WI0100671_Well Construction Record_20230515

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WELL CONSTRUCTION RECORD (GW-I)
1. Well Contractor Information:
Clint J Babbitt
Well Coninctor\amc
NC-3556-A
\C Well Contractor Certification Number
AAA Sweetwater Well & Pump, Inc.
Company Nante
2. Well Construction Permit #:
I IS! al! apphcahic civil construction periniti (i.e. UIC Connn•, Stare, Pariemce, cle.)
3. Well Use (check well use):
Water SuDDIv \l ell -
Oral ❑ Municipal/Public
nal (Heating!Cooling Supply) [DResidential Water Supply (single)
l/Commercial DResidential Water Supply (shared)
Non -Water Supply Well:
-I\Tonitorine
Injection Well:
� Aquifer Recharge
Aquifer Sim —age and Recovery
� Aquifer Test
tl Technology
(Closed Ltxip)
4. Date M ell(s) Completed:
5a. WeR Location:
)dM du �� ClTYU'e
z: Addro�. (_rtg, and Zip
�12-
For lntemal Use
14. WATER ZONES
FRO>i
TO
DESCRIPTION
tt.
ft.
1 15. OUTER CASING (far mull -cased wells) OR LINFR of analicable)
FROM
TO
DIAMETER
THiCKNES3
MATF.RUI.
ft. ft.
in.
16. INNER
CASING
OR TUBiN
othermai closed400
FROM
TO
Dt.c+tF.TER
MATERiAL '
PVC '
ft,
�/( Dft-
���
in.
SDR- 1I
fL
ft.
17. SCREEN' " '
FROM
TO
DIAMETER
I SLOT SIZE THICKNESS I MATERIAL.
ft.
ft.
in.
I
ft.
ft.
In.
I i
CEMENT METHOD s AMO ' r
ft. TO- I Bentonite
ft. it. 7
ft. I ft.
Groundwater Remediation
19. SAND/GRAVEL PACK if applicable)
DSalinity Barrier FROM To MATERIAL.
DStolmw-aterDrainage ft. ft.
DSubsidencc Control ft. ft.
Tracer 20. DRILLING LOG (attach additional sheets
Othcr (explain under =21 Remarks) FROM To DESCRIPTION (co
ft. ft.
Well EN ft. l ft.
ft Ql We ft.
i
i� I a , ft. ft.
Facility ID= tit applicable) ft ft.
/I1I A /) 0/AI G ft. ft.
Parcel Identification No. (PIN)
=L-. Latitude and longitude in degrees/m(nutes/seconds or decimal degrees:
,:ell is lc urw' tat iung is sufficient)
W
6. lsdare) the rvell(s)G'Permanent or Temporary
1s this a repair to an existing well: OYes or �rTo
1l lL .. a /.paJ (i// nnl kni . a a,'/I ao6.n w tiun mfor/nulion and raplain the nalut a of the
/.�,✓•ruder 71remork5secnonoronlhehackoithis,form.
r. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
_. I-irdWon, Only I (jW-I Is needed. Indicate TOTAL NUMBER of wells
9. 1(,1a1 wrtl depth below land surface Ci � `— (ft.)
,1, 1, iWid.plh./ltldlrlrnt(u/u11(11ad)
l It, Stator wrtrr fetid brl(#% top of casing: X (ft.)
ll LOt, r 1I'.1-1 IL ljiwlY// //il/l if )/A/'
I I, Mwehoir diameter: 6 (in.)
12. wrfl cansfrnetiun method: Drilled
,.utr/ tdny conk nnnll,u06 cl: I
FUR WA'iVR %I PVI V Wi 1.1.ti9111,11:
Ira. Yield (Kim)
IAt. hhinirrilon tyitir; GCH
, Timed
ft. I fr.
21. REMARKS
Grouted On:
22. Certifi ation:
017
gnature of C tified Well Contractor Date
All signing¢ this finni. 1 herehr certifi,' that the ntll(s) itaa blere) consinicied in acewdan,
with 15A NCAC t11C.0100 or l M .YCAC 02C.0200 Mell Construction Standards and that a
copy of thi.t record has heett provided to the hell ourter.
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,
SU BM ITTAi. INSTRUCTIONS
2411. For All Wells: Submit this form within 30 days of completion of well
construction it) the following:
Division or Water Resources, Information Processing Unit,
1617 Mull Service Center, Raleigh, NC 27699-1617
24h. For luleellou Welir: lu udditiun to sending the turns to the address in 24a
above, also submit one copy of this form within 30 dip's of completion of well
cunsRuctiun to the tulluw•iny:
Dlvlslou of Water Resources, Undvrgrouud 111Jcctittn Control Program,
1636 Mull Service Cemer, Raleigh, \'(' 27699-1636
24r. D W» ter S�Inlrcllou N'dlr: In uddluan to xnding the time to
111c addless(es) above, alms submit one copy of Ibis Lunn within all days of
cunlplcliuu of well consllucuon 141 Iho cuunfy health depattulcnt of the coutlty
whrre consilutted
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