 :44.....43,6.Is(are)thewell(s) tPermanent or Temporary' rgnature of C tilled Well Contractor
By signing this farm,1 hereby cert/t that the well(s)was(were)constructed in accordance
7.is this a repair to an existing well: ❑Yes or 1/No , with 1 SA NCAC t12C.0100 or 15A.NCAC 02C.0200 irell 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 hack of-this firm.
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 needed. 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: ? (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well list all depths if different(example-3.rc 200•and 2enr100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
If water level is above casing,use'-" 1617 Mail Service Center,Raleigh,NC 27699-1617
I1.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:
li.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
Timed 24c.For Water Supply&Injection Wells: In addition to sending the foam to
13a.Yield(gpm) Meth
o test: g
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-I North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 2-22-2016