WI0100428_Geothermal Well Construction Record (GW1)_20160322

CANS UCT CN R1
This form can he used for single or multiple wells
1, Well Contractor Information:
Robert Larry Wells
Well contractor Tune
2603-A
Division of Water Rescur
M AY 1 6 2011
Water Ouality Rpoonal Or
NC Well Contractor Certification Number
AWD Services Inc
Company Name �1 f
2. Well ConstrueffonPermit#: WID 1 00428
List all applicable well construction permits (i.e. County, Stare, Ynriance. ete)
3. Well Use (check well use):
Water Supply Well:
4Agricultural
k6eathermal (HeatineCooling Supply)
❑ Industrial/Commercial
i]lrrigatiorl _
Non -Water Supply Wen:
❑Monitoring
Injection Weft:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
El Aquifer Test
[]Experimental Technology
RUeothermal (Closed Loop)
❑MunicipallPublic
El Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Groundwater Rem ediation
❑Salinity Harrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
ucfeotttermal HeEgU/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date'Well(s) Completed: 3/22/16 well Ill#
3ti. Well Location. -
Michael Schneider
FacilitylOwner Name Facility 104 (ifapglicable)
6 Mayflower Dr. Asheville, NC 28804
Physical Address, City, and Zip
Buncombe 9649854351000
County
Parcel idcatifioation No. (PIN)
5b. Latitude and Longitude in degreeslminutes/seconds or decimal degrees;
(ifwell Held, one Iat4ons is suif'icient)
35 36' 320' N 82 32' 17" W
6. Is (are) the well(s): XPermanent or []Temporary
7. Is this a repair to an existing well: ❑Yes or XNo .
If this is a repair, fill our known well construclion information and explain the nature of the
repair under,121 remarks section or on the bock of this• forum.
8. Number of wells constructed: 2
For multiple injection or non -water supply x•ells ONLY with the same conslrucdon, you can
submit one form.
9. Total well depth below land surface: 2 @ 260' (ft.)
For multiple wells list all depths ifdffferenr (example- 3@200' and 2@100')
10. Static water level below top of casing: NIA (ft.)
If wafer level is above caslgg, use " t "
6 25tt
will, 15A NCAC 02C -0100 ar 15A NCAC 02C.020D Well Canrtructian Standards and that n
copy of lids record hat been provided to the mvil otiryrer.
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 ifnecessary.
SUBMITTAL INSTUCTIONS
24a. For All Well : Submit this form within 30 days of completion of well
construction to the fallowing -
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699.1617
11. Borehole diameter: (in,) 24K For In ecti n Fells: 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 coustrucilma method: rota construction to the following:
(i.e. auger, rotary, cable, direct push, etc.)
Division of Water Quality, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY; 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. 'Yield (gpm) Method of test: 24c. Fo L&L&R& & I o We n addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h Disinfection type: Amount: completion of welt construction to the county health department of the county
where constructed.
Faun Gw-1 North Carolina Depa0ment of Environment and Natural Resources - Division of Water uali
Q ry Revised Jan .2p13