GW1--02977_Well Construction - GW1_20240513

Wry)L>L.CU�1S'Il'I[tUCTIION RECORD OW 1
For Internal Use Only: -------
1.Well Contractor Information:
Chris King
Well Contractor Name 14.WATER ZONES
FROM TO DESCRIPTION
' 2080-A
NC Well Cntttrtctor Certification Number
15.OUTER CASING for multi-cased wells OR LINER If a. licable)
M
Aqua Drill, Inc. ��
FROM TO DIAMETER
THICKNESS
Company Name 1112231
rim MEI
2.Well Construction Permit#: „ 16.INNER CASIN BIN aI closed-Ion
Liu all applicable well Construction peen is(l.c.UIC,Count,.State.Variance.eta) FROM TO DIAMETER
®® THICKNESS
3.Well Use(check well use): tO
Water Supply Well: MIEN ft. in. 11.11111111111111.11
FROM TOO DIAMETER SLOTSIZE THICKNESS
iirnaMME
)♦Agricultural �IlyunicipaVPub11Cft- Mil
>♦Geothermal(Ncati»g/Coasns Supply) Csidcntial Water Supply in. --
a IndustrialiConrtytercial pP Y(single) ft.
Rcsidcntial Water Supply(shared)
H. ®_--
•Itrieation IS.GROUT
�
Non-Water Supply Well: FROM TO MATERIAL EMPLACEMENT METHOD$AMOUNT
Injection Monitoring
®� ` hi
Well: ORccovery f e
*Aquifer Recharge ®Groundwater Remediation ® e.
'Aquifer Storage and Recovery oSalinity Barrier
IS.SAND/GRAVEL PACK a;;•likable
*Aquifer Test �•'-�y FROM TO MATERIALL�O 5tennwater Drainage NMEMPLACF.AIENT METHOD
a Experimental Technology ft. 111111111111111
Subsidence Control
a(Geothemtal(Closed Loop) ® R,
Tracer 20.DRILLING LOG(attach additional sheets if necessary
ir
_ Geothermal(Heating/Cooling Return) ( (lOther(explain under#21 Remarks) MEMEEN TO DFSCRIP ON(color.hardness,son/rock h, "rain
n® s� ele!
4.Date Well(s)Completed: —V�1-1 Well ID#
5a.Well Location: ran ef R. id 'vet
FacrhtylOwner NameR'
Facility ID#(if applicable) ® ff.
i4yt`rP ' C
Physical Address.Cny,and Zip
��il ®MI ' MAX 1 . Z0Z4
County
Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field.one Iatflong is Sufficient)
•
22.Certification:
N
W
6.Is(are).the AyeH(s) i^ ermanent or I empornry •
Sy;naturc ofCenrficd c11 Con ctor _ C/
7.Is this a repair to an existing well: lies or Date
Bwith Mit y signing this form,I hereby err*that the ut!/(s)was(were)eonrtnrcted hr accordance
Iflhis Lea rymir,•r//nut known well r°nrtrnrtlon Ir finmatio,and erplain due nature of the copy'(Phis recordC C.O1Rt)or/SA NCAC 02C.0300 Well Construction Standards and that a
(ear been pmvided to the ur//ouster.
repair nodes 42/remarks swim;or of the hark(Phis Arm.
23.
m or
ils:
8.For Geoprebe/DPT or Closed-Loop Geothermal Wells having the same You S use back additional tthi a well
Sto provide additional well site details or well
construction.only I GW_1 is needed. Indicate TOTAL NUMBER of wells maypage p
drilled: construction details. You may also attach additional pages if necessary.
9.Total well depth below land surface: ,,� SUBMITTAL LN'STRUCTIONS
For multiple wells list all depths ifdli/f rein(example-30090 and 3 (fL) 24a For All Wells: Submit this form within 30 days of completion of well
(a;loo') construction to the following:
10. waterStatic level below top of casing:
l0. •rlevelisabort•easing.use"+.. �6 (ft.)
Division of Water Resources;Information Processing Unit,
11.Borehole diameter• 1617 Mail Service Center,Raleigh,NC 27699-1617
(in.)
12
24b.For In(ection Wells: In addition to sending the form to the address in 24a
.6ticll construction method: D(Z �;jJ above,also submit one copy oft is form within 30 days of completion of well
(i.i.e.auger,rotary,cable,direct push•etc.) construction to the following:
FOR WATER SUPPLb'WELLS O\LY: Division of Water Resources,lUnderground Injection Control Program,
13a.Yield 636 Mail Service Center,Raleigh,NC 27699-1636
(tipm) - Method of test; 4_____
24e.For Water Su only&Iniection Wells: In addition to sending the form to
13b.Disinfection ype: the addresses) above, also submit one copy of this form within 30 days of
Amount:/� completion of well construction to the co Inty health depertinent of the county
where constructed. .
Form OW-I
North Carolina Department of Environmental Quality-Division of Water Resources
Revised 2-22-2a16