GW1-2021-03349_Well Construction - GW1_20210603

i
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher
Well Contractor Name FROM TO DESCRIPTION
3568A
54 ft. 70 ft.
ft. �
NC Well Contractor Certification Number ftI5 011TERICASIN; for—d16*Agecl veORgT INE12 tib7
MIA
Gpm Pumps & Irrigation Inc FROM TO DIAMETER tl " THICKNESSf' ATERL
Company Name 0 ft 60 ft. 2 i in SCh 40 1 f VC
357293 1Gf1NNER,CASING U INGa tt�er�nlr�, -t
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17;?SCREE)`t„� - -
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 60 ft- 70 ft- 1.25 in. 0.010 40 pvC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single)
Industrial/Commercial 1311esidential Water Supply(shared) WININ
rg,GROU3' t'
Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 e• 30 ft• hole plug poured
Monitoring Recovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
19:t.SA1VI)%GRAN,EIP%ClzfA`"'licatile
Aquifer Storage and Recovery ElSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 30 ft. 70 ft. filpro poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20:DRMIJAN' 4 GT"1l&eI additio l liffelf(nice§i
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.
0 rt. 2 e• topsoil
4.Date Well(s)Completed:5/24/2021 Well ID# 2 tt. 7 rt. clay
5a.Well Location: 7 t`' 29 f`' sand
James Klender 29 ft• 54 ft• clay �.-
Facility/Owner Name Facility ID#(if applicable) 54 ft- 70 ft. sand
1384 Northside Road Elizabeth City
Physical Address,City,and Zip
ft. ft. 3 0 J
Pasquotank62'1RElRKS
�'In#orrr:a�
County Parcel Identification No.(PIN) p sedon
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one[at/long is sufficient) 22.Cer' Ieati
36 24 02.3 N -76 18 34.2 W
.- 5/28/2021
6.Is(are)the well(s) x Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or EJNo with I5A.NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction 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 I GW-I 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: 70 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@100') construction t0 the following:
10.Static water level below top of casing:8 (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: 5 7/8 (in.) 24b.For infection Wells: In addition to sending the form to the address in 24a
Rotory 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cen' ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: pump 24c.For Water Supply& Injection Wells:: In addition to sending the form to
the address(es) above, also submit I one copy of this form within 30 days of
13b.Disinfection type: hth Amount: 1/2 gal completion of well construction to the county health department of the county
where constructed.