WI0100480_Geothermal Well Construction record (GW1)_20170518

WELL CONSTRUCTION RECORD
This ffinn can be weed for singla or multiple wells
1. Well Contractor Information:
Robert Larry Wells
(Guest House Sandyland Cove)
F'or Infernal t7se�3NLY: .
'Wal CcA}ra6tpr Name
2603-A
NC Well Contractor Certification Numher
AVM Services Inc.
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I Well Construelf on Permit 4:
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3. Well Use (cheek well use):
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Water Supply Well:
❑ [cultural ❑Municipal/Public
MOcotharnud (Heating/Cooling Supply) ❑ltesideruial Water Supply (single)
CllndusttiallCommercial ❑Residential Water Supply (shared)
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Non -Water Supply Well:
IlMonitoring' ❑itacovery
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I eetlion Well:
❑Aquifer RachaW 110roundwater Ranediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
Mwifer Test ❑Stornnuater Drainap
❑Experitnelntal Technology ❑Subsidence Control
514thermal (Closed Loop) ❑Tracer
Mpotfwmal eati li Retum ❑Dther lain under #21 Remarlrs
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4. Date Wells) Completed: 5/17/17 Well JD#
Sa.Well I,vcativn:
Guth , Wfliam R & Jackson
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Physical Addraw City, and Tip
Transylvania 8512-84-2354-•000__
Coanty Fuaol Wandfic ticn'No" (21N)
5b. Lati[vde and Lougltwde •n de eslmimr teh d de • 1 d
' 21. R>£
by*,':.': z.hs ..•;,, x
gre eeoa s or aura egress.
(tfwell field, one Wong is sitflicieu[) Efev. 2481
35 7' 32" N 82 57' 8" w
6. Is (are) the well(s): MYermaneat or ❑Temporary
7. Is this a repair to an existing well[ MYes or li(
(f ebts es a repair, fill my knuwve well cawnuclion lnfarmafian and erplghz the erorurc of the
repa►r under 421 remarks saerlon or On the 6nck ofW45101m.
S. number of wells constructed: 3
For merlriple W0011on ornon•walersupplywalk ONLY with the smxe cmaT tC&,& you ran
mbmit one farm.
9. Total well depth below land surface:2a200' 10-275' (it.)
For muldple wells list all ikpila trdpreal lemnpk. 3@300' and20100)
IQ. Static water level below top of easing N/A (ft)
dfwater level is a6ovs casing, arse "+"
11. Borebole diameter: 6.25 (in.)
12, Well Construction method: rotary
(i.e. auger, rotary, cable, direetpualk etc.)
FOR WAT)KR 911PPLY WELLS ONLY;
13a. Yield (gpm) D Method of test: (4a i ro nta inesr
13b. Disinfaettan type._ Tab IPfS Amount: 2
n Certificat,
• - 5J1 �r17
gaature a d 6_11untor Date
By stgrting this , T "My car* oral As well(s) wns 6vera) comerwNd in aerordrnce
wlrh IM NCRC 02C.0100 ur IJA HCRC 02C.0200 Fall Comremeflon Standarrk and ►hat a
COPY Oflka racordhn have p aWd¢d lO ikexwll aKner.
a3. 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 popes ifnecessary.
SLIBMTTTAL 1NSTi MONS
Zits. For, Wells: Submit this iaft within 30 days of completion of well
construction to the following.
Division of Water Quality, Informatlan Processing Uri%
1617 Mail Service Center, Raldgh, NC 27699-1617
24b. For ft&etion Wells; In addition io sending the form to the address in 24a
above, also submit a copy of this form within 34 days of completion of will
construction to the following
Division of Water Qualify, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
x4e. Welb, jp addition to sending the form to
the address(es) obovb, also submit.one copy of this form within 30 days of
completion of well construction to the county health department of the county
„here constructed.
Form GW-1 North Caroline Dwortmett afEnvimnment and Natural Resources —Division of Water Quality Revised lan.2vl3