GW1-2022-10394_Well Construction - GW1_20221115

NVELL CONSTRUCTION RECORD(G'W-1) For Internal Use Only:
L Well Contractor Information:
RAWLINS CLARKE IV 14.WATER ZONES
---•• '- FROJt TO DFSCRIPTIOIY
Well Contractor Name 22 tt. 44 R.
4234-A
NC Well Contractor Certification Number y5 OUTER ER CASI1dG or rtulli-cased wells OR LINER if a ticable
-REDOX-TECH LLC MQ1$I To DL!-,ILTER TxICKtiFSS 1fATERL-,L
"_.'...-_.. 0 fL 24 fL 2 rn• SCH40 PVC
Corttpany Name
2.Well Construction Permit##.
UIC Permit W10400345 FROJIVERC o1NGORTUBDLe0Grttitther I THI�NM MATERIAL
List all applicable irell construction permits ft a UIC.Coann:State.Variance,etc.) rL ft. UL
3.Well Use(check well use): fL R in.
-- - -- 17.SCREEN
Water Supply Well: FMO.01 TO DL411LTT.R SLOT SIZE THIMNESS at►TERLAL
Agricultural [3municipaltPublic 44 ft. 24 ft. in,
Gcother=I(Heating/Cooling Supply) ❑IResidential Water Supply(single) rL rL is
Industrial/Comincrcial DRe sidential Water Supply(shared) I&GROUT
FROJI TO NIATERIAL E11PLACEa1L`fT SIETHOD&A NIOUNr
- -- - 20 fL 0 !r tJFjlT POURED
-Non-Wafer Supply Well: _
L6(onitoring Recovery % ft.
injection Well: rL R.
Aquifer Recharge DGroundwater Remediation
19.S.4ND/GRAYEI,PACK(if a lieable)
Aquifer Storage and Recovery Salinity Barrier__ FRosI TO a1ATERLaL ►CE-,IL�T METHOD
Aquifer Test DStormwater Drainage 44 ft- 22 D.
r
Expedmenlal Technology DSubsidence Control ft. It.
Cr�¢hermal(Closed Loop) DTracer ;. 20,DRILLING LOG attach additional sheets if necessary)
6120b/ TO DESCRIMON(solar,tardam st0ratk Iy2e,grain s¢a etc-)
Geothermal(Heating(Cooling Return) Other( . lain under d21 Remarks) fL
- --- 0 .75 COWCRcTE
—r—
_.. 4.Date Well(s)Completed: 1019/2022 Well IDff IW 11 .75 ft• 1.25 fL GRAVEL
Nis rL 44 ft. DAM GREY SILTY SAND
5a.Well Location:.
_Energlzer_Batte NCD000822957
iL it.
Facility/OwrwName Facility ID#(ifapplicable) `1
419 Art Bryan Driver Asheboro 27203 fL fL
Physical Address,City,and Zip fL fL-.
Randolph - 7753756912 21•R, '"':K�
Ittlo;laZation r cae�as.^,g A
C—y..__ Parcel Ideatification No.(PIN)
5b.Latitude and longitude in degrecs/minutes/seconds or decimal degrees:
tifwcll field,ore taVlong is sufficient) 22. a fication:
• 35.76967440331657 IN--79.81816859946849 W11 It 12Z
SignatreofCcnificd Well Contractor Date
o.Is(are)the wetl(s) Permanent or Temporary
g.,Aigning thhrjarm,I berefir•certi&that tie erellts)tray(were)constructed in accordance
7.Is this a repair to an existing-,yell: OYes or X]No iririr lSji XCAC O2C.0100 or Ii.4.,VC.4C 07C.0200 Nell Ce-Inicrion Standonts and brat a
/!this is a repair fdl ant knovn well constrtn lion infannatian and esplain fire nature ai•the cols•of fibs retard bar kern provided to the trell owner.
repair tinder R21 remarks section or an tire back ofthicJana. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You rtlay use the back of this page to provide additional evefl site details or well
construction,only I GWA is needed- Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SU .-MITTAL INSTRUCTIONS
9.Total-,veil depth below land surface: 44 (ft-) 24a. For All®yells: Submit this form within 30 days of completion of well
For medriple ttells list all depths iftlyJereiu(example-3(4200"aird 2CRI U07 construc¢ian to the folloeving:
10.Static-,Pater level below top of casing:22 00 Division of Water Resources,Information Processing Unit,
If tsarcr lerel is above coring,use"+'" 1617 hail 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:
(i.e.auger,rotary,cab[c,direct push,cnc.)
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 Suppht&Iniection Wells: In addition to sendine 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 county health department of the county
cohere constructed,
Form OW-1 Noah Carolina Department of Environrt and Quality-Division of Water Resources Revixed 2-22-2016