GW1-2022-07626_Well Construction - GW1_20220817

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
JOHNNY BURR 14;WATER ZONES
FROM I TO I DESCRIPTION
Well Contractor Name ft, ft.
A - 3098 ft. fL i
k ,
NC Well Contractor Certification Number 15 OUTER CASING for.multi-cased:wells,OR LINER if:a licable
FROM TO DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION
ft. ft. in.
Company Name +;,16.INNER CASING OR':TUBING `eothermal closed-16 '
2.Well Construction Permit#: FROM TO I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0.0 It- 23.0 ft- 2.0 t' SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well: IFROM
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL 33.0 It- 2.0 'n' 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) OUT
❑Irri ation ❑Wells>100,000GPD TO MATERIAL EMPLACEMENT MLrHOD&AMOUNT
Non-Water Supply Well: 0.0 ft 13.0 fL PORTLANDBENTONrrE SLURRY
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
' 19:-SAND/GRAVEL`-P,pCK'ifa licable ` ,"- •>
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 19.0 ft- 33.0 ft. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.D. RILLING LOG attach'additional'iluiti:if'ne"eessa
FROM TO DESCRIPTION color,hardn soil/rock e. fain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 0 ft. 2 0 ft. RED/ORANGE SANDY CLAY
4.Date Well(s)Completed: 06/21/22 Well ID# MW-1 AR 2.0 ft. 100 It. BROWN SILTY CLAY
5a.Well Location: 10.0 If 33.0 It. GRAY PWR
ASHEVILLE AIRPORT `t' "
Facility/Owner Name Facility ID#(if applicable) ft.
FERN CLIFF DRIVE ASHEVILLE 28732 ft. ft.
Physical Address,City,and Zip ft. ft.
BUNCOMBE 21.=REMARKS' w ��
County Parcel Identification No.(PIN) BENTONITE SEAL-13.0 19.0 FEET
***U-PACK SCREEN***
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: _
350 25' 31.70'' N 82° 32' 26.65" W � cf E91
6.Is(are)the well(s): I91'ermanent or ❑Temporary Signature of Certified well Contractor Date r
By signing this form,I hereby term that the well(s)was(were)co ffuef el a7cor �vith
7.Is this a repair to an existing well: ❑Yes or I!5NO 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ojihe ofthis record has been provided to the well owner. 10kfiY aU0,'1 P fir,*uRdtg Unit
repair under#21 remarks section or on the back of this form. 31 A�ul c�0{3
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over in Remarks Box).Y,ou may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 33'0 (f�)
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
20.0 24a. For All Wells: Original form to Division of Water Resources (DAIR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
R
f Borehole diameter: 8.0 (in.) 24b.For Injection Wells:Copy to DW ,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NCi27699-1636
12.Well construction method: AUGER 24c.For Water Sunni Sunniv and O e -Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producin¢over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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