WI0100421_Geothermal Well Construction Record (GW1)_20160211

WELL CONLTAUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
Robert Larry Wells
Well Contractor Name
2603-'A
NC Well Coatractar Certification Number
AWa Services Inc
Company Name p r
2. Well Construction Permit #: ,V ►t I01 0041 6
list aAappllcerble well construcam, permits 0.a. County, Stare, Variance, e1c.)
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural ❑Municipa[IPublic
JiGeothermal (Heating/Cooling Supply) ❑Residential Water Supply (singie)
❑Industrial/Commercial 0Residentia] Water Supply (shared)
supply.well:
UAquifer Recharge
❑Groundwater Rern ediation
❑Aquifer Storage and Recovery
OSalinity Barrier
❑Aquifer'I"est
❑ Stormwater Drainage
11F.xperimental Technology
❑Subsidence Control
Geothermal (Closed Loop)
❑Tracer
❑Geothermal (HeatinglCooling Return)
❑ Other (exulain under #21 F
4. Date Well(s) Completed: 1 /21 / 16 Well ID#
Sa. Well Location:
Kirk & Minette Johnson
FaeilitylOwner Name Facility rM (if applicable)
272 Snow Ridge Drive Hendersonville NC 28
Physical Address, City, and Zip
Henderson 9693694668
County
Parcel identification No. (PIN)
fib. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwclI field, one latllong is sufficient)
35 27' 40" N 82 22' 15" 1125/16
3igna re f CcrtiI ell Contracts pare
6, Is (are) the well(s): 3qPermanent or ❑Temporary
By
signing a is f nr. 1 hereby certify Ilia; the wcll(s) was (ware) cmislructed In accordance
ti,41h 15A NC'AC • 02(' .0100 ar• 15A NCA(' r12C' .0200 Well Constructlwr Wcmdards and 4wz a
7. Is this a repair to an existing well: ❑Yes or �iVo ,.,opy of this ,rrurel bar been provided 10 the Kill owner.
y tits is a repair, fill our known we11 consirucliatl information and explain the rra;urn of the
repair tinder 921 remarlrs section or on the hock of thm.foren.
S. Number of wells constructed: 3
For rmli,ple infection or non-winer•supply v ell,; oNLYwah the some colrar VICA91i, you cau
submit one form.
9. Total well depth below land surface: 3 @ 330' —Vt.)
I:Or mulllple m-ells list all depths ifdlfferew (example- 3[r 200' and 2@100')
10. Static water level below top of casing: UZA (ft,)
!f water lens/ is above casing, use "-i "
It. Borehole diameter: 6.25" (in.)
12. Well construe Non method: rota
ry
(i.e. auger, rotary, cable, direct push,
FOR WATER StPPLY "Etk&iA'-'G"'
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details ar well
construction details. You may also attach additional pages ifnecessary.
SUBMITTAL INSTUCTIONS
24a. EaLALI 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 'ec o 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 to] [nwing:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: __- i' 24c. Fo r Sulu[ & In' n e]ls: addition to sending the form to
�� the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfeetio type: _ mount. � completioo of well construction to the county health department of the county
where constructed
Form GW-] i Waa{;irlile?r )ik, i „N ,�h C Tina gepartmeufE t.pnviroiuncut ron ofWateruali
aid Natural Resources Division j f:':! L�f'AI� [ I1S h Revised Jan.2013