GW1-2023-00770_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Ind it 2:
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WeO Contacor Name f ,ROM T TO D68GWRr1014
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NC Well Contactor Certification Number IS OUTER CASING f fsI md0-cued weW OR LINER wasOe6k
Cascade Drilling LP IDIOM 1'O I DIAMRTER Tm`'CK/N� KSS MATERIAL
ft It 1 7
Company Name 1f.INNER 77
CASING OR TUBING m lherale
2.Well Construction Permit 0: PROM TO I DIAMRTKR TNIC'IUVnss s1AtL1AL
Lis(all applicable well carulrocrion permW(la WC Gummy,.State,Variance,etc)
3.Well Use(check well Dee): R' ft Io.
Water Supply Well: mom I To I DIAMErza I si.or sin I THIN: se MATxRIAL
OAgriculmrel 01thwicipaVPublic r R /pfR Y in .D/7J sC/ir yi7 ✓t_
OGeothermal(Heating/Cooling Supply) ORmidential Water Supply(single) R ft iw
❑IndlrstWCommeecial DResideltial Water Supply(shared) IL GROUT
OIrrigationt DWells>100000 GPD PROM TO IMA1xRIAL EMML'aseEW MerHOD a AMOUNT
Non-Water Supply Well: O R /SSR %bCN4 d //eiHM `
mitering ORecovery /f,jr-h Zp ft Pell, s �pri,i
Injection Well: R h
OAquifer Recharge DGroun lwater Remediation 0.eANDM.RA
DAquifer Storage and Recovery OSalinity Barrier Mo � PACK MATxRu� olmwCEAKIM efETROD
DAquifer Test OStormwater Drainage I? e' �O�' / �• i
DExperimental Technology OSubsidence Control R h
OGmthermal(Closed Loop) OTracer 2L DRILLING 1AC.tlteek additional skeet,if netewa
11C othennal (Heating/Cooling Return OOtba lain under#21 Remarks mom R TOftffl eRlmoN mobs h
aveeam toniVroca ate.
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4.Date Well(s)Completed: Well 1110 �y11 h ft ova 'f
R ft
5a.Well Location:
Abemarie Corporation
Facility/OsenerName Facility IDM(ifapplicable) B' h wi
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348 Holiday Inn Drive, Kings Mountain,NC 28086
Physical Addrou,City,and Zip
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2
Cleveland L REMARKS
county PMcel Identification No.(PIN)
5b.Latitude and longitude In degrees/minuteshecends or decimal degrees:
(Dwell field,one la song is sufficient) 22.CertlBeation:
N W .7--�— �7^7 •?1
6.Is(are)the weB(s): V111ereument or OTemporary Signature of Certified Well Contractor Date
B),,ignt,g this form,thereby comfy that the well(,)wa,(ware)cwssmscadht acrordance-osh
7.Is this a repair to an existing well: DYes or flNo 15A NCdC 02C.0100 or 15A NCAC O2C.0100 Well Consouction Smndardr and that a cony
1fUu I.a repair,fill out mown well rounvcdon information and explain the nature of the oftlas record has been provtded fa the well owner.
rquo r under s21 remark,section or on the back of thu farm. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Leap Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add See Ova'm Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: r (BJ Submit this GW-I within 30 days of well completion Per the following:
For sesd4ple walls Well depth,ifdifferent(example-3®200'and 2@100)
24s. For AB Wells: Original form to Division of Water Resources (DWR),
10.State water level below top of casing' 00 Infomnttim Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level o above casing,u t"+" It 24b.
11.Borehole diameter: U (in.) Program,
For 1636 tineMS Ralelleigh,
Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: rO.VzC 24e.For Water Su I and Open-loop Geothermal Return Wells:Copy to the
(te.auger,rotary,cable,deeet push,etc.) comty enviroomeotai hea�tt t epamnmt o �mty whew installed
,.--� FOR WATER SUPPLY WELLS ONLY: 24d For Water Wells Droduchut over 100,000 GPD:Copy to DWR,CCPCLrA
Pmmt Program, 1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of teat
13b,Disinfection type: Amount:
Form GW-1 North Carolim Department of Envimnmmnud Quality-Division of Water Resources Revised 6-6-2019