WI0100643_Geothermal Well Construction Record (GW1)_20220815

WELL CONSTRUCTION RECORD
I. wen Contractor Information:
Clint J Babbitt
GW-1)
Well Contractor Name
N C-3556-A
\C Well Contractor Certification Number
AAA Sweetwater Well & Pump, Inc.
Company Name
2. Well Construction Permit #: 1 0 k cL�p
List all applicable ii .'1l construction perm
Al
is (i.c. ZIIC•, County: State, i'ariancce, c'tc.)
3. Well Use (check well use):
Water Supply Weil:
� Agri 'ultural
teothenmal (Heating/Cooling Supply)
Industrial/Commercial
Irritation
:Municipal/Public
EJ Residcntial Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring
DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Ex erimental Technology
eothermal (Closed Loop)
Geothermal (Hcating'Cooling Return)
4. Date Well(s) Completed:
Sa. Well Location:
Facility -Owner Name
IJGroundwater Remediation
Salinity Barrier
LJ Sto;mwater Drainage
['Subsidence Control
DTracer
(Other (explain under t2I Remarks)
OP WellLD#
Obtvdk tb4S'I
Facility 10# (if applicable)
Sjg���fi'7�ek-a Vi1Cl1
Physical Address. City, and Zip '
5Lms 10—e-all? i Leacila(os1
ountv Parcel Identification No. (PIN)
513. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Pt ell field. one laJiong H sufficient)
N
6. Is(are) the well(s)iermanent or Dremporary
7. Is this a repair to an existing well: jjves or
If this is a repair,_/ill out known well construction inforinution and explain the nature of the
repair under =21 remarks section or on the hack of this form.
8. For Giroprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only l GW-1 is needed. Indicate TOTAL NUMBER of wells
dulled:
9. Total well depth below land surface:
multiple wells list all depths if different (example- 3200'@and 2(u)1001
l U. Static water level below top of casing:
lj water level ik ahot a racing. use "
11. Borehole diameter: 6 (in.)
12. Well construction method: Drilled
(r c. Bogcr. rotary, cable, direct push, ctc.)
FOR WATER tJPLY WELLS ONLY:
horn GW-1
X
North c41011114 i)cpaitinviil or 1
(ft.)
(ft,)
Print Forrr
For internal Use Only:
14. WATER ZONES
FROM
ft.
10
ft.
1)ESCRiP'I'ION
ft,
ft.
15. OUTER CASING (for multi -cased wells) OR LINER if a _
FROM TO i11.1METER THiCKNES►S MATERIAL
ft.
ft.
in.
16. iNNEK CASING OR TUI3(Nt otherntal closed-loo
FROM
fy ft.
ft.
17. SCREEN
TO
it.
ft.
DIAMETER
licabie
MMATERi1t.
I in' SD Roe PVC
in.
FROM TO
ft.
ft.
DIAMETER
in.
SCOT SIZE
THICKNESS
MATERIAL
ft.
ft.
In.
18. GROUT
FROM
0 ft.
ft.
ft.
TO
ft.
ft.
ft.
MATF.RIM,
Bentonite
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT M1ETHOi) & AMO
rt m
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
ft.
TO
DESCRIPTION (color, bardness, soil/rock type, grain situ, etc.)
ft.
ft,
f
ft.
ft.
ft.
ft.
ft.
ft.
ft.
f
f
21. REMARKS
Grouted On:
22. Certification:
*c'
Signature of Cyftified Well Contractor
By signing this ftwnt, 1 hereby certffr that the itell(s) was (were) constructed in accordance
with I iA NCAC 02C .0100 or 1 SA N1'CAC 02C .0200 Well Construction Standards and that a
copy o/'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
24b. Vur )nitction 'Welts: hi addition to sending the rum to the address in 24a
above, also submit one copy of this fomm within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mull Service Center, Raleigh, NC 27699-1636
24e. Fite Water Supply & Ink alon 'Wells: In addition to sending the tbint to
the address(es) above, also sublttit one copy of this form within 30 days of
completion of well consuuction to the county health department of the county
where constntctcd.
tivttuiiineiitil Quality - Division °t Wino Rceuurce&
Revsxl 2-22-2016