GW1--00407_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
Well Contractor Name FROM ft. ! TO ft. 11ESCRIPiIO A
NC-3556-A
ft. ft.
1
NC Well Ctmtmrtor Certification Number IS.OUTER CitSING(for multi-cased wens)OR LINER(if applicable)
AAA Sweetwater Well & Pump, Inc. FROM TO DIAMETER 1 THIt 'xEC4 1 MLATERIAl. ,
ft. ft. in. 1
Company Name
1 (� /,,f�`�'j� 16.INNER CASING OR TUBiN eothertniai dosed-Ion
2.Well Construction Permit#:WI 0 l d o v/(.) I FROM 1 1M DL MLTER 11nC MATERIAL
List all applicable well construction permits(i.e.111C;County,Stare,Variance,etc.) ft. 1 2bb ft. I in' SDR�`i PVC
3.Weil Use(check well use): ft. ft. in,
Water Supply Well: FRO TREE.TO 1 DIAMETER SLUE SIZE 1 THICKNESS u MATERIAL
U.Agri ultural DMunicipaltPublic H. ft. in. 1 1 i
e othe oral(Heating/Cooling Supply) QRcsidential Water Supply(single) ft. ft d in, ;
1
111 Industrial/Commercial Residential Water Supply(shared) I&GROUT
Irrigation FROM i TO MATERIAL. I EMPLACEMENT METHOD&AMO T i
Non-Water Supply Well: kr fr. f ft. Bentonite P
*Monitoring L
Recovery ft. ft ?LIM A-1-'
Injection Well: ;,--
t. ft.II Aquifer Recharge ()GroundwaterRemediation - t t
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery QSalinity Barrier FROM i To MATERIAL EMPLACEMErrMETHOD
ill Aquifer Test QStotmwaterDrainage ft. • ft.
is Es.erimetual Technology OSubsidenee Control ft. it.
(! euthermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 1 TO DESCRIPTION{color.hardness.soilfruck type.grain size.etc.)
■Geothermal(HeatingiCooling Return) 00ther(explain under 521 Remarks) ft. ft.
4.Date Well(s)Completed:9-3D'23 Well iD#le i ft ft. 3
Sa.Well Location: ft. 1 .ft. -.4 (..„P1,.,,,,ii - e 3
i
Alan kt 1lty* ic+t I?-ederr‘en. ft. , fL I JAN 1 (; �9
FacilityDom-4rName Facility IDP(ifapplicable) ft. ft.
i S L�2�
10 K.i ier Q.a, >),h0-Val" Zsrsrz4 ft. ft.
Inforraegien r1'r c:° erg Uis
lsicaI Addtes&,City.and Zip
ft ft. LYsvClu
h !!la' 91PIG9382:37ccabb 21-REMARKS ,
V �`"
nanny Parcel Identification Na.(PIN) Grouted On: 9/3012 3,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one tatlong is sufficient) 22.Certification: '
N W CZi i !D-3 '- �3
t or Tem oralti S`gna ofC ifiedWeilCon ctor Date
6.Is(are)the well(s)GPermanen ❑ p -
i
By signing this form 1 herelnr certiJi'that the a 111s)was farce)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or IlKo trial MI NG4C 02C.0100 or 15.4 NCIC 02C.0200 Well Construction Standard and that a
If this is a repair.silt ant biotin well coastruction information and explain the nature of the copy of this record has been provided to the sell ons:er.
repair under'21 remarks section or on the back 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 __-
constmction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: `3 ,,r� SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: ✓ Zw (fG) 242.For All Wells: Submit this form within 30 days of completion of well
For multiple cells list all depths if dilleren:(example-3 rt 200-and 2F1000) constmetion to the following:
10.Static water level below top of casing: X (fE) Division of Water Resources,information Processing Unit,
limner level is above rasing.use"--'• 1617 Mail Service Center,i aleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Infection Wells: In addition talisending the form to the address in 24a
Drilled above,also submit one copy of this farm within 30 days of completion of well
12.Well construction method: construction to the following:
lie.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Unde.round Injection Control Program,
FOB.WATER SUPPLY WELLS ONLY:' 1636 Mail Service Center,Raleigh,NC 27699-1636
Timed 24e.For Water Supply&Injection Wells: In addition to sendingthe form to
t In.Yield(gpm) Metho o test.
the addresses) above, also submit one copy of this form within 30 days of
136.Disinfection type: CCH t: completion of well construction to the county health department of the county
where constructed.
Form.GR-I North Carolina Department of Ens*onsnental Quality-Division of Water Resources Revised 2-22-2016
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