GW1-2022-10392_Well Construction - GW1_20221115

NVELL CONSTRUCTION1 RECORD (GNV-1) For Internal Use Only. -
1.Well Contractor Information:
RAWLINS CLARKE IV 14.WATER ZONES
FROM TO DFSCRIPI'10N, -
-
WellContractorName 22 R• 30 f4
4234-A rL R.
NC%Veil Contractor Ce"iticali®n Numb" 15.OUTER CASING (or uulti cased hells OR L1NER t(a livable
REDOX TECH LLC FR031 To DLAMLTER TRIC64`iFSS M.ArERIAL
0 R. 10 ft. 2 in SCH40 PVC -- -- .-
Company Name 11 INNER CASING OR NBING eotherm2l doseddoo
2.wellConstrDceunPermitfl UIC Permit W10400345 FROIN TO DIAMETER Tn1C&NESS NATERL4L
- --- R. in
List all applicahle ereB constnection permits(i.e U1C,Co-Ir.Smle.Variance_,ere.) R.
R ft. in.
3.Well Use-(check Well use):
----— 17.SCREEN -----
Water Supply Well: -- - - FROM To DL4IIETEbt SLOT SIZE 7nlCti,Ness ,114TERIAL
Agricultural DMunicipaUPublic R. 10 ft.
Geothermal(Hrating/Cooling Supply) DResidengal Water Supply(single) A. (r•
IndustriaUCommcrcial DResidential Water Supply(shared) 18,GROUT
Irrigation FROM TO 51ATERLAL EMPVACENFArMEfnODd AJ10U\T
Non-Water Supply W_ell:
7 0 NEAT POURED
monitoring Recove R (t.
-�t - -—
injection Well: R, €t.
Aquifer Recharge DGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage-and Recover,* DSalinity Barrier __ FROM TO btATERLAL FAMPLACEMFAT MET11013
Aquifer Test DStormwater Drainage30
Experimental Technology Control tt• rt
e - -
Geothermal(Closed Loop). DTracer 20.-DRILLING LOG a add ttach itional sheets irnec
' -- -._ _..._.. FROi11 TO DFSCRIPITON(color,hardam soillreck t e.train etc.)
Geothermal(1-Ieating%Cooling Return) Olber(ec lain under#21 Remarks) 0 R, 75 R. CONCRETE
- - - - - -
4.Date Well(s)Completed: 10/6/2022 Well M#OB-1 O .75 tt• 125 R GRAVEL
5a Well Location: --- - "' 39 R DARK GREY�LTY SAND
_Energizer..Battery ._NCD.0.00.822957 -
FacilirylCwaccNarec .Facility ID#(ifapplicablc?, ✓ +n,
419 Art Bryan Drive, Asheboro 27203 R. ft.
V -
Physical Address.City.and Zip. _
-Randol h - - - 7753756912 21.REMARKS r
Parcel Identification No.(PiN) v
Cotmry OG
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(irwell CieId,one rat/long is sufficient) J22.C1➢cation:35.76967440331657 N 79.81816859946849 Wi 1of Ccrtifccd CVcII Contractor Date
6.Mare)the Wells)(EPermanent or Temporary� By sigting drLi farm,I/rrreBr vc7gfy that the ueflls)was/everel cmutnrcted in accordance
7.Is this a repair to an existing well: ®Yes or I^tNo with 15.4 tVCAC 02C.0160 or 15.4 tVClC 02C.0200 Mell Crrtrstnrction Standards and that a
//'this is a repair,ill mot knolva weft comma tion information and erplain the nature of dre coin'of dui record has hem provided ra the well owner.
repair under#21 remarks.verrian or an the hack"filds ana. 23,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 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 if necessary.
drilled:a SUBMITTAL INSTRUCTIONS
9.Total Well depth below land surface: 30 (ft-) 24a. For All Wells: Submit this form Within 30 days of completion of well
For multiple cells list off deptlo ifdiQ&renr(example-J@260'and 2(?10tY) construction to the following:
10.Static Water level below top of casing:22 (ft.) Division of Water Resources,information Processing Unit,
lfcraterlevel is above casing use '+- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For Iniection 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 follooving:
(i.e.auger,rotary,cable.direev 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&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this fora within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
FmTtt G%%'-f
North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016