GW1-2021-02737_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr ,Mia:�VATERtLUI�fES , s 4r. v `asp., •; t <F *xi.
Well Contractor Name FROM TO DESCRUITION
3568A 32 ft- 40 ft- Sand/sfiell
ft. ft.
NC Well Contractor Certification Number y,
15:OU'f•ER:CASING fSr�rnTilh car'seU(ivclls,OR=I;IIYER ifs "licafile"' '
GPM. Pumps & Irrigation FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft- 30 ft- 2• ' i-J Pr 200 PVC
rid
:'1G.INNER•CASIIUGOR0Tl-BING` eothermsl losetl1fdd 1-`-
2:Well Construction Permit#: FRO:U TO. I DIAMETER I THICKNESS I MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. It- in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
11401 TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
Agricultural []MunicipaUPubtic 30 ft- 40 ft' 1.25 '"' 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) R. 11L in..
Industrial/Commercial 13Residential Water SuPP1Y(shared) 1R.GROUT
X llri ation i-ROM . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 f- 30 rc. Hole Plug Poured 150 pds
:monitoring Recovery ft. ft.
Injection Well:
rt.Aquifer Recharge E)Groundwater Rem ft.
h
�19:.SAND/GIi+1+V<EI�iP,ACiZ"ifs`"'liciitile� `�•� �I� ,,�:���st��
Aquifer Storage and Recovery Salinity Barrier F1tOiiNl TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 30 1" poured
__ - 40 ft- fitpro
Experimental Technology OfSubsidence Control fr. ft.
_ Geothermal(Closed Loop) r.... Tracer 20..012ILLING.;1sbG,bttacliradthtioniiitili ati'.ifn1ki r"1'..
Geothermal(Heating/Cooling Return) E1,Other(explain under 921 Remarks) FROM TO DESCRIPTION color,hardness,soitfrock type,gnin size,etc
0 rr. 2 rt. Topsoil
4.Date Well(s)Completed:7/22/202 Well ID# 2 ft• 7 ft, Clay
5a.Well Location: 7 ft. 32 ft' Sand
Brian Jewell 32 rr• 40 ft- Sand/Shell
Facility/Owner Name Facility lD#(ifapplicable) ft. rt.
274 McPheerson Rd South Mills 27976 rt. Vie re!
Physical Address,City,and Zip fr• ft. V 3 2
r
Camden .1.R1:�1.1RK5' a� ,zt� ;:
County Parcel identification No.(PIN) .hPmFe pled
5b.Latitude and longitude in degreeshttinutes/seconds or decimal degrees: �W
(if well field,one lat/long is sufficient)
_.Certification:
36 20 27.0 N 076 20 03.0 W _ 7/26/2021
6.Is(are)the well(s) x,Permanent or QlTenrporary Sngiiaitirc ofCertiAcLWr4Kontractor Date
Br r;nin,L this form.I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: n.1'es or Qx No muh 15.4 XCAC 02C.0100 or 15A NCAC 02C.0200 Nell Construction Standards mid that a
If this is a repair,fill out known well construction uilbriination and erplain the nature ofthe "..i,J dtis record has been provided to the well owner.
repair under r21 rennarks section or on the back of ihis jornt.
2 silt diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal\Veils having the same You play 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 coli,irucl inn details. You may also attach additional pages if necessary.
drilled:
S! 10II-('TAL INSTRUCTIONS
9.Total well depth below land surface: 40 (ft•) 2.1a. For All Wells: Submit this',form within 30 days of completion of well
I%or nnrhiple wells list all depths fdderent(example-3(ri12u •and 2@100') en,l traction to the following:
10.Static water level below top of casing:7 Division of Water Resources,Information Processing Unit,
/jwater level is above casing,use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:5 7/8 (in.) 2-th. For Iniection Wells: In addition to sending the form to the address in 24a
Rotary al also submit one copy of this form within 30 days of completion of well
12.Well construction method: co intetion to the following:
(i.e.auger,rotary,cable,direct push,etc.)
flip ision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
!
13a.Yield(gpm)25 iMcillod of test:pumped 2.'r, For Water Sunaly&Iniection Wells: In addition to sending the form to
13b.Disinfeetion type: hth
U:c :idoress(cs) above, also submit'one copy of this form within 30 days of
Aurouttl: 60Z completion of well construction to!the county health department of the county.
whrre constructed.
Forts GW-1 North Carolina Department ofEnvimnmental(in6ty-nivicinn nrWnt—Roennmoe