GW1-2022-10161_Well Construction - GW1_20221110

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: j
�
6s came.
Well Contractor Name FROM TO DESCRIPTION
it ft.
32.1 ft. ft.
NC Well Contractor Certification Number "15:OUTER. G fot<.maltl-e ased;ivbtle ORiLIlHE1E'It etiible'F
Cascade Drilling LP F,R�O{MT TO DIAMETER I THICKNESS I MATERIAL
Company Name R. 0 JrL i in. VG
d6 1NN);R,Gi48TNG UTt>'CIM eotheririet;closed-loo`:'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits 0.e.VIC,County,State,Variance,etc.) % ft. in.
3.Well Use(check well use): it, It, in.
17d8G'REEN a;,
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public . 5 ft. If ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n n, in.
❑Industrial/Commemial ❑Residential Water Supply(shared) iB GROUT.
❑Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: /7 O �'or7 odd'
❑Monitoring ❑Recovery 114 n.
Injection Well: IL tt.
❑Aquifer Recharge ❑Groundwater Remediation
19 taelrlA/cRAVEL PACK fa 'Iltpble ,
[]Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage a a fL ft.
❑Experimental Technology ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20:DR1L>L1NG iWOG attaehidtHttonal s6eetslE oecess
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM fL TO ft. DESCRIPTION color,hardness,soillrock n size,etc,
4.Date Well(s)Completed: //"a� We11ID#iS fL>r��'Z It. ft
fL it.
Sa.Well Location:
( Abemarie Corporation tt fL NUV 1 02022
Facility/Owner Name Facility ID#(if applicable) fL ft.
ooc
348 Holiday Inn Drive, Kings Mountain,NC 28086 fl. % awcv
Physical Address,City,and Zip It. ft.
77
Cleveland 21:R1<MARK9 "
County Parcel Identification No.(PIN) le 'P/C f-)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latflong is sufficient) 22.Certlfica'
N W
6.Is(are)the well(s):G§zermanent or ❑Temporary Signatu clot
Date
By signing this farm.I hereby ertlfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes orN0 I SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a copy
If this 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 shin 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'Se a Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (ft-) 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)
I .
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 00 Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"
11.Borehole diameter: (in,) 24b.For Injection Wells:Copy to!DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) counye�nv health department Othe C ere Installed/1 FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing 100,000 GPD:Copy to DWR,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
I
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources ! Revised 6-6-2018
i