GW1-2023-00768_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
I.Well Contractor I i rotation:
14.WATER TONES
PROM M OMMMON
Well Connote Nissan fi.
R R
NC Well Conlnomr Certification Nombcr IS OUTER CASING far etadLL<rwd weD OR LINER 0fEcable
Cascade Drilling LP PROM I lY1 DUMRTaa TImCKNlSa MATERW,
Company Name vC-
IC INNER CASING OR TUBING el
2.Well Construction Permit#: PROM TO nIAM erP.a TnICK14699 I MATERIAL
List all applicable well comtruction peredn(Le.U1G County,Safe. Parlance,etc.J R R hi
3.Well UM(check well use): fit. A.
Water Supply Well: 1%SCREEN `.
PROM TO mArR1ER 1LOTMPS TmL2LMae aUTrAtAL
DAgricultund OMunicipaVPublic 3Y,�R ,a .?D. In. J �UL
DGeothertnal(Heating/Cooling Supply) OResidrntial Water Supply(single) R. I tL I
[ Industrial/Commercial DResidential Water Supply(shared) lE GROUT
Oftrigation OWells>100000 GPD mom m iM�]]A'ramAL x1tPIACmmmrrM OD&AMO
Non-Water Supply Well:M O' 8107 R ft Ion r r m
onitoring DRecovery Q`I pZ R 3 p P<ffers s /
Injection Well: R R
❑Aquifer Recharge OGmundwator Renunciation
f SAND/GRAVEL
DAquifer Storage and Recovery DSelindy Harrier 1PunIraPACK sfAtRRtALe eurr.77—erarAOD
OAquifer Test ❑Storrnwater Drainage Jo ft. a.S "' �1n Oa/
DExperimental Technology OSubsidence Coatrol R. h
DGeothennal(Closed Imp) OTrac n, 2L DRILLING LOG ft additional saeeo If seemaa
DGeothermal(Heating/Cooling oolin Return) OOther lain under#21 Remarks) PROM To oescmmon color,s.ree Mvtwt err.
R I R.
4.Date Well(s)Completed: Well EDR 1rA—a—'=7 R ft �6_ t
_ 5s.Well Location:
R ft
Abemade Corporation
Facility/Owner Namc Facility ID#(if applicable) it. R
R R JAN
348 Holiday Inn Drive, Kings Mountain,NC 280g8
PhyincidAddreas,City,andzm R' ILIr..`�r:r.-::i:.-i?._._:•:��-3UD:t
Cleveland 21.REMARAS -
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(Dwell field one leNlong is sutficienr) 22.CertlDeadon:
N W /z —
y� a
6.Is(are)the well(,): OjPermanent or 1-17'empnrary Signature of Certified Well Contractor ate
,�'' By signing thisform,I hereby certify dad the well(s)was(were)mnrowcled in accordance with
7.to this a repair to an existing well: ❑Yet or ,upay..no 15A NCAC 02C.0100 or 15A NCAC 02C A200 Well C.rrvctan Standard,and thou a copy
lfMu 4 a repair,iB out known well covnvetion inf rewfion and a lain the nature ofthe of like record Far beat provided a the we0 owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geopnbe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add,See Ovee In Remarks Box).You may also attach additional pages if necessary.
dolled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (O-) Submit this GW-1 within 30 days of well completion per the following:
For mdliDle well,liar all depths ifdiBerent/example-3Q200'and 2®1007
24a. For All Wells: Original form to Division of Water Resources (DWI),
10.Static water level below top of using: (ft) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level u obove caring.use"+"
24bit
11.Borehole diameter: (Ip,) Pro For Infection WeBei Copy to DWI,Underground Injection Control(IW7
Program,163E MSC,Raleigh,NC 27699-1636
12.Well construction method: r o/✓t C 24e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to 01e
(I.e,auger,roar y,cable,[trcct push,ale.) county environmental health department o�Vie county where installed
'^ FOR WATER SUPPLY WELLS ONLY:
Pere.For Water Wells producing over 100,00027699-GPD:Copy to DWI,CCPCUA
Pemu[Pmgm 27699-m, 161 I MSC,Raleigh,NC 1611
13a.Yield(gpm) Method of tart
13b.Diduleetion type: Amount:
Prom OW-1 Nonh Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018