WI0100632_Geothermal Well Construction Record_72020122

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CONSTRUCTION RECORD (GW-1)
actor Information:
Chi i JJabbitt
Well Contractor Nam
NC-3556-A
NC' Well(, .,, �.t„� r, ,
AAA Sweetwater Well & Pump, Inc.
('umpany Nance
2. Well Construction Permit #:
List all appkcablcut'llconcouctinn pear is fi c L'!(', ('ut 1�Sl� lima err.)
3. Well Ise (cheek well use):
Water Supply Well:
JAgri -ulturil
Teothennal (heating Cooling Supply)
Dindustrial iCommcreial
1Inieation
Non -Water Supply Well:
DMonitoring
Injection Well:
0Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Ex crimental Technology
leothermal(Closed Loop)
Geothermal (Heating Cowling Return)
4. Date Well(s) Completed: 12412) Well ID#
alunicipal/Public
jJRcsidcntiol Water Supply (single)
jResidcntial Water Supply (shared)
ORccovcry
r: Groundwater Remediation
['Salinity Barrier
QStolmwater Drainage
iSubsidencc Control
Tracer
[}Other (explain under r21 Remarks)
Ss.WWellLocation: I ��
kgi SS �P(J le
Facility iD I bl )
Fir tq..OHn� Xanc act ny ."• lira piCa �� /
Bee lam 1NQUI Awl
Pht_i:ai Address. City. and Zip
Co -Ms Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fold. vac fat "iong is sufficient)
N
6. Is(are) the v.ellts)IPermanent or JTemporary
7. is this a repair to an existing well: OYes or +To
1f Oil, fs u repair. fill out knousn 'Welt con.dlurlinn urformuuon and explain the nature of the
repair:rnder - 2i remarks seceta on the hack of this fonn
S. For GeoprobefDPF or Closed -Loop Geothermal Welts having the same
construction. only 1 GW-I ism cded. Indicate TOTAL NUMBER of wells
drilled:Ca �-�}—� P°
9. Total well depth below land surface:
1 tau n;u/ti/.Ir ... 1l. lift all depth• if tldfrrent kW/Vie- 3112140 arkl 2i1 11E1i l
10, Static *attar level below top of casing: > 1
iei.elitakin casing .trse'I ..
11. Borehole diameter: 6
12. Well construction method:
t l e augu. rmdry, titbit. direct push. etc.)
Drilled
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm)
13h. Disinfection type: CCH
I urm (AV-1
Merh(i
test: Timed
t0
DESCRIPTION
n.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM j TO Ill.%METER THICKNESS MATERI\I.
ft.
ft.
in.
16. iNNt:R CASING OR TUB!oop
FROM TO DIAMETER ZrnCxNesS
() ft.
ft.
17. SCREEN
Sift.
ft.
in.
SDR-41
FROM TO I DMAMET ER
ft.
SLOT SIZE j THICKNESS ; MATERIAL.
ft.
ft.
In.
18. GROUT
FROM TO MAT FRIA .
0 ft. 30D 11. Bentonite
ft.
ft.
ft.
ft.
EMPLACEMENT METHOD & AM(tt
I
PO ill Recl X‘.72.—.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL
ft.
ft.
EMPLACEMENT METDOn
ft.
L
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color. hardness soil/rock hpm grain size. etc.)
ft.
fL
ft.
ft.
fL
fL
fL
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Grouted On:
22. Certification:
I on
actor
\V I
filatureUt C ti
By signing this form, 1 hereby certify that the uellls) was (were) romrn:clt d u: ura+ltimlrr
with /SA .VC/IC 02C.0100 or 1 SA XCAC 02C.0200 Well Construction Standen de and that a
copy ,Jtlti.s record has been provided a; the well outer.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAi. INSTRUCTIONS
243. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b. For loicctiun Wells: In addition to sending the form to the address in 241a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Wafer Resources, Undergruuud Injection Control Program,
1636 Mull Service ('eater, Raleigh, NC 27699-1636
24e. For Wafer SIIDDiV &Yc InlecUnu Wells: In addition to sending the tbnn to
the address(es) above, also submit one copy of this limn within 30 days of
conlpldiull of well Con%IIUClinn to the county health department of the county
Where constructed.
fled e
C
Nvtlh (alUhlla 1)cpatnoCIlI UI f-Ii%ln,tllllenldl Otrebly • DR ',ion of \Vatol Resoulces
2/ 2.-00-I
ide
Retail 2-22-2016