HomeMy WebLinkAboutGW1-2022-10375_Well Construction - GW1_20221115 i
NVELL CONSTRUCTIO RECORD (GNV-1) For Internal Use Only.
1.Well Contractor Information:
RAWLINS CLARKE IV 14.WATER ZOWi
--- FROM TO DEscmvnox
Well Contractor Name 22 R 35 R,
4234-A rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for®nlritasPd wens OR LINER if a ticable
REDOX TECH LLC FRoat TO DL401tREt8 Tmctowc s 51ATERLAL
- - - - 0 ft- 1 15 R• 2 in SCH40 MfC
Company Nam 16.INNER CASING OR TUBING(geothermal closed too
2.Well Construction Permit#:UIC Permit W10400345 FROM TO DMIETER THICt4�[ESS nl\TEtil:►L
List all applicable cell construction permdts(i.e.U1C,County.State,Variance,ere.)
r4 rt. in.
fL R. in.
3.Well Use(check well use):
Water Su 17.SCREEN
PP1Y Well: FROM TO DL4NIL-rFR 3L0T5IZE TtI1Cl41'FSS H:►TEAL\.
Agricultural []dlunicipaUPublic 35 iL 1s
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) R, R, ter.
indusiriaUCommercial [31tesidential Water Supply(shared) IS.GROUT
—)irrigation FRO31 TO AIATEttAL EDIPIACE�IE`IT iliLTFIOD lc:W101JYT
Non
-Water Supply Well:
11` a' 0 NF1\T POURED
monitoring DRcxovery (L R.
Injection Well: ft. ft.
Aquifer Recharge DGroundwater Remediation 19.SAPiD/GRAVEL PACK(if a icable)
'Aquifer Storage and Recovery 'Salinity Barrier FROJ1 TO I m'%TE uAI• EalrLacENEN r etLreton
Aquifer Test OStormwater Drainage. 35 ft, 13 IL
Experimental Technology O-Subsidcnce Control ft rr• —
Geothermal(Closed Loop) Dfracer _ _10.DRILLiNG LOG attach additional shtu if
FROM I TO DE301IPTSOi<r Iwtor,banimss,sotlrrerk trP4 Arsia srzq etc.)
--�._---' Geothermal(Heating/Cooling Return) " FlOther(explain under#21 Remarks) 0 R, 75 R. COW-R TE
10/9/2022 IW 9 .75 R 1.25 ft' MAXIM
4.Date Well(s)Completed;--__Well ll➢#_
5a._W_ell.Loratimn: rat it. 35 R. DARK GREY SiLTv SAM
Energizer Battery"_.. NCD000822957
-- - - -- y R. CL
Facilit/Ormcr Name Facility iDn(ifapplivAk) r'_
419 Art Bryan Drive, Asheboro 27203
Physical Address,Ciry,and Zile
Randolph 7753756912
;+ 11.REn1ARKS e' '
County ?=eel Identification NO.(PiN) tr r�IJR
CJd rQf�r
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: _
(if we➢➢Prmld,one IaUlong is sufficient) 22.C ation:
35.76967440331657 -79.81816859946849 W
- Si-K=of Certified Wen Codrtractor D•te
6.ls(are)the well(s)0'Perawnent or [--Temporary
Br signing this form,1 lterek'certi(v rime dry well(s)cvus(wrrey cmnrtrrrereal in accordance
7.Is this a repair to an existing well: ®Yes or xlco aide 159:,YcAc 03C.0100 or 15.1 mc-IC 021C.0100 Well Coastruea m Standards and that a
Ijthis is a repair.ill out kurnvn well cansrrra7inn inilormatian and explain the nature ojtGe cap)•oftris recard has bet providal to the cell awned
repair under 911 renrarkr serrian or an the flack o%this•/bma 23.Site diagram or additional well details:
S.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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary-
drilled:' SUBMITTAL INSTRUCTION
9.Total well depth below land surface: 35 00 24a, For All %Veils: Submit this form within 30 days of completion of well
For mnkiple wells list all depths ii'difjerent(example-J[!00'and_(kr 100') construction to the following:
10,Static water level below top of casing'22 (ft.) Division of Water Resources,Information Processing Unit.
ijtsater level is above casing,use-+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8 (in.) 24b.For infection Wels: 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 i.e.auger,rotary,cable,direst push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,field(,-pm) -Method of test: 24c,For Water Supply&inieetion Wells: In addition to sending the form 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 county
where constructed.
Form GW-t North Carolina Departmem of Enviramuental Quality-Division of Water Resources Etecised=?2-2D{6
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