GW1--03023_Well Construction - GW1_20240520

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATERZONES
Well Contractor Name FROM ' TO DESCRIPTION
NC-3556-A ft.ft ft
NC Well Contractor Certification Number IS.OUTER CASING(for asult eased wear)OR LINER(if ap ' Me)
AAA Sweetwater Well & Pump, inc. FROM TO DIAMETER THICKNESS MATEIUAL
ft. ft in.
Company Name
/) z F4AigRft CASING
2.Well Construction Permit#: Q .2�2._ 23 I �J2 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(TIC,County.State.Variance,etc.) '1 1 tL al ft 6-1/4 1d SDR-21 PVC
3.Well Use(check well use): ft. ft' in.
Water Supply Well: 17•SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
•Agricultural Municipal/Public ft FL in.
a Geothermal(Heating/Cooling Supply) x Residential Water Supply(single] ft. ft in.
•Industrial/Commercial DResidential Water Supply(shared) IS.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
.ater Supply Well: 0 ft. 20 n Bentonite Screened
a Monitonn_ DReco .' ft. ft
Injection Well:
ft. 1t.
•Aquifer Recharge 2 Groundwater Remediation -
19.SAND/GRAVEL PACK(if apptiable)
a Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
U Aquifer Test • '.•r water Drainage ft' ft'
■Experimental > nology 0Subsiden• 'ntrol ft. ft.
•Geo al(Closed Loop) DTracer 211.DRILLING LOG(attach additional Moen gore essary)
FROM TO DESCRIPTION(refer,holiness,wWre&type,trait ice,etc.)
P ,'thermal(Heating/Cooling Retturnrn)' Other(explain under#21 R ) ft. tt
4.Date Well(s)Completed:,)I ull V/ Welll ID# / { ft. R'
Sa Well Location: / l.�/u``^ ' ��
i"grl Fnedli LipM 440 ft. ft.
Facility/Owner Name Facility ION(if applicable) ft. h ';
1020 Min* G,frue l n. n�-ith er 2c 13 2— ft ft.
Physical Address,City,and Zip
1��('`/�L ft. ft
KS
County l Parcel Identification No.(PIN) , `t) F (_.-1
1+�� D 69' �WF
qiSb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: ��g(l a l2:0 b •
(if well field,one Iat/long is sufficient) 22.Certification:
� ��
N W Date 11 ee/ib/d ti.
6.Is(are)the weil(s"s"tilPernsaa or Temporary S ofC Well Contractor
By signing this form,I hereby certify that the well(s)war(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes o 1E3121110 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 x21 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: (0 15 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-9 0200'and 2 a@10/0') conslru ion to the following:
10.Static water level below top of casing: 5`7 D ' (It) 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 lniection 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: Tinted 24c.For Water Sntwly&'niceties Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
lib Disinfection CCH ^Arno t:�� completion of well construction to the county health department of the county
not `„D l n t 119
1 J, where constructed.
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