GW1--01501_Well Construction - GW1_20240312

WELL CONSTRUCTION RECORD Pot'Nand UscONLY:
This kiln can be used far single ormultiple wells• i •
1.Well Contnu for Information:
• ":11.WATER ZONES
Robert Miller - . •- - . FnOM rO DFSCRLPI1ON•
WellConiranot.Nane. • ft.' ft. I `,
2675-A ft ft.. I
NCWcdI Confine-tor CcniftentionMabel :15.OUTER CASING tfnr"rnuttbeikdvictls)OR,LINERfifa`p ncsbk)
FROM TO '- MAMETER.' TInCNNIESS \:ATEMAL
SAEDACCO . • .fit- . (L. la
Congrvrj Name,e, '- E6::INNS?R CASING OR TUBING(gcrotbermal closed- ap)'u
•FROM To - DLA1UETSR 7IIICKNES. MATERIAL
2.Wcli-Conttruetinn Penult 8:m0100704 - 'R. . R. M.
List ailapplkobk rsrllprintits fie.County.Suoe.-Vprianco.Iniettigl etc.-) R ft. In.
• 3.Well•.Use(chCClcUlell We): 17:SSf RLEN •
Water-Supply Well: ' ' - - Emma.• . TO .DI MaT-R St,OTStn. T IICICNTTS. . MAIMIA!.
' DAgricultutal DMuntcipaliPttblic . . ft. fl: in
DGeothetmal(Heating/Cooing Supply) - ®ResidentiatWater Supply(single) IL ft. ia.
DlndUstriallContntercial ®Residential WaterSuppl (sla itrd) osrC� 70 . AfATERGLL i Ed[PIACV,II iT\:E11101}S AMOUNT
' 171rripatian -. " . tt. -It. i.
Nod-Water Supply Well:. R.
L1 .
.Moniioring ..i7Recoycty. . . - - ,
:Injection Welt: - .• . . . . . - R•• •ft
' ®ARRifcr tcchargc 181Groundsiatcr Rentediation 19 SANUJGRAVRL•I ACK(If applicable) -
"FROM TO' MATRRrAt: EMPI WE:to:STMFTnOn -
DA"quifcr.Storage..and RCCovety- , 178alinity farrier R.. ft.. .
DAgniifer Test '. ..CISformnatcr Drainage ft. ft.. •
• [71 irpctimctrtal Technology DSFtbsidcncc Control -11n.,DRILLING'LOG(uitacb additional shcMs if accessary) -
DGeotltelmal(Closed Loop) . t]Trdcer . . Fnobi• TO ' ' DESCRFP110r Rolm.hardac.+,wnWrcklrot.'artia eire.'Nk.)
. DGeothetlual(Hea6ug+CoolIRg Return) .•DOiiter(explain under A2I Retina's) :IL rt. _ r
4.Dart Wel(s)Completed:•2/22/24 Well m E`l E-4 • (t.: , ft 4 i r OW y>1 r!a
ra ft. MAR 1 2 2024- " .
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54:Wsd1 Location: . .14 ft.. I
Zboyovski Property ' ' ' It, ft • i• 'Frye+.^ t y
Fa ctlifyi0uocrNnitte • Facilll)•ID#,(ifappii:ablc). LVd T ��1
h: rt.m ,
146 Smokey Park.Hwy., Asheville, .NC, 28806 . ' :R, rt,..
Plnsicnl Address City.and Zip' '2L.Kl)IARI{S •
Buncombe . . Injected 104 gallons of Cool-Ox per boring;
Ccmuty • . • �areIldolitieruian No,(PIN) • 20-33'
51)-Latitude and Longitude in degrees/miruteslscconds or decilifa'degrees: 22-Cerdfieation: .
• (1fnc11 rocld.mk 4tV1onS is Srrtttcl:iu)
•
N • W �/J ; ' 2/28/2024
. &E mit=ofs::c:;.o.4s;cs_ f:t.;f - date
6.Is(are)the nell(s):.DPcrmarrent. .or luTemporary • signing ilrit farm 1 hereby cerr• t os tbp,tell+I errs(Ken curigtitaed hr,uct.vrrlmice
• Bp 6 K f tIX (•. .
ivith 1511 NOW'02C.0100 or I SA NCr1C 02C.0200 WO Construction Standards and that a •
7.Is this a repair to an existing n'ell: DYe' or ;1Nu wire i fMd1 rrrnrd hos Nen hraritkd.hr:Fr url ou,rrr• •
IfttWs•is a repair:fill oe;5nondnvdl coacrntctloa.brformetion and ciplahr he tiarnn,of rho -
• rcpair touter 1121 ketnarCv.ireliun ,r On the bail of titiS form. .23.Site 4-ingrain-or or additional well details: '
Thu-may use the back of this page to preside additional well site details or.well.
8.Numyer of-wells consinicted: 4 'constiuctimi details. You-may also attach additional'pages if necessary.•
For rnaltlple Irefecilnn or mist-yrtrer sirpphr molls ONLY mirk the some construction,yea ri m
sukmir'oneform. • • SUBl)IITTALINSTUCTIONS
9.Total well depth below land surface: 33" (I).) 24a. Fur AU Wells: Submit this farm within 30 days of completion of Well •
For mublplcn,ellr list ail depths'(Idijoinena(example-3@200'mkt 2CAV) constuiction to the following;
10.Static water level below top of easing: (t't) Division of Water Resaun.e't,Information Orlicessin;,Unit,
if wow i level Is above costa::ate'•+" '1617 Mail Service Center,Raleigh,NC 27699=1617
• II:Dorchotc-diamctcri?r 5" . '(in,) - 24b.liar Infection Weliv ONLY: In!addition to sending the form to the address-in
24a above,also submit a copy of this form within 30 days of completion of well
12.Well cousmiction method:DP.T - consini Lion to tort follohiag:• i ,
(Lc.auger.rotary.cable direct gush.etc.) I ;
Dlylsion of Water Resources;IIndcrground Infection Control Ptngratu, •
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FOR WATER SUPPLY WELLS ONLY: 1636 gill Service Center,Raleigh;NC 27699-1636
13a,Yfclil Wpm) Method of test: 24e.•Flrr Water Supply&[plectron Wells: •
Also submit one cops of this form'within 30,days ofeonnpletlonof
•
13b.Disinfection type - Amount: well:constniction to the county hcalih department of the.Cotrnty.where
constricted.
Faun G W-L 'Noah Carolina tATanieteni of Environment and Manual,Resources-Division of Water Room m Revised August 2013
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