GW1-2021-03176_Well Construction - GW1_20210625

Print.Forr, �
1.We8 Contractor lofenuadon. '
Clint.l Babbitt 1 14.WATER rnNF_Q
Weil Contractor Name tw<sZ; txs ;::xti t�ttsti /1
NC-3556-A
n n
NC Well Contractor CenificatiortNumber
7 iS asu!'Gn-a`,nmlvv-ior-mniii--N ,fools-lirt ilerieR u a oar
AAA Sweetwater Well& Pump, Inc. FROM 7O DIAMETER', rI11Cx�Ecs aurER1AL
it. ft. In.
Company Name
�W 20 J y 16.INNER CASING OR T[JBING eothermal closed too
v MOM TO n1AMF.TF.'I THf('KNicc MATi.Rrar.
1
List all applicable wit construction permits(i.e UIC,County,State,Variance,etc.) ft. 6114 SDR-21 PVC
3.Well Use(check well use): 1'V
Water Sunaty Welk 17.SCREEN-
i rK."n ,ir- uii,ni¢ILK 3wi aiiis lnILL"ai• ILKFAL
Agricultural [JMunicipaUPublic 11 % n in.
Geothermal(Heating/Cooling Supply) residential Water Supply(sin ft n to
Industrial/Commercial Residential Water Supply(shag)
gle) �kll.GROUT
b:i lion PROM TO IWATF.01At. EmV A-_e"F_¢T METROD&AatOUNT
Non-Water Supply Well: 0 ft• 20 ft• Bentonite Screened
Monitoring ORecov n n
1.Injection Well:
Aquifer Recharge /) nOdher
dwatox 1Zemediation d i 1
19.SAND/GRAVEL PACK rf a 'cable
Aquifer Storage and Recovery Barrier FROM - TO HATERIAI.
Aquifer Test ater Drainage n n
_2cpettm_W I Techrrnlegyence Con--at
Geothermal(Closed Loop) 2 DRILLING attach arlditlmtal a it
Geothermal(Heating/Coolinex lain under#21 Remarks) FROM fL TO DFSCRII'7TON ImMr,hsrdn aoturnclr w atc
8 f.
4.Date Welt(s)Completed: Well ID# ft. f
SSaa.Well Location: ft
YacilityAnter Name Facility ID#(ifapplicable) ft fa S ulllt
,.• n!` Slfl.
_ICI ��ber& ►� �QV�1�V1 n QVvE
n
'
eci;o
N/ � "` - - �o3oCJr0muted0n:
ARKS
County Parccl Identification No.(PIN)
2 ! 20
Cl. I-KI.+Je..J) J..L J-.e.-��+.C-..w..G�--J----J..-2...-1 J-•....-..
(if well field,one lattlong is sufficient) 22.Certification:
W � z�
6.Is(ttre)theweWS) erMffltertt or UTemporary `"`�`"" "" """ ""`
B},signing this form,I hereby certifi•that the weil(s)was(were)constructed in accordance
7.Is this a repair to an existing wets: Oves or /Wo with LU NCRC 02C.01M or 114 NCdC 02C.0200 Well Catrstructron Standards and that a
Ifthis is a repair,fill out known well construction h formation and erp/ain the nature of the copy of this record has been provided to the net/owner.
8.For Geoprobc(QPT or Closed-LQpp Geotherml Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GVf(J7 is needed. Indicate TOTAL NUMBER of wells consVncvon deWis.Yon may a)so anaeh additional pages it necessary.
drilled: � SURMITT AT.IN.CTR_T.ICII'linNC,
Q
9.Total well depth below land surface: / U S (n) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulilate we1h list all depths f dfferv-(-ample-3 tQt 200'and 2 r@r 1001) construction to the following:
10.Static water level below too of casing:, T_.s! HL) INviidan nrWntor Rvcnnrrrq;IInfarm9tinn Rrfr~11ne rinW
f:.werlevel is above acing,use 1617 Afar Service Center,Raleigh,NC 27699-1617
11.Hocehate diameter: (n•) 24b.)or Idtectitm Wells: In addltioifftD sm!#ng Abe form to Abe address in 24a
Drilled above,also submit one copy of this form within 30-days'of completion of well
12.Well trnntrtrnrtipq.rnMhnrlr.. c., �_�_„�_
(t.e.BageP,Cafaly,c'BtitC.daerY()a5lt,d&:.} wu4i�uvil ii,u,r avu,r.e.�,.
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Trrtmtl i
'old(man) I� iricwriii ail iicai: .'+'a.:y-::';:--_•--_�o ._:�..uv;.?c:u: L,au'u'wv� D�c.�`.:.0 .:i:..�;
the address(es) above, also submit one copy of-this form within 30 days
13b.Disinfection type: CCH completion of well construction to the county health department of the coc
where constntcled.
Form GW4 North Carolina Department of Envirunmettra(Quality-Division of Water Resources Re%ised 2-2. l
I
f
pi
1