GW1-2021-07143_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 4 Wr1fERh7,(SNElSs„ � 7 ,fa "
Well Contractor Name FROM TO DESCRIPTION
3568A � 20 it. 30 it.
T ft. rt.
NC Well Contractor Certification Number 15:..OUTER_CASING.lorinulh:casetlells OR-hTNER'if licabl ,_
Gpm Pumps and Irrigation_lDrc'WrocessingtJnit FROM TO DIAMETER THICKNESS MATERIAL
n W Secti 0 ft. 5 ft. 1025 t" sch40 PVC
Company Name D R t,T6.4NNEW G A'SINQ OP.'"B I N G1(jjLJ herinatclo�ed,liib°
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Sate, Variance,etc) ft. ft. in•
3.Well Use(check well use): ft. ft. in.
Water Supply Well: FROM,RVE.o ;.. DIAMETER .,���,;
SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public 25 fc• 30 ft- 1.25 in. 0.010 sch40 JPVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) Ig,GROUI-AT r"Y WIr,
X Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tc• 25 fc• Hole Plug Poured
Monitoring DRecovery
Injection Well:
ft ft
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E3Stormwater Drainage 25 ft- 30 ft- Filpro Poured
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20DR1LLINGIOG "ch:ad'ditiohrietsitnbce�sa" " wg 4zsa. '..,K ';
Geothermal(Heating/Cooling Return) !Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
- p ft. 2 s. Topsoil
4.Date Well(s)Completed:9/15/ZO21 well ID# 2 tt. 6 ft. Cla
5a.Well Location: 6 it 30 ft• Sand
Bolander
Facility/Owner Name Facility ID#(if applicable)
106 Pisgah DR Moyock Nc 27958 ft.
Physical Address,City,and Zip
ft. ft.
Currituck21RI A4t(RIt5i 3' f,. .,y vag .
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ertificati
36 20 00.8 N -76 01 58.5 W
9/23/2021
6.Is(are)the well(s) x Permanent or Temporary Signature of Cc well Corn. r Da e
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: Yes or EJNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
1f 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-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: 30 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iif'diijferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:7 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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: pump 24c. For Water SuDniv&Infection 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 toi the county health department of the county
where constructed.
c---ntv_i Unrrh('arnlina Tlenarrment of Fn,i—mental 0—lit,-nivkinn of Water Recnurcec i Revised 2-22-2016