GW1-2022-04473_Well Construction - GW1_20220509

WELL CONSTR`UCTION=RECORU For lntcrn�lUscON1.l':
This fonn can be rind for singk or mulliple sells \�
1.Well CAmiractor information:
44.%RATER ZONtiS
Stefan Smith FROM TO DFtiCRIP1tON
%VeltCo ttrtctor Nam A. ft.
n. n.
3576A 15.OTFRCSINGior' uftIki icQs f.a MNC%VellContractorCcnifwalionMinter 1 R rTHICTNES5 A11
f.RtAt
SAEDACCO Inc 0 It. 20 It. 4 in. 1 40 PVC
C;hiigrim'"Cvsntc 16-INNER CASING OR'7 U111ING f eulAernial tlowd•Idt"):`
FROM I TO D[ASti'TER 'MICTNESS MATERIAL
2.Well Construction Permit i1: it. ft. hn.
Lin Ali nprtlirahle'"Tit pernit (i.e.C,rnmty:Sia"..Varinrcrr. em.)
ft. fl. M..in.
3.Well Use(chat:well use): 77S:Se RLEN
Water Supply Weil• FROM TO DIAMkTrR SLOT51 if, Tto(-KNt`5 I MATFRIAI.
CIr1$tictLllutal IJMunit ipctlll'atbliC 20 ft. 50 ft. 4 in, 010 40 PVC
1743cothemlal(1-ieatin0ooling Supply) OResidential Rater Supph•(single)
ft. ft. to
DindustrialfCommcrcial (]Residential Rater Sllpph•(shared) FROIOUT TO MATERIAL I E\rPLACT.MCNT METHOD R AMOtiNT
❑irci ation 0 rL 16 It. Portland/beITDeAte
Non-Water Supply Well:
Ohtonitoring (Mitcco"rty
injection%Veil•
❑Agrtifer Recharge OGronndwatcr Rcoicdiation 19,SANDiGRAVEL PACK(if itkable
YRMf TO MA'1'R.Rlit. HMPt..\fYAt`\Y MI;'ti1011
❑Aquifer Storage and Rcco%rn' ❑Salinity Harrier R ft. 50 ft. 2
O,agnifcrTest ❑Stormw;atcrDrainanc n. ft.
OF_xIrrimcntat Technology ❑Subsidence Control
20.DRItAJ iG'LOG fattaCI1 71d1I1t1` d11I1lNt ff;lleCCSla11'
0GLvittemial(Closed Loop) ❑Tracer FROM TO nI sratvnoN rtubr,hattlnctt wdVnick tyrie,AWO be.eua
DGeothennal(Rcatinge(Cooline Return) ❑Oil►er(explain udder 621 Remarks) o ft. 12 a. Clayey silt
12 ft. 27 ft. Si
Q.1 ay_
4.Date�Vcl1(slConipleted; 4-12-2022 WcltllDl9Rw1 n, n. F 4 e
5a.Well Location: ft. ft. MAY/ 0 92027
n. ft.
Fac 4),/'On'xr,Name Facithy IDg ff ippliatblc). ft. 1L r:+.a, 11iT
2580 Hendersonville Rd. Arden, NC 28704 Buncombe C, ft, ft.
Arden, NC, 28704 Ph)SiCAIAddrrss.Cit}•.;tndZp 21iR11:MARILSi
Buncombe
Caath Patte)Id,111iroaitianNb,(PiN.1
Sb.Latitude and Leingitude in degrreslminuteslseeonds or decimal degrees: 22.Certification:
(if cell field,on:latlloq is sunickidi
35.451488 N 82.509268 tad' _ _ ___ n�. � � 4/20/2022„
Signet of CcYficd 14'cll Comm for Da
6.is(arc)the well(s): :KlFennanent or OTtmporan
M,39gning this fUnn,I herrltY certify rhrn thr ur11(s)uvt.P f yrrir)ianeuricterl iii rnz•ordanrr
with 1 M NOW 02C.01 M or 1,t NC4C 02C.0200 Well Cotrsirrwrion Stan4artrs And Hurl a
7.Lc this A repair to an existing well: 0Ycs fir ZNo "Py of rhis rerrml has hrrn 1mvided rs'l dw styli nu+ner.
1f iltls h n wivir,fill air knouet well Cruss1tu,'1rnq iltfarrnatta$1 onrl fX1110kl the Wrare of rht'
relmir uteirrA21 rnnarkv see•riorr or on thr bark nfdtis(anti• 23.Site diagram or additional well details:
You may use(lie back;of this pad to provide additional well site details or well
8.Number of wells constnicted• 2 cons(mction de(ails. You may also unach additional poly's if necessary.
For smdrVe lrtfeerk,n of nrm-wa:e•r supp1 y 1+'0111 OJVI,)'Milli file,wme construction,y0a Can
.%utnnit nnr fnmt. .S(jBl►1_(�'f A ,IKC'�•ls'T1pNS
9.Total well depth below land surface: 50 lft,) 24a. For All Wells: Subnnl this fonn within 30 days of completion of well
F•nr atirhipir wells list all defnlu if dif ierrnl and 201lua•) constmction to the folhiwinG:
10.Static water level below top of casing: (n•) Division of Water Resources,Information Processing unit.
If idler ler,rl is ahoee eosin;,aq"4 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter:3-0 (in.) 24b.For InJZaIta Welts ONLY: In addition to sending the fomt to tine addrtw in
24a above. also submit.a copy of this form within 10 days of completion of well
12.Well construction method: HSA construction to Ilse follow'ine:
(i.e.auger.rotary.cable.dines push etc.)
Division of Water Resources.Underground.Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
l3a l'idd CJ.Tm) ,Nctliod of test 24c.For Water Supph•ei:Inject6 m Wells:
Also submit one copy of this form within 30 daysofcompletionof
13b.Disinfection type:_ .__ _ Amount: health dctxanmclrt of the coimh.\chcfc
well conslnlcnon to the county health
constructed.
Form GW-1 tNonb Carolina MTaknrrn of Em iroi ma and Nawral Resources-Division of W'aterResotrcm kcvised August VN 13