GW1-2022-10389_Well Construction - GW1_20221115

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tiVE LL COl\STRI3CTIOl1 RECORD GAS-� ForIn1 3
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L Well Contractor Information: - -
RAWLINS CLARKE IV 14.WATERZON)?S
_ - Molt TO DffSCR[t'rt N
Well Conlractor Name 22 ft. 37 H.
4234-A ft. ft.
NC Well Contractor Ceraifaca[ion Number 15.OUTER CASING for®ulti•eased yells OR LINER [f Geatile
REDOX TECH LLC FROM To mWtETER Tntcicivss JIATERWL
_ - 0 IL 17 B- 2 [�' SGH 40 PVC
Company Nate 16.INNER CASING OR TUBING(aeotbertnal closed 1
2.Well Const>DcliDn 8ermil U I C Permit W i 0400345 FROM To DLk1tETER THIC[4�M 31ATERL.L
_ B. pa
Liss all applicable>rell construction permits(r.e.UIC.County:Srare,Variance,etc.)
fl. R. is
3.Well Use(check well use): -
---- 17.SCREEN
Water Supply Well, I To DI.►-%wm wrr size THICatlFss LAL
Agricultural 0dlunicipal/Public $7 ft. 97 fL im
Gcothcnnal(Heating/Cooling Supply) Residential Water Supply(single) 2 fL
lndustrial/Commercial DResidrntial Water Supply(shared) 18.GROUT
Irri ation FROM TO J9:►TERLlL EJIPLAC&1ItE+VT METHOD I;A3tOUN I
Non-Water Supply Well: - 13 ft- o I- FIERY POt)tiED
idlonitoring Recovery ft. It.
Injection Well: ft. R.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK if fe)
Aquifer Storage and Recovery. OSalinity_Barrier- - - FROJI To J1AT1Td1.AL &NPLACE�1&�T J9EfT10D
Aquifer Test _ DStormwatcr Drainage 37 a- 15 0'
Experimental Technology OSubsidence Control R•" H
Geothermal(Closed Loop) ----DTmcer - - 20.DRILLING LOG fattae6 a"tisraal sheets if necesn )
FROM I TO DFSCRIPra M(color,hardnem solyrork Brain soG etc)
_._ Geothermal(lieatingIcaclmg Retum) rJotha(explain under 921 Remarks) o R. .75 H- cow-t>YE
4.Date.wen(s)Completed:10/612022 well_t[x#IW-7 .75 ft- 1� et. �,,�
' to fL 37 ft,
OkRR GREY SILTY StVlbD
5a.Well Location: - -- - --
Energizer.Battery. NCDO0.0822957 H
_ Facili[y/Ocerc m rNac
Facitiry If3M(ifWplicablc) R' 0.
419 Art Bryan. Drive, Asheboro 27203IL kin-
Ptysical Addrtss.Cay.grad zip
Randolph 7753756912 21.REDIAPXS '
County Parcel Ideeaif[sation No.(PIN) riA
D4t1
5b.Latitude and longitude in degreeslutfnntesfseconds or decimal degrees:
(if well field,one Lvllong ig suf icicat) 22.qftrwicafiow.
35.76967440331657 N -79.81816859946849 W - 11111122
Si aure ofCettifed Well Contractor Date
6.Is(are)the well(s)EIPermancut or oTemporary
Br signing[his form,6 luarhr eerti(v slurt the well/sJ tress(were)constructed in uccnnhenre
7.Is this a repair to an existing well: Oyes or EINo with 15A NCAC 02C.0100 or 15.4 IVC,4C 02C.OZW Aell Constrrrrtior,Standards and drat a
ff tbis is a repair,r1l1 our kwIM well caustructian in(nraurlion and explain the nature n(the can,of leis re,and has beer;pro[•ided ra the rvdl envaer.
repair ender M21 remarkssecrian or on the back afth4r/erne. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or weDl
S.For CeoprobelDPT or Closed Loop Geothermal Wells having the same
construction,only I 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: 37 (ft-) 24a. For All Wells: Submit this foam within 30 days of completion of well'
For multiple hells list all depths if dierent(example-3@200 and'(d1001 construction to the Mowing:
10.Static water level below top of casing:22 (ft.) Division of W ater Resources,information Processing Unit,
If eater lerel is above casing,are-+" 1617 Nail 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 24a
above,also submit ow copy of this form within 30 days of completion of well
12.Well construction method: HSA construction to the following:
I i.r.auger,mlary,cable,direct push,etc.)
Division of WaterResonrces,Underground injection Centro)Program,
FOR WATER SUPPLE"WELLS ONLY: 1636 Nail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24e.For Water SuDuiv&injection Wells: In addition to sending the form to
the addresses) above, also submit one copy Of this form within 30 days of
13b.Disinfection tyre: Amount: completion of well construction to the county health deparimena of the county
where constructed.
Fonn OW-1 `lortb Carolina Departmrut of Environmental Quality-Division of Wager Resources Revised 2-22-2016