GW1--00404_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor Information:
Clint J Babbitt 14.WATERZONES I •
Well Cont aclarNamc FROM H. TO DESCRIPTION
NC-3556-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(far multi-cased wells)!OR LINER(if ap livable)
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER I THICKNESS MATERIAL
K. D. in.i
Company Name ti
� 'VO� 16.INNER CASING OR TURIN thermat dosed-loot
2.Well Construction Permit#: WI FROM TO DIAMETER I THICKNESa MATERIAL •
List all applicable well cansnvrtian permits(Le.IBC,County,State,Variance,etc) Zr. ft. 2_e7O ft. I in'I SDR-1 i PVC
3.Well Use(check well use): ft tt. in
N I
Water Supply Well: FROM TO { DIAMETER SLOT SIZE i THICKNESS f MATERIAL
Agri•ultural OMunicipal/Publie ft. ft. is I.
eothermal(Heating/Cooling Supply) OResidcntial Water Supply(single) ft. R. is
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT I I
Irrigation FROM 1 TO MATERIAL I !EMPLACEMENT METHOD 8 AMO
Non-Water Supply Well: X it 120Oft' Bentonite
Monitoring ORecovery ft. ft. I'll r L Injection Well: f. ft.
Aquifer Recharge DOroundwater Remediation ti.--)
79.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwaterDtainage ft. ft.
Ex crimental Technology OSubsidcnce Control ft. ft.
euthermal(Closed Loop) OTrdcer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness.soil/rocktvpe.grain sir.del
Geothermal(Heating/Cooling Return) Other(explain under�2lRemarl ) ft. ft.
4.Date Well(s)Completed: (g)17/n 4S Well BM ft. it. I ;
P "^
Sa.Well Location: ft. f` r-:'"�••..Lm.r 9 V )`
4- —Siith ft. ft.
JAN 1 2024 1
FaaccciiitQyiOwner Name /� C�Wt/�/ Facility 104/(ii ft f`f applicable) i
l— Chap a,' 2d m1.I11Eia-f 2111I ft. it. info:vn;r,ticn Pr^ao`.s..t':g URN
OG
Physical
tAddress,City.and kip ft ft. �V CjF"
�urA`I tom Wtilli (,- oos ,3/yq v II.REMARKS ?
/
County Parcel Identification No.(PIN) Grouted On: i oi'Z 7 1Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: I
(ifwell field,one lat/long is sufficient) 22.Certifi ation:
N W /� a( 23
orTem of ate _nature of C ified Well Con actor Date
6.Is(are)the well(s)efermanent p -
� Br signing this form,I hereby certifi•that the nell(sl was(were)constructed in accordance
7.Is this a repair to an existing well: OYes or I.I"o with iSA NCAC 02C.0100 or iSA NCAC 02C)0200 Well Construction Standards and that a
if this is a repair,fill out larown well construction information and explain the nature of the copy of this record has been provided to the mil/nano-.
repair under=21 remarks section or on the back of this,farm.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having die same - You may use the back of this page to provide additional well site details or well - -
construction,only I GRr 1 j,needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ✓iI 2 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: ✓ e y� (ft) 24a. For All Wells: Submit this form'within 30 days of completion of well
Far multiple wells list all depths if different(example-.C200'and 2aa 100') construction to the following I
I
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.) 24h.For Infection 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
(i.e.auger,rotary,cable,direct push,etc.) I
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 Supple&infection Wells: in addition to sendingthe form to
13a.Yield(gpm) Metho o test:
the address(es) above, also submit one 1copy of this form within 30 days of
13h.Disinfection type: CCH o t: completion of well construction to the county health department of the county
where constructed.
Fame GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016