GW1-2022-10378_Well Construction - GW1_20221115

NNTLL COINSTRUCTIONT RECORMGW-1) For Internal Use Only.
1.Well Contractor Information:
RAWLINS CLARKE IV 14.WATER ZONES
Well Contractor Name FROJI TO DFSCRIMMN
22 It- 37 ft:
4234-A
fL R.
XL C Well Contractor Certifteacion Number
15 OUTER CASING for multi cased xelts OR L➢NER d a 1[ca6le
REDOX TECH LLC - FROM TO Dlaa N R TRlctc,YFM 1 MATERIAL
is SCH40 PVC
Company Name claw"
2.Well Construction Permit#:
UIC Permit WI04'00345 1166.O INNER C O➢NGOR7T16NG(geRhe�TNICt4`fFSS aLATERLtL
List all applicable nell construction permits(i.e.111C.Cormh%Stale,Variance,etc) iL R. in.
3.Well Use(check well use): f. R. try
y _
- - Water Supply Nell: 17.SCREEN
FRO,II TO DI.A,VIE M SLOTSIZE THIMNESS 3LATERUL
Agricultural []Municipal/Public 37 ft, 17 fL in.
Geothermal(Heating/Cooling Supply) ❑IResidenlial Water Supply(single) fi. ft. in
Industrial/Commercial ORcsidcotial Water Supply(shared) ➢&GROUT
'Irrigation FRO,l1 TO MATERIAL EJIPLACEM 4T METHOD&AMOUNT
- Non-Water Supply Well: 13 R 0 0- NEAT POURED
Monitoring DRecovery R. IL iL R.
Aquiti r Recharge DGroundwater Remediation
19.&UND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery .- Salinity Barrier - FRQM TO MATERML IMM ACE,MF\,T JlEMOD
Aquifer Test DStormwater Drainage 37 R• 15 ft.
Experimental Technology Dsuwidcnce Control R; R.
Geothemud(Closed_Loop) _Tracer---____ ________ __ 20 DRILLING LOG altac6additiom➢shtetsifnecssa )
FRMI TO DESCRIMON cabr,6udvos,s&Wrmk t . sit-ate➢
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks)
0 ft.
.75 ft- CONCRETE
_. 4.Date Well(s)Completed:9237/2022 Well ID#1W-5 75 [L tom, [L GRA
VEL
5a SVe11 Location: 37 R. DARK GREY SILTY SAID
Energizer Batte NCD000822957 °'
-. Faciiii3dOwrterNamo Facility IDk(ifalyrieabic) iL
419 Art Bryan Drive, Asheboro 27203 ft. R. �-
Physical Address,City,and Zip ft. R. 2022
Randolph 7753756912 21.R➢MARKS
County Parcel Identification No.(FRIG r 11t
5b.Latitude and longitude in degrees/minutesfseconds or decimal degrees:
(ifwAl field,our WIong is sufficient) 22, e '[cation:
35.76967440331657 -79.81816859946849 ev -�
l ZZ
6.Is(are)the well(s)Jg Permanent or DTemporarg Signaaure ofCettifted WcilCargisctor Date
By signing 11mi farm,1 Macke-carrijv flat the well/s)war(here)constructed to r cnrrfsnar
7.Is this a repair to an existing well: Yes or ElNo with 15A IMIC 03C.0100 ar 15.1 MC-tC OIC-011t913eq Canstructinn Stamlardv and that a
!Rids is it repair.ill ant known well caustruction iglorntanitm and t rplain file unra a of the copy o/this reeenrd has bear press hial to the well owner.
repair antler T21 remarks section or on fire back nl7bi�form.
23.Site diagram or additional well details:
S.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 I GW-I 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: 37 (ft-) 24a. For All Well%: Submit this fowl within 30 days of completion of%veil
For multiple wells list all diptlu ijd erent(erumple-3(ru200'and 2`4Mtn construction to the following:
10.Static water level below top of casing:22 (ft.) Division of Water Resources,Information Processing Unit,
ljtrater tcrel is above casing rise '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 2 Fa
above,also submit on form e copy of this fo within 30 days of completion of well
12.Well construction method: HSA construction to the follo%ving:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground injection Control Proggram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
On.Yield(gpm) 'Method of test: 24c.For Water Supply&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%yell construction to the county health department of the county
where constructed.
Form G`r@--t North Carolina Department of Eavironmemal Qualicy-Division of Water Resources Revised 2-22-2016
I