WI0100702_Well Construction Record(s) (GW-1)_20240212

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WELL CONSTRUCTION RECORD (GW-1) For internal Use Only:
L Well Contractor information:
Clint J Babbitt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
NC-3556-A
NC Well Contractor Certification Number
AAA Sweetwater We I I & Pump, inc. OUTER CASING for multi-used wells OR LINER if a lien
FROM
I
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft.
Company Nam `W' :01 00-70a 16.INNER CASING OR TUBING eothermaI closed-loo
2•Well Construction Permit#: VV V o 100 y-7� FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction pernrltc(i.e. L11C,Cormty,State, Variance,etc.) t IL
ft. 1 in SDR-11 PVC (X )
��`"' in
3.N\'ell Use(check well use): ft. ft.
Water Supply W 17.SCREEN ell: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
i OMunicipal/Public 0 ft ft. is
71 Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
IndustrialICommercial Residential Water Supply(shared) 1&GROUT
lIrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supph•Well: 0 rL fa Bentonite Pumped (x )
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
E. tau Technology Subsidence Control ft. ft.
X Geothermal(Closed Loop Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) MOther(explain under#21 Remarks) FROM ft, ft.
TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.
4.Date Wells)Completed: Well Hm ft. ft.
5a.Well Location: =Q i'l ft. ft.
t40--I. ►�p( _Y, G� 11I�V��1 L �tJ1�/ ! i ft. ft.
Faality/�V. Facility 1D#(if applicable) ft. ft
2-29 i ft. ft.
Physical Address,City,and Zip Ze->tb ft. ft.
B
tf�fTom, J �,aIAU,321.REMARKS
�ty t��l i—t Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees.
(if well field,one lat/long is sufficient) ?22.Cerdtiffiction• `-
N W r we — .
6,Wsre)the wells Pervunent or Temporary Signature of CertiOd Well Contractor Da Ye'
By signing this form, I hereby certify that the well(s)was(were)constructed in accordance
7.b tints a repair to an existing well• Yes X No with I SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information ex aln the nature of the copy of this record has been provided to the well owner.
repair under r21 remarks section or on the back of thisform. 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
construcxion,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: -3 li C20—(ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multrp/e wells lnl all depths Jdiffierent(example-3 tD 00'and 2 r(�r 100') construction to the following:
Io.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,lbileigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b. 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 construdkin method: construction to the following:
(i.c,auger,rotary,cable,direct push,etc.)
Division of Witter Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Milli Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) X Method of test: x 24c, For Witter Simply A Iniecliou 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. X Amount: x completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Deparlrrlenl of Environnientrd Quality-Division of Waler Resources Revised 2-22-2016