WI0100616_Appendix A_20210427

APPENDIX A

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JOHNNY HART, JR
Well Contractor Name
B - 4446
NC Well Contmclor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit p:
List all applicable wed construction permits (.e. County. Stare. Variance. etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑Irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
LMondoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remedlation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 1121 Remarks)
For Internal Use ONLY
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
rt.
15. OUTER CASING (for multi -eased wells) OR LINER Brim Iicable)
FROM THICKNESS 1 MATERIAL
TO
n.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
o.o fr.
50 D•
1.0
in.
SCH 40
PVC
ft.
H.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft'
20.0 it•
10 in.
.010
SCH 40
PVC
R.
ft.
in,
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft,
2.0 D•
PORTLAND BENTONITE
SLURRY
ft.
ft.
f.
ft.
19. SANDiGRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 te.
20.0 H'
20-40
FINE SILICA SAND
ft.
R.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
O.o n.
TO DESCRIPTION {color, hardness, soil/reek type, train size, etc.)
5.0 ft•
CLAY/GRAVEL
4. Date Well(s) Completed: 08/07/20 Nell IDt1
ga. Well Location:
CLEMENT RESIDENCE
MW-1
Facility/Owner Name Facility IDN (if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
AS HE
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one Iatllong is sufficient)
35° 36' 08.51" N 82° 36' 26.56"
6. Is (are) the well(s): l2JPermanent or ❑Temporary
W
7. is this a repair to an existing well: ❑Yes or ❑No
If this is a repair. fill out known well construction information and explain the nature of the
repair under • 21 remarks section ar on the back of this firm.
8. Number of wells constructed: 1
bar multiple injection ar non -water supply culls ONLY with the same constructions. you can
.submit one form.
9. Total well depth below land surface:
For multiple wens list all depths if di(jerenr (example- 3 a 100' and 1 r@e 100)
10. Static water level below top of casing: 5.0
If hater level as above casing. use
11. Borehole diameter: 8'O (in.)
AUGER
20.0
12. Well construction method:
(ft.)
(ft.)
(i.e auger, rotary, cabk. daeet push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
5.0 R.
20.0 ft.
SILTY CLAY
ft.
ft.
ft.
ft.
n.
ft.
ft.
ft.
f1.
n.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
Li. IJJ
08/14/20
Signature of Certified Well Contractor Dale
Hy signing this form. i hereby certify that the well(%) was (were) constructed in accordance
with ISA NCA(' 02(' 0100 ar ISA N('AC 02('-0200 Well Construction Standards and that a
copy of this rrcard has been proeided to the well 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. For Ail 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 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24n
above.. also submit a copy of this form within 3J days of completion of well
construction to the following
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water SuooIv & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction 10 the county health department of the county
where constructed
Form GW-I
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jim. 20 t S

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JOHNNY HART, JR
Well Contractor Name
B - 4446
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable •rail construction permits (i.e. County, Stare. Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
15. OUTER CASING (for multi -rased wells) ORT LINER (if appjlicobk)
FROM THICKNESS I MATERIAL
TO
n.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
0.0 H•
TO
5.0 tt.
DIAMETER
1.0
in.
THICKNESS
SCH 40
MATERIAL
PVC
R.
rt.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑Municipal'Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
lMonitoring ORecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
OGeothermal (Closed Loop)
❑Geothermal (HeatingfCooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Slormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 08/07/20 Well ID# M W -2
5a. Well Location:
CLEMENT RESIDENCE
Facility/Owner Name Facility 1Dd Of applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
ASHE
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latllong is sufficient)
35° 36' 08.51" N 82° 36' 26.56"
W
6. is (are) the weil(s): IZ1Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or E1No
lfthis as a repair fill out ksw,in well conxtruc•tum infirnradon and explain the nature of the
repair carder r2! remarks .section or on the back of this Arm.
8. Number of wells constructed: 1
bar multiple infection or non -water supply wells ONLY with the same ennstructlan, you can
.submit one form.
9. Total well depth below land surface:
i •car nrtakiple i lis fist ail depths ifd erent (example- 3fa1)00 • and 2(3100)
20.0
10. Stalin water level below lop of casing:
war: r level ( akw'e caning ore "
11. Borehole diameter: 8.O (in.)
AUGER
12. Well construction method:
5.0
(ft.)
(ft.)
(i.e. auger, rotary, cable, daecl push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: - -- Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 n.
20.0 (t.
1.0 in.
.010
SCH 40
PVC
ft.
n.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 fit.
2.0'
POnILAND SSNTONnr
SLURRY
ft.
Ft.
ft.
R.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 ft.
z0.0 fi•
20-40
FINE SILICA SAND
n.
J
n.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft.
5.0 ft•
TO
5.0 H.
20.0 R•
DESCRIPTION (snIuv hardness, sail/rock type, strain size, etr.)
CLAY/GRAVEL
SILTY CLAY
ft.
ft.
(t.
n.
R.
R.
ft.
fit.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
U. kJ,/
08/14/20
Signature of Certified Well Contractor Date
8y .signing this farm, 1 hereby certify that the well(s) was (were) constructed in accordance
with 154 N(AC 02C 0100 or ISA NCA(' 02C' 0200 Well Construction Standards and that a
ropy of this record has been prorided to the well 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. For All 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 27699-1617
24b. Fqr Injection Wells: 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
construction to the following.
Division of Water Quality, Underground Injection Control Prograni,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunnly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of Well construction to the county health department of the county
where constructed
Form GW-1
North Carolina Department of Environment and Natural Resources - Drvisnn of Water Quality Rerrsed Jan 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JOHNNY HART, JR
Well Contractor Name
B - 4446
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County. State, Variance. etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural °Mum ipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑ Industrial/Commercial ❑Residential Water Supply (shared)
❑ Irrigation
Non -Water Supply Well:
VIMonitoring ❑Recovery
Injection Well:
❑ Aquifer Recharge ❑Groundwater Remedialion
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 08/07/20 Well ID#
50. Well Location:
CLEMENT RESIDENCE
MW-3
Facility.Owner Nan ie Facility Ifni f if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
AS HE
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iatllong is sufficient)
35° 36' 08.51 " N 82° 36' 26.56"
6. Is (are) the well(s): OPermanent or ❑Temporary
W
7. Is this a repair 10 an existing well: ❑Yes or ❑No
tithes is o repair fill out known weil construction information and explain the nature of the
repair under .21 remarks section or an the back of this foray.
8. Number of wells constructed: 1
For midi* infection or non -water supply wells ONL 1' whir the same construction, you can
submit one farm
9. Total well depth below land surface:
For multiple hells list all depths if different (example- 3 rr 00' and 2@!00)
20.0
10. Static water level below top of casing:
If water level is above casing. use " "
11. Borehole diameter: 8.0 (in.) 24b. For Iniection Wells: In addition to sending the form to the address in 24:i
AUGER above, also submit a copy of this form within 30 days of completion of wel
12. Well construction method: construction to the following.
(re auger, rotary, cable. direct push, etc )
5.0
(ft.)
For Internal Use ONLY
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
IS. OUTER CASING (for multtamed wells) OR LINER (if ap livable)
FROM THICKNESS 1 MATERIAL
TO
re.
ft.
DIAM ETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 f'•
5.0 ft'
1.0
in.
SCH 40
PVC
n.
re.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 D.
20.0 f•
1.0 in-
.010
SCH 40
PVC
ft.
re.
In.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT M ETHOD & AMOUNT
0.0 re.
2.0 ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
re.
19. SANDiGRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 ft•
20.0 ft•
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (atlaeb additional sheers if necessary)
FROM
0.0 R.
5.0 ft'
TO
5.0 fi•
20.0 ft•
DESCRIPTION (tolay hardness, sailiroek type, grain sire, rte.)
CLAY/GRAVEL
SILTY CLAY
ft.
ft.
n.
n.
D.
ft.
ft.
ft.
ft. n.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
Uijj
Signature ofCertitied Well Conlraclor
08/14/20
Date
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
By signing this Jirrni, 1 hereby certify that the whew was Orerej constructed in accordance
with ISA NCAC' 02(' 0100 or iSA N(A(' 02(' .0200 1Ve11('onvrurrion Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional wek site details or well
construction details. You may also attach additional pages tf necessary.
SUBMITTALINSTUCTIONS
24a. For All Wells: Submit this form wilhm 31.r days of completion of well
construction to the following
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction 10 the county health department of the count
where constructed
Form G W-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Res,sed Jan )(11 )

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
JOHNNY HART, JR
Well Contraclor Name
B - 4446
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable ireN construction permits (r e ( unary, State, Variance etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipai/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
ElMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under 1121 Remarks)
4. Date Well(s) Completed: Q8/07/20 Well ID#
Sa. Well Location:
CLEMENT RESIDENCE
MW-4
Facility/Owner Name Facility IDN (inapplicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
ASHE
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Of well field, one Iatllong is sufficient)
35° 36' 08.51" N 82° 36' 26.56"
6. Is (are) the well(s): l21Permanrnt or ❑Temporary
NV
7. Is this a repair to an existing well: ❑Yes or EDNo
If this is a repair. fill our known well construction information and explain the iuitrrre of i1rr
repair under .21 remarks secant; ar on the hack of this farm.
8. Number of wells constructed: 1
For multiple infection or non -water supply wells ONLY with the same construction, 2wu cox
.submit one form.
9. Total well depth below land surface: 20'0
For mrduple hells list all depths ifderent (example- 3 re 00' and 2@100')
5.0
ID. Static water level below top of casing:
lfwater level is abore casing. use " "
11. Borehole diameter: 8,0 (in.)
12. Well construction method: AUGER
(ft.)
(ft.)
(i.e auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY.
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
rt.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (If ap triable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
fi.
in.
16. INNER CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
5.0 ft.
1.0 in.
SCH 40
PVC
ft.
rt.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOTSIZE
THICKNESS
MATERIAL
5.0 ft'
20.0 ft'
1.0 in'
.010
SCH 40
PVC
R.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft'
2.0 ft'
PORTtANDBENTONITE
SLURRY
h.
ft.
ft.
h.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENTMEIIIOD
3.0 ft'
20.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING
LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION {color, hardness. soil/reek type, train size. etel_
0.0 ft-
5.0 ft.
CLAY/GRAVEL
5.0 It
20.0 ft'
SILTY CLAY
ft.
rt.
ft.
ft.
rt.
ft.
ft.
ft.
re.
rt.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
Signature of Certified Well Contractor
08/14/20
Date
By signing this firm. 1 hereby certify that the writes) was (were) constructed in accordance
with 1SA MAC 02(' .0100 or 1SA Nl'AC 02(' 0200 Well Construction Standards and that u
cop) of this record has been provided to lire well 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. For All 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 Censer, Raleigh, NC 27699-1617
24b. For Iniection Wells: 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
construction to the following
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supplv & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed
Form C W-I
North Carolina Depanmeni of Environment and Natural Resources - Division of Water Quality Revised Jane 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JOHNNY HART, JR
Well Contractor Name
B - 4446
NC Well Contractor Ceruficaiion Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits 0.e County. Stare, Variance. etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
OMunicipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
LMonitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
For Internal Use ONLY
14. WATER ZONES
FROM
TO
DESCRIPTION
rt.
ft.
ft.
15. OUTER CASING (for multi -cared wells) OR LINER (if ap livable)
FROM THICKNESS 1 MATERIAL
TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 n.
5.0 it
1.0
in.
SCH 40
PVC
n.
rt.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0
20.0 It
1.0 in.
.010
SCH 40
PVC
f1.
R.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD J+ AMOUNT
0.0 ft.
2.0 n.
PORRUND rWTONnE
SLURRY
ft.
n.
ft.
n.
19. SAND/GRAVEL PACK Of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 f1.
20.0 n•
20-40
FINE SILICA SAND
n.
6I.
20, DRILLING LOG (nits h addiliooal sheep ifnetessary)
FROM
0.0 ft,
TO
5.0
DESCRIPTION (color, hardness, sail/reek type, grain sine, etc.)
CLAY/GRAVEL
4. Dale Wells) Completed: 08/07/20
5a. Well Location:
CLEMENT RESIDENCE
Facility/Owner Name
Well ID/4
MW-5
Facility IDIi (if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
ASHE
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iatllong is sufficient)
35° 36' 08.51" N 82° 36' 26.56"
W
6. Is (are) the well(s): t2lPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or No
this is a repair. fill out known well cmrstructian information uric! explain the nature oldie
pair under =21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or ton -,rater supply wells ONLY with the same construction. you can
submit one farm.
9. Total well depth below land surface:
err multiple wells list all depths ifd different (example- 3.iil290' and 2QI00)
5.0
20.0
10. Static water level below top of casing:
fJ'+raMF �. el is allure casing, use " "
11. Borehole diameter:
8.0
(in.)
12. Well construction method: AUGER
ti.e auger, rotary, cable, direct push, etc )
(ft.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
5.0 rr.
20.0 ft'
SILTY CLAY
It.
ft.
n.
n.
n.
ft.
f1.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
Li. IJ)
08/14/20
Signature of Certified Well Contractor Date
By signing this farm. 1 hereby cent' that the well(S) was (were) constructed in accordant....
with 15A NCA(' 02C WOO or 15A NCAC 02C .0200 Well Construction Standards and Mot a
copy of this record has been provided to the well 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 1NSTUCTIONS
24a. For All 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 27699-1617
24b. For lniection Wells: 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
construction to the following:
Division of Water Quality, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed
Form GW-I
North Carolina Department of Environment and Natural Resources Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This thrill can be used for single or multiple wells
I. Well Contractor Information:
DAVID HALL
Well Contractor Name
A - 4459
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit 11:
List all applicable well construction permits (i.e. County, Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial DResidential Water Supply (shared)
Dlrrigation
Non -Water Supply Well:
©Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge DGroundwater Remediation
❑Aquifer Storage and Recovery ESalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (cleating/Cooling Return) ❑Other (explain under 421 Remarks)
4. Date Well(s) Completed:10/14/20 Well ID#
5a. Well Location:
CLEMENT RESIDENCE
Facility/Owner Name
MW-6
Facility ID(/ (if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
ASHE
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35° 36' 08.51" N 82° 36' 26.56"
6. Is (are) the well(s): ©Permanent or ❑Temporary
W
7. Is this a repair to an existing well: DYes or ONo
If this is a repair, lilt out known well construction in/ormation and explain the nature of the
repair under 1121 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple in/ecnon or non -water supply wells ONLY with the same construction..you curt
submit one Jornr.
9. Total well depth below land surface: 15.0 (ft.)
For multiple wells list all depths if di//erent (example- 3/200' and 2L100')
5.0
10. Static water level below top of casing: (It.)
If water level is above casing. use A
11. Borehole diameter: 8.0
(in.)
12. AVeil construction method: AUGER
(i.e. auger, rotary, cable, direct push. etc.)
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi
-cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
1t.
in.
16.'.INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
5.0 ft'
2.0 in.
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft•
15.0 ft•
2.0 in'
.010
SCH 40
PVC
ft.
ft.
in.
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
20 ft•
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PAC II
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 ft•
15.0 ft•
20-40
FINE SILICA SAND
ft.
ft.
21). DRILLING (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain sin, etc.)
0.0 ft'
5.0 ft•
CLAY/GRAVEL
5.0 ft•
15.0 ft•
SILTY CLAY
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
22. Certification:
Signature of Certified Well Contractor
10/29/20
Date
13v signing this/bon, 1 hereby certify that the well(s) was (were) constructed 6t accordance
with /5A NCAC 02C.0100 or 154 AtCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the well 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. For All 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 27699-1617
24b. For Injection Wells: 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
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form) to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GAV-1
North Carolina Department of Lncironmeut flnl Natural 12esources- Division of VOiter Quality° Revised Jan. 21)13

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
DAVID HALL
Well Contractor Name
A - 4459
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑O Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
For Internal Use ONLY:
14.'WATER ZONES
FROM
To
DESCRIPTION
ft.
ft.
A.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if at) Roble)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
m.
16. INNER CASING OR TUBING. (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0
ft.
5.0 tt.
2.0
in.
SCH 40
PVC
ft.
ft.
in.
17.'SCREEN
FROM
TO
DIAMETER
SLO r SIZE
TInCKNESS
MATERIAL
5.0 ft.
15.0 rt.
2.0 in.
010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL.
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
2.0
ft.
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL.
EMPLACEMENT ME'Ft1OD
3.0
ft.
15.0 ft•
20-40
FINE SILICA SAND
rt.
ft.
20.DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 I.E.
TO
5.0 rr.
DESCRIPTION (color, liminess, soil/rock type, grain size, etc.)
CLAY/GRAVEL
4. Date Well(s) Completed: 1 0/1 3/20 Well ID#
5a. Well Location:
CLEMENT RESIDENCE
MW-7
Facility/Owner Naive Facility ID:1 (if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
ASHE
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
35° 36' 08.51" N 82° 36' 26.56"
6. Is (are) the well(s): ©Permanent o' ❑'I'entporary
W
7. Is this a repair to an existing well: ❑Yes or DNo
/f this is a repair./ill oat known well construction info5nuuion and explain the nature of the
repair under 1t21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection a' non -Crater supply wells ONLY with the same construction, you can
submit one fans.
9. otal well depth below land surface: 15.0 5'0
T(ft.)
For multiple wells list all depths if different (example- 3@200' and 2(100')
10. Static water level below top of casing: 5'0 (ft.)
(beater level is above casing use '•+"
11. Borehole diameter: 8.0 (in.)
AUGER
12. Well construction method:
(i.e. auger, rotary., cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
5.0 ft.
15.0 ft.
SILTY CLAY
ft.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
Signature of Certified Nell Contractor
10/29/20
Dale
By signing this farm, 1 hereby certi(i' that the teell(s) was (n'ere) constructed in accordance
with 15.4 NCAC 02C .0100 or 15,4 NG4C 02C .0200 tfel/ Construction Standards and that a
cop)- ofdtis record has been provided to the well order.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well she details or well
construction details. You may also attach additional panes if necessary.
SUBMITTAL INSTUCTIONS
24a. For All 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 27699-1617
24b. For Injection Wells: 1n 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
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources -Division orAArater Quality
Res ised Jan. 25 13

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
DAVID HALL
Well Contractor Name
A - 4459
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑O Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
4. Date WeII(s) Completed: 10/1 3/20 Well MN
5a. Well Location:
CLEMENT RESIDENCE
MW-8
Facility/Owner Name Facility ID# (if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
ASHE
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35° 36' 08.51 " 82° 36' 26.56"
6. Is (are) the well(s): C21Pernianent or ❑Temporary
W
7. Is this a repair to an existing_ well: ❑Yes or 1?]\o
/This is a repair..fill out knot 1n well construction information and explain the name o fthe
repair under 1121 remarks section or on the back of )his Join.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, von can
submit one fora.
9. Total well depth below land surface: 15.0
For multiple wells list all depths if different (example- 3 a.200' and 20)100')
10. Static water level below top of casing: 5•0 (ft.)
!firmer level is above casing. use " 1
11. Borehole diameter: 8.0
(in.)
12. Well construction method: AUGER
auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
131). Disinfection type: Anu) ur,•
For Internal Use ONLY:
14.WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER. CASING (for multi -eased wells) OR LINER (if app icable) '.
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16 INNER CASING OR TUBING (geothern al closed -loop) S:
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
5.0 ft'
2.0 in.
SCH 40
PVC
ft.
ft.
in.
17`SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft'
15.0 ft.
2.0 in'
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL.
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
20 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACE. (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3.0 ft•
15.0 ft'
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary) -�
FROM
To
DESCRIPTION (color, liminess, sou/rock type., grain size, etc.)
0.0 ft-
5.0 ft•
CLAY/GRAVEL
5.0 ft.
15.0 ft•
SILTY CLAY
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
Signature of Certified Well Contractor
10/29/20
Date
By signing this form. 1 hereby certi/i that the well(s) was (were) constructed in accordance
Irish 15A AtC.IC 02C.0100 or /54 NC'AC 02C _0200 Well Construction Standards and that a
cope of this record has been provided to the ue// 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.
SUB\I1T1'AL 1NS'FtJCTIONS
(ft.) 24a. For All 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 27699-1617
24b. For Injection Wells: 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
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form (1W-I
Noah Carolina Department of Euvironmenl anti Natural Resources - Division of\Vales Quality Revised.lan. 2013

WELL CONSTRUCTION RECORD
'this form can be used for single or multiple wells
1. Well Contractor Information:
DAVID HALL
Well Contractor Name
A - 4459
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Nance
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring EaRecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Reined iation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 1/21 Remarks)
For Internal Use ONLY:
4. Date Well(s) Completed: 1 0/1 3/20 Well 1D#
5a. Well Location:
CLEMENT RESIDENCE
RW-1
Facility/Owner Name Facility ID!! (if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address City, and Zip
ASHE
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
35° 36' 08.51 " 82° 36' 26.56"
6. Is (are) the well(s): ©Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or LINo
flans is a repair, fill out known well consm'uctian al/in-motion and explain the na1n'e oldie
repair under tt21 remarks section or on the back of this form1.
3. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction. rot can
submit one form.
9. Total well depth below land surface: 20'0 (ft.)
For multiple wells list al/ depths if different (example- 3@200' and 2 a 100')
10. Static water level belowtop of casing: 6'0 (ft.)
If water level is above casing, use "-1-"
11. Borehole diameter: 10.0 (in.)
AUGER
12. AV'ell construction method:
(re. auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. 't id (gpm) Method of test:
13b. Disinfection type: Amount:
14.WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
5.0 ft.
4.0 in.
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5.0 ft.
20.0 ft.
4.0 in'
.010
SCH 40
PVC
ft.
ft.
in.
13.'GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
20 ft•
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL
PACK.
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT ME'IIIOD
3.0 ff.
20.0 ft•
20-40
FINE SILICA SAND
ft.
ft.
21). DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/inch type, grain size, etc.)
0.0 ft•
5.0 ft.
CLAY/GRAVEL
5.0 ft.
20.0 ft.
SILTY CLAY
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21.REi\IARNS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
Signature of Certified Well Contractor
10/29/20
Date
By signing this farm, 1 hereby certify that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NP.IC 02C .02(1(1 Well Construction Standards and that a
copy of this record has been provided to the well onner.
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. For All Wells: Submit this form within 30 days of completion of well
construction to the lollowing:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: 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
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Injection Wells: In addition to sending the firm to
the address(es) above, also submit one copy of this form within 30 days of
completion of welI construction to the county health department of the county
where constructed.
Form GAV-1
North Carolina Department of tiny imnment :111(1 Nattu'al Resources - Division of Water ()Minty Revised Jan- 201

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
DAVID HALL
Well Contractor Name
A - 4459
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Cmnmercial
❑lrngation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
Monitoring tZJRecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer "hest
❑F_xperinlental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
DOther (explain under #21 Remarks)
For Internal Use ONLY:
4. Date Well(s) Completed: 10/14/20 Well ID# RW-2
5a. Well Location:
CLEMENT RESIDENCE
Facility/Owner Name Facility !DP (if applicable)
149 ELIADA HOME ROAD ASHEVILLE 28806
Physical Address, City, and Zip
ASHE
County Parcel Identification No. (PIN)
5h. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
DI well field. one fat/long is sufficient)
35° 36' 08.51" N 82° 36' 26.56"
6. Is (are) the well(s): ©Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
IJ1his is a repair, ill out known well consnrucion in/invitation and explain to nature Oahe
repair under P2/ remarks section or on the back o(this Joan.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction. you can
submit one Jornr.
9. Total well depth below land surface: 20'0 (ft.)
For nndtip/e wells list all depths if different (example- 3@200' and 2@100')
J0. Static water level below top of casing: 6'0 (11.)
I/ ooler level is above casing. use
11. Borehole diameter: 10.0 (in.)
12. Well construction method: AUGER
auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13h. Disinfection type: Amount:
14. WATERZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15.'OUTER CASING (for multi -cased wells) OR LINER (Hap dicable)
FROM
TO
DIAMETER
TIIICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING 012 TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
5.0 ft'
4.0 in.
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
TIIICKNESS
MATERIAI.
5.0 ft•
20.0 ft.
4.0 in'
.010
SCH 40
PVC
ft.
ft.
in.
18• GROUT
FROM
TO
MATERIAL
EMPLACEMENT METIIOII .k AMOUNT
0.0 ft'
2.0 ft'
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL.
EMPLACEMENT METHOD
3.0 ft-
20.0 ft•
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach' additional sheets if necessary.)''
FROM
'f0
DESCRIPTION (color, hardness soil/rock type, grain size, ele.)
0.0 ft'
5.0 ft.
CLAY/GRAVEL
5.0 ft•
20.0 ft.
SILTY CLAY
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REDIARKS
BENTONITE SEAL FROM 2.0 TO 3.0 FEET
22. Certification:
10/29/20
Signature of Certified Well Contractor Date
By signing this /Orin, I hereby cer0B. that the Trell(s) was (mere) constructed in accordance
with 15A NCAC 02C.0100 or /5A NCAC 02C.0200 Nell Construction Standards and that a
copyf of this record has been provided to the Ire!! 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_
SLTB\1ITTAL INSTUCTIONS
24a. For All 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 27699-1617
24h. For Injection Wells: 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
construction to the following:
Division of Water Quality, , Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC: 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this font within 30 days of
completion of well construction to the count- health department of the county
where constructed.
Form GW-1 North Carolina Department oflit ironmenl and Nantral Resource;- Division of AArater Quality
Revised fall_2013