WI0100701_Well Construction Record(s) (GW-1)_20240201

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
\\'dl Contractor Name
FROM TO DESCRIPTION
NC-3556-A ft. ft.
rt. rt.
NC Well Contractor Certification Number
inc.
OUTER CASING for multi-cased wells OR LINER if a licable
AAA Sweetwater Well & Pump, Inc. FROM I TO I DIAMETER THICKNESS MATERIAL
_ ft. ft. in.
C Ml1pIIR\'Name W.a-a 1��'�O I
•- 16.INNER CASING OR TUBING(geothermal closed-log
_
2.Well Construction Permit#: W V U 11 1 y —1 4 FROM TO I DIAMETER THICKNESS MATERIAL
i
List all applicable well comiruction permits(i.e. UIC,County,State, Variance,etc.) +rj ft. � R. 1 in. SDR-11 PVC (x )
3.Well Ilse(check well use): fr. ft• in.
\'ater Suppl} Well: 17.SCREEN
FROM TO f DIAMETER SLOT SIZE I THICKNESS I MATERIAL
Agricultural QMunicipal/Public 0 ft. ft. in.
JNo�n-W'ater
eothermal(Heating/Cooling Su 1 DResidential Water Supply(single) ft. ft.
ndustrial/Commercial Residential Water Supply(shared) 18.GROUT
rrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Supply Well: 0 ft. rt. Bentonite Pumped (x
onitoring DRecovery ft. ft.
TO
Injection Well: ft. R.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
.E mental Technology DSubsidence Control ft. ft.
x Geothermal Closed LOO Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return)
) Other(explain under#21 Remarks) ft. rt. DESCRIPTION color,hardness,soil/mck tmin size,etc.)
4.Date Well(s)Completed: q Well 1D# ft. ft.
5a.Well Location: ft. ft.
�&n n&n 1 rr b► u e-I-�e �m ft. ft.
Famim""Own,.Name Facility iD#(ifapplicable)
Physical Address,City,and Zip J ft. ft.
Cl
I I r 1 9—1 q I Inv) 21.REMARKS
n' Parcel Identiifti'cation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field one lat/lonp is sufficient) 22.Certili -tion:
N W
6.Ware)the well x PetRtanen or O'remporary iytatore ofCertifi Well Contractor Date
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7,Is this a repair to an existing well• [3 Yes 0 aieirpilain
with 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
If that u a repair,fill art known well construction information the nature ofthe copy oflhls record has been provided to the well owner.
repair under-21 remarkr section or on the buck of this form.
23.Site diagram or additional well details:
P.for Gt probe/DPT or Closed-Loop Geotbermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 (;V(-1 is needed. lndicate'FO'I'AL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled :� ^1� t5,UOMI'l-FAL INSTRUCl'IONS
9.Total well depth t elow land surface; (�wow �w (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Por muliipie well;In/all depths ifdJferent(esmnple-4p_700'mud 4000') construction to the following:
10,Static water keel below lop of cabing: X (fl.) Division of Water Resources,Information Processing Unit,
if wain/evri a above casing wir ''- " 1617 Mull Service Center,ITalelgh,NC 27699-1617
11.Borehole diameter: 6 00 241). For Inlectluli Wells: In addition to sending the form to the address in 24a
Drilled above, also mibmil one copy of this 1brin within 30 clays of completion of well
12.Well construction inethod: construction to(lie lollowing:
tic augr,rotary,Lable,duet Push,do)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WF IA S ONLY: 1636 Mull Service Ccutcr,Raleigh,NC 27699-1636
13m.Yield(gpm) x Method of tebl: x 24c, For Wnte•,Nlmiw& lulecllon Wells: In addition to sending the form to
(lie tlddress(es) above, also submit one copy (it' this torn within 30 days of
13b.Disinfection type: X Amount: x Completion of well construction to pile cottuly health depatiment of the county
where constructed.
form 0W-1 North C'a0li ns Deputtnbul of8uvutntwentul Quality-Division of Wulor Resourceit Revised 2-22-2016