GW1-2021-00537_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher 1auvrEnN
FROM TO DESCRIPTION
Well Contractor Name 20 ft- 32 ft.
3568A
NC Well Contractor Certification Number y
JIt bUZ WMSIR f - ultf- li 1OII INLTt�Sf li le
Gpm Pumps & Irrigation Inc FROM TO DIAME2J41
THICKNESS MATERIAL
0 ft- 20 ft- 1.25ch 40 Pvc
Company Name 16JINNgR[i3XSSt6l 01'imlaIN
2.Well Construction Permit#: FROM I TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.VIC,County.State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROSMREN
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 22 ft' 32 ft' 1.25 in. 0.010 Sch40 Pvc
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft- 22 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18GRO3 y
l9Irri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 22 ft* Hole plug Poured 150lbs
OMonitoring ORecovery
Injection Well:
ft. ft.
OAquifer Recharge ❑Groundwater Remediation
9:tISA"NDYG11XV fP,PiCKI [, 1iftl
OAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test OStormwater Drainage 22 ft. 32 ft. Filpro Poured
❑Experimental Technology ❑Subsidence Control
OGeothermal(Closed Loop) ❑Tracer 20 `AIM1198MCIG ii`ftach dili INWMf nec u
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)J
FROM TO DESCRIPTION color,hardness,soiVrock type rain size,etc.
0 ft- 2 ft- Topsoil
4.Date Well(s)Completed: 01/04/20214W Well ID# 2 tt. 6 ft. clay
5a.Well Location: 6 fr. 32 fr. Sand
Kevin Milcarek
Facility/Owner,Name Facility ID#(if applicable)
ft. ft.
553 Middle Gibbs Rd Knotts Island NC 27950 ft. ft.
Physical Address,City,and Zip ft. ft.
Currituck i1 R'9MXRiz
goctlon
County Parcel Identification No.(PIN) �4R
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:t�
(if well field,one lat/long is sufficient) 22.Certi ion:
36 32 04.1 N 076 05 47.7 2/6/2021
E�
6.Is(are)the well(s): OPermanent or ❑Temporary Signature Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ItNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction in/bi-maFion and explain the nature of the of this record has been provided to the well owner.
repair tinder#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 construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 32 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
6 24a. For All Wells: Original form to Division of Water Resources (DWR),
If
f water level is above casing,use"+"Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 5 7/8 (in.) 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotary.
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) 25. Method of test: PUm
p Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: hth Amount: 8oZ
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018