GW1-2022-10393_Well Construction - GW1_20221115

NVL1LL CONS'TRUOTION RECORD(62 -1) For7n3erna]Use Only.
1.Well Contractor Information: _
RAWLINS CLARKE IV 14.WATER ZONES
_ FROJI TO DFSCRIMON
Well Contractor Name 22 ft, 43 R.
4234-A - ft. n.
NC Well Contractor Certification Number 15.OUTER CASING or T!L, axed creUS OR LINER if a le
REDOX TECH LLC FRO31 To DLL\I@TER TnlctcsFss ,ITeRLaL
-- D ft. 24 R 2 in. SCH40 P+IC
Company Name Permit
¢ /�/ 16.INNER CASING OR TUBING cothermal closeddoo
2.Well Construction Permit#:U 0 C I�erm i a 411J 10400345 FRool ro DLLMMIt T[IICKNESs aLeTERLu.
_ in
List all applicable well construclion permits(l.e.UIC,Count;Stare.Variance,ere,).._.
_ R R. in.
3.Well Use(check well use):
Water Supply SCREEN
pp Y Well: FR FRost TO OLaItEfER SLOT 517E THICIG�'ESS aLaTEtttaL
Agricultural DMunicipal/Public 43 ft. 23 R, tO•
Cseothcrrnal(Heating/Cooling Supply) DResidential Water Supply(single) R, ft. in.
lndustrial/Commercial DRcsidential Walcr Supply(shared) IS.GROUT
hri ation FROM TO �SATERIAL 6:\IPLACE11EtlTelE7HOD&.L\IOU�ir
19 n, D .. .(t' NEAT PJtIt3ED
-Non-Water Supply We11:----- �•—p
Monitoring DReeovcry R R.
Injection Welk
Aquifer Recharge DGroundwater Remediatian 19.SAPID/GRAYEL PACK if applicable)
Aquifer Storage and Recovery __-____ DSalinity Barrier-_.. FRo,\l TO MATERIAL &\(PLaCE\IE�TAtET1 O
Aquifer Test DStomtwater Drainage 43 ft 21ft. rL
f4
Experimental Technology DSubsidence Control
i GeedterDtal(Closed Loap) --DTracer-_ - ---- - Z0.DRID LiNG LOG(attach additional sheets if netessa
FROM TO DESCRIPTIOPi Ieo:ar,k:rdoess,sm"HrrxL t a '. .fie•)
Geothermal(Heating/Cooling Retum) Other( . lain under#21 Remarks) D n• .75 R. CQNCREFE
_ 4.Date Wells)Completed: 10/1 1/2022 'Well iD#IW 12 .75 n 125 R, GRAVEL
5a.'Ye11 Location: .. . .. _ +� L DARK GREY SILTY SAUG
R' 43
Energizer Battery ..._._. iVCD000822957 ft. r ^
Facility/OwnrrNamc Facility IMP(7f aMUicabk) R. f4
419 Art Bryan_Drive, Asheboro 27203 n, R. �—
- --__ -- - rL 1
Physical Address,City,and Zip. R.-._. - -
-Randolph 7753756912 21.11ED1AR1cs
- - r ►s
County Parcel W--miftration No_(PIN) u
5b.Latitude and longitude in degrees/miautes/seconds or decimal degrees:
(ifwcll field,one hVlong is sufficient) 22.C " cation: '
35.7696744033,1657 n N .-79.81816859946849", L 1 I l 2 2
Sugwur of Cartifted Well Contractor Date
6.Is(arc)the weU(s)Dx Permanent or DTemporary
By signing dris form,1 herein•certify drat the weills)was(trem)cemarercted in ac corelance
7.Is this a repair to an existing well: Dyes or XDND with 111 NCAC 02C.0100 ar i3A NCAC 02C.0100 Well Cnnstrrniion standard&and drar a
Jdris is a repaii fill ant knacva well cnn&trucrian information and explain the aorraz ojdre ropy of drls recant has been prm•idal to ilia well nrvner.
repair tinder R31 remarks seraim or an tire back afthis farm. 23.Site diagram or additional well details-
3.For Gcoprobe/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 G%V-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages i£necessaty
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 43 (ft•) 24a,For All Wells; Submit this form within 30 days of completion of well
For narrlriple wells list all deprbs tfdi#erenr(erample-j@200"aad 21[&109) construction to the following'
I D,Static water level below top of casing:22 (D•) Division of Water Resources,Information Processing Unit,
ifwarer level is above casing,use-+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (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: HSA construction to the following:
Ii.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 N12il 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 addresses) 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.
Form Gbb'-1 North Carolina Department of Enviranntet[tal Quality-Division of Water idesonrces
[devised?lido i 6