GW1-2022-07235_Well Construction - GW1_20220805

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr :14.WATER.ZONES—
Well Contractor Name FROM TO DESCRIPTION
95 It. 110 ft.
3568A
NC Well Contractor Certification Number
15.OUTER CASINCr foe triaiG cased-wells"OR LINER if,u'°"licabie
Gpm Pumps& Irrigation Inc FROM TO DIAMETER; THICKNESS MATERIAL
0 ft. 95 ft. 2 'in. sch 40 PVC
Company Name
I'6''INNEt2 CASING"OR TUBING eotlfe"rmal
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County.State,Variance•etc.) ft• tt. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17,SCREEN --
FROM TO DIAMETER' SLOT SIZE THICKNESS -MATERIAL
Agricultural Municipal/Public 95 ft, 110 ft. 1.25 In•. (0.010 sch 40 pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) ?,'v18.GROUT
FROM TO MATERIAL °n EMPLACEMENT - _.. -
',Iri ati0n NT METHOD&e4MOUNT
Non-Water Supply Well: c r[' 25 rt• hole plug poured 140 Ibs
Monitoring ORecovery
Injection Well: ft ft
Aquifer R charg DGroundwater Remediation
i•19:SAND/GRAVEL SACK if applicablej
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 75 R. 90 ft. concrete sand poured
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer =20«DRILEING LOG'(ditacfi'Sddinon"al,stieets if necessar
Geothermal(Heating/Cooling Return) Mother(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
0 ft. 2 ft, Topsoil
4.Date Well(s)Completed:7/14/2022 Well ID# 2 fc. 6 ft. Clay
5a.Well Location: 8 ft. 52 rt• Sand
Daniel Meade 52 rc. 65 ft. clay `, ra
Facility/Owner Name Facility ID#(if applicable) 65 ft. so ft' sand
320 Harris Rd Elizabeyh City 27909 80 rt. 95 rt. clay AUG 0 5' 2022
Physical Address,City,and Zip 95 rc• 110 rt• Sand Gr� f Urgft
Pas9 utank :11,11EMARKS. __°._ DW
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one lat/long is sufficient) 2.Certi 1 tion:
36 10 02.4 N 076 08 06.7 W
7/31/2022
6.Is(are)the well(s)oPermanent or OTemporary Signature ofC14
fied W ontractor Date
By signing this fora,1 herebv certijy that the ivell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or [KNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Constritction Standards and that a
Ifthis is a repair,fill our known well construction information and explain the nature ofthe copy ofthis record has been provided to the welt on•ner. —
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: 110 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 6 (ft.) Division of Water Resources,Information Processing Unit,
1f rater level is above casing,use"+" 1617 Mail Service Center',Raleigh,NC 27699-1617
11.Borehole diameter: 5 7/8n (in.) 24b.For Injection Wells: In addition lto sending the form to the address in 24a
12.Well construction method: above, also submit one copy of this�foimi within 30 days of completion of well
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) 75 Method of test Pump 24c.For Water Supply&Iniectioli 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: 12 oZ completion of well construction to the county health department of the county
where constructed.
Fonn GW-I North Carolina Department of Environmental Quality-Division of Water Resources 1 Revised 2-22-2016