WI0100639_Geothermal Well Construction Record (GW1)_20220324

r—illlt I V/g•e
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Clint J Babbitt
Well Contractor Name
N C-3556-A
NC Well Contractor Certification Number
AAA Sweetwater Well & Pump, Inc.
Company Name �y /� ,q
Construction Permit #; V00t`
2. WellV y '�S`
List all applicable ut'll construction permits (i.e, WC, Countv, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
kg ' iltural
othermal (Heating/Cooling Supply)
Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Ex. mental Technology
othermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
Well Loca
a i li ty Owner Name
1;
vsicai Address, Cit1;and Zip p
tarirrlit,
Zi1�-iev�
1¼$avJ 3A,/
JMunicipal/Public
❑iRcsidential Water Supply (single)
DResidcntial Water Supply (shared)
°Recovery
LJGroundwater Remcdiation
DSalinity Barrier
EJStormwater Drainage
IJSubsidcnec Control
UJTracer
rOthcr (explain under #21 Remarks)
Well II3#
v\wt
Facility ID# (if applicable)
`,t' ( Li S/C4
91 a ip alutti-)
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
tifwcli field. one la1JIong is sufficient)
•
6. Is(are) the well(s) 4j,'I'crmanent
or EiTemporary
7. Is this a repair to an existing well: Yes or
If this is a repair, fill out known well construction information and explain the nature of the
repair under r21 remarks section or on the hack of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction. lion. only 1 GW-1 ceded. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface:
for multiply' wells list all depths if different (example- 3@200' and 2@1O0')
10. Static water level below top of casing:
1J water level is above casing, use " - "
11. Borehole diameter: 6 (in.)
12. Well construction method: Drilled
X
4ugc, rotery, cable, (1uce( push, ctc.)
FOR WATER SUPPLY WELLS ONLY:
132. Yield (gpm)
13h. Disinfection type: CCH
Meth d of iebt: Timed
A iounl:
Form GW-1
For
Internal
Use Only:
14.
WATER
ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER
CASING
(for
multi
-cased
wells)
OR
LINER
if a
1
,
licable
THICKNESS
MATERIAL
FROM
TO
DIAMETER
ft.
1
ft.
closed-loo I
16. INNER
CASING OR TUIIIN
. ,.,` ermal
MATERIAL
' SS
FROM
TO
DIAMETER
.`
ft'
7,5O,
GOP I In.
SDR-ti
PVC
ft.
in_
Soy
I i
?we.,
gstft.
17. SCREEN
SLOT SiZE
THICKNESS
MATERIAL
FROM
TO
DIAMETER
ft.
ft.
in.
ft,
ft.
in.
18. GROUT
FROM
TO
MATERiAI,
EMPi.ACENIENT METHOD & AMOUNT
p ft'
%in
ft.
Bentonite
S� d
-VV(
ft.
cD
rt.
1 l'
vukylAfwer e /r . 4.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type,;rain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21.
REMARKS
Grouted
On:;4)1)-0---
22. Certification:
,-/Ve
Sature of Cjftified Welt Contractor
131' signing this form, I hereby certfr that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A 1s'CAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
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.
SUBMITTAL INSTRUCTIONS
24a. 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 Mail Service Center, Raleigh, NC 27699-1617
241r. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the lbllowing:
Division of Water Resources, Underground injection Control Program,
1636 Muil Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this lone within 30 days of
completion of well construction to the county health ► epart ment of the county
where constructed,
North Carolina Department u1 Environmental Quality - Division oil Water Resources
Revised 2-22-2016