WI0100496_Well Construction Record (GW1)_20180709

'LL CONSTRUCTION RECORD
ifdrm can be used for single or multiple wells
1. Well Contractor Information:
RnhArt I Arry MA/Allc
For Internal Use ONLY:. 454999
Wall Contractor Name
2603-A 00i
NC Well Counselor Certification Number!
AWD Services Inc. O
Company Name ]
I
2. Well Construction Permit N: W10100496
List all applicable wit construction permit, r.. e. County, Stale. Variance, etc.)
t
3. Well Use (check well use): ,
zu Icultural OMunicipal/Public
eothennal (Heating/Cooling Supply) DResidential Water Supply (single)
Olndustriat'Commercial ❑Residential Water Supply (shared)
DAquifer Recharge
DGroundwater Rcmediation
DAquifer Storage and Recovery
OSalinity Barrier
DAquifer Test
OStonnwater Drainage
OFjlpetimental Technology
OSubsidence Control
tbennal(Closed Loop)
OTracer
4. Date Well(s) Completed: 7/06118 Well
Sit. Well Location:
Barbara L Palmer
Facility/Owner Name Facility ID# (ifapplicable)
295 Mountain House Trail Brevard, NC 28712
Physical Address, City, and Zip -
Transylvania 8574-85-2958-00000
County Parcel Identification No. (PM)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one Iatnong is sufficient)
35.233447 N 82-734292 W
6. Is (are) the well(s)l4rinament or OTemporary
7. Is this a repair to an existing well: DYes or �o
Ifthis is a repair, fill out known well consewalon Information and explain rho name ofthe
repair under #21 remarks section or. the back of/hisform.
S. Number ofwells constructed: 2
For multiple injection or non -water supply wells ONLY with the same construction, you run
submit oneform.
9. Total well depth below land surface: 2 fQ 260'
For mulllple wells ltst all depths lfdWemnt (example- 3@200' and2®100)
10. Static water level below top of casing: NSA VQ
lfwaler level is above casing, use "+"
11. Borehole diameter: 6.25 (in)
12. Well construction method: rotary
R. I ".
ft ft l
TIER CASING for noth.rased wells OR 1;RVERfifappfieeblel..
TO DIAMETER THICKNESS MATERIAL
ft. ft' i in. I 1
NFR CASING.ORTURING. tothermaldwed•loo
' TO . DIAMETER THICKNESS MATERIAL
ft' 260 ft 1.26 fm 8DR11 HDPE
ft. ft I.
REEN
TO DIAMETER SLOTSIZE TNICIOfE83 MATED
ft ft in.
ft ft in.
.OUT
TO MATERIAL EMPLACEMEWMETHOD&AM
ft. 0 ft. Thermal Pumped
ft ft
ft. ft
1'D/G1tAVEL'PACK ifa'diiable
T'U MATERIAL EMPLACEMENTMETHOD
ft. ft
In It
iLEINGLOG aftarti alldiddnstabeehtfnadessi
TO DESCRwTiON roior baMaess aolVroek rain dze, e
ft. ft.
ft. ft
ft. ft. --
ft. ft.
a. ft —
ft ft -
ft. ft
(ARKS .•
22. Certification:
7/09/18
Signature ofCenia6d Well Contractor Date
By signing this form, I hereby ce"try that the well($) was (were) amulrvcied in accordomes
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided to the veil ouner.
23. Site diagram or additional well details:
You may use the bade of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unil,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h. For Infection {Yells: in addition to sending the forth to the address in 24a
above, also submit a copy of this font, within 30 days of completion of well
construction to the following:
(I.e. auger, rotary, cable, direct push, etc.)
Division of Water Quality, 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 Suooly & Iniectio Wells: 1 addition to sending the form to
the addresses) above, also submit one copy of this form Within 30 days of
13b. Disinfection type: Amount• completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Depaimxnt ofEnvnunnant and Natural Resources —Division of Water Quality Revised len.2013

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i. WFIA. (VNTRAcT lk WRILTW*AP.se
Robert Larry Welle q�}_ e.�aW wyt: �. .,.w 0. Ulamace' ...1.25.._,
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s1Rt i l ADDRCs.. 258 North Tu
Leicester NC
828 i . 883 9223
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lip Colo �
2. WELL INPORMATNN(:
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a. WI 11. t(x'ATION: I I
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NAMI Barbara Palfner
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07/24/18
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07/26/18
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rrtapdwat hilivilludwan&'MAilTah em fuvh:r midenLd well
m autadaiaB � 'SA ,- lC X A113.1
Robert L : , .ass
PRINTRfl NAAtff Fh'+lpAC�r ARAYaONINC:TIR: NT4A.
. .cwlnMf Y rnryY fa i he Owner and the arfalnal 10 the Dlnkfoa of Willer paaRly W0111111.116 dayt. Pawn (W.in
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