GW1-2023-00767_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contract r aformation:
'.' ��� K WATER FA
Wen Gdmaelor Name FROM TO D►bM"ON
R I it
"?73oa R ft
NC Well Cnmrxctor Certification Number 15.OUTIR CAGING far mailieased web OR LINER
Cascade Drilling LP FROM TO DIAMRTER TInCI(NFbB M,txnf L
D IL h 1 5L4 o U C-
Company Name IC INNISA CASING OR TUBING
2.Well Construction Permit f: IROM TO I DUMis Q 778rwema MATBIAL
Liel all applkAble wail conrbuclion permW(Le.UfG Cmady State Penance.ele.) h fL Id
3.Well Use(check well use): R' h i`
Water Supply Well: 17.SCREEN
TaoM I To I DIAMrrxa I SLOTEM IrmCRnese MAnRrAL
OAgricultuml OMunicipaVPublic .7IL /OR S iw O/O fL/.e yV 4,C,
OGeothertnal(Heating/Cooling Supply) .ORaidential Water Supply(single) R. R. in.
Omdtutrial/Commerciai ORaidential Water Supply(shared) I&GROUT
01ringationt OWells>100000 OPT) FROM I TO MATsaIAL xsrn.ACnetxNr Mrrnoo•AMOvir
Non-Water Supply Well: /, IL D' PD/ a ��is7Mr'
❑Mm utoring ORecovery /S 1L e7O ft Allel-f ax
Injection Well: D. D-
❑AquiferRecharge OGroundwater Remediation
19.SANDIGRAVILL PACK Me
OAgtrifa Storage and Recovery OSalinity Barrier FROM TO MATERIAL xMlm.ACEbmILIT MIrROD
OAquifer Test OStormwater Drainage o It. �a5 IL BLr/
❑Experimental Technology OSubsidence Control R R
OGeothetmal(Closed Loop) OTacer 20.DRILLING LOG h addideW dea K
OGeothermal(Heatin lint Return) OOther(explain under 021 Remarks FaoM m nFscarmmoN aalw rrvreet scam
R R
4.Date Well(s)Completed: Well IDO.5 l/z""— O it. R _
5a.Well Location: IL
it, R
Abernarie Corporation
Facility/lamer Nam Facility m0(if applicdle) R JAN
Elm
348 Holiday Inn Drive, Kings Mountain,NC 28086 h it.
Physical Address.City,sad Zip R ft ['•`.t�....1,V
Cleveland 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minutee/seconds or decimal degrees:
(if aen field,nor lat/Iong is sufficient) 2L Certification:
N W _�;k .f,_. Ili_ -7,7-•. _
r lament or OTemporary Sigoaune of Carolled Well Contractor Date
6.islets)the weB(s): ,t3'�e
8ysigsing this form,!hereby certify dwr de xeU(,)corn(were)cdwauctedts accordance add
7.Is this a repair to an existing well: OYes or 0 No ISA NCdC 02C.01 0 or I SA NCAC 02C.0200 Well Caunxctioa Standards sad that a copy
lfdir u a repair,fit/oxl kno»a well conetrvetion informmien and Tspla'n mho naave ojde of for record har been provided 0 the sell oxner.
rrpa r under#21 remub section or oa the back of this form.
23.Site diagram or additional well details:
S.For GeoprobeMPT 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,Sw aver in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCITONS
r
9.Total well depth below land surface: /�� (L) Submit this GW-1 within 30 days of Weil completion per the following:
For mWdple well,Wall depths if different(example-3(r9100'e d 2®1007
24s. For AB Wells: Original fan m Division of Water Resources (DWI:),
10.Static water level below top of"sing: (h) Information Pmcasing Unit,1617 MSC,Raleigh,NC 27699-1617
If tsster level is abme casing,we"+" r
11.Borehole diameter: v (in.) 24b.For Injection Wells:Copy toDWR,Underground Injection Control(RUC)
Progrem,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: •r J h rL 24c.For Water Su. and ■-Gw Geothermal Return Wells:Copy to the
(i.e.sugar,catery,cable,direct peak roc.) county envim m TTiWtth department o e county nl�msta 0l d
FOR WATER SUPPLY WELLS ONLY:
Perm For Water Wells orodMMover V27by - bI I Copy m DWI?,CCPCUA
Permit Program,1611 MSC,Raleigh,NC 27699-i611
13a.Yield(gpm) Method of tub
13b.Disinfection type: Amount:
Firm GW-1 North Carolina Department of Environmental Quality-Division of Water Rosoum es Revised 66-2018