WI0100433_Geothermal Well Construction Record (GW1)_20160428

Division of Water Resources
can be used for sineo or multiple wells
I. Well Contractor Information:
Robert Larry Wells
Well Coatraotor Manic
2603-A
NC Well Contractor Certification Number
AWD Services Inc
MAY 4 6 2016
Water Oalerllty Regional Opera
Company Marna W 10100433
2. Well Construction Permit #:
List all applicable well constructions permits T e. County, Slate, Parlance, etc.)
3. Well Use (check well use):
❑Agricultural
JiGeothennal (Heating/Cooling Supply)
❑ IndustriallComm ercial
Well:
❑Monitoring
Injection Well;
DAquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
fRGeothermai (Closed Loop)
❑MunicipailPublic
❑ Res idential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater IRentediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
QTracer
❑Other (ex olain under #21 I
4. Date Well(s) Completed: 4/26/16 Well ID#
5a. Well Location:
Thomas & Jeanne Rennard
Facility/Owner Name Facility rD# (if applicablc)
95 Brookline Drive Asheville, NC 28803
Physical Address, City, and Zip
Buncombe
County
96454999830000
parcel rdentification No. (PIN)
5b. Latitude and Longitude in degreeslminnteslseconds or decimal degrees:
(ifwcll field, one latllongis sufficient)
35 30' 4211 N 82 32' 43" W
6. Is (are) the welt(s): JQPermanent or ❑Temporary
7. Is this a repair to an existing well: ©Yes or ANo
If this is a repair, flit out known well construchon inforinaliatr and explain the nature of the
repair under #21 remarkv secliwt aeon the back of this f rnn.
8. Number of wells constructed: 3
For multiple il;fecfrare or• non -wafer supply w•elk 01VI,Y with the same construction, you can
submit one_form.
,�,
9. Total well depth below land surface: q ' L'• � 3 50' 2 @ 260r fft.)
For multiple wells fist all depths tfd�erent (example- 3 rQ200' and 2@1001)
10. Static water level below top of easing: N LA (ft.)
Ifwaler level is above casing, use "+-"
II- Borehole diameter: 6.25't (in.)
Hy signing this form, 1 hereby cereify that rho well(j) was (were) constructed in accordance
lvifh I5A NC'.A(• 02C .D100 yr 1.5,4 NCAC 02C• .0200 Well Consaructipr Syandards and hal a
c•npy of ibis record Has been provided to the xell owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. Fo r Ali Wells: Submit this form within 30 days of completion of well
construction to the following;
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699.16I7
24b. For Iniec Qn• Wells; In addition to sending the form to the address in 24a
above, also submit a copy of titiS form within 30 days of completion of well
II. Well construction method: rota construction to the following:
(i.e. auger, rotary, cable, direct push, etc,)
Diviston of Water Quality, 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 SupplV& on Weiss addition to sending the form to
the address(es) above, also submit one cagy of this form within 30 days of
13b. Disinfection type: Amount; completioa of well construction to the county health department of the county
where constructed.
Form GW- I North Carolina Department of Eaviranmen( mid Natural Resources — Division of Water Quality Revised sari. 2013