GW1-2021-00229_Well Construction - GW1_20210702

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WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW-1 Well Construdon Electronic •
North Carolina Department of Environmental Quality
April 1,2021
Page 1
Submission ID#
GW 1-2021-00229
CONTACT INFORMATION
..................................................................................................................................... .........................................................................
Contact Name* Email Address*
Rawlins Clarke IV [e-mail]
Is this a revision to the form you have previously submitted?
f Yes r No
WELL CONSTRUCTION INFORMATION
.........................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
4234 A RAWLINS CLARKE, IV Redox Tech IIc
2.Well Construction Permit#:
List all applicable well construction permits(i.e.Ivbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3. Non-Water Supply Well* r Monitoring
r Recovery
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/10/2021 (gallons per minute)"

Page 2
5.Well Location
Facility/Owne r Name*
Robert and Karen Lane Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Buncombe
Physical Address* Street Address
115 S and T spirit dr
Address Line 2
City State/Pro\ince/Region
candler nc
Postal/Zp Code Country
28715 buncombe
Latitude* 35.4950120000 Longitude*82.6784120000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a)plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 5
9a.What is the depth of the casing from ground
9.Total well depth below land surface:(ft.) surface?
2@5',2@10'and 1 @25' 2@5'2@10'and
For multiple wells list all depths if different 1 @25'
(example-3@200'and 2@1001 in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
18' 2.25
If water Ie\el is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other

Page 3
14.WATER BEARING/FRACTURE ZONES
From To Description
18' 25'
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 5.00 2.25
in feet in feet in inches
0.00 5.00 2.25
in feet in feet in inches
0.00 10.00 2.25
in feet in feet in inches
0.00 10.00 2.25
in feet in feet in inches
0.00 25.00 2.25
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
18.00 25.00 in inches
in feet in feet
18.GROUT
........................................
From To Material Emplacment Method &Amount
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only

*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
6 A&Zlr
Signature of Certified Well Contractor
Submittal Date 7/2/2021