GW1-2022-03535_Well Construction - GW1_20220324

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information: f
Paul Lacher Sr
FROM TO DESCRIPTION
Well Contractor Name 3568A 68 ft. 80 ft. Sand
ft. ft. I
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NC Well Contractor Certification Number s:150113- R„Crr111G'fur" `ult,neas"eil we119 OR IsINER,"ira IiE><b1e
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 rt 70 ft 2.0 '" 40 pvc
Company Name a s
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. (11C,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
:;
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunicipal/Public 70 ft- 80 ft' 1.25 in. 0.010 40 pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
c
Industrial/Commercial DResidential Water Supply(shared)
!I�Rt?U2';��
X'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 25 ft hole plug poured
Monitoring [3Recovery
Injection Well:
31 Aquifer Recharge Groundwater Remediation
t1:db e F
_ Aquifer Storage and Recovery L Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 60 ft 80 ft Filpro poured
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) OTracer r"20,: R1> ts,ifneccssu .'
Geothermal(Heating/Cooling Return) 'Other(explain under#21 Remarks)
FROM fL TO ft- DESCRIPTION color,hardness,soil/rock e,g rain size,etc.
0 2 topsoil
4.Date Well(s)Completed:3/17/2022 Well ID# 2 R. 26 ft. sand ,
5a.Well Location: 26 ft. 40 ft. sand gray
Chris Gay 40 rt• 68 ft- clay
Facility/Owner Name Facility ID#(if applicable) 68 fr' 80 ft sand course Vcvr--
117 Slingo Dr Moyock 27958 fr.
Physical Address,City,and Zip ft. ft.
Currituck
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certific
-76 04 44.5
36 27 03.8 N
3/21/2022
6.Is(are)the well(s) Permanent or Temporary Signat of Ce i ted Wel 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: DYes or JBNo 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#21 remarks section or on the hack 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 1 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: 80 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For inuhiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of easing:5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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
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13a.Yield(gpm)60 Method of test: pump 24c.For Water Suunly& Injection 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:the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016