GW1-2021-07144_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr
Well Contractor Name FROM TO DESCRIPTION
20 ft. gp rt.
3568A
ft. ft.
NC Well Contractor Certification Number 5.°OUTE1t t AS31fT' u tr=ea56il t �O1L«LTITt:ifa licatite ,, ..'
Gpm Pumps and Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
p ft 5 rt. 1025 '" 1sch40 PVC
16"<1IVNETt,C. ItN000, s'BINGE" Yheririat'tos id46
2.Well Construction Permit#: FROM I 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): rt. ft. in.
Water Supply Well: SCI2EEN
FROM TO DIAMETER. SLOT SIZE THICKNESS I MATERIAL
Agricultural 13Municipal/Public 25 ft- 30 ft' 1.25 '"• 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft• ft. in.
Industrial/Commercial Residential Water Supply(shared) =18:=G9OUTcA ;,,
X'Irrl ation FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ff• 25 ff• Hole Plug Poured
Monitoring EIRecovery
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 25 ft- 30 ft. Filpro Poured
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer Z v""' 7 a 7
Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soittrock e, rain size,etc.
p ft. 2 ft. Topsoil
4.Date Well(s)Completed:9/15/2021 Well ID# 2 rt. 5 ft. Clay
5a.Well Location: 5 ft. 30 ft Sand r—
Prescott
Facility/Owner Name Facility ID#(if applicable) ft. ft. O
109 Pisgah DR Moyock Nc 27958 ft. ft. ess�n9
Physical Address,City,and Zip ft. ft. �Fi¢Gi�'3' SgCYlOn
Currituck
1 R) iG1eR1�s "`' ¢ . . s� ,,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) CertiT tion•
36 27 58.9 N -76 01 53.9 W •
9/23/2021
6.Is(are)the well(s) Permanent or Temporary Signature o Certified Well Contractor Date
By signing this orm.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or X®'No with 15A NCAC 02C.0100 or 15A 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 921 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 l 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: 25 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ij'dijferent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing:6 (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 Welts: 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: pump 24c. For Water Sunaly& Iniection 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: hth Amount: 12oz completion of well construction to ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources j Revised 2-22-2016