GW1-2022-10386_Well Construction - GW1_20221115

NITLL C ONSTRUC Y10iX RECORD(GW-l) For Internal Use Only_
1.Well Contractor Information:
RAWLINS CLARKE IV 14.WATER ZONES
FROM TO DESCRIMON
Well Contractor Name
22 ft. 38 ft.
4234-A
rL IL
NC Well Contractor Certification NnnrbeC I&OUTER CASING(for multi cased wells OR LINER it a livable
REDOX TECH LLC FRasl TO DL4DIErER THICKNESS HATER411
D ft' a. 2 is SCH40 PVC
Company Name
2.Well Construction Permit#:
U I C Permit W10400345 Mo�R�o,NG OR TU p�31�ermalTHICK�Fss MATERM
List all applicable tretl construction permits(i.e.111C,County,State.Variance,etc.) fL R. in.
3.Well Use(check ovell use): fL R. in.
Water Supply Well: 17.SCREEN
FRO31 TO DL�titETEn, SLOTsIZB TIIICI4�TS5 aLTTERL4L
Agricultural DtblunicipaUPublic sa ft- 18' ft. in.
Geothermal(Heating/Cooling Supply) DResidcntial Water Supply(single) R, ft. in.
hmdustrial/Commercial DResidential Water Supply(shared) 18.GROUT
-'Irrigation FROa9 I TO �IATER1AL EJIPLaCEAt&rTd1ETHODL-AOIOU'iT
- = - i4 fL R.
Non-Water �VeJI: 0
- - -
4lonitoring DRecovery
Aquifer Recharge DGroundwater Remediatien
19.Sr4siD/GRAVEL PACK ifapplicable)
Aquifer Storage and Recovery DSalinity Barrier FRav1 TO MAT MIA. Wk6T',%19 MOD
Aquifer Test DStormwater Drainage 38 R 16 H
Experimental Technology DSubsidence Control R• 0
Geothermal(Closed Loop) DTracer-.. 20.DRILLING LOG attach additional sheets if necessary)
To DFSCRIPf90N eebr hardness smNreaOa n etc.)G ma entherl(➢IeatineCooling Return)) Other(explain under#21 Remarks) FRo11
R
f
9/27/2022 ._- ... .. IW 04-- - J5 ft• 1.25 IL -
4-Date Nell(s)Completed: Well ID#
tZs ft. 38 It.
5a.Well Location: S
Energizer
-` - Batte NCD0008229 57ry fR aR 1 2022Facilety/OwncrName FacilrylD# faµplirabk)419 Art Bryan Drive, Asheboro 27203 fLD"
Physical Address,City,and Zip
Randolph - 7153756912 2' IU'"'"tKS
County Parcel identification No.(PIN)
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field,ow lat/long is snfcicrm) 22.Certil➢ea n:
35.76967440331657 r--79.81816859946849«,
6,Is(arc)the wcll(s)0Permanent or DTemporary 5iptaaturc©fCenificd e+/cll contractor to
By sigrtiag[biro form,1 herehr certiftt•[bar the nell(s)tray(trerel constrnrted in mcardo ace
7.Is this a repair to an existing well: Dyes or HINo with ISA tiCAC 02C_OIINI or 15A NCAC 02C.0200 Mull Construction Standards and turf a
f%drzs is it repoir.ill ara unenvu well c omarretion information anti erplain Ike nature a%dre call o%this record hav been pra id al to the well wvner.
repair under R21 remarks section or on the hack ofthb.form.
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 1 GW-➢is needed. Indicate TOTAL NUPt113ER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL IN'STRUCTIOtiS
9.Total well depth below land surface: 38"4 00 24a, For All Wells: Submit this form within 30 days of completion of well
Forandaple,[cells list ill deplis if different(example-3(m_260'and 2@100') construction to the following:
10.Static water level below top of casing:22 (ft.) Division of Water Resources,Information Processing Unit,
!f water terel is above casing,rise"'+" 1617-Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
above.also submit one copy of this form within 30 days of completion of well
12.Well construction method: HSA construction to the following:
ti.e.aueer,rotary,cattle,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: 24c.For Water Suoah•&Iniection 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 tyre: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Encironewatal Quality-Division or Water Resources Revised 2-22-2016