GW1--07751_Well Construction - GW1_20231201

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: 1
Blair Mitchell 14.WATER ZONES I I
Well Contractor Name FROM TO DESCRIPTIONI
ft. ft. I I
4419-C
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING,(for multi-cased wells)OR LINER(if ap licable)
Redox Tech, LLC FROM TO DIAMETERI I THICKNESS 1 MATERIAL
ft. ft. linjt
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: WI0501065 FROM TO DIAMETER, THICKNESS MATERIAL _
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. Im.
3.Well Use(check well use): ft ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER 1 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. '
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation FROM TO , MATERIAL I, EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery ft. ft. .
Injection Well: I -
I.
❑Aquifer Recharge I Groundwater Remediation ft. ft.
19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO - MATERIAL EMPLACEMENT METHOD
•
0 Aquifer Test ❑Stormwater Drainage ft. ft. ,
❑Experimental Technology OSubsidence Control ft. ft.
❑Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soNrock type,grain size,etc.).
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft ft.
11/13/23-11/15/23 IP-01 through IP-07 ft ft.
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft ft. f"", --
Party Beverage ft. ft. , , ,k..,ti.,_ _...' 1
Facility/Owner Name Facility ED#(if applicable) ft. ft. n r r
5200 Western Blvd. Raleigh, NC 27606 ft ft. ) / 2023
ft. ft. I IP or7r,:tea p ,,--,- -
Physical Address,City,and Zip .•..7 1� 1•
Wake 0784511432 . 2t.REMARKS I= ;k,:, :`,;
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(ifwell field,one lat/long is sufficient) 22.Certification:
35.786729275476546 N -78.71309576066118 w 0 �� • 11/17/23
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature ooff�Ceetttiifieed Well Contractor I Date
i
By signing this form,1 Hereby cerlt&that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or ❑No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:7 SUBMITTAL INSTRUCTIONS i
r
9.Total well depth below land surface: 28 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of.casing: (ft.) Division of Water Resource4,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,;Raleigh,NC 27699-1617
11.Borehole diameter: 1.5 (in.) 24b.For Infection 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: DPT construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
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 Supply&Injection 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 well construction to th i county health department of the county
where constructed.
' Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016