GW1-2022-10391_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Lacko 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
24 ft.
3516-A ft.
ft. 40 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Redox Tech LLC FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 20 ft. 2 tn. Sch 40 PVC
Company Name
ING
2.Well Construction Permit#:
U I C Permit W10400345 FROM CTSOING OR TU DIAMETER L
hcrmalTHICKNESS MAT
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Su 1 Wcll: 17.SCREEN
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) ORcsidential Water Supply(single) ft, I ft.
Industrial/Commercial E]Residential Water Supply(shared) 18.GROUT
Irrigation rR TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. 16 ft.Monitoring Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge 0roundwater RemediationND/GRAVEL PACK if applicable)
pAquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test I�StonnwaI r Drainage 18 ft- 40 ft- Neat Pouted
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) DTraeer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Co0ling Retum) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soittrock a rain size,etc.)
0 ft. .75 ft. Concrete
4.Date Well(s)Completed:10-9-22 Well ID#IW-13 .75 ft. 1.25 ft. Gravel
Sa.Well Location: 1.25 ft, 40 ft. Dark Grey Silt with Sand
Energizer Battery NCD000822957 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft..
419 Art Bryan Drive, Asheboro 27203 «� �'
Physical Address,City,and Zip ft. ft. ^ ^
Randolph 7753756912 21.REMARKS c r
County Parcel Identification No.(PIN)
i µ �
DWQ/r3oG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latdong is sufficient) 22.Certif at JtfL Jar
35.76967440331657 N -79.81816859946849 wB �d 11/4/2022
6.IS(are)the well(s):01'ermanent or IOTemporary Signature of Certified Well Contractor Date
By signing this form,I herehy certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©I IYes or 'x No with 15A NCAC 02C.0100 a•15A NCAC 02C.0200 Well Construction Standards and that a
If this Ls a repair,fill out known well construction information and explain the nature ofthe copy of this record has been provided to the well owner.
repair wider 1121 remarks section or on the back ofthis 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 1 GW-1 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 wells list all depths irdifferent(example-3 200'and 2 cr 100') construction to the following:
10.Static water level below top of casing: (ft•) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 lilt.) 24b.For Inicction Wells: In addition to sending the fond to the address in 24a
Hollow Stem Auger above, also submit one copy of this forth within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division ofVVater 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 SuDDIv&Inicction 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016