GW1-2022-10374_Well Construction - GW1_20221115

NVELL CONSTRUC3I0i1 RECORD (GIV-1) For 1niernal Use Only:
1.Well Contractor Information:
RAWLINS CLARKE IV 14.WATER ZONES
---- --- FROJI TO DESCRIPTION
Well Comractor Name 22 f1 29 R-
4234-A
NC Well Contractor Certification Number 15 OUTER CASING far multitased exalts OR LINER if a licahle
REDOX TECH LLC FRoat To DLMIt?TER TRICt4YESS DL►TERIAL
0 fI• 19 R 2 sn 'CH40 PVC
company Morgue 11➢NNER CASING OR T[IIBiNG(eotlicrMA clOstd-1090)
z.WeueautrDttiDnPermit#:UIC Permit W10400345 FRoat To DLA,IETER TiIICtcNFss aLATERLAL
- f1 R
Lis[all applicable trell construcrion permits(Le.UIC Canna•.State,Variance•era) in
3.Well Use(check well use): rn
- - Water SD 17.SCREEN
Supply Well: FROM I TO mx%rTER sLOTsizE THICI4Y " MFERLAL
Agricultural []dlunicipal/Public y fL 19 fL is
Geothermal(Ileating/CoolingSupply) OResidential Water Supply(single) R• R. in.
industrial/Commercial ❑IRcsidcntial Hrater Supply(shared) 18.GROUT
_11trigation FROM TO FNPL►CEMERF IETHOD&.AmouNT
-Non=Water SupplyWel1: _. 15.-- .% -.a --fL NEAT POURED
Monitoring []Recovery R t�
-injection Well: _ R. Ct.
Aquifer Recharge DGroundwater Remediation 19.SANWGRAVEL PACK(ifapplicable)
Aquifer Storage and Recovery - DSaliniiy Barrier- __ -_ FROM To MATERIAL F,tPLA IF\"I JIETIIOD
Aquifer Test DStormwater Drainage 33 R' S7 R
Experimental Technology DSubsidence Control
r��T
20.DRILLING LOG(aDacIs additional sheets it n ) -
GeqtherMA(Closed Loop) Lam.
racer_
FROM TO DPSCRIMMM esbr•6ar,Inns.xsSPr,xltt siz<,eu1
Geothermal(Ileatin Cooling Return) Other lee lain under#21 Remarks) ® R 75 R CONCRETE
10/9/2022 1W 10 75 R. 125 t1 GRAVEL
4.Date Well(s)Completed: Well ID#
Sa Well Location: DARK GRZI StLfY SAND
- fL
Energizer Battery _ NCD000822957
- -- Facility/OtvttcrMame Facility iDO(ifWlicsble) R R 1+.s `s R•
419 Art Bryan Drive, Asheboro 27203
R. tzv V 1 11
2022
Physical Address,City.and Zip
Randolp-h 7753756912 21•REMAR➢GS
Co,rmy Parcel Idcraifrcation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll Fwld,one lat/loug is suf icicra) 22. tcaflon:
35.76967440331657 IN. -79.81816859946849 W _ 11` 12Z.
6.Is(are)the,7eII(s) xPermanent or DTemporary SlgliaturcoECmtif"ua W6HCoutraeter Date
By signing tlru form,I herehp certi(r'drat the well(s)star(nere)constructed is acrnnluace
7.Is this a repair to an existing well: [3Ye5 or EINo evil,li:l uSCAC tnC.Ologur 1i4 IVC.aC 01C.glo iieM Canstnulion Standards and that a
!f this is a repair.ill oat keen well camina•tian i0 mrarian and esplain the nature ofthe cap}•of this retard/rev been provided to the well mmur.
repair tinder#21 renurrkrserrian or an the buck a thir(ann. 23.Site diagram or additional well details:
You may use the back of this pave 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 INSMUCTiONS
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this foam within 30 days of completion of well
For nnrltiple rvell7 list all depths if dif(erenr(trample-3@200"and?C'IW) Co"mfrCtl6n.w the following:
10.Static water level below top of casing:22 (ft.) Division of Water Resources,Information Processing Unit,
if stater level is above easing,use-"+•• . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in,) 24b.For Iniection 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: HSA construction to the following:
f i.e.auger,rotary,cable,dimes pushy 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 SuDDh�&Iniection 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 coumy health depanment of the county
cohere constmcied.
Fawn GW-I North Catalina Department of Environmema(Quality-Division of Wafer Resources Revised 2-22-2016