GW1-2022-10395_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Chris Lacko 14.WATER ZONES I
Well Contractor Name FROM TO DESCRIPTION
3516-A 24 ft. 40 ft.
ft. 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
Company Name 0 ft. 120 ft. 2 in. Sch 40 PVC
UIC Permit WIO400345 16.INNER CASING ORTUBiNG eothermalclosed-loo
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) fit1
ft. in.
3.Well Use(check well use): ft. I ft. in.
Water Supply Well: 17.'SCREEN f ..
FROM I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 20 ft- 40 ft- 1 2 r"' 1 .010 1 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. I ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
Irrigation .FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 16 [t.
DMonitoring Recovery ft. R.
VlAquifer
tion Well:
uifer Recharge'Groundwater Remediation ft. ft.
19.SAND/GRAVELTACK if a licable Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
[DAquiferTest ]StormwaterDrainage 18 ft. 40 ft. Neat Poured
Experimental Technology DSubsidence Control ft. ft.
WGeothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary) I'
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain sae,etc.)
0 ft. .75 ft. Concrete
4.Date Well(s)Completed:9-28-22 Well ID#IW-1 .75 ft. 1.25 ft• Gravel
5a.Well Location: 1.25 £t. 40 ft- Dark Grey Silt with Sand
Energizer Battery NCD000822957
Facility/Owner Name Facility ID#(if applicable) fit. ft.
419 Art Bryan Drive, Asheboro 27203
Physical Address,City,and Zip ft. ft. . t
Randolph 775375691-2 _ 21.REMARKSNov .1t, L
County Parcel Identification No.(PIN)
-5b._Latitude and longitude in degrees/minutes/seconds or decimal degrees: lnfarzal coil hrocw' @ Unit
(if well field,one lat/long is sufficient) 22.Certifi or'
35.76967440331657 N -79.81816859946849 W 11/4/2022
6.Is(are)Me well(s).;x permanent or Temporary F'- Si re or Certified Well Contractor Date
By signing this form,1 hereby cc,•tify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ©(Yes or E No with 15A NCAC 02C.0100 or I.iA NCAC 02C.0200 IVell Construction Standards and that a
If this is a repair,fill out known well construction information and erplain the nature of the copy of this record has been provided to the well owner.
repair mtder 1121 minarlu section or an the back 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 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 (fit-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Crd.200'and 2«.100') construction to the following:
10.Static water level below top of casing: (fit.) Division of Water Resources,Information Processing Unit,
If water level is above casing,rue"=" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:8 (irl.) 24b.For Infection 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.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) Method of test: 24c.For Water Simply& 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.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016