WI0100452_Geothermal Well Construction Record (GW1)_20160930

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1. Well Contractor Informa
Rex Meadows
Well CoMmotor Name
2113-A
NC Well comraotorCenification
IVED
sr Resources
,JAN 2 3 2017
Water Quality Reglonal bperatlons
Asheville Reolonal Office
Clearwater Well Drilling, Inc. Hot Springs, NC 28743
company Name {f �r�� �.�
2. Well Construction Permit#: r of
Gfs► ail app11cable well perch►., f1,e. County, State, Mrfame, injection, etc}
3. Well Use (check well use):
(HeatinglCooling Supply)
❑Industrieucommercial
❑Aquifer Recharge
OAquifer Storage and Recovery
❑Aquifer Test
QExpeflmeatol Technology
o0eathermal (Closed Loopy
4. Date Wallis)
❑Municipal/public
OFLesidential Water Supply (single)
❑Residential Water Supply (shared)
oGroundwater Remediation
❑salinity Barrier
❑stomtiwater Dmia w
OSubsidence Control
OTracer
Well MN
Art. Well L;
FadlityMwnerNona l' Facility W4Ofapplicohle)
Physical Address, City, and Zip d
County Pawel ldonueeatian Nu(Pre)
5L Latitude and Longitude in degr'eeslminateslartands or dtcimal degrees,
(ifweil field, ana lad eng is sufficient) D
3,F9. a n N. OU 093.: W
6, Is (are) the well(s): I,ermanent or C1Temporary
7. Is this a repair to an existing well: ©Yes or 04,
If dt►s IT a repair, fill owi known wall ca Aarvelion tnfarmation and explala The nafare of the
repair Tmder 021 remarks 5wifon or an the hack of ibis form.
S. Number of wells constructed: 5
Fbr muhtple 11yeelloo or iron-weler.suppiy evolls OA7Ywith Ifrasame araualrgah". ynrr am
.submu one faNa.
9. Total well depth below land surface: C `-' (R)
For muftipie iMls 4se at1 dspihs ljd&rent (example-1@200'and2®1005
10. Static water level Below top of casing: ()
{(water revel it above easing, we "+"
11. Borehole diameter: (In.)
12. Well construction method:
For itnetnal llso ONLY:
flea n:
-A— 130/ 1
signawe ofcer"ed Well Contractor Data
Ay ,signing ►Iris form, 1 heruO cero& that the ivell(s) was Pwra) canstmc►ed In accordamw
with 15A NrAC 02C .0100 or 15A NCAC OX .0200 Well Construction Maadards and thin a
copy of►his record has been provided io the w1l amwer.
23. site diagram or additional well details:
1100 may use the Lack of this page to provide additional vMl site details or well
oonstruction details. You may also attach additional pages if necessary.
SUJ Mi7"PALINSTUCPIONS
24a For All jI: Submit this form within 30 days of completion of well
construction to the fallowing:
Division of Water Resources, Information Processing Unit
1617 Mali Service Center, Raleigh, NC 27699-3617
24h. Eqr Infection Wells ONLY: In addition to sending the thrm to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
construction to the fallowing: '
(Lee auger. rotary, cable, direct push, etc.) Aivision of Water Resources, Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test-. 24c. For Water Supply & Inlectivn wens:
Also sthbmit one copy of this forth within 30 days of completion of
131►. llfsinfecdon type: Amount: yell construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Depwbanent ofEnvimnmrntjmd l4naral Resaurcea —Division of Wamr lteruumca kaviaed AugnA2013