GW1-2022-10390_Well Construction - GW1_20221115

WELL CONSTRI C-MN RECORD(GI -1) For Internal Use 0111Y
I.Well Contractor Information: --
RAWLINS CLARKE IV 14.NATERZONES
FROM. TO uscmrnm!
Well Contractor Name 22 fL 40 R.
4234-A (L R.
NC Well Corivacior Certification Number 15.OUTER CASING for mniti-eased wells OR LiNER I if a Sicable
REDOX TECH LLC - AL
FROM To DL4viLTER TnIC14`itSS aIA,"_L
D ft. ft- 2 in. SCFt 40 PVC
Company Name p ' n ,g ,q 16,INNER CASING OR TUBING geothermal dosed 1 )
2.Well Construction Permit#: in.
V IC Permit
t NN 10`t003`•F5 FROM TO DLa\LEPER TnICI4� DLATERWL
List au applicahle well COMIMClion permits(i"e"VIC COUM):Stale.Va"ance.etc")
R. ft,
fL ft. in.
3.Well-Use,(checkwell use):
-- 17.SCREEN
Water Supply Well: FROM l To DIAMETER SLOT SIZE T11ICMNTss MATERL4L
Agricultural []Municipal/Public 40 IL 20 ft. 1°
Geothermal(Heating/Cooling Supply) DResidcritiall Water Supply(single) I, fL in
:)Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Ind s1OUN r
`lETWO D.4c:4
�1 TO b1ATER0.AL, ESIPI..tCE�elEtl7'[
hri ation_- -. FROM - .
Non-Water Supply Well: tB fL o ft- NEAT POURED
IYlonitorina. Recovery_ == ft. ft.
Injection Well: ft. R.
Aquifer Recharge 13Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery _ . Salinity Barrier FRost TO btATERIAL ENPL6CEilEOT PIEIHOD
Aquifer Test [3StormwaterDrainage 40 ft, to R•
Experimental Technology [3Subsideme Control ft. R.
Geothermal(Closed Loop) Tracer- -2o.DRILLING LOG attazh additional sheeb if oecess
I FRO31 TO DESCRIPrIOIY csbr.6arrin s5,swBrach t sari '/
Geothermal(Heatin ling Return) r1other(explainonder#21Remarks) D ft. 75 R- CO4CRM
-_ 4.Date}Yell(s)Completed:9/27/2022 Well ID#OB-9 .75 R 1-25 R' GRAVEL
r.2s ft. 40 2 DARK GREY SILTY SAND
-5a.Well Location: -
-- Energizer Batte ._-_ _.-...._ ..-.... NCD000822957 `L `t
-rya
Facility rf likable ft. R.
Facility/O n r Name ID#( )
419 Art Bryan Drive,Asheboro 27203 k. R. r f
ft. ft. f
Physical Address.Cny..and Zip -
Randolph 7753756912 21.RIMIARICS NeVZ
County - Parcel identification No.(PiN)
ifhrflfGYir3U0.1 i'f.•C.
5b.Latitude.and longitude in degrees/rainnttt (seconds or decimal degrees:
(if well Geld,one lat/long is sulliicicm) 22.Ce ten' n:
35.76967440331657 t 79.81816859946849 W t i'L 2'L
Si t of Ce ified%V fl Contractor Dam
6.Is(are)the well(s)OX Permanent or OTemporary
Bp sig»ing dris fnaT!!.i hciefn•eertili�drat[he tse(1(s)rcrzr(rseie)eonstnuTed in accordance
7.Is this a repair to an existing well: DYes or Xllo with IJd NCAC 02C.0100 ar IJ 4 iVCjfC 02C.0200(tell CansaTrcrion SramlarzG and dear it
U(his is it repair,ill our known well cansrrrrcrian in(armarian and esplaia die nalttre a!lire cop,•of rltis recortl/aas hee n provided to fire[sell M wee
repair lender#21 remarks section ar on fire hack ojthisJtrrne 23.Site diagram or additional well details,
You may use the back of this page to provide additional well site details or well
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:' SUBMITTAL INSTRUCTIONS
9.Total-well depth below land surface: 40 (ft•) 24a. For All Wells: Submit this form within 36 days of completion Of well
For multiple wells list all deprJu i#'dijferenl(..ample-JC4200"aml2'<&I l(Y) construction to the following:
10.Static seater level below top Of casing:22 (M) Division of Water Resources,information Processing Unit,
V'tvaier level is above casing,rase"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter, 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in_'4a
above.also submit one copy Of this form within 30 days of completion of well
12.Well construction method: HSA construction to the following:
Ii.e.aug,r,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 Suanly 3 lniection iYe11s: In addition to sending the form to
the address(es) above, also submit ohe copy of this form within 30.days of
13b.Disinfection hype: Amount: completion of well construction to;the county health department of the county
cohere constructed.
Fonn GW-I NanEt Carolina Depanmrnt of Environmental Quality-Division of dater Rrsoorces �
Revised 2-22-2016