GW1-2021-00863_Well Construction - GW1_20210404

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WELL CONSTRUCTION RECORD FmttennraluseONLY:
TM fonn can be nand for single or mWlij o wells
1.Well Cnntmetor.IRrormatlon:
VL H'A3]2IR ZONES
2ach Thompson MOM To onCRIt'rrq.
Well('00racial NATM n. R.
4478A A. ft.
NC Well CornmctorCeniflemion Nur*rr 1 It,OIT1IM CA S INt1(to ram1tP ased nreA OR:Iai OM f i f a drab
FROM To PTAI+tFF6R T"WKNFS9 I ATMERTAt,
SABDACCO Inc 0 ft, 31' tL 2" an Schedule OPVC
tnrnprolyNavy 16.1 CASING"OR'17)B1N0- edfMetiaatttl anp
FROM TO MANTGR TnTt1.MSS I MATERIAL
2,Well CAnstnmtfi n Permit#: A. ft. h-
GO all applicahlr wril permu:(Le.County.Sartr,Variance,ff*dat or-)
3.Well Use(ehecle well gsc): 0$C
WaterSuplriy Wc41: FR M TO DIAIVtLTBR I StATSM. I 7111r9 OR I MAT'RRIA
-11
®Agrictal[ural DlVlmniCip<Llflrtlbl)C 31' ft. 41, A. 2" Ia. 0.010 Schedule oPVC
eothemlal{HealingCooling Supply) DResidential Water Suppt)'(single) A' A. in
©CT
Dlodustria!/Conimercial DRes*ntial Water Supply(shamd) FROM
CROT)T
FROM TO 1t1ATERUIL 1t111pLA xLrTltOn fi A3110tJNr
Ohti tion 0 A. 27, ft Portland Cem6ntection
Non-Water Supply Well:
fL
Mmorlitorin DRcca+
Injection Well:
❑Agt"cr Rccha,rge DGmral+aterRemediation SANDIGr
❑AquWa.StorAgc and Recovery 0Saiinity Harriet Pr: M 4, Filter a tG pI A..1r MF'r 1Qn
rift.
41 A. Filtered Sand #2
❑Agn'rfer Tend OStommater Drainnge
D15,rcrimcntat Technology DSubsidevcc Control ft.
20..I1R11,ttT{fLOG atlarb.addlilo»st,rticd3il' r►
OGeodtermal(Closed Loop) OTracer FROM I TO olzrRfrno'q tow,lordfim lowmek n sims.ere
❑Geothermal(Hest' >Caoli Renmo 00diet(emlain under p21 Remarks) M A.
A. A.
4.DateWell(s)Completed: 3/18 WidllD#MN-14IR
fi. ft.
Ax.Well t tieation: (, A, P
Dynamite Roasting Company n. ft.
Faciliq-;Owr cr Nam Fkility IDN(irapplicable)
ft n.
2744 US Hwy 70, Swaaaanoa, NC, 28778
Pfiaical Addmss.City.and Zip 2t 1ti:1►fARttS 5
Buncombe Bentonite seal from 27 �>tR SQct,pfl
Canal), Petrel ideatifigtrion No.(P1.4)
Sh.lattitudeand1,lingltudeindegtreslmimtteslseenndsordecimaldegrecF. 22 Certilicatinn:
Of well field,orte h oons is stdnclern)
35.601477 N -82.370933 W 3/18/2021
Sip3tale ofGM[fied Well Coli1mmy Dare
6.Is(are)thenell(s): 2ipermaneut or ❑Temporary By signing whir fmm 1 hereby eerrfr rhiu the awls a/eons(itri>)rrnss?nMltd in atrar»urire
0A I M NCAC 02C,010b or 1 SA NCAC fr2C.0200 Well Caastm4iim Standards a d that a
7.0 this amiairtoanexisOngwell: Mo. or Mp rc�,pr�fbtftm»1hp5'bemlirmtdrdmihe++rltmt+rcr,
1f;*fs it o rrpatr.fill mi bww"uvff eorartr wdon bnfomwtk wW rwfal"rho ttarvre of drt
rrpairnndrrfi3l rnmat s arrriam or.on rhr bae�of rMs fnrac 23.Site diagram or additional we[i detalts:
You may use the back of this page,to pto+ide additonal well site details or well
8.Number of wells aansmicted: 1 consmmian demits. You tray also Mach additional pages if necessary.
For vast(efe hrjwMnr tw Non-4wer AW.ph wells ONLY ulfA dte same ronsrwdon,,Vial CM SU N 11TAL iNC T 1 CTI0M
sub
form
9.Total Twd[depth below land surface: 41 {R.) 24a. For A Neils: Submit this fonts within 30 days of compkdon of well
for owlitiokKxflsutralldephy*ydbyrrenr(e.rmw►r3@200'Bud2!@My) constnuctionto the:follorc+ing:
10.Static water level Below top of easing: {R.) Dicisfftn of Water Resdtlrtes.Information Processing Unit,
lj%VW111rve1 A OfttT eaalag,We"+ 1617 Mail Service Center,Raleigh}NC 296994617
11.l ardiolc diameter:8 01L) 24b.For 1njWnn WWls ONLY:it.In addition to sending dw form to the address in
24a above. also submit a copy of tilts form trithin 30 days of completion of well
12.Well conAroction method:Bored construction to the(bilowing:
(i.e.anger,totaty,cable,diner pask etc.)
Mislon of Water Resoumcs Underground Injection Control Program,
FOR WeATFR SUPPLY%YELLS ONLY: 1636 Mail Senile Center.R9ld&.NC 29699-1636
13a,Vidd(gpm) "demod of test: 2r-For Water Sappy&Ipject[nn Wells-
Also submit one coin, of this foot:%ithini 30 days of completion of
13b.Disinfection hpe: Amount: well construction to the coimly heatih depntmen►of the county when:
constructed.
Form GSV-1 North Carolina DgvArml of Enviionarnr and Natural Resotams-Division of``Pater ResoIro Revised AggUA 2013