GW1--05068_Well Construction - GW1_20240827

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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 Name FROM TO DESCRIPTION
ft ft.
NC-3556-A h. ft.
NC Well Connecta Certification Number IS.OUTER CASING(fir rMli-ea.ed wells)OR LINER fd )
AAA Sweetwater Well & Pump, inc. FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 141tt#tt1R CASING
2.Well Comtntctioa Permit#: �)t%L ���Lt—i.0 i�s
j,�
FROM TO DIAMETER TRICKINESS MATERIAL
list all applicable well construction permits(i.e./4C,County.State,Variance,etc.) +1 R 2 c ft 6-'I/4 m SDR-21 PVC
ft. ft.
3.Well Use(check well use):I III ill.
Water Supply Well: it SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public ft. 1t. in.
Geothermal(Heating/Cooling Supply) x Residential Water Supply(single) ft. tt. in.
Industrial/CommercialResidential Water Supply(shared) iL GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
menu Supply Well: l�� 0 R 20 ft- Bentonite Screened
�Monitorin DReco ft. R.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remedtatwn 19.SANDiGRAVEL PACK Of ypicaale)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test water Drainage ft. ft. _
QExperimental ology 0Subsiden 1 ft. ft.
(Closed Loop) Tracer 26R DRILLING LOG Vaasa additional aims Naaaoary)
FROM TO DESCRIPTION(color,arirea,satireck type,pale am,etc.)
(Heating/Cooling Return) nOther(explain under#21 R ) R ft
4.Date Well(s)Completed: I/i g I 24f Well iD#
ft. ft
Sa. •
Well Location: ft. f. , `�-`• �•• %, 1._i,
F ,YC4' ft. ft. AUG 2 7 1f124
acuity/(honer Name Facility IDlI(if applicable) ft. R
31 , ^/ f ' Li-,,, ) 1r,g;r.-.;,c':. : •- : `: ,.:r:z
[,U'j nJl1/' ' l(Olh� C`t.".ta(..,
ft. ft.
meal Address,City,and Zip
nc_r)rn °I7-7 av3gl iteCeb
21. �Lv ry l� la-q�/�County Parcel Identification No.(PEN) 'Sb.Latitude and longitude is degre ma
s/miautes/secoads or decil degrees: SC Y it
(if well field,one lanlong is sufficient) 22�:Z7:
N W �/'G�i'�"" __//I 2 /
6.is(are)the wells(©Permanent or ()Temporary Signature of C Well Contractor Date
By signing this form i hereby certify that the wells)was(were)constructed in accordance
7.is this a repair to as existing well: QYes o 1On" with ISA NCAC OX'.0i00 or ISA NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out brown well construction infttrnuttion and explain the nature of the copy of this record has been provided to the well owner.
repair under.21 remarks section or an the back of this form.
23.Site diagram or additional well details:
S.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: WA SUBMITTAL INSTRUCTIONS
9.Total well depth below laud surface: (120 (ft-) 24a.for All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-34 200'tad 1 I �� construction to the following:
10.Stalk water level below top of casing: 1) (IL) 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'election 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) I Method of test Timed 24c.For Water Snooty&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinction type: CCH
fe Amount J ) completion of well construction to the county health department of the county
where constructed.