GW1--03056_Well Construction - GW1_20240520

Print Form
WELL CONSTRUCTION RECORD(GW-I) For Internal Use Only:
1.Well Contractor Information:
Clint J Babbitt 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
ft. ft.
NC-3556-A ft. ft.
NC Well Contractor Certification Number 11&OUTER CASING(fr m ca d- ed web)OR LINER(d>tpp6a�61e)
AAA Sweetwater Well & Pump, inc. FROM TO DIAMETER THICKNESS lI MATERIAL
ft. ft. in.
Company Name 0 ;�/' �/ 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: lI V I I l O /143 FROM TO DIAMETER THICKNESS MATERIAL /
List all applicable well construction pe us(i.e.UK',Count',State,Variance,etc.) +3 ft. 100ft. 1 in- SDR-1 I PVC (x it.. )
3.Well Use(check well use): ft ft. in.
Water Supply Well: FROM RE PTO DIAMETER SLOT SIZE THICKNESS MATERIAL
/Agricultural QMunicipal/Public 0 a ft. in.
©Geothermal(Heating/Cooling Supp) ()Residential Water Supply(single) R ft. is
/lndustriallComrnercial ()Residential Water Supply(shared) la GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD qt AMOUNT
Non-Water Supply Well: 0 fL /OD ft. Bentonite Pumped (x )
/Monitoring ()Recovery ft. ft.
Injection Well: ft. ft.f�I
•Aquifer Recharge l�C,roundwatered 19.SAND/GRAVEL PACK(if applicable)
/Aquifer Storage and Recovery EiSalinity Barrier FROM TO , MATERIAL EMPLACEMENT METHOD
/Aquifer Test QStormwater Drainage ft ft.
/Experimental Technology ()Subsidence Control ft. ft.
Q Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additisaal sheets ifaecesaary)
FROM TO DESCRIPTION(cigar,hardauL m a rsck type,amain liar,etc.)
■Geothermal Tit-eating/Cooling Return) Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed:6-LI'2 Well ID# ft. ft.
Si.Well Location: ft.
ft.
i1. . kV Gif11 IS ft f "LLY 2 ;i •i:j1
Facili I t new Name Facility IDN(if applicable)
11 —Lk c, h P.d ThiveVitLo 287?D ft
Physical Address,City,aikl
,^Zip
,ir\( T\L co II I gte3 I l 7 21. MARKS
County Parcel Identification No.(PIN) 4 S 9/Abled c2T •
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C fl ' n:
N W ;:1Ii 1 6—, 7 ?
6.Is(are)the well(4x Permanent or ()Temporary S e of C well Camactor Date
�� By signing this forte I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ()Yes o.B E;I IS with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out blown well construction information and explain the nature oldie copy of this record has been provided to the well owner.
repair under e1!remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW_lkis needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: LJf (� �/'� SUBMITTAL INSI'RUCTION1
9.Total well depth below land surface: 4 @ /-.� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: X (IL) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Drilled above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct pusb,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) X Method of test: X 24c.For Water SRDobv&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: X Amount: X completion of well construction to the county health department of the county
where constructed.