GW1--00408_Well Construction - GW1_20240116

IPunt Forn
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
I.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES i
Weil Contractor Name FROMft. TO ft. I DESCRIPTION i }
NC-3556-A it ,
I
NC W e:ll Contractor Certification Number
Ix OUTER CASING(furmulti-cased wells)'OR LINER fifa 1➢rabte)
AAA Sweetwater Well& Pump, Inc. , FROM 1 TO DIAMETER I THICKNESS MATERIAL
R. ft. in.4
Campany&nue
I 16.INNER CASING OR Ti BINf<gotberma('eiosed-loop'
2.Well Construction Permit ft: 0D _IRON 1 TO DIAMETER i T IOTNESs MATERIAL
list all applicable well construction permits(Le.MSMC.County.Stare Variance;cte.t ft. I O50 ft- ` in.a SUR-•1 I PVC - .--3--\)
3.Well Use(check well use): R' I ft' sa
Well: 17-SCREEN
Water Supply
FROM TO i DIAMETER SLOT SUE i THICKNESS 1 MATERIAL
Agri hurai DMunicipaliPubirt fr. ft. I in. #
eothermal(HeatingiCooling Supply) OResidential Water Supply(single) ft. tL RE. I 2
lndustrial/Commercial QResidential Water Supply(shared) 1 t
18.GROUT I i i
mutation FROM t TO MATERIAL. I EMPLACEMENT METHOD&AMO' T
Non-Water Supply Well: X f4 P5 0 D' Bentonite 1
?U
rn Monitoring DRecovery ft. ft. i (�{ i d X 13
........—)
Injection Well:
it. ft. •
AgttiferRecharge DGmttndivaterRemediation '
19.SANDIGRAVEL PACK(if applicable) ,
Aquifer Storage and Recovery EISalinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DSionnwaterDrainage it ft
Ex erimental Technology EiSubsidence Control ft. 1 ft.
othermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary) i
FROM. i TO DESCRIPTION(cotur.hardness.soil/cock ripe.asinsitu.etc.)
Geothermal(Heating(Cooling Return) nOther(explain under-2l Remarks) ft. I ft. ;
1 1
ill
4.Date Well(s)Completed: .1 j9-05
ft. ,Well iD# fL t I 5a.Well Location:
ft. fr.
Facility:Owner Name Facility Mu(if applicable) - it. ft. j; t„' 4i
5 12 1rs1 i Im I'I 12v1 I It
D. It. JA N 1 L 2024
Physical Address,City.and zip T• ft i ft. It1fvi"fiti0 ^t
P3b01 W'r 1 b& l 21.REMARKS i 1 . ,,'c:,as:,a��,f 1S
��a sa-5g�3� �l 1-� JQ3 �Dry
(booty ParcelIdentifcationNo.(PIN) Grouted On:
RI.Latitude and longitude in degreeslminutesiseconds or decimal degrees:
(ifwell field.one Wong is sufficient) 22.Certifi alien: '
N ' •` At*** ' 0 3-
6.Is are the wells ermanent or ['Temporary t4mattaeofC edlYellConnactnr Dale
� Ito signing this joint.I hereby cert(Ji•that the-well(s)was(were)coas6'uctcd in accordance
7.Is this a repair to an existing well: Dyes or U"o ssith ISA VC-0C U2C.011.10 or ISA iCAC 02C 1,ii2 p0 Well Cunstnntian.Stardacris and that a
If this is a repair.lilt out known welt consa uctinn information and explain the nature of the copy of this record has been provided to the xrt{ossccer.
ragtair under e21 rem.aris scaion or on the back of this join.
23.Site diagram or additional well details:
S.For GeoprobelDPT 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 t-GW-1 is needed. indicate TOTAL NUMBER of wells construction details.You may also attach additional pages if necessary.
drilled: ' 2.50SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 e {ft) 24a.For All Wells: Submit this form'within 30 days of completion of well
Far multiple we&lit:all depticc ifdiieernt(eromple-3@200'and 2L1011) construction to the following: j
10.Static water level below tap of casing: X (ft.) Division of Water Resources,Information Processing Unit,
ft water lewd is ahosecasing use"-" 1617 Mall Service Center,��Rateigh,NC 27699-1617
t I.Borehole diameter.6 (in.) 24b.For Infection Wells: in addition tb 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:
(ic.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
i3a.Yield(gpm) Metho o test::limed 24e For Water Supply&Infection WeOc: In addition to sending the form to
the address(es) above, also submit oneIcopy of this form within 30 days of
13b.Disinfection type: CCH completion of well construction to the county health department of the county
where constructed.
Form GW-➢ North Carolina Department of Environmental Quality-Division of Water Resources , Revisal2-22-2016