GW1-2023-02906_Well Construction - GW1_20230420

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor information:
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Howard L.Rushing Jr. 411141VATER,ZONES
,� -77777777M 777777,1r
Well Contractor Name FROM TO I DESCRIPTION
tt. ft. I I
3342-A
Yt. ft.
NC Well Contractor Certification Number .ItSE:OItTRR`CASiNG 0ruu1N citsed velis)':pR:hiNER•(itaA" iicaMe='
Carolina Well Drilling FROM TO DIAMETER THICKNEtiS MATERIAL
Company Name 0 fit' 96 rt• . 6 5/8 1n Galv.Steel
i16:;tNNFR'GASINC INC,(4e6therinahiI6iid loot)''..v ,',:•,. ? .-:
2.Well Construction Permit# 23-44 FROM To I DIAMETER THICKNESS MATERIAL.
List all applicable well constriction permits(i.e.U1C,Cotmry,State,Variance,etc.) 0 et. 96 ft• 4 in' SCH40 PVC
IWell Use(check well use): R. tt. In,
Water Supply Well: ;17:SGREBN t .r, s' „:`�; vt'} ,•-= , .�,. ,- ..�
FROM TO I DIAMETER I SLOT S17.F. I THICKNESS I MATRRLAi
Agricultural QMunicipal/Pablic (L R. is
Geothermal(Heating/Cooling Supply) laResidential Water Supply(single) g. In.
htdustrial/Comindreiad 13Residential Water Supply(shared)Irrigation FROM TO f MATERIAL EMI•LACEMENr METHOD&AMOUNT
Non-Water Supply Well: 0 tt. 96 n Portland Pour(17)471b Bags
Monitoring Recovery fit. tt.
injection Weil• ft. fit.
Aquifer Recharge Groundwater Remediation
_19 SAND/GRitVfirP,ACK#(ifn illcaGle t
.,,_»•
Aquifer Storage:mil Recovery []Salinity sorrier FROM TO M TERIAL EbIPI AC.EMENT METHOD
Aquifer Test [3Stormwatet•Drainage
Experimental Technology 13Subsidence Control n. ft.
Geothermal(Closed Loop) oTracer 120.?DRIL------ QG,fiattncFC'tidditi'oii4ltsheefsii.necessa 1' '"st w
FROM TO' DFSCRLPTiON(color,hardn sontrock rain si etc)
Geothermal(Hcatin Coolin Return Other ex lain under#21 Remarks tt [t
4.DateWell(s)Completed: 3-31-23 Well ID# t.
Sa.Well Location: ft. ft.
Matt Kopley A.
Facility/Owner Name Facility ID#(if applicable) ft.
1621 Waxhaw-Marvin Rd. Waxhaw 28173 rt. rt.
APR
PhysiaA Address,City,and Zip fit. It.
Union 06-228-004E
County Patel Identification No.(PIN) `4"PVC liner installed to 96'depth per Union Co.repair permit
5b.Latitude and longitude in degreeshninutes/seconds or decimal degrees:
(if well field,one lattlang is sufficient) 22.Certification:
34.58.599 N 80.48.574
4-3-23
6.Is(are)the well(s)UPermanent or Temporary Signature of Certified Well Contractor Date
By signing this font,I hereby certify Thai the well(s)it-as(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or InNo Milt 15A NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Constriction Standards and that a
If this&a repair,fill out launnn well eorstntctioli information and explain die awture of the, capy of this record bar been provided to the well on7aer.
repair a nder#21 renirarks section or on the back of this forni.
23.Site diagram or additional well detaffs:
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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details.,You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 220 (It 24a. For All Wells: Submit this form within 30 days of completion of well
'For nndtiple wells list all depths{idifjerent(example-3@200'and 2@7001 construction to the following:
10.Static water level below top of casing: 36 Division of Water Resources,Information Processing Unit,
1f water level is above casing,ose + 1611 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole.diameter: 6 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Air Rotary above, also submit one copy of this fortn within 30 days of completion of well
12.Well constr cable,
method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) - �. ,
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 11636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield($pm) 12 Method of test: Alr 24c.For Water Supply&Injection Wells, In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
13b.Disinfection type: 70%HTH Amount: 15oZ completion of well construction to$he county'health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Waler Resource.% I Rcvised 2-22-201 fi