HomeMy WebLinkAboutWI0100445_Geothermal Well Construction Record (GW1)_20160811MLLCONIDLUCUN C
This form can be used for single or rnuldpk wells
t. Weil Contractor In4errnation:
jYl i� lief 1�L:�CILIL(:CiS
Robert Larry Wells
Well Contractor Name
26o3-A
NC Well Contractor Certification i4t1n be,
AWD Services Inc
C ompany wame �I;i#nr
2. Well Construction Permit * ..._. — ��
list all applicable well construction permlls ri.,r 1'nunly� Stars.
3. Well Use (checkwell use):
Water Supply Wen:
AEG 2 3 20ib
pperations _
16. CASING C
- MM { 320
Variance, erc'.1
i
❑Agricultural a7 Munlcipalff'obhc
6Roeothermal (Heating/Cooling Supply; i7Residential Water Supply (single
�industriallCommercia[ DResidenfial Wager Supply (shared
Non -Water apply W el}:
DMonitoring - _ ❑Recovery
lnjeetion Wen: _ -
0
17..SCREEN
VROM
r o
-
rr.
i ra. GROIPr
-..
FRONT -
rn
� . .350.
350
0
oAquifer Recharge 7Graundwater fZernediation
19
❑Aquifer Storage and Recovery 38alinity Barrier
❑Aquifer Test -�iSurrmw;tte, Drainage
a Experimental Technology ❑Subsidence Control
2C
RGeothennai (Closed Loop) 77 racer
i-.iF
[:I Geothermal (Heath Coolie Return) ❑father (explain under 47.1 Remark,,
4. Date Well($) Campleted: $-01 6 ►Veil Tit#....__
ga. Well Loeaflan:
William H Dascombe
Faciiitylowner Name Facility [Da (if applicable)
4 Casey Lane Brevard, NC 28712 `
Physical Address, Ci�. and Zip 8592-4$-0482
Bravura 11 r' ����U�
�r
County J �cct ideittificativn i�io. (Plh
3b. Latitude and Longitude in degreeslminuteslsecond9 or decimal degrees-
(ifwell field, ono iatllang is sufficient)
35 8' 45" N 82 41' 55"
6- Is (are) the well(s): Permanent or :�iTemporary
7 Is this a repair to an existing well: Flyes or XND
if lhls• i:: a rapair, Tl1 our known wall cunsrnrc17on ,a ferrnallori rnr<I axpla,n the ew;r're y7'o
apatr under 92) remksar.seCllotr or on the back of thm for•n,
8. Number of wells constructed: 5
I.ar mumple ir:)eallorr or non -water .tupply melty OXY.Y with the same cansfrrrelion, ya„ �•
.rubmlrone form. �j�]
2 354030320'
9. Total well depth below land surface: Ifr
,,op multiple wells &I all deplhs if diiferenr rexample- 3@200' and 20100')
NIA
10. Static water level below top of casing: its
if warar level to above casing, use ' -
11. Borehole diameter: 6.25 _--_ (in.,
12, Well coastmetioa method.
yr ..
{,.e. sugar. rota , eable, direct push, etc I
FOR WATIR SIMPLY WELLS ONLY
13a. Yield (spat) -- ..---..... ... Method of tesf:
13b. Disinfection type: —.. Amount
4 `806 7
ff, in.
iR:'TilllitFhG o�fitisaid"'
'125 Si
5 .2ntS�
ata It't'es st.oTsrxs �
in.
IMRrnl. l3PHl'
ft- Thermal En
Thermal Er
T ..
i1 ir.
ii Ft.
rc Fr.
it]I
1. REMARKS
.. �.elnitls:a4ttn
8/11/2016
bate
,f",.,+r: he,,6v cur,?fy tlml the weNrs) was (were) rani ucled in accordance
rr 1 010t1 ar 13A NCAC 02l - .0200 Well Comiruclivn Standards and that a
uz.+ been provided In the wall osnner.
`Sitr dfagraw at, additional well details:
,n, back of this page to provide additional well site details or well
,t.ql - • Von may also attach additional pages if necessary.
iBMI'l'I As ItNSTUCTION8
4a "I Ail Wells: Submit this form within 30 days of completion of well
Iritr ,c : ,�- the following
't'ivisiart of Water Quality, Information Processing Unit,
h 17 Mail Service Center, Raleigh, NC 276"-1617
4h. Ito infection Wells: In add iLioil to sending the form to the address in 24a
,ov, ,is• +ahtv.it a copy of this Form within 90 days of completion of well
.•ICl.-i�II.. +;, following
Division u)f Water Quoifty, Underground Injection Control Program,
t 03b Mail Serviee Center, Raleigh, NC 27699-1636
tt .Cu Water 3&ggiv & iniectiwtWells, In addition to sending the farm to
ddresstr•• ' Above, also submit one copy of this form within 30 days of
-vdi construction to the county health department of the county
Form r3W•i tiorth Carolina Department of'Eimronrne,I ,+.,- 'atPr; ! . : revision of Watcr Quality Revised Jan. 2013