GW1--02791_Well Construction - GW1_20240506

•
•
dOi�A.Ili:Q:Q91�1 'Il'IlwC�'Y�Ni YRIECO G -1
For7nternal Use Only: •"
I.Well Contractor lnformationi, -
CFiris Kin •
g:
Well Coatiactor Name
FR017 TO • DESCRIPTION .
NC.Wel!Contractor Certification Number
Aqua Doll, Inc, 1S OUTERGASIhG far multi-cased wetls ORLiNER ifs' liable '
.. MOM` . • TO - :DIAMETER•' .• •THICKNESS.'• .MATERIAL " "
Caitipany Namc •
2.Well Constrnctiriti Permit#: �p, �L."
• t6 INNER .To. • O . I othermtal closed-loo
. List all upplicnhle url!coiiTinrction penn/ts p e,'VC Cortnh:State.Variance.etc.) • "
.
..FROM TO. � ••. DIAMETER THICKNFSS .
3.Well Use(check�edl use): .. '• :R f
•� In
Water Supply Well: •
.
. t 1 n
• • 17.SCREEN.
1�!4gri- •- •l FROM"• ' TO DIAMETER SLOTSIZE - •
. lb Municipal/Public • '• . -ft." • ft. Io. TNiCtL4ESS : 'tifATERtA4
'Getilhennal(Heating/Cooling Supply) . csidential Waters I sin lc
Supply(. g 1•. R. •
. II Industrial/Commercial t-�
csidclidal Watcr:Supply(shared) "
�•Irrieation. . , . •1S:GROUT'• _ R.
la
•
Non=Water Supply Well: • .. • '- _. PROM . TO . • ' •. • MATERIAL . ',EMPLACF,MEAT.METHOD&AMOUNT.
.Monitoring
...It'. '�� ft.: Ian•.• •
Injection wen: ,r...• ,. ry:. " .
ft.• L, .
]hAquifi:rRecharge •• • • . '
GroundwaterRemediation, : •
ft.
Aquifer Storage and Recovery Salini 19.SAND/GRTO PACKtifu llwble
. . AI Aquifer Test•;. . : TO MATFRIAi -
• ty t3arrier . .. FROM.
J Aqui4743a or Test
TechnologyDrainage. •
. .DSubsidenceControl '
. . •
,1�iG�themial(Closed Loop) • :�fTmcer• ,..• .. . '. . � : .. . ,
Geothermal(Neating/Cooling Return)•. Other( .lain under(#21 Rci'arks) •
10:NI.•• • TG LOG'attach additional ON coo banInary .• ' . •• '
FR011:.. • TO. DESCRIPTION filar hardness solVrack n to size etc
4:pate"F�cll(s)Completed:L R': � ft !t ia.i
e11 iD# • it .
• 5a:Wei[.'1.ocaHon: •
.. . .. . . . . � /'Z t; ..
Facilityt(hvra Namc .. .
. ra •. ctt try'1D;9(ifa •licnblc
•
•
Physical nda:�.c�n'✓� /and zip. f _ ,� �,. j ..
dV I Zt. .
ceanty ." . ; REMARxs 61 i,
Parcel identification No.(PIN).
non
Sb.Latitude and longitude in.degrees/mivacea/secondt3 or decimal degrees: •• (if well field.one 1aVlong is-sufficient) • • • R r:•,: ^
. .: 22.Cer'tlficatlOn: .. .. .. .
•
e' . -
�° W. "� i. •
_. _ a. : .6.Is(aec)thevcll s11ermaaent,.or• Tmporary" Sigoatute ofCctttfiell C tractor Date,": " •
•
7:Is tlils'u repel!'to an erdsthig well: ,Dyes or ONO . B,t'slgaing'(Ids fiat,:I'heirht•rest •that i/id utfl'•s)iris(here)c nistru led In acr .
• ur•(h 1SA NCAC 02C:0100 or ISA NCAC o2e•.O? 9 ?nee
. . •Ifthls•ie a repair,•lil/mu knaim 441 i•amM ion h jnnrat on and mplain the mNrirc Oldie c'opr eft/ds tta•uni hachceri prorldad to the.uullonnen' "
n�uir nnrler ti31 rinrurkr see thin orntr lire bark rfthic form. 00 f#'elFCnnstntrilun Standwtdr arid dtuc u
•
•23.
ite
S.For Geoprobe/DPT or Closed-Loop Geothernutl Wells having the same • Yo mayl se the.back o thisaM or p Page to provide additions
conic uclio:i,"only'I OW-1 is needed::Indicate TOTALNUMBER of c oa� l well cessar details or well
drilled:' ' mctiondetails: You may also attach"additional pages if necessary, •. '
cbnst
•
•
9 Total WO depth below land sarface e-}. SUBYIITTAL INSTRUCTIONS
For ltiple ells/lst all deptlu ild fe surface::
a(esanr lc-afar 24a.Fop All W Os •
p vo and_a100') • (R•) —�_• Submit this,form within;30 days of'coincompletion of:well
10.Stai:c.lvater level below top of casing:_ constluction to the following:"• •"
If.St lei c!Ls',haveeel b el w •p ' (ft) Division of Water Resources,Information Process Ing•Unit, •
11.Boi clinic diameter: 1617 Mail Service Center,Raleigh,NG 27099-1617
(In.) 246.For inleetlon Wells:.In.edditionl to sending the form to the address in 24a .
12.Well cor�struCHon.method: ^�. .• �.].� cone, ctso.so the
copy of this forth within 30 days of completion of well
(i:c;auger,rotary,cabie,'dintct push;etc,) -•i► construction to the following: j ,
F012�1ii�TL'•Y2 SIf. ..Y FELLS O;oLY• • Division of Water Resources,Underground InjectionControl Pro
1630 Mail Service Center;Raleigh,Ne 27.690-1636 .gym,
131t.1'ieid(f,'P?n) tlf. . Method most ' j I''I;
- 24c.For.Water Sit Iv&in ecti o�lls: 7n addition to sending the form to
• 136 Disittcctiaa type: / ' '- the addresses) above, also submit one copy of this form Within 30 days of
" / Amount:l(o Q's" completion of well constriction to the county health department of the count re constructed. Y
Form OW-I
North Carolina Department of En ironniental Quality-Division of Wntcr Resources j _ - --