GW1--01495_Well Construction - GW1_20240312

I -
WELL CONSTRUCTION RECORD For internal Use ONLY: I r
This formats]be used for single or mullipk wells
1.Well Cant.ictor Information:
- 4..IWATERZONFS ,
Robert Miller FROM I TO P tIIIPt1ON
Well Common!.Name ft. It, .
2675-A ft. It.
NCWcflCanlmctor Certification Niri,ei '1S.OUTER CASING(for multl-cdsedwcns1GRLtNERRfhptleubld -
- FROM I TO • DIAMETER• THICKNESS- MATERIAL.
SAEDACCO (1- f(. la.
Co mun.game I6.INNER CASING OR TUBING( withortnal dosed-hinny_
•FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constructiiin Permit tl: WI0100704 ft. ft. ht.
listuR applicable well peineirs(ise.County.Mali;Variance.1r)'xo'citetc.) R. ft, is.
3.Welt,Use(cited:well use): t7.SCiti:>:N ,
-Water Supply Well: -- ---- FROM. TO • DIAMETER SLOT SUE TntCKNESS I MATERIAL
•
CiAgricultufal . ClMuuicipal/Public ft. R. in. 1
®Geothermal(Heating/Cooling Supply) ©Residential Water Supply(single) ft. R. in, 1
•
0hidusiriallConuuci al ©Residential Water Supply(slimed) RorRQ� 10 MATERIAL I EMPLACEMENT\IEi1tOD&AMOUNT
Dkrigntion ft. ft.
Non-Water Supply Welly
R.. rt.❑Rcco\rty' T
injection%Yelt:- n. ft.
DAquifcrRecharge lit)ioundw:ttcrRenicdiation' r19.SANI!CILtVEL-PACK titalrplkrbtel -
IDAgniforStoragean(IRecovery CISalinity Haney ft.
10 1L\'rHRCaI. EMPLACEMENT\rr METHOD
R. R.
IJAgtiifcr Test t7Stormwatcr Drainage•
R. ft.
i71 Xperimental Technolog ❑SllltSidCrKC Control •20:IRWLL1NG'LOG(attach additional shectdif accessan•i
ClGeorltemtal(Closed Loop) EITtacer, .FROM- TO . DESCRIPTION(eo r.hANaes+;uriTotekO(x.prtin we.Nt}
ClGeatteittal(Heating+Cooling Return) DOiher(eNplaitt under A21 Renraiks) -ft. . ft.
ft. ft. I. T. 1‘...,..
i , .7''''''' l,.....
�)Completed: 2/22/24 A-1 - A-5 r;a,4• t;,,o' 'A I
4.Date Weil(s)s Com teicd. Will 1D(I n. tL r. I" 1....?.f'
54.Well Location: .ft. ft. Mt.'t- 1 2 2024
2boyovski Property ft. ft,
Facllity/OtsocrNamc Facility iDk(if applicable) - - la;s4r-, ,1, „ -:g ,. .,,•_ -_
fi.ft. ft.ft. a .t a...y
146 Smokey Park Hwy.,.Asheville, NC, 28806 . Uifrt ��C,
,
Pit)sical Address City.and Zip '21.REMARKS
Buncombe Injected 104 gallons of Cool-Ox per boring;
County Parcel lilenti(teation No,(PE') 20-33'
56.1,4tititdc.ariil Longitude in degrres/minutc3/Seconds ar decimal degrees: 22.Cettlfendnn:
(if hell field,oat L•W7oug t3'Sidnckall
N W 2/28/2024
Sianatu�of',.cc:i.:4r. k'r'_!x_:,<;r::Y �,'^--- Dale
G.Is(arc)the well(s):.DPetm utrnt. or XTemlwrary •dy"signing this form.-1 hereby eerrifr dun Mr lrel!fsi was iwerc)cony:raveI br accordance
with 1 SA NCAC O2C.0100 or LTA NCAC 02C.0200 Well Corrsrracnorr Standards and kw a
7.Ls this a repair to an costing well: fYcv or i 2No 'rote rhir record loos l'ccrl prorirhd to [till miner.
If rh Is.is o ripely;fill ou'U knoiwi Ledl curuvscrloa hrforotrrtion mid espial);the turmre of the
repair rader021 remarks secilou or on nco bail;of deer form. 23.Site diagram or additional well details:
You may use the back of this page.to provide additional well site details or well
8.Niunlier of wells constructed: 5 construction details, You stay also allaclrudditiotal pages if necessary.
For malrlpfe htjeerlon or orm-trnrer.ripply idle ONLY with rut some cmrstrucfurr,you cart -
.cubmir one form. SUBNIITTAL iNS')UCTIONS
9.Total well.depth below laud surfice: 33 (ft,) 21a. For All Wells: Submit this-limn within 30 days of completion of well
For rntbiplc.'veils lisr off drlultrifdi rut:(erocrpfc-3.200'am-2r3100) construction totltcfollotting;
10.Static water level below tap of casing: • 00 Division of Water Resources,Information Processing Unit,
If tmhr level is above casing.use••+'• 1017 Mail Service Center,Raleigh,NC 27699-1617
11.Dorchotc-diamcten 1.5" (in,) tab.For infection Weils ONLY: in addition to sending the form to the address in
24a above. also submit a copy of this form within 30 days of completion of well
12.Well eonstrttetion method:DPT constmetiou to the following:
(i.c:auger.rotary.cable direct rush etc.}
Division of Water Resources,Underground Injection Control Program;
FOR WATER SUPPLY WELLS ONLY: • 1636 MALI Service Center,Raleigh,NC 27699-1636
13 L Yield(gym) Method of test: 24c,For Water Supply&Injection Wells:
Also submit one copy of this faint within 30 days of coutpleftoti of
13b.Disinf'eetion type: Amount: well construction to the county healii-4 department or(tic county.where
contacted.
Form GW-1 Noah Camllna Depar(ment of Enei(anuistu and Natural Resuutecs-Division of Water tmotreea Revised August Yen