GW1-2022-10388_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Lacko 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3516-A 24 ft. 40 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
Redox Tech LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 20 rt. 1 2 SCh 40 PVC
Company Name
U I C Permit W 10400345 16.INNER CASING OR TUBING(geothermal closed-too
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.a.UIC,County,State,Variance,etc.) +f't
in.
3.Well Use(check well use): ft. in.
Water Supply Well: 17.SCREEN i
PP y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 20 ft. 40 ft. 2 in. 010 SCh 40 PVC
Geothermal(Heating/Cooling Supply) D'Residential Water Supply(single) ft. ft. in.
r-llndustriaUCommercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 16 ft.
Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
i .IAquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EMPLACEMENT nfETHOD
PAquiferTest E3StormwaterDrainage 18 ft. 40 ft- Neat Poured
Experimental Technology E3Subsidence Control ft. ft.
bGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 To DESCRIPTION(color,hard-,soil/rock type,grain size,eta)
0 ft- .75 ft- Concrete _
4.Date Well(s)Completed:9-28-22 Well ID#1W-2 .75 rt• 1.25 ft- Gravel
5a.Well Location: 1.25 ft' 40 ft- Dark Grey Silt with Sand
Energizer Battery NGD000822957
Facility/Owner Name Facility IDN(if applicable) ft. ft. y -- "�p
419 Art Bryan Drive, Asheboro 27203 ft. ft. t t-i
Physical Address,City,and Zip ft. ft. NOV 1 ,5 2022
Randolph 7753756912 21.REMARKS
Wori7na tan Pr.^c3e�D;rt3 Unit
County. Parcel Identification.No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IaUlong is sufficient) 22.CcrtifZion-�f
ZI
35.76967440331657 N -79.81816859946849 W 11/412022
6.Is(are)the well(s).OPermanent or OTemporary Signatfim<ftertified Well Contractor Date
By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: EIYes or jNo with 15ANCAC 02C.0100 a•1SA NCAC 02C.0200 well Construction Standards and that a
If this is a repair,fill out blown well construction h1formation and explain the nature of the cope ofthis record has been provided to the hvell owner•.
repair under 1121 remarks section a•an die hack of this form.
23.Site diagram or additional well details:
8.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 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS -
9.Total well depth below land surface: 40 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wel/s list all depths ifdierent(example-3Iib200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use +" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (irl.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Hollow Stem Auger above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.anger,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) Method of test: 24c.For Water SunDly&Injection 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 type: Amount: completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016