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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 I '