WI0100673_Well Construction Record_20230515

WELL CONSTRUCTION RECORD (G«--t )
1. Well Contractor Information:
Print Fora
Clint J Babbitt
Wcol Contractor s,unc
NC-3556-A
\( \\;Ii (,I'll (':i;04,,l„at NwW,,i
AAA Sweetwater Well & Pump, Inc.
2. 3N c11 Construction Permit #: W
D
I oo4
--a -
1:•t;:i, gp1ilinthle urR,onsmichonperma,
pc [7('
(nr,nnt
J7atr. Pa,tnnce, cI,)
3. Well Use (check NVcll use):
LZ-ater Supple \L ell:
ri ultural
,co iennal (licatinelCoulin, Supply)
Industrial Vommercial
Ini_,ation
\on-NVater SupplyWell-.
Monitoring,
Injection Nell:
.__f Aquifer Recharge
Aquifer Stongc and Recovery
Aquifer Test
Exocrimental Technology
thermal (Closed Loop)
`'o)
Loth, -rural t Hating Cooling Return)
4. Date Well(s) Completed: -
Sa. Well Location:
Faciiit% Owne—. sameji
Municipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
QGroundwater Remediation
Salinity Barrier
oStotmwater Drainage
DSubsidence Control
Tracer
under =2I
Well 1D#
Facility 1Dr (if applicable),
5
ISM L�l y
Vol r
ZIIJZ—L 0-1
0--. N Parcel Identification No.
5b. latitude and longitude in degrees/minutes/seconds or decimal degrees:
t:i ucll f._id. arc tat Tong is su(ficienI)
IN'
6. Is(are) the well(s)Qrpermanent or 13Temporary
7. Is this a repair to an existing well: Oves or [g o
01 •,ul i.no;,n r. r /I t un,o u, Inn wroi niunon and raplain the rmtme of the
,;-G �;r ;,rdc•r 2i rdmark, sr�(rr,n nr In the had: o/this (onn
fi. For Geoprobt/DPT or Closed -Loop Geothermal Wells having the same
-(:nSSndtu)G. (mlv i CiW-I is needed. Indicate TOTAL NUMBER of wells
9. Total well depth below, land surface: V (ft.)
r M,.rli,ptr , b. )„i all d,pil" r/ d.tln r nl (r, urnpl, - 3 ((2(yi tuu12 I1011)
I(r_ itatir water Inrl below wp of using:_ (ft.)
ii ...o-.lr.,; ,, .,i.l.., IUNnY i, b•
11. Fforchole diameter; 6 (In.)
12. Nrp construction method: Drilled
..:,Mr r4eary. conk. 0ur,I push cot )
POR V►A7MSt. PtP1-Y WF'1 I %0%IX:
13a. Y)rld ((purr) Nfr1hX111MJ4,
est
13b. lr(tr(nfcetlun type: CCH H:
. 'rimed
1.1. WATER ZONES
MOM
I TO
I DESCRIPTION
ft.
ft.
ft.
ft.
1 15. OUTER CASING (fnr multi -eased wenni nR LINTR of annile.h1ol
FROM
TO
DIAMFTER
THICKNESS
�L�TERL(L
ft.
ft.
(n.
I tb. I N NLK CASING OK 7 CHI.N(Nmeothermal c(oned-loonl T
FROM
TO
m W."FER
%IATERL(L
PVC V
ft.
ft.
in.
SDRY) I
ft.
ft.
in.
I 11. NE RF: F:N v
FROM
TO I DIA'MIAER
I SLOTSIZE
THICKNESS
AfATER1A1.
ft.
ft. in.
ft.
ft. In.
ft.
ft. I ft.
Bentonite
ft.
ft.
19. SAND/GRAVEL PACK(if applicable)
FROM
TO
I MATERIAL
I E1IPLACEMENT METHOD
ft.
ft.
ft
ft.
fl. ft.
ft, ft.
fr ft.
ft. I ft.
ft. I ft.
ft. I ft.
ft. I ft.
{ Grouted On:
22. Certirt ation:
07
15
Ignalnre of C tified Well Contractor Date
Br s(gning this firm, 1 herehv certily that the iiell(sl ww 11wre) Constructed in accordance
with 15A NCAC 02C ,t1100 or 15-A \'CAC 02C .0?00 (Fell Construction Stonda+ds and that u
Copy nj'thit record has been provided to the well ouver.
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
24m. For All Wells: Submit this form Nsithin 30 days of completion of well
construction to the lullowing:
mosion of Water Resources, Information Processing Unit,
161711tall Service Center, Raleigh, NC 27699-1617
24h. bur lid"lluu Wells: ht addition to sending the barn to the address in 24a
above, also submit one copy of this tirrm within 30 days of completion of well
construction to the lulluwing:
Division of Water Resources, Underground Injection Control Program,
1636 Mull Service Center, Raleigh, NC 27699-1636
24r. For Water ti llly .fit lidectlon Wells: In addition to sending the timm to
the addiess(cs) above, also submit one copy of this form within 30 days of
cunipleliun of % ll cuustnieliun to lilt! Cnuuly health dcpa11n1cnt of the eounly
µhcic constructed
i .n,:, (,'.S - I ti„nL ( p,vhnn Ihpd,tn„nl I'll nuunun:nLd l)u,iln) - IhuM,nl of wutet Wsoluccs
Rcslxcd i•"_2016
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