WI0100429_Geothermal Well Construction Record (GW1)_20160328

I 17lvlsion of Water Resources
r ms roan can be used for single or multiple
I. Well Contractor Information:
Robert harry Wells
Well Contraomr Name .
2603-A.
NC Weii Contractor Certification Number
AW❑ Services Inc
For
MAY 1 6 2D16
Water Ouallty negional Operati ns
{ r'Pio '.11 %fll co _ .. .
Company Name t1r1
2. Well Construction permit #: W 1 0 10042 9
List all applicable wail construction permlis (i.e. County, Stare, Variance, etcj
3. Well Use (check well use):
DAgricultural ElMunicipal/Public
RGeothermai (Heating/Cooling Supply) t7Residential Water Supply (single)
131ndustriallCommercial a?Residential Water Supply (shared)
Supply Well:
©Aquifer Recharge
❑Groundwater Rem ediation
MAq uifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
ClEkperimental Technology
QSubsidence Control
RGseothermal (Closed Loop)
❑Tracer
❑Geothermai (HeatingJConling Return)
❑'Other (explain under#al Remarw
4. Date Well(,) Completed: 3/25/16 Well ID#
Sa, Well Location:
Colin & Sian Brunton
Facility/Owner Nome
335 Cragmont Rd
Physical Address, City, and Zip
Buncombe
County
Facility ID# 0fapplicable)
Blk Mountain, NC 28711
0609668186200000
Parcel identification No, (?IN)
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5h. Latitude and Longitude in degreeslmfinutes/seconds or decimal degrees:
(ifwelI field, eat= lat'long is sufficient) 22. Cer on:
35 37' 1 " 82 20' 31 " 3128116
6. Is (are) the well(s)r XPermanent or []Temporary
7. Is this a repair to an existing well: []Yes or RNo
If this is a repair, fill our known well comiruction informanon and explain the nature of th
repair under #21 remarks section or on the hack oflhisfonn
8. Number of wells constructed: 2
Fbrmultlple Mlection or non-watereupply welly 01VLYwr1h the same aoushvrcllatr, you cc
submit one, form.
Signature ofCertifie ell Contractor Date
By signing this form. I hereby certljy that the xettfs) way (mere) constructed in accordance
x�iilr 15A IVCAf 112L' .0100 yr 15A NCAC. 02C .11200 W-11 Conslructtwr SranrxYerds and that a
copy of thin record har been provided to the well Ginner.
e 23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details ar Weil
construction details. You may also attach additional pages ifneccssary.
SUBMITTAL INSTUCTIp115
9. Total well depth below land surface: 2 @ 260'
For malliplewetlslist all depthsifdoerem(arample-3@2Q0'and2@100') (B) constructionto helfollowing-
Submit this form within 30 days of completion of well
10. Static water level below top of casing: NJA(ft.) Division of Water Quality, Information Processing Unit,
If water level is above casing use "+" 1617 Mail Service Center, Raleigh, NC 27699.1617
11. Borehole diameter: 6.25" (in.) 24b. For I__ nie�tiou) tom; In addition to sending the form to the address in 24a
above, also submit a copy of this fornr within 30 days of completion of well
12. Well construction method: rotary construction to the following:
(Le. 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. F W ter IF
& Flo in addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13h. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina DrPartmeut ofEnvirorinient and NaturaI Resources — Division of Water Quality
Revised Jair. 2 013