GW1-2022-00264_Well Construction - GW1_20221222

WELL CONSTRUCTION RECORD((M-1) For Internal Use only:
I.Well Contractor Inrormadon: .L�j
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.lit/1_� GRA•s�i �_ : 14=tJTFR
WATER ZONES I .I
DESCRIPTION I I
Well Contractor Name It. J,
-2 730—� (f
NC Well Contractor Certification Number moltltme wells OR LINER f spell leable
Cascade Drilling LP FROM TO DIAMF.TF.R nlICKNESS MATERIAL
It. ft. In.
Comparry Name '16:INNER CASING OR TUBING freathermail clomed400loi
2.well Construction hermit#: FROM I TO I DIAMETER I TilICKNESS MATEM AL
List a0 applicable welt eomtrvction permits(i.e.UIC Counly Sta(e,Variance,etc.) R. It. In. i
3.well Use(check well use): 2 It. In.
Water Sn I Weti: ':17:SCREEN
SLOT pp y FROM TO DIAMETER S17F. THICY-MESS -MATERIAL ,
❑Agricultural ❑Municipal/Public. et. ( E It. io, y py
❑Geothermal(Heating/Cooling Supply) ❑ResidmLial Water Supply(single) n tti, in.
❑Indtssttial/CoraM=ial ❑Residential Water Supply(shared) Ig7GROtrI
❑Ini ation ❑Wells>100,000 GPD FROM TO MATERIAL E.MPLACEMENr METHOD G AMOUNT
Non-Water Supply Well: R
onitoring ❑Recovery- O t4 'I� ft r/15 v
Pf Injection Well:
fL ft.
❑Aquifer Recharge ❑Groundwater Remediation
�19.SAND/GRAVECPACK f a liable
❑Aquifer Storage and Recovery ❑SallnityBaR]er FROM - TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 701 m Jo3 ft. I A,
❑Experimental Technology ❑Subsidence Control it. R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG anacb sddidanal meets it
❑Geothc mal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO aFscRlerloN mint,a,rdneu wmiv<k e, .ta ne
a n.
4.Date'Well(s)Completed: wen ID11 I K�:���13� ft ft.
SAL well Location: fL ft. -
n. ft.
Abemarie Corporation
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Facility/Owner Name Facility ID#(ifapplieable) ft' n•- - J,� DEC v 2022
348 Holiday Inn Drive, )tangs Mountain,NC 28086 D. ft. ,, ;
Physical Address,CiM and Zip ft.. ft.: tl.ri i3J+af tt» r.a
Cleveland 21:REMARKSr _
County parcel Identification No.(PIN)
Sb.i-adtude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwcU field,cncletllong is sufficient) 22.Certification:
1\ V 7 -- I-7_ j _2?
6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor 7 Date
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By signing this form.1 hereby certify(hot the well(,)war(were)constructed in accordance with
7,Is this a repair to an eFlsting well: ❑Yes or Me, 15A NCACO2C,0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy.
If(h1r is a repalr,fill out keowst well construction information and explain the nature of the of this record has been provided to the wtiH oiiner.
repair under 1121 remarks section or on the back of this form.
23.Site diagram or additional well detail's:
B.'Bor Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page'to provide additional wroll construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'Seo Ovee in Remarks Box).You may atso attach additional pages if nttessary.
drilled: 24.Suitmir AL INSTRUCTIONS
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9.Total well depth below land surface: (ft*) Submit this GW-1 with In 30 days of weU rnmpletfon per the following:
For,multiple wells list all depth,(fdperent(example-3@200'ad 2 rt 100�
10:Smtle wa ter level below top of easing: (ft) Information
For All Wells: Original form'to Division of Water Rcrources (DWR),
/1 wares dolev is above casing, Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: _(In.) 24b.For Injection Wells:Copy to DWR(,'Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-163
12.Well construction method: f 0,J t e 24e.For WaterSu ly and Orsen-Loon Geothermal Return wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county emvirolllllenta tea I epanmem of o county Av et a lnsla c
FOIL WATER SUPPLY WELLS ONLY: I'
24d.For water Wells producing over 100.000 GPD:Copy to DWR;CCPCUA
PC;mjtT_ragm_m_,_1_61 1 MSC,Raleigh,NC 27 I99-161
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Yield(gPm) Mctbodof fat:.Dlslnleetlon type: Amount:
Perm OW-I North carnlina Department of linvitonmemd Quality-Division orWsier Resources i Reviscd&6.2019
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