WI0100421_Geothermal Well Construction Record (GW1)_20160211 (2)

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Uivir, ui Ye. •.:r�i+ci l,+ct+s
-this form can ac uscu Tor sfng[e or TmahPle
1. Well Contractor Information:
Robert Larry Wells
Well C ontraotor Name
2603-A
NC Well Coolractor Crrtiffa%ion Number
AW❑ Services Inc
IRD For Internal c OM Y
APR � 5 2016_ i.ts
14. WATER''ZONES
:noM TO _
Company Name 1 q l .f
2. Well Construction Permit#: V u 10 1 00421-
List all applicable a•a11 construction permils (i.e. (.'nunay, Slats, yarfancv, etc•-j
3. Well Use (check well use):
DAgricultuml ❑MunicipallPublic
Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑EndustriallC:ommercial 0Residentia] Water Supply (shared)
Non -Water Supply Well:
❑Monitorina. ❑Recovery
[]Aquifer Recharge
❑Groundwater Rem ediation
❑Aquifer Storage and Recoyery
❑Salinity Barrier
❑Aquifer Teat
0 Stormwater Drainage
❑Experimental Technology
El Subsidence Control
Geothermal (Closed Loop)
❑Tracer
❑Geathermal (fleatinlalCoolinx Return)
❑Other (explain under #21 1
4. Date Well(s) Completed: 2/10/16 Weil ID4
Sa. Weil Location:
Meredith Ellison
Facility/Owner Name Facil ity ID# (i f app licablc)
257 Jones Cove Rd Asheville, NC 28805
Physical Address, City, and Zip
Buncombe 9770097801
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/mina teslseconds or decimal degrees:
(ifwell field, one lavlong is sufficient)
35 39' 5" N 82 27' 54"
434G3'7 !
I k I ft. I tn. I I I
0 fr. 32�0ff. I.25 in. Z5UKI HUH
i-' - in. 17.SCREEN
FROM To DMMETF.R SLOT 312E THICKNUS MATERIAL
ft. f • in.
ft. ft . in.
IS. GROIIT.
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
-320fr- 0 ft Thermal Enhanced Pum e
ft- �- -- ft.
ft.
ft.
ft.
F ft
ft,
ft.
ft.
ft,
ft.
:r 21, REMA
22. Certification:
ft.
it.
"I l■NIT
1..� s,gnature' "PEIIRT� tar [ Date
& Is (are) the well(s): QQPermanent or ❑Temparary
iJ•.,iglrtrri fh+- !artr reby ccrtyy roar the eel(.r) was (were) conri ucled irr ucwordance
vrth 1 5A N"AC' 112 1100 ar 15A NCAC 02C' .0200 iVull C'or,.rtrwiiwt Staudards and thaf a
7, Is this a repair to an existing well: ❑Yes or f�1No
npy nfthi.r +ccr:r rres hr:n rprnuided to the .r01 owner•
If Ibis is a repair,. j111 one known well construction infwrlraelon and explain the nalum of the
repair rmder #21 remavkr secrion or on the hock of this form.
23. Site diagram or additional well details:
2
You may use the hack of this page to provide additional well site details or well
S. Number efwells constructed:
4:onstnlction details You may also attach additional pages if necessary,
For muleeple lnlecelon or non-iraler •itrllply wefts ONLY wfth 1f16 satire fwistruedon, J'a:! Gan
mbmie one.form.
SiIBMITTAL INSTUCTIONS
rat
9, Total well depth below land surface: 2 @ 320 (ft, l
24a. For All 'Wells: Submit this form within 30 days of completion of well
For rnulople weils list all depths if different (erumpla- 3Q200' and 2 r@100')
construction to the following:
10. Static water level below top of casing: - t� (ft.)
Division of Water Quality, Information Processing Unit,
If water 149s+el is above casing, use " 1 "
1617 Mail Service Center, Raleigh, NC 27699-1617
11. borehole diameter: 6.25" (in.]
24b. For Iniectlan 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
12. Well construction method: rotary
:onstruction to tlme followine:
V
(i.e. sugar, rotary, cahh, direct push, etc-)
Division 0I'WaIei• Quality, Underground Injeetion Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Mail Service Ccnter, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test:
24c. For Water Supply Wells: In addition to sending the form to
_._ _ _ _. _ ...
the addresses) above, also submit one copy of this form within 30 days of
13b. Mstnfection type: Amount-
completioll of well construction to the county health department of the county
where constructed
Fomm GW-€ North Carolina Department of rnviroHtmeLit and Natural Resources ❑ivimri of Water Quality Revised Jan- 200