WI0100485_Well Construction Record (GW1)_20170921

WELL CONSTRUCTION RECORD
nessrmuabeueed kre gl rmulripla well¢
1. Well Contractor information:
Robert Larry Welly.,
Wrll Conuaca Nama �1 OCT�-
2603-A
NC Well Greatest Cerdgeadee Number
AWD Services Inc. '
Company Neme ). -
2.Wall ConstruetionPmmitg: W10100485
urt on appntama aanaanet,artwnTarmu. (.e, Cowry, JMm, Pvnvna ern)
3. Well Use (checkwell use):
CAgriwLLural CMunkipal/Publie
CGeothermal(HeaHns/Cooling Supply) ORendential Water Supply (single)
EledusMal/Commercial 011midental Water Supply (shared)
OAQater Recharge
OGemadWater Reraliatlnn
CAquifbr Storage and Recovery
p3alirdry Bander
OAWifer Test
CStanmwaterDrainage
DEspeo named Technology
OSubsidence Control
E4othermal(Closed Loop) Residential
CTmes
4. Date Wells) Completed: 9118117
xd
Well Rlq
St. Well Iarmthi:
Scott Austin Olivette LLC
Feeiliry/owner Name
Fatiliv Mff bfapplieable)
26 River Run Asheville, NC
28804
Physical Addess. City, and Ye'p
Buncombe
972173137200000
Cowry
Parul fda nificewa Na. (PIN)
Sb. Latitude and Lousitude in degreadininutesheeond ' Id
Fw lnpmal Uee GNLY: 446337
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21.MMABRS'
eo came agrees.
(ifwell field, one Iallong i¢ mtgeim0
22. OMERea".I
35 39' 21" N 82 36' 43" Wa
w !' 9/21/17
aweof anified asseememsee, Dee
6.1s (are) thewell(s): 1114maeant or CTemporary
By,./gnmg doft'm l knea costly last the well() war Wn) re mtmtred In aacmama
1. is this a repair to an edhdeg well: CYes or S
was 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Can9rawlan baandrrdr aadtaat a
mpyofih&wordhmasenpmv/dadmmeweliawan
jtMetirorepolmJdlOur btwvn well a'Wunumlwrfvrmouvn snd pomeM nature oj0m
memo- umk•na/mmvar rm0on or on roe MsR o)majvnn.
23.S1h diagram or additional well details:
2
You may use the back of this page to provide additional well site details or Well
B.
canaltamion details. You may also match additional {ages ifnecesss,
For ahcerofwells rcatruehd:
For mulgple InJmliw rr ntn-wnler n Why wet/e GNLY wifi toe vame aor,vlrvetlon, yru con
'mama —A.
SUBMITTALINSTUCTIONS
9. depW below e: 2 @ 280 (B.)
24a. For All Wells: Submit this farm within 30 days of completion a wall
Far mce"], at"a, V gare.1
For mnlltple wellalBloll PeptM1s lfd((Rmn(rexample- 3@200' aad2duria)
eonstmetlon to the follawdng
10. Static water level below top of castes: N/A (0)
Division ofWakr Quality, Mrmmalon Processing Unit,
rywabrlevcusaasw evens, as -,-
1617 Mail Service Cook', Raleigh, NC 27699-1617
11. Borthole dkanakr: 625 (m.)
24h For Injection Wells: In addition 0 sending the form to the address in 24a
rotaryabove,
ago submit s copy of this form within 30 days a ompletian of well
12. Well eoay, aly,&.0 otl:
o0nstmction to the following:
(i.e. auger, rotary, cable, diredpuah, exJ
BlWsim of Water Quality, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
196 Marl Service Center, Raleigh, NC 27699-1636
Ise, Yield (grand N/A Method of test. � N/A
24e, Eor Water Sumely A, balance W addition to¢codingthe faunw
N/A
the addne rb s) be., else submit one copy of this form within 30 days of
13b. Dhiefeedan type: Areavaft N/A
mus platdon of well can aced. t0 the aunty health department of the county
where constructed.
Form GW-I North Galin¢ Department ofEnvimanbnt and Nomnal Reaomcu- Division of Water Quality Revisedho.300