GW1-2023-00769_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well
//�Coirtrlc'to'r/Informandr:
Lice 14.MATLR ZONi9
Well Contractor N mom TO WISC'RIMON
�,/n R D.
�3© 14 R R
NC Well Comractor Certification Number 1S OUTER GAPING far mtd6a =& OR LINER
Cascade Drilling LP PROM TO puMeTu rmcxrvrss MArawAL
Co> yNarm O IL ,?S.Z IL in. se", /✓ pve
If.INNER CARING OR TUBING
2.Well Construction Permit#• PROM I TO DIAMETER THICRNESS I MATERIAL
Lire dl goplicable.11 roviruct o t peraia(tar UfG Corwty,State.Variance,etc.) D• J&VR � OL
3.Well Use(check well axe): R I R in.
Water Supply Well: 17.SCREEN
PROM TO Disa rrEa sL su"' "ah"'la10.4 MATERIAL
OAgriculNrsl ❑MmicipaVPublic R IL in
S•L 6S� Di o 5�H NJ ✓f
CGembetmal(Healing/Cooling Supply) []Res idential Water Supply(single) R R in,
Dlndusbial/Commercial OResidential Water Supply(sham) IL GROUT .
01rrigation OWells>IOOODO GPD FROM ATERIAL EMPWC'EMLNr MrI'RODlAMOUNI'
Non-Water Supply Wen: () R' TO M r410 (:turn'
XWortimring []Recovery 17 R' a1' R el C ot s pt2Gr/
Injection Well: R I R
OAquifef Recharge OGmundwatcr Remediation
[]Aquifer Storage and Recovery OSalinity Barrier PROM /GI TO PAC I MA1TJt1ALI EMFLACEME Mtmob
CAguifer Test OStormwater Drainage R, (/5•fR l4 0,,4 pa,
.(
[]Experimental Technology OSubsidence Control IL I R,
OGeothermal(Closed loop) OTmcer 2L DRILLING LOG:AMbaddlWrl Shoals if nweaas
CCxoNrm eal satin sin Return) OOtller lainorder#21 Remarks)
PROM ft. TO ft.
DEBCRRDONmW hulaw Vmek retr.
ID `
4.Date Well(&)Completed: Wen d 7TD KAV;k R R 11
SL Well Location: R. R
Abemade Corporation R R
Facility/Owmr Name FaeOity roll(ifapplieabb) ft. JNIV L J
348 Holiday Inn Drive, Kings Mountain,NC 28086 R R
Physical Address,City,and Zip R R
Cleveland 21.REMARKS
County Parcel Idemification No.(PIN)
5b.Latitude and longitude In degreedminutes/seconds or decimal degrees:
(if well field,nee Iat/long is sufficient) 22.Certification:
N W
6.Is(are)the well(s): 4permanent or OTemporary Stgunaa ofCartifid Wes)Contractor Daft
Byaigmig Ow forts,I hereby certify dot the well(a)was(wvwa)constructed 1.accordance wick
7.Is this a repair to an existing well: DYes or ANo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consbaotion Sk dards and that a cnly
If 1hir B a repay.Ill out known well co otoaction he/bratadon and arpinin the mare ofthe ofthlr record has been provided 0 the well awn".
repair under#21 remarb section or on the back of thb form.
23.Site diagram or additional well details;
8.For Geoprobe/DPT or Cloffed-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'See Over in Remarks Box).You may also attach additional pages if necessary.
drilled' 675. 5 1 24.SUBMCITAL INSTRUCTIONS
9.Total well depth below land surface: (D') Submit this GW-I within 30 days of well completion per the following:
Aor multiple welb list all depths ifdiffereat(example-3@200'and 2@1003
24a. For All Wells: Original form M Division of Water Resources (DWR),
10.Static water level below top of casing: 00 Information Processiag Unit,1617 MSC,Raleigh,NC 27699-1617
If inter level it above coatng.we
11.Borehole diameter: 8 fin,) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
CC Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: —%y-,i C. 24e.For Water SuppI and en-Loa Geohrermal Return Wells:Copy to the
(i.e.augur,rotary,cable,direct push,etc.) eoDnty environs ca th department o e coulf�my hole ms�en
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Ralcigh,NC 27699-1611
13s.Yield(gpm) Method of tree:
13b.Disinfection type: Amount:
Pram GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Resod 6b2018