GW1-2023-00771_Well Construction - GW1_20230112

WELL CONSTRUCTION RECORD(GA-1) For Internal Use Only:
1.Well Con7eetor Inform lei
/`1 ���A �//d✓I�' u.wAnawNBs
PROM TO nrecRvnoN
Well Connneror Nana R ft.P30 A- IL I R
NC Well Contractor Cemfirmion Number Ii OUTHR CAgING far mati4easM wed OR LINER
FROM TO n1AMETER TMCKNa:sa MATERIAL
Cascade Drilling LP D R 35- R G• $10 I �v
Company Name 1L INNERC TO DIAM
OR TU In .
TEST
2.Well Construction Permit#: FROM TO TwICtDfis9 MATERIAL
I.
List all applicable well constriction permits(Le.DIC COURO,State,Variance,e1c.) It. ft.
R R be.
3.Well Use(check well am):
17.lREN
Water SoPP hWell: ...
. MATERIAL
MticPublic OOAoculmral 3 9Je
OGeothennal(Heating/Cooling Supply) OResidential Water Supply(single) R.
industrial/Commmcial ORaside ntlal Water Supply(shared) IN.W I/T
_71rri ation OWclls>100000 GPD mom TO MAtuw. EMFr.AC1a@rt M6rHOD A AMokw1
Non-Water Supply Well: L R a6 R' 7bothal /
Wonitoring OReeoVery R• C/
injection Well: R. R
OAquifer Recharge OCm undwater Remediation 19.B6NDRiRAYEL.PAC7C f e
DAquifer Storage and Recovery OSalinity Barrier FROM TO MAlER1AL a1Fr.AcaMwr Mg1ROD
OAquifor Test OStormwater Drainage O fi' 9 rL
OExpenmental Technology OSubsidencc Cootmi R R
OGeothermal(Closed Loop) OTm 10. GLOG entente admtlaaal aheeb if
PROM TO DESCRIPTION wbr hardy wl0wek tie
OGeothermal satin Conlin Return) OOther lain under#21 Remarks IL TO
4.Date Wallis)Completed: Well m#S.v1,rrn�a-ef.�8 R' ft. . .
R IL - t^ .: '
Sa.well Location: -701
R. R
Abemade Corporation
Facility/Owmr Name Facility ID#(itappliWne) It. R I 1 J
ft. IL348 Holiday Inn Drive Kings Mountain NC 28086
Physical Address,City,and Zip
Et.REMARKS
Cleyeland
County, Parcel identification No.(PM)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2L Certification:
N
gigestoremf Certified Wall Contractor late
6.le(aro)the well(s): Btermanent orDTemporary
ByalgMng Wlr form,!hereby cemfy thM the wtl!(sJ was(wweJ oomUaclad in accordance with
7.Is this a repair to an existing well: DYea or ANO 15A NCAC 02C.0/00 or 15A NCAC 02C.0200 Well Conrovctian Standards and that er.l y
Il out b,own we/!conetroclion lnformaHon and esplain the native affhe ef"record bar been prod en the well owner.
lfthu it a r#21 Jl
repair under s2/remarks section or on the back of tau form. y.Site diagram or additional well details:
You may use the back of this page to provide additional Well comttuction info
8.For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the more
cocamuction,Only I GW4 is needed. Indicate TOTAL NUMBER of walla (✓� Oval in Rertutka Box).You may also attach additional pages if noceaseny.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land an -cc: PS r (ID) Submit this GW-I within 30 days of well completion per the following:
For multiple weld list all depths lfd/i ercM(aaample-3@200'aad 2®1007
2/a. For AN Walls: Original farm to Division of Water Rcmmumm (DWR),
10.Static water level below top of using: IN Infonna Pt gProcessing Unit,1617 MSC,Raleigh,NC 27699-1617
Ifivater level i'above caring,We"+" er
246.For Injection Wells:Copy to OWE,Undergnund Injection Control nUQ
11.Borehole diameter: X (in.) Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: fovt C 24c.For Water Sppp1Y and OpeRTLaop Geothermal Return Well Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county enVUDnmenfat neazin aepasuncai G,iie County:,..ere..stains.
FOR WATER SUPPLY WRId.S ONLY: 24d.For Water Wells K dueine over 100.000 GPD:Copy to DWI,CCPCLIA
Permit Prog o n,1611 MSC,Raleigh,NC 27699-1611
13s.Yield(gpm) Method of tart
13b.Dlalialmdou type: AMURL'
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resouaea Revised 6-6-211 19