GW1-2022-08257_Well Construction - GW1_20220906

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 14.WATERZONES'
Well Contractor Name FROM TO DESCRIPTION
3568A 20 ft. 30 ft• Sand
rt. rr.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells.OR LINER if a licable .
Gpm Pumps & Irrigation Inc FRZINNER
O DIAMETER THICKNESS MATERIAL
00 rt. 2 in. PR200 Pvc
Company Name16SING'OR TUBING eothermal closed-loo2.Well Construction Permit#: FRO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, f/ariance,etc.) ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17..SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
AgriculturalMunicipal/Public 20 ft. 30 ft' 1.25 in. 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
X'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft• Hole Plug Poured
Monitoring ORecovery ft. ft.
Injection Well: ft. rt.
Aquifer Recharge Groundwater Remediation
19.SANDIGRAVE`L PACK(if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLA CEMENT METHOD
Aquifer Test OStormwater Drainage 20 ft- 30 ft. Concrete Sand Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Traeer 20.DRILLING LOG`attaich additional sheets if necessa"
Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soittrock type,grain size,etc.
0 ft. 2 ft- Topsoil
4.Date Well(s)Completed: Well ID# 2 ft. 7 ft. Cla Y`T
5a.Well Location: 7 ft. 26 Sand Yellow
Jim Mcgee 26 ft- 30 ft- Sand Gray
Facility/Owner Name Facility ID#(if applicable)
ft. ft. a
22
118 Pogoda Trail Moyock 27958 ft. ft.
Physical Address,City,and Zip
ft. ft. ,a,J15 v`
Currituck 21.REMARKS
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.Certification:
36 51 15.1 N -76 24 18.2 W
8/29/2022
6.Is(are)the well(s) Permanent or OTemporary Signature of Certified ontractor Date
By signing this farm,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[Pell Construction Standards and that a
Ifthis is a repair,fill out known well constvuction information and explain the nature ofthe copy ofthis record has been provided to the it-ell 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(laving the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I 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 ifiliferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing:9 Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:5 7/8 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
12. RotOry above, also submit one copy of this form within 30 days of completion of well
(i.e.Well construction method:.auger,rotary,cable,direct push,etc.) construction to the following:
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 25 Method of test: PUMP 24c.For Water Supply& 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: 80Z completion of well construction to the county health department of the county
where constructed.
Font GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016