GW1--03022_Well Construction - GW1_20240520

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor information:
Clint J Babbitt 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft ft.NC-3556-A
ft. ft.
NC Well Contractor Certification Number IS,OUTER CASING(for t of d wells)OR LINER(if applicable)
AAA Sweetwater Well & Pump, inc. FROM TO DIAMETER THICKNESS MATERIAL
H. H. In.
Company Name
�n�22 f( IiapAflWt CASING
2.Well Construction Permit#: 0 �0c:)J—l(.1.7 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIIC,County,State,Variance,etc.) +1 ft. /30 f- 6-1/4 in' SDR-2 1 PVC
3.Well Use(check well use): ft D in
Water Supply Well: FROM SCRE PTO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural Municipal/Public it. ft. is
•Geothermal(Heating/Cooling Supply) x Residential Water Supply(single] R. ft. in.
•industrial/Commercial OResidential Water Supply(shared) t>l.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
1 .ater Supply Well: 0 ft- 20 - Bentonite Screened
OMonitorin: °Recov ft. ft.
injection Well: ft. —
DAquifer Recharge a Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
•Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
• Aquifer Test ■ - r water Drainage ft• ft
•Experimental nology °Subsidene •ntrol ft ft
•Geo • al(Closed Loop) °Tracer 20.DRILLING LOG(attach additional shams if arcessary)
t thermal(Heating/Cooling Return) [Other(explain under#21 R• ,..• ) FROM TO DESCRIPTION(nor,►a.d as r Wr,ck type vela Ise eta)
/ I // ft. ft
4.Date Well(s)Completed: I/a?/2 7 ' Weil no ft.
ft.
5 Well Location: ft ft ��/k'
ft, ft.
a1�.e r-1- Love-
Facility/Owner Name Facility iD/I(if applicable) ft. ft.
/ 7V louuc/ 6rov-e 2,,/tPit%r . ft. ft.
Physical Address,City,and Zip ft. ft
I - <AO Lc) 1 VDd&O 7 / . 21.RE ,, .: / r/� n�`J L
County Parcel identification No.(PIN) �p 1 p (.,,,,,r� �C//' 67,1
or decimal degrees: q C2r��7`'r [/•- r) •
6y)
Sb.Latitude and longitude in degrees/minutes/secondseg
(if well field,one lat/lorrg is sufficient) 22�C' so:
N W
,a—all6.is(are)the well(s(©Permsfor °Temporary signature ofCatiSfiNd4--
eU 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: °Yes o 1 E121110 with ISA NCAC 02C.0100 or ISA NCAC 02C'.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
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
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: N/A _ SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Gt 200'and 2@100) construction to the following:
10.Static water level below top of casing: ,,,9 L O (R) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,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 construction method: construction to the following:
(i.e.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
13a.Yield(gpm) a Timed Method of test: 24c.For Water Suably&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 Amount: la completion of well construction to the county health department of the county
where constructed.