GW1-2022-10371_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD Far Internal Use ONLY:
This form can be Used for single or multiple Neils
1.Well Contractor Information:
1-1.WATER ZONES
Zach Thompson FROM TO DFSL'Rtt'fR)�
1�cJIGorAractortrame R. ft.
e. n.
4478A
NC Well CantinerarCcriiiizationNimber .OUTER CASING abr'Qulll isiselrnellsl OR f:ItYER'l a'"fltabk
FROh1 TO DL4�rETHR TnIC�C,'vE55 MATERIAL
SAEDACCO Inc 0 ft. 1 140' fL 6" in Schedule 0PVC
Coa%piq-Nana WANNEWCAStNG OR:TUBING 1krrnal closed-loo :.
FROM TO DMIETER THICKNESS hfAIERIAL
2.Well Construction Permit#: R. ft. hL
Lf5r91117pplicable wallprrmils(Le.Caanht St¢te,drariartre.f1a:t9at err...)
3.Well Use(checicwell usc): I7_SCRClN
Water Supply Well: FROM TO DTAINIFTFR SLOTS17% THICKNMS I MATERIAL
❑Agmultural ONfunicipallPubjic ft. rL iR,
®Geothermal(Heating,'Cooiing Supply) ❑Residential Watcr Supply(single) rL ft. is
❑ludustrial/Conunctcial ®ResidentialWiter Supply(shared) 1&GROUT FROM To ,rrTEItIAL earPLACEM TMEfI1QDRAh1oDNC
❑liri ation 0 ft. 140, ft. Portland CeiTtatection
Nan-Water Supply Well: tL
ENtonitodng l]Rcco-cry IL
Injection well: n. IL
DArtuft Recharge []Groundwater Rcmcdimion 19.SANDIG%LVEL PACK Gf olicabtel
FROM TO I MATERIAL. I ftMP1JkCn7EVTM►TNO11
❑ATiifer Storage and Recovery OSalinity Barrier ft ft.
❑AquiferTcst ❑Slorrmvatcr Drtiiiaac
fL ft.
❑Expctimcotal Toclmologp ❑Srtbsidcncc Ca1ltloi rltl;DRILLIII G'I.OG(ausch addhiovial skdg if i►eeessan•1
❑Grwiliemtal(Closed Loop) ❑Tracer .FROM I TO DESCRIrrllOv evbr.harduen,w4nkktr tea eie.I
❑Gevthennal(HeatirglCoollug Retum) ❑Outer(m-plain under 921 Remark) 0 ft. 651 ft, Brown silty sand
65' ft. 501' fL Rock
4.Date NVeli(s)Completed, 10-6-2022 WtIE[)#RTKM 22-392 ft. ft.
ip;Well Gtcatinn: ft. tL ( -
Albemarle ft. IL
FacilitpOwncrName Facility ID#(ifapplicable) R z
. ft. �% LUL
348 Holiday Inn Dr. Kings Mountain, NC 28086 Cleve, , , (t. fL
m;�faltriti;,ie;l ear,^^ •�--
PhtiTical.address.City.and zip 2 L RE61ARtCS
Open Borehole from 1401-5011
Canna• Parcel l&jilif(Calign No.(FIN)
Sb.I atitude and I.Qngitude in dcgrccslminutes/seconds Dr decimal dcgnecs: 22 Certification:
(lfett ll fiord,One I4long is gldiicletd)
35.1331 N 81.2058 W 10/7/2022
Sigiuture ofCchified Well Contractor Dale
6.Is(are)the.well(s): EPermanent or DTemporary
Hy signing tiers farm.1 hercL}•eertife chat rhr u•d!(s')x-rtt{krry.).euarrnreted is aecorrl.mcr
with PM NCAC 02C.o1(k)or 13A NCAC 02C.0200 Well Coj istrij criar Srarrlards and door a
7.G this a retiair to an existing well: ❑Yes or ®No copy ofthit rrconl has(nien pmeidvd ra rile en:ll metier,
11 this Is o repalr,fill calf knuarl Ivell caiutnfeefon hrfonwfion and a plabi rho rutrare of flit
repair andcr a131 remarks arclina or as the brisk of this•fornc 23.Site diagram or additional well details:
You may use the back of this page:to provide additional well site details or[sell
S.Number of wells cottstrncted: 1 construction details. You ulay also attach additional pages if ttn:essary.
For rnulrlple lydeerla)i or nevi-roarer Wplr Ivells ONLY mlrh die same eoirsrrurtion,}eau can
sui<rnitane form. SURNICPTAL INSTUCTIONS
9.Total well depth below land surface. 501 (p,) 24a. For all Welly: Subtuit this fame within 30 days of completion of well
For nwhiple lve'lls fin off dep bs if different(trample-30200Y arul 2@ IM) constmetion to tha foltowing:
10.Static water level below top of casing' (!Y,) Division Uf Water Resaurces,Information Processing Unit,
if 1valer level Lr above casing:am"+" 1617 Mall Service Center,ltalei*NC 27699-I617
11.Borehole diameter. OLO 24b.Fnriirleceinn Welly ONLY: in addition to sending the foul to the address in
24a above.also submit a copy of this forru within 30 days of completion of well
12,Well construction method:HSA/Air Rotary construction to tlw following:
(i.e.au.•r.rumq,cable direct paste etc.)
Division of Water Resources,Underground Ltjecdon Control Prngtz»tt,
FOR NVATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test: 24c.For Water Supply&Injection Wclls:
Also submit one copy of this forth'within 30 days of completion of
13h.Disinfection typt. Amount well construction to the county health department of the counh-where
constructed,
Fenn GW-t t+onh Calnllnt Depumtrnt of Emirorun_ni and Warns!Rmurces—Divii Ion of WalrrRL--atrCeS Revised,trgust V 1.1