GW1-2022-10160_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.NAII Contractor Information:
Atl t �. �.• � I (Gp X 14 1Vi1T$R ZONES
( I DESCRIP
Well Contractor Name FROM TO ft. � TION
121; A
R. ft.
NC Well Contractor Certification Number 15 0 R C1SING for-:inalti•Cambll!.Svepe:OIt`;1IlVRk ite livable
Cascade Drilling LP FROM TO DIAMETER THICKNESS MATERIAL
it ft. ( in.
Company Name
16•1NN15R GA,SING ORT[1BiNG :`eotheriaaF closed-Ido'
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. it. in.
3.Well Use(check well use): M ft. in.
Water Supply Well:
FROM I TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public -?s n ft in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n, n, in,
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irri ation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: a ft o ft. por001,11a1 P<M P
Monitoring ❑Recovery ft. ft.
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19;8AND/G YRLYACIG to 1fa61e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 30 IL )ts fL N 5-101 D4,p
❑Experimental Technology ❑Subsidence Control ;v tt. 3 p M td 6)e tab. b A M
❑Geothermal(Closed Loop) ❑Tracer 20:<DRII I ING;:I C1G'attach,addtdouiil'A66*lfneeessa
❑Geothermal eating/Cooling Return) ❑Other lain under#21 Remarks) FROM TO DESCRIPTION color hardn eolUroek to s eta
ft. rt.
4.Date Well(s)Completed:)p"j'a Well ID# IN'-'J RO
5a.Well Location: R R
�--� m Abemarle Corporation rt NOV 2022
Facility/Owner Name Facility ID#(if applicable) n' R
348 Holiday Inn Drive, Kings Mountain,NC 28086 IL ft. DWQMOG
Physical Address,City,and Zip R' FL
Cleveland 21''
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 Z
lo-S-Z�
6.Is(are)the well(s): dPermanent or ❑Temporary Signature of Certified Well Contractor Date
i
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 8No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe ofthis 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:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: l f3 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if eli Brent(example-3©200'and 2@100) 1
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft,) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use
11.Borehole diameter: f`7 (in.) 24b.For Injection Wells:Copy to iDWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: - r� 24c.For Water Supply and!Rpen-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where instated
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing of cr 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh;NC 27699-161 l
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount: f
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2038