GW1-2022-10377_Well Construction - GW1_20221115

WE'LL COINSTRUCTION RECORD(GW-1) For Internal Use Only.,
1.1Well Contractor Information: _
RAWLINS CLARKE IV 14.WATER ZONES
-- \Yell Contractor Name FROM TO I DESCRIPTION I
22 fill
42 ft.
4234-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a licable
REDOX TECH LLC MATERLiL
SCFt 48 PVC
Natrx
UIC Permit 1n/10400345 16.INPiERCASTNGORTUBING eotbenualclosed•too
2.Well Construction Permit# FRoat To Dt,1111MR THICK, xl.►TEtttaL
Cut all applicable mll construction permits(i.e.U1C,County.3rare,Variance,etc.) ft. R, is
3.Well Use(check well use):
- - - Water Supply Well: - FRUIT E TO DLat+It:TF.R SLOT SIZE TIUCKNESS JL4TERLiL
Agricultural ®'lttnicipal/Public 42 R- 22 fit. �•
Geothcmmal(Heating/Cooling Supply) [3Rea-idential water Supply(single) ft. It. ;n
_ Industria/Commercial QlResideutial Water Supply(shared) I8.GROUT
Itria tion FROM TO MATEmAL E.11PL.AC0IENT dIETHOD&AJIOU.�{T
11ton-Wales Supp_ly iYell - -
- 18 0 NeAT Pt26tRED
-monitoring DRceovcry fL fit.
Injection Well: _ --:.-- ---------
ft. R.
Aquifer Recharge []Groundwater Remediation '
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery _ Salinity l3�rfle6, _ - ._. FROM To btaTERLSL 01PLACEi1�T O1F.TIIOD
Aquifer Test OStorrawater Drainage 42 ft- 20 fit.
Experimental Technology DSelhsidence control ft. fit.
3- Geothermal(Closed Loop) DTraeer __ --_ --__ _20.DRILLING LOG attach additional sheets if necessary)
FRUIT TO DFSCmPI•ION color,hardaess,so7DracLt Ax etc) ..
Geothermal(Ileatin Cooling Retum) Other(explain under#21 Remarks)
0 ft. 75 R• CGINCRETE
i
4.Date Well(s)Completed: 10/5/2022 Well iD#IW-6 .75 ft1.25 ft- GaAVE
5a.Well Location: Us ft. 42 ft. DARK GREY SILTY SAhO
Energizer-Battery.. NCD000822957 FL It.
Facility/OivncrNa= FacilityED#ffapplicabk).
419 Art Bryan Drive, Asheboro 27203 -
It. ft. i r �r r
Nov 1
Physical Address•City,and Zip ft. I rL
Randolph 7753756912 21.REMARKS 2022
County Parcel Idernifteation No.(PIN) Irl(t7rc1' ''-
�VIiQiSx,
5b.Latitude and longitude in degrees/minutes1second4 or decimal degrees:
(irwell field.one lat/long is sufficient) 22. ation:
35.76967440331657 r -79.81816859946849 W
Cer
6.Is(are)the well(s)[x Permanent or OTemporary S;anatuix:of Certified Well Contractor Date
Br signing this farm,1 herein certifi,drat the trellis)win(were)camtrneted in accordance
7.Is this a repair to an existing well: []Yes or ®No trith i5A JVCAC 02C.010o or 15A MAC 02C.0100 Mall Cinvo tetio"Standards and deal a
fftltis is it repair.fill ant known well canstruction h7formatian am/explain the"attire o1•die copy of iris record has been provided to the well owner
repair tmder mJ remarks sectionor on rite back o/dtis/ants
_ 23.Site diagram or additional well details-
S.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 GIV-1 is needed. indicate TOTAL NUMBER of tyells construction details. You may also attach additional pages if necessary.
drilled: SUBiIITTAL INSTRUCTIONS
9.Total well depth below land surface: 42 (fit•) 24a, For All Wells' .Submit this form within 30 days of completion of well
For multiple nells lift all deptlu i/tlijferenr(evample-3@200'and 1@100 construction to the following:
10.Static water level below top of casing:22 (150 Division of Water Resources,Information Processing Unit,
!f Crater level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above,also submit one copy or this form within 30 days of completion of well
12,Well construction method: HSA construction to the following:
(Le.auger,rotary,cable,direct push,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) ilethod of test: 24c.For Water Supply&Iniection iVells: In addition to sending the form to
the address(es) above, also submit one copy of this farm within 30 days of
13b.Disinfection type: Amount* completion of well construction to the county health department of the county
cohere constructed.
Form GET"-I North Carolina Department of Ent iroamernal Quality-Division of Water Resources Revised 2-22-2616
I