WI0100462_Geothermal Well Construction Record (GW1)_20161208

WELL CONSTRUM
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DIVIsfon of Water Resources
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1. well Contractor Information.
Robert L Wells
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Well CoatractorName
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AllVa Services Inc.�.
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2. Well ConstruetfonFermlt#: W10100462
Llsl all appllcable well aonslrxcllnn perml(s p.e. County. ,stare. Yarlane6, el6)
3. Well Use (check well use);
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THICIMM
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320 fL
1.25 "'1
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Water Supply Well:
❑Agricultural t7Municipalfftblic
Raothennal (Heatingicooling Supply) ❑Residential Water Supply (single)
01nd strlallCommereial W
u OResiaeneal stem Supply (shares)
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C]Manitoring ❑Recovery
320
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Pumped
Injection Well:
MAquMr Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
ClAquifer Test ❑Stormwater Drainage
RExperimerdal Technology ❑Subsidence Control
C&hcmtal (Closed Loop) <aTracer
11(kothermal (Heating/Cooling Return 00therLexplonunder#21 Remarks)
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4. Date Well(s) Completed: 1215116 Well wo
Sa. Well Location:
Joshua D Paynich
Facllitylowner Name Facility IN (ifapplica6ie)
712 Bane Berry Court Asheville, NC 28803
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Physical Address, City, and Zip
Buncombe 9645-53-8069-0000
Couaw Parcel Identification No. (PIN)
5b. Latitude and Longitude in degreeshnlnuteslsecouds or decimal de rees:
(ifweli geld, one latliong is suf ineat) Elev. 2302
35 29' 31" N 82 32' 32" w
6. Is (are) the well(s): 00ccrmanent or OTemporary/^
7. Is this a repair to an existing well: ❑Yes or i9tgv
!f rhls is a rspair,•i11 oulknown well commecdon lnformalorr and erplaln the Harare of the
repair under #21 remarks seadan oron the back ofthlsfa,m.
S. Number of wells constructed: 3
Far mnulpple injucllon or nan•walersupply wells ONLYw#h the soma consbuCdam; you ran
suhmh one foram. ,
9. Total well depth below land surface: 1 @350' 2@320' (ft.)
For nmuA'lple wells llsl all& -plks lfdfffererx (example. 3®200' and 2®100')
10. Statle water level below top of casing: N/A (ft )
lfwaler level Is above casing use "+"
11. Borchnte diameter: 6.2 (I-)
12. Well construction method: rotary
(i.e. augur, rotary, cable, direct push, otc.)
FOR WATER SUPPLY WELLS ONLY:
138. Yield (gpm) Method of test.
13b. Disinfection type: Amount:
22. Certificatio
� a •- N 12/8116
Signanrre or t etnnea wwr kU W— Date
By srgrling lhls flan, I hsreby cer* lhal the Krk(s) was (were) consinmd in accordance
whh IJA NCAC 02C.0100 or IBA NCdC 02C.0200 Well Carr imelloa Standards and rhal a
uopygflhis record has bean praalakd to the well owner.
23. Site diagram or additional well details.
You may use the back of this page to provide additional well site details or well
construction dotaiIs. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24%. For All Wells: Submit this fauttf 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 ectiog Wens: In addition to sending the farm to the address in 24a
above• also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. nr y1ter Sunnuv & ImIlWpa Wells: Tn addition to sending the form to
the address(es) abovb, also submit. one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment aria Natural Resources — Division of Water Quality Revisedlan.2013