GW1--07312_Well Construction - GW1_20231109

.:iJua,a;vl�ailius.h U V lis✓LURD.(GW:1)
For Internal Use Only: -
1.Well Contractor Information:' .
Chri King • - :
Well Co tractor Name. : : _ - •
14.WATER ZONES t
2080 A. • c ft. C31.1
-FROM
•
DESCRI
: : -NC Well Contractor Certification Number ' • • •
• ft ft.. �.
' 15.OUTER CAS h
-Aqua Drill,, Inc: • : — -
. . -
LNG(for multi-cased wells)OR LINER�(if an'lieeble)
-FROM TO DIAMETER THICKNESS M TERIAL" ' -
Coro an Name
2.Well Construction Permit# C.V f .i(,j• .: : FROM C•O1NG TU DAMG E Eehe t EO.
List all applicable lie construction permits(ie:U/C Coun ,:'State Variance;eic) . • . • . R.. .. • - .'- (a,•. - -
in
,:. h, -. _ Oft•: .. . .
MATERIAL,
3.Well Use(checkwell;use)p . R,- ::,. „ 1 .
= Water. apply Well. ,.
AgriC.ltural, . • - DIAMETER'! •SLOT SIZE THICKNESS MATERIAL •: '
LjMunicipalPublic •
' FROM'- TO`
.It ft. in
Gcoth Imal(Heating/Cooling Supply). idcntfal Water Supply(single)
Indus ial/Commcrcial • • • .-Residential Water Su 1 shared • • -
pP y� ). ft
tt UT ,ni.
7 . FROM-' TO_ • 'MATERIAL EMPLACEMENT METHOD&'AMOUNT
Non-Water Supply Well:.. • • ``,,�
Monitoring. RccovcryX'lU• '�lil r'K _
Injection Well;.
•• Aquifer Recharge'. • • :. DGroundwater Remediation •. ft
Aquifer Storage and Recovery, .Salinity Hamer' •: . ..FRa SAND/GRAVEL:PACK(if AtIicale)
Aquifer Test s • •• CE•MENT METHOD-
• FROM TO MATERIAL � EMPLA
•
•
., toiniwatt:r Drainage • : '.:8 ft . 1, . •. .
'• Experimental Technology • • • .OSubsidence Control' •. . • • - •• ". • _.•�,
( e- g ) f Other.(explain,under#21•Remarks)
• O• 20.DRILLING LOG(attach addl lonalsheets If necessary).; '; .
Ge0t11C rtnal. Heatln COOIin Return -- FROM.. .' TO :DEsaurn. , ON(color lardoess,satUrocktype.,aretu size,etc.) .
.• p R �• ff.•
4 Date Wells Com leted•J� : �S ::'t'•2 * - 1-
.O P 'ell1D# _ r :. tt ), - -•:! .' . . .
• 1 /� f7�
5a Well °cation:, . : - - ' , . . ' 1.. R.• /3/L a.iI LSO)/12/1�•e• • _• • • • • - •'
Facility/Ofncr Nante . L
• Facility lD#(ifi ppheahle) f • i
'
:3 7 :.ft
Physical A dress:•City,and Zip • •• • • ft. : ' :
ft:
•
•
� NUV •t) y ZUZ3
: County-:. , : . ire'. •• •. •
'21 REMARKS
Pared Identification No:(PIN) '• �,s .��.,
5b.tali de and longitude In degrees/mututesfseconds or decimaldegreea:. • • •-
.(rfwell Rol ,one lat/long*sufficient) . ' •.: '22 Certificationr : • i• -
N i'
6.Is(are) he well(s ermanent' .o e Signnaatute of Cortifi d!.elf Contrator ,'. . • :r �T mporary _ ,. . . � - - Date
' Bi signing this form,I hereby.:evil fi that''the wells)wOs(were)conxouried In accordance "7:Is this repair to an existing well: Yes. or o with 15A NCAC 02C.0190 or 1SA NCAC 02C,0?00,Well Construction Stantlords:and that a
If t his Is.'d pair,Jill old known well conshpcnnn in ornjarion•and explain the nature of the: roPY•nitl+ls►erard'hav been provided fn(hc ire!!owner
repair•und. 921 pampas.sectioa•or oil.the back of th1s form
• • Z3 Site Iagr_atn or additional well details. .
• 8 For.Ge•probe/DPT or•Closed Loop.GeothermalWellshaving thesame You may use the•back of this page to provide.additional'well site details or well
••' construbti n;only 1 OW-1 is needed.:lndicate-TOTAL NUMBER of wells', ':• construction details;'You:may also'aftach additional pages'ifnecessary
drilled:. . .
SUBMITTAL INSTRUCTIONS '.j
.
9 Total ell depth below land surface Q. }
" -. (ft.) '.24a•. For All the o Submit this form within••30• days'of completion of well
•• Forarultipl wells,lisi all depths{fd8erent(example=3(a�,20D'and?(a310U') - ,
Ili.Static ater level bel•ow' •top of c•as•ing.•- ' - . '(ft.) a Ce .
onstniction to the followmg:
'. If water/ev i is cbove casing,use. +�' _ � . . • Divieionof Water.Resoar •s,Information Processing Unit, .
1617 Mail Service Center,Ralelgb,NC 276991617: •'
I1 Boreh le diameter (in:) 24b.ForcIniection Wellse. In addition to sending'the form to the address in 24a
l2.Well onstrucHon method:" �)�Z .4 iv i'f above;also submit.one:copy of.. is I onn within 30 days of completion of well -
' (i.e..auger. fury,cable,diiectpush,etc.) : to•.
• const uction the following.
Division of Water Resource Underground Injection Contrlol Program,
FOR WA ER SUPPLY WELLS ONLY: • ` s' -
1636 Mao Service Center,Raleigh,NC Z7699,>t636
•• I3a Yid (gpm) " S . . - Method:of test: 51(;,h` ilk.,For Water' aplv-&Intection`Wells: In addition to sending the form to
'/ • the addresses)above,, also submit one copy'of'this.form within•30 days of
13b Disi faction type '. /'1 ' Amount - / •.l tO �/�— completion of.well construction to!,a county health department of the county
where constructed.
li ; .
Form OW- . North Carolina Department of Environmental Quality=Division of Water Resources • Revised 2-22=2016. " '