WI0100684_Geothermal Well Construction Record_20230613

WELL CONSTRUCTION RECOM) (GW-1)
1. Well Contractor Information:
r hitemal Use
Print Fora
Clint J Babbitt 14, WATER ZONES
FROM TO
\\'ell Contractor Name
it. ft.
NC-3556-A
ft. ft.
N(' \\'ell Connractor C'-nificatioll N*ulllb`r 15. OUTER CASnG for
AAA Sweetwater Well & Pump, inc. FROM I To
- — - -- ft. I ft.
Cumnam \ant
2. Well Construction Permit #: � 1
List all appllcahic iwil cons t+uctioapertnits (i.e. UIC', ('ount_v..State, I'arian•e, etc.)
3. Well Lase (check well use):
Water Supply Well:
Agn •ukural ONlunicipal/Public
therinal (HeatingiCooling Supply) Residential Water Supply (single)
r1ndu
strial'Commercial DiResidentia( Water Supply (shared)
]trigation
Non -Water Supply Well:
\lonitonllu
QRccovcry
Injcction�tcil:
bAquifer Recbarge ElGroundwater Remediation
DAquifer Storage and Recovery D-Salinity Barrier
rt3.aquifer Test []Stonntvater Drainage
tD1=toerimental Technoiogy DSubsidcnee Control
eothermal (Closed Loop) Tracer
Geothermal (H ating'Cooling Return)
Other (explain under =21 Remarks)
s. Date Well(s) Completed:
Sa. Well Location:
n` t [S\MoNn
n c t�YYI
Well 1D#
DI ► U -af-
Facility M# (if applicable)
Pycrl TdcnuGcatiori No. (PIN)
-b- L•atitude and longitude in degrees/minutes/seconds or decimal degrees:
;u[ig i:.uf{icicnt)
N
6. Ware) the wetl(s)QZPermanent or DTemporary
\i'
'. is this a repair to an existing Kell: {Yes or [ja<u
lib- t:tt oat kno.'.n % i,h f,,mllu'firm inrorn'ulion And,-X htht the nufule ol'tht
f. ,rnrder 2i ,emurk-, section or on the hack o/t1d.t form.
in.
vr• ran Trviv rC r.. ..,1.,.�.,. ni ..ln edrnnnl
TERL-1L
FROM TO
DiAMETER
SDR
PVC
Ft t.
in'
ft. I ft.
in.
1
�^-
,
22. Certification:
0
tmuture of/IifiedWellContracim Date
Ry signing this form, 7 herchr verb!"' that the 14r1/0) Aus lll'ere) coast acted in uccordance
frith 15A :VC9C 02C.010)o or- 11-4 2 CAC 02C.0200 111111 Construction Slond"Fdv and that u
Copt' a/'thi.; record has heen pros ided to the it -ell oxater,
23. Site diagram or additional well details:
For GeoproFx/UPT or Ciosed-Loop Geothermal Wells having the same You may use the back of this page to provide additional 'Well site details or well
%tttarr.. nnly 1 GW-I Is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
3 VLl SIML%1ITTAL INSTRUCTIONS
'�.1 otil well depth bek w land surface: O`-O0 (ft.)
l ,. ....•tq.;r , ; lr. by t ,d/ a,p1h, l rldh'n ta (r.fund, - 311 20(I aid f lab __!)') 24a. 1r Ali Wells: Sllllllllt this forill withill ,10 days of completion of w-lll
consuttctiou to the tililowing:
}{t, isiwti{ v,atrr Irirl Irrlus;, lap of raring: }�
(ft.) Division of Walur Resonrces, Information Processing unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
II,l3txatuiirdlrrrtdcr: t^�_� (in.)
DFIIIEd
2411. Gar Ittiection wells; In addturttt
addition to sending the M the address in 24a
12, "fait u,nrtructlun mathud: above, also MAIM"( une cony of this lurnl within 30 days of completion of "-ell
,:.:{;cr T,e c�. cnr.lr, on, tl p;r-i, t 1. It — -- consntiction to tilt lulluwing:
HYR %A'f i,k M PVI-V WV.LI.r, U �f.l': ilivislon of Water Resources, Underground Injection Control Proa
1636 Mull Service ('enter, ,[deign, N(: 27(199-1636 �t atn,
t k;r, Vir14 Qpir'► Mrthu tr teat: I Irnbd
µi!!41•_ �IA11)3's'k_1L1641i2111 :Yells: In addition to sending i3b.IJirinicrtiuu{ Iho addresses) abotc, also Mubnlit une col of this klnn within 3p ti'nn to
3pr, GGH i
no it: _ conlpieliou of well culwilictiun lu (ile tuuut health delartntent of tile
of
- where cunslrucled, y I tuuut5
f, .4
V„ttl, { ,u„hnd DcP.,,t,nc,d of I'uvunlln,ulal 0iialily I)il,,wn of Vt'atut Itcanurh's