GW1-2022-10158_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: 1
1.Well Contractor Information: J
UAy 1 L cn) Ic O FROM I
FROM TO DESCRIPTION
Well Contractor Name I
Iy L)I3aa 3 A ° ft. fl.
NC Well Contractor Certification Number 15'OUTFIt Ylia 81N11,ror in'ilH-cased''ills t)R t NER if 9' Lcable
FROM I TO DIAMETER THICKNESS MATERIAL
Cascade Drilling LP ft 3� ft. C, in. V,L
Company Name Ifi:1191ER ChS[i�1G[1R`CiJBINGi etithdrmaT closed-too
2.Well Construction Permit#: FROM I TO DIAMETER I THICKNESS i MATERIAL
List all applicable well construction permits Q.e.UIC,County,State,Variance,etc.) ft tt in.
n• ft in.
3.Well Use(check well use):
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE I THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3�ft. j y Ott in. p
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt n in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1B'GR
❑hri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: f+S It
bUonitoring ❑Recovery % Ree' -S
Injection Well: it ft
❑Aquifer Recharge ❑GroundwaterRemediation 19:'BAND RAVB[�pA(4C'is "Iie6lle
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL l EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage y OR d It.
❑Experimental Technology ❑Subsidence Control tt ft
❑Geothermal(Closed Loop) ❑Tracer 20: .1tIILIN 1<bG attach'sddiNoaAi'shbetsftoti�esa
FROM TO DESCRIPTION color hsrdn soll/roek In sl ett.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) M
4.Date Well(s)Completed: J a Well ID#S N u 2-�-" � n• ft
tt ft
Sa.Well Location:
tt ft.
Abemarie Corporation
Facility/Owner Name Facility ID#(if applicable) M ft
n ft. 1,%fWw%;,uan rx
348 Holiday Inn Drive Kings Mountain,NC 28086
it ft
Physical Address,City,and Zip
21'IDt1VtAA1Cl3: �
Cleveland
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: )
N W �..�.lZ�✓ c1 o?o?—a��
6.Is(are)the well(s): ❑Permaneet or ❑Temporary
Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ONo 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well construction info
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (D') Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2@100)
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below bop of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
11.Borehole diameter: 'r (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: S 0 i',1 G 24c.For Water Supply andOpen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental heal apartment of a county ere costa
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test:
f
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources I Revised 6-6-2018
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