GW1-2022-10376_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD (GNY-1) For Internal Use Only.
I.Well Contractor Information:
RAWLINS CLARKE IV 14.WATER ZONES
-- F'RO31 TO DFSCRIFER
Well Contractor Name
4234-A rt ft.
NC Well Contractor Certification Number 15,OUTER CASING for maltitased,vens OR LINER ;frNIAT"EML
REDOX TECH LLC PROM To o7A3tETER THICI YESS
O R, 17 n• 2 ;n' SCH40
Company`(am 11.INNER CASING OR TUBING the at closed-1000
UI C Permit V d I0`1F003`•'r5 PROS[ To DIAMETER TH1CI4�M iLATERLIL
2.Well Construction Permit#:
ft.
llsr aN applicable pall ctnestraction permits(i.e.U1C,Cotam:State,[variance,ere.)
rl. in
(L A. in.
3.Well Use(check,veil use):
-— Water Supply Well: - 17.SCREEN
_ FROM To DL4�tLTER svDTs1ZE Tx1CK:�'ESS S1:,Ti£RLaL
Agricultural DVlunicipal/Public 39 B. 19 fl, in.
Gcotherinal(Heating/Cooling Supply) DResiduntiall Water Supply(single) P. rL in.
Industrial/Commercial --Residential Water Supply(shared) IS.GROUT
IrTi a¢ion - FROA1 TO SIATERLAL E3IPLACEMEdfT3tErlon&A MOULT
._ --- - - 17 - -fL 0 --IL NEAT' POURED
Plop-Watei Supply Well:- -
Iblonitoring DRecovery n, fL
Injection Well: ft. fL
Aquifer Recharge - DGrotmdwater Remediadon 19.SANDIGRAVEL PACK if applicable)
Aquifer StorageandRecovery- .- D!SalinityBarrier -- .-_.-__ �%ft.
To MATERIAL MPLACEaILN-I'MEn
ROD
Aquifer Test DStormwater Drainage 17 n.
Experimental Technology, 'DiSubsidence COntml IL
.- Gcothermal(Closed Loop) DTracer.—_- _ 10.DRiLLiN_G LOG attach 2111I;801221 chests if ne
FR031 TO DFSCRIPTi0,N cob",hardnext,sud/rock .+EMPr etc)
---- Geothermal(Heating(Cooling Return) rJOther( . lain-under-#21 Remarks) o n 75 n. CONCRETE
10/6/2022 IW-8 75 n• 125 n. GRAVEL
._ 4.Date Wells)Completed: wen IDff
12� n, 39 % DARK GREY SILTY SAND
.5a.Well Location:
Energizer Battery NCD000822957 n
- ft. fL ^
FacifityiOwnerNamc FacilhyiD (;fapplicabliz) --
419 Art Bryan Driver_Asheboro 27203 '�
�'
Physical Address.City.and Tip
Randolph 7753756912 ic,�tJ7 pr��e
County Parcel ldemificaieonNo.(FIN) all
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifercll rwK one l0long issuffteicnt) 22.Certificati n:
35.76967440331657 N J9.81816859946849.Y ZY
r1 11 22
Sigrat o- �. "tt:d®Yeti Cotctractasr Date6.1s(are)the well(s)JDPermanent- or DTemporary
Br signing this form,I herein'c-ertifv that dte wrell('v)was(were)constructed(a accordemee
7.Is this a repair to an existing'veil: Dyes or JNo with 15A iVCAC OZC.0100 or ig.4 NC.lC OZC.OZOO Irell Camirrection Siandanls and,lust a
Iftltis is a e epair.fill out knenvn well construction irtfornration and esplain,lie nature aftbe cap)-of rhts record lies been pror•idal to the well owner
repair aides M21 remarks sertion or on the back ojtleis fnnn. Z3.Site diagram or additional well details-
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional weil site details or well
construction,only I GDV-1 is needed. Indicate TOTAL NUMBER of've1Ls
construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL LNSTRUCPIONS
9.Total well depth below land surface: 39 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nudtiple wally list all depths it diJJerent(erantple-I(iZOO"and!`'44 U') construction to the following:
10.Static water level below top of casing:22 (ft.) Division of Water Resources,Information Processing Unit,
f water[ere/is above easing,use"+" 1617 flail Sen7ce Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 8 (in.) 24b.For Injection Wells: In addition to sending the form to the address in'_'4a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: HSA construction to the following:
t i.e,auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Alail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test* 24c.For Water Supply&injection Wells: In addition to sending the forth 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 coumy
where constructed.
Form G1Y-i
North Carolina Department of Environmental Quality-Division of Water Resources Revise!2-2Z-2016