GW1--02228_Well Construction - GW1_20240408

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: I
Howard L Rushing,Jr. 14:WATER ZONES • I " `
Well Contractor Name ,FROM TO DESCRIPTION
ft. ft.
3342-A
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if a licable) ,
Carolina Well Drilling FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 60 ft. 4 , in. SDR21 PVC
24-32 16.INNER CASING OR TUBING(geothermal closed-loop) . ., ,
2.Well Construction Permit if: FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(Le.UIC,County,State,Variance,etc.) ft. ft. In.
3.Well Use(check well use): ft et in
Water Supply Well: 17.SCREEN .
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 0MunicipaI/Public ft. ft. in.I I
Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft. ft. In.
Industrial/Commercial EiResidential Water Supply(shared) 18.GROUT '
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. Bentonite Pour(4.5)50Ib Bags
Monitoring ElRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge OGroundwater Remediation 19.'SAND/GRAVE4PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft. ft.
Experimental Technology 0Subsidence Control ft. ft. 1
Geothermal(Closed Loop) OTracer 20.DRILLING LOG.(attach additional sheets if necessary)'
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness soil/rock type,grain size,seal
ft. ft.
4.Date Well(s)Completed: 2-22-24 Well ID# D ft.
5a.Well Location: ft. ft.
Brenda Mosley ft. ft. - t;—.u,�,,i:� bra ;r
Facility/Owner Name Facility ID#(if applicable) ft ft.
�PPOS 6509 Lancaster Hwy Waxhaw, NC 28173 ft. ft. ����+
Physical Address,City,and Zip ft. fL lRiL io-�}r�4,..•_ .;�2,v: 3 i:i
Union 04-312-028 - .21.REMARKS _ ..,.'''w.:3''-' .,
County Parcel Identification No.(PIN) Installed 60'4"Liner
Chlorinated Well
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
34.52.490 N 80.38.480 W *Ward L lZu3hina,'�i
cl 2-22-24
6.Is(are)the well(s)53Permanent or Temporary Signature of Certified Well Contractor Date
By signing this fort:,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: BYes or ONo with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Constriction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page,to,provide additional well site details or well
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
i
9.Total well depth below land surface: 400 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@!00') construction to the following: I
6'
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Air Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 4 Method of test: Air 24c.For Water Supply&Iniectilon Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 120Z completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016