WI0100487_Geothermal Well Construction Record (GW1)_20171108

WELL CONSTRUCTION RECORD
This form can he used forstogle or multiple walk
F✓�
I r rt Use ONLY:
1. Well Contractor Information:
;
Robert Lar YI 11i;1:,i: r•.
ry Wells
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Wi 11 CcntracrorNarno
2603-A
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NC Well Contactor CerGticationNumber `�
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AVVD Services Inc.ft.
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CompanyNama {','4;"•"•_`
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Well CnnstractionPermit0: kk1Q1ONO
F 0
List ull a ppheahla wall cons'-cdon permlls Ae. Coun% Slate, Yatiatcq etcJ
0 285 I•
3. Well Use (cheek wen use):
'
Water Supply well:
-617.6
R�i cultural ON[unicipaliPublia
R'
hermal {Heati*Cooling Supply) ❑Residential Water Supply (single)
&
❑IndustliaVc=mercial ❑Residential Water Supply (shared)
1 [�R W
Lbe�v
❑Aquifer Recharge ❑Groundwater Remediation
ClAquifer Storage and Recovery Osohnity Barrier .
OAquifer Test t7Stormwater Drainage
rerimernal Technology Osubsidence Control
�Cleothermal (Closed Loop) Onacer
-285 0 ft. Thermal
rt. ft.
AY.8,4NAT fETi,PACif if ¢able
FROM TU ngW
ffi• ft:
2Q a
TO
fr. ft.
a. Date Wei4s) Completed: 11 /08117 Well rDff
3a. Well Locatlow
Kenneth Kahn & Joanne Kalp
Facilityldwaor Name Facility JIB# (Kapplicable)
21 Tulip PQplgr T il A§heyift,
ftsical Address, City, sod Zip
Buncombe 97217239500000 71
Cnuary Parcel Idtnsficew No, (FIN)
5b. Latitude and Longitude in degrceslndnutesimonds or decimal.degre".
ofwtll Bald, one Wong h macim) n
35 39' 17" EIev.2160
N $2 36' 42"
6 Is Sig
s.
fe.
it.
7
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U 4i1
11/09/17
{aro) the well{s): Permancut or CITemparary
By afgsing lkls foni%b "* terry &at the aeR(aJ was 6w ra) swttducmd in orcor�mca
air to an existing p ' tang well.. ❑Yes or 7. Is this a re 'w
�1Yo
Ifrhre to a repair, jilt orlt lovotwt well
wllb 15A 1 CdC 02C.0100 or 15A NC4C 02C A2d'0 Well Canaan l m, &Ondards and that a
ccpy pfrhla retard has beenFzw&dto Ike weir miner.
cornauellari Irdormarlon and explamrthe nalum of fhe
Nparr tinder 021 remads section or on the hack aflhtsfotm.
23. Site dillMm or additioaal well details:
S. Number ofwells constructed: 2
You may use the back of this page.to provide. additional well site details or well
cortstrtiotion details. You may also attach additions]
Far mulrlpte infsarlovt ornam wareraupply wells ORLYw o the eaaos� you amy
aubark erte form,
pages if necessary:
SUBAUTrAL INSrUCPIONS
9. Total well depth below land surface: 2 @ 285
For mulllple wells list all pths lfdt�§rene (exam e- 3 p0 arad3 1 { ')
F" M
�' �l All WARS: Submit this form within 30 days of completion of well
construction to the following!
I% Stado water level below top of casing: N/A (B,)
lfwaler level is ohm toeing trot +
Division of Water Quality, Information Processing ilnit,
6.25
1617 Mail Service C.Bnter, lialeigh, NC 27699-1617
11. Borehole diameter: {io.)
UL ]lLaiubg elm: In addition to sending the foram to the address in 7.4a
12. Well construction rots
: rotary
above, also submit a copy of this farm within 30 days of completion of. well
(i.e. auger, +Diary, cable, dirm u
sct ppush, ata.}
construction to the following
WELLS ONiLrY:
Mwbion of Water Quality, Underground Injection Control.Prmgram,
1636 Mail Service CenW, Raleigh; NC 2769994636
EWATERPPLY
Method of test:
24c. addition to.sendingthe farm to
the address(ea) abcvb, also submit..one copy ofthis form within 30 days of
pe: Amount:
completion of well construction to the county health depaiiruent of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natwat Resotccts—Divigort of Water QualityRevised?an.2D13