GW1-2022-10695_Well Construction - GW1_20221205

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WELL CONSTRUCTION RECORD (QW-1) For Internal Use Only: )
I.Well Contractor Information:
l
RAWLINS CLARKE IV 14.W.1'ITItZONrS
t lto+l '10 D{S([UPflop
Well Contnctot Mama ft. ft. )
4234-A )
NC Well Contractor Cendica(on Number 15.OUTER CASING(for multi-cnsed;wells)OR LINER IF, Ileablc)
REDOX TECH LLC uu)+I To 1 nlA+lt.ItR rin(KNus% +Iu1ulu
ft. fl. in.
Company Name
W 10700534 16.INNER CASING ORTIu41NG(eeolbermal closed-lou
2.Well Construction Permit tt FROM To nit+u IFit TIIICK\I:SF sl.+rt:ru•+1.
Ltv all aplyhroble urll cnnstna7tort permit,It e.L'/C.cof ly.State.Variance•etc.) ft. ft. in.
3.Well Use(cheek well use): _
R. ft. In.
Water Supply.\Nell; 17.SCREEN
FROM TO nf.%%I TF.11 SI or S17.F. rll('F\F.SS +1•+iFRL\I.
Agricultural FIN(unicipal Public h. ft. In.: ,
Geothermal(I[eating/Cooling Supply) Residential Water Supply(single) D R• in.
IndusinaliCominerciiil []Residential Water Supply(shared) 18.GROUT
Inl4altOn FROM I To MA FRI U. F.y1PL\('t.+ll_\T virri1(ln h AN1011 r
Plan-Water Supply Well: fl, f6
Monitoring QRcco+cry fl. n.
Injection Well:
fl. fl.
Aquifer Recharge Mioroundwater Renlediation
17.SANI)ICIL\1'El.PAC K i(n Ileablc)
Aquifer Slor-ige and Recovery E3Saliniry Barrier MOM I to +I\I)Rl el, F+IPI-%(t+IFV1 Nt IHOD
Aquifer Test 0Stonna;uerDrlinage
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) OTraccr 111.DRILLING LOG(mast[additional sheets If necessary)
FROM 'TO DFSCRIPI ION Icolor,hardnns.,ulUmck type.groin dta arc.)
Geothermal(IlrninP�Coolin,Return) Odler(ex lain under=21 Remarks) ft ft
4.Date Well(s)Completed:111312022 Well TD?f IW1-06 n. ft-
tl. u. '
,a.Well Location: _
Dupont Kentec Facility ft• ft. _�
Facility"/Owner Name ractlity IDn(irappbcablel ft. ft, -
4610 Braxton Rd Grifton, NC I' " DEC 0
Ph}-�ival Addres;•City,and Zip ft. ff. -
21.REMARKS ;:irm....r_•1 i'fC',va a 7 11
PitULenior ,
D"•M1r'i`t�./BOO
County Parccl IdcnuRcation No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field,one Iadlung is sufficient) 22. .e lication:
na na W 11/20/2022
6.Is(are)the stell(s)�IPermanent or ©ITemporary ;nature ufCendied Well C rem Date
Ur.,ignnng lhia Juno.l hemby serif/b that the ucf/ri/uw 6.e e)crnutructcd of n¢ro,&ai,V
7.Is this a repair to an existing well: []Yes or 0No utth 15,!A'CIC 02C.010n or 15.1 KC IC 02C 0200 Well Consintrlton Sia nduriA and that a
If this is a repair,fill out knooa well construction inhinnation and expla n the nature of the �fi'of rifts rcrord has hear proridea tmrlre,reel,ai,r,:r
rrpry untter:'l refaarkr sectinn or nit the bark of uhis jorni
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having rite same You may use life back of this page to provide additional well site details or well
constriction,only I GW-I is needed. Indicate TOTAL NUNTABR of wells
construction details. You may also.artach additional pages ifnecessary.
drilled:° SUBMITTAL INSTRUCI•TONS
9."rutai hell depth below land surface: 20 (ft*) 24;t• For All Wells: Submit this form nilhin 30 days of completion or INCH
For inuliiplr nr//,In!a1l.h7/Irs i/rh/j:•ern/(eronip/e-"r4i?q0•and 14i Itin•)
construction to the fvllo••yinc: ,
10.Static water level below lop of easing: na Of-) Division or Water Resoitrces,Information Processin-Unit,
!!rate•,level is aba,erasing"use"• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Inflection Wells: In addition to sending the form to the address in 24a
Direct Push above,also submit one copy of ibis:finrm within 30 days of completion of well
12.Well construction method: construction to the following:
it c auger.rotary,cable.direct push"etc I
Division of Water Resources.lUdderground Injection Control Program,
FOR",%TER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(",pill) Method of test: 24c. For Water Supply& Iniectiori Welk: In addition to sending the form b)
the address(es) above, also submit lone copy of this form within 30 days of
131).Disinfection l}pe: Amount• completion of well construction 110 ilie county health department of the county
where conoIFUCtcd.
F-an G1l'-I Nenh Carutma Dcparfnicm of En%1,0 11tal quality-Dnuwn o1 N eF:r Rcs1111fCC Revised•_!'-gill
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