WI0100630_Geothermal Well Construction Record (GW1)_20220718

WELL CUNSTRtiCTION RECORD (GIV I)
1. Well Contractor Information:
Clint J Babbitt
WeII Contra rtor \amc
NC-3556-A
\C Well Contractor Certification Number
AAA Sweetwater Well & Pump, Inc.
Company Name
2. Well Construction Permit to: t{ hQ 0 Q
Cnl all apphcahle urll ranttnrcaon pennrrs (I C U/L',Cbunnt State, tSaance, crt-.r
3. Well Use (check well use):
Water Sunni• \\•rn•
Ter�i- Rural �Afunicipal/Public
ereotttermal (Eleating/Cooling Supply) oResidcntial Water Supply (single)
Industrial/Commercial QResidential Water Supply (shared)
Water Soppy
Recharge
Storage and Recovery
Te_ct
ental Technology
na] (Closed Loop)
Rctum
4. Date �Vcll(s) Completed: �� �%i
Sa. Well Location:
I�JPYri& LUiino IMIrt-4w,iko
Facility
O+rnttNarrie
❑Groundwater Remcdiation
QSalinity Barrier
�Stomrwater Drainage
Subsidence Control
Tracer
Facility ID# (if applicable)
01/111O L��Xv7
Physical Address. Gty, and Zip - —
I t� � °/Ja1%
('runty Parcel idendfication No. (PIN)
5b. Latitude and longitude in degreeslminutes/seconds or decimal degrees:
1 1 f uell fold. tint IaL1ong is sufficient)
G. Is(are) the well(s)�Permanent or QTempot•a»•
7. is this a repair to an existing Nell: OYes or [B o
If this A a repair. (ill am knmtn +tell cottmuction infiirmutinn and etp/ain the nuturc of the
repair under =21 remarks section or on the hack of'rhia•iorm.
Print Fom
(1. i fts
n; tL
-- �^ tnermu umea-I )
FRO\I I TO DI eM1TER ! ' \t %TLRI \L
U n! 0 tL SDR4 j I PVC
R j n cn
I7- SCREE,
FROM TO D14METER CLOT SIZE TnnCh-NTSS i MATERJILL
hR
. . I i
fie fL I In.
ta. GROL. I
FROM TO \t \TERI\I. FNPI-\GENE\T VETHODS A\IO T
D h 200 R' Bentonite (6bf9LUetlr �/
R. I h.
rt. rL
_ _ aa�aa sank net, t` a ssre. rt:.l
fL I fL
I
fL rL
ft fL
fL R-
ft R. .
R. R-
R. it.
22. CetY(fiSSation:
0 %/I 4 (
Stvnature of C dried Well Contractor Date /
u/
Be s(gning thin Intr,t. 1 herrh+• cernA, that the rlllit uta lurrr•J cnrttrtuctod in a.vnt,i t.tai•
frith 1 t f VC'4C (LIC.01m) or IgN SCdC 02C49200 WC11 Co lawns Sandatil.- and that a
rnpr o% rhts n caw,/ has been prucitIM to Me uell runner,
23 Site diagram or additional well details:
8. For Geoprobe/DPT or Closed -hoop Geothermal Wells buying the stare You may use the back of this page to provide additional well site details or wellconstructioD. only I GW needed. Indicate TOTAL NUMBER of wells construction detail& You may also attach additional pages if necessary,
cz drilled: SUBMITTAL INSTRUCTIONS
9. Tool well depth below land surface: O (R•) 24s. For All Wells: Submit this fame within 30 da3s of completion of well
Far multiple urlls list all depths i(didarnr (erampleft 3 r921N1' mil t rQi 1111Y) construction to the following:
10. Static water level helo% top of casing: X (RJ Division of Water Resources, information Processing Unit,
1/ Kairrhirtelisabosectising, use " 1617 Mall Service Center, Raleigh, NC 276WI617
11. Borehole diameter: g (in.) 24b. For inlection Wells: In addition to sending the form to the adtimm in 24a
c auger, rotary.
Drilled ubove, also submit one copy of this form within 30 days of completion of well
t
1 Well construction method:, cable, direct push, etc.) construction to the following:
I
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WILLS ONLY: 1636 Mall Service Center, Raleigh, NC 276WI636
13m. l'leld (gpm) Meth a Ink: Timed 24e. For Water Supply tit Iniection Wells: in addition in sending the tann to
13h. I)WnfrctioD ()-PC: CCH
the addresses) above, also submit one copy of this fount within 30 days of
it, t: completion of well cousuuction to the county health department of the county
111 Wilert COI1slILl'lCtl.
I arrn Ow -I North Camluw Ikpanmuu of limumutncutul Quality - l)tvuu+n tit Watct Rerotxtrces Rc\+se d?-2'_-2616