GW1--00409_Well Construction - GW1_20240116

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WELL CONSTRUCTION RECORD(GW-I) For internal Use Only:
1.Well Contractor Information:
Clint J Babbitt' 14.WATER ZONES
Well Contractor Naa a FROM TO DESCRIPTIONI
NC-3556-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-eased wells)OR LINER(if ap lieable) t
AAA Sweetwater Well& Pump, inc. FROM t TO DIAMETER 1 THICKNESS MATERIAL
ft. I ft. in.I ; f
Cumpanv Name1-- - ;
11Ple e)3 16.INNER CASING OR TURicI�q*,Lotherrnat closed-loop)
2.Well Construction Permit#: X��/U FROM TO DIAMETER I 7tuCr�ESa MATERIAL i
List all applicable utll construcrion pe nits fie.WC,Coan4;State,Variance,etc.i ft. JcD ft. ter.I SDR-^1 1 PVC X 3 3.Well Use(cheek well use): iz ft. to I '
Water Supply Well: 17.SCREEN f i
FROM TO I DIAMETER ' SLOT SIZE THICKNESS i MATERIAL 1
Agri (Mural QMtmicipal/Public ft. ft. / to. f )
I i
eothermal(Ifeatin Cooling Supply) OResidential Water Supply(single) ft. it. j to ' j
Industrial/Commercial (shared)Residential Water Supply t t
18.GROt;T 1 '
Irrigation FROM I TO MATERIAL I !I EMPLACEMENT:METHOD&.SMO
Non-Water Supply Well: ..Ir ft• 1,300 R• Bentonite I ' t
Monitoring DRecovery it. ft.
i L ).-
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation- - - - { t
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery DSalinity Bather FRost 1 TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test DStomwater Drainage it. I ft.
Ex crimental Technology QSubsidencc Control it. 1 ft.
othermal(Closed Loop) ElTracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) f Other(explain under=21 Remarks) FROMI To DESCRIPTION(iofot.n,ranes sottrrocknix�atn sic etc-)
I I ,�•
ft. I D. ; .
4.Date Well(s)Completed:JO/k//(/2.3 Well ID# V • ft. ft.
5a.Well Location: ft ) ft. k• ..f ,� =��°a
(L 1 ft. i �) k
Facitityf--0
filet L mterYame ( Facility CM'(ifapplicable) ' ft. 1 ft. `A N 1 V 2024
3iK ileirpa-i- Vieig,t Atil AElleutle 2siof ft. ft.
lAtii
P csical Address,Cit,end Zip ft. ft. Q ry
I Ur1Cw►� �� �
21.REMARKS / I j
'aunty Grouted On: 10I f3/2 j
N. IdentiS�ation No.(PtIh)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one iatllungis sufficient) 22.Certification:
N W f
lgeh e,
6.Is(are)the wells) Permanent or DTemporar guatrae of C ifled Well Can attar I 'Date
��� By sia ring this farm,I herebr cerrif'that the aell(s)eras(were)consBucted in accordance
t•
7.Is this a repair to an existing well: ❑Yes or 1io with ISA NCAC 02C.0/oo or IS.d NCAC 02C.�t2011 Well Construction Stmdmds and that a
If this Ira repair,•fifl vat bensn well construction information and explain the nature of the copy ajthis record has been provided to the well owner.
repair under=21 remarks section or on the hack of this/tern.
23.Site diagram or additional well details:
8.For Geaprabe/l)PT or Closed-Loop Geothermal Wells having the same You may use the back of this pace to provide additional well site details or well -_. - -_-
construction,only 1 GW- 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: e30. (R.) 24a.For Ali Wells: Submit this form within 30 days of completion of well
Far multiple wells list all deptks if different(example-3e200'and 2@101Y) construction to the following
10.Static water level below top of casing: X (ft.) Division of Water Resources,Information Processing Unit,
If:cater level is above casing.use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 1 i24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method:
Drilled above,also submit one copy of this formlwithin 30 days of completion of well
(Le.auger,rotary,cable,direct push.etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Service Center,Raleigh,NC 27699-1636
1
13a.Yield(gpm) Metho o test:Timed 24e.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: CCH o t: completion of welt construction to the county health department of the county
where constructed.
Form(1W-I North Carolina Depurment of Entiromnentat Quality-Division of Water Resources Revised 2-22-20 16