GW1--07750_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: I
1.Well Contractor Information:
Blair Mitchell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft. 1
4419-C
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if app)&able),
Redox Tech, LLC FROM TO DIAMETER THICKNESS I MATERIAL
ft ft. I in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WI0501065 FROM _ TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. I in.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. • ft. I'
• Injection Well:
ft. ft. I'
•
❑Aquifer Recharge a Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL' ' EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control ft. ft. I
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG(attach additional sheets if necessary) __
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it. ft.
11/13/23-11/15/23 IP-01 through IP-07 ft ft.
4.Date Well(s)Completed: Well ID#. -.
5a.Well Location: ft. ft. ! • r ' ._,,` �t k. 'i`y
Party Beverage ft ft. D
r, J 1 2P23
Facility/Owner Name Facility TN(if applicable) ft. ft.
5200 Western Blvd. Raleigh, NC 27606 ft. ft. ,P;, ;c;r,-,3
Physical Address,City,and Zip ft. ft.
Wake 0784511432 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.786729275476546 N -78.71309576066118 w h;2, Mt615 -D11/17/23
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor i Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ❑No with 15A NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the i,:vell owner.
repair under#21 remarks section or on 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.
I
drilled:
SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
1
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,IRaleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Injection 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: PT 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 Supply&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. j
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016