GW1-2022-08258_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 14.,VATERZONES
Well Contractor Name FROM TO DESCRIPTION
3568A 87 ft- 110 ft• Sand
ft. ft.
NC Well Contractor Certification Number 15OUTER CASING fog mulfi-cased wells .OR LINER.'if a licable
G p m Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft- 100 ft- 2 in PR200 Pvc
Company Name 16.INNER CASING OR TUBING' eothermal closed-loo"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, variance,etc) ft. ft. 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 100 ft. 110 ft, 1.25 in. 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) rt. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18,GROUT
X'Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 40 ft• Hole Plug Poured
Monitoring EIRecovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
Aquifer Storage and Recovery Salinity Barrier F01 ND/GRA )L PACK if a IlicableOV
MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 90 ft. 110 ft. Concrete Sand Poured
Experimental Technology OSubsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING:LOG atfnchadditionnl-'sheets:ifnecessa "
FROM TO DESCRIPTION(color,hardness,soil/rock e, ruin size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 2 ft. -rOPSOII
4.Date Well(s)Completed: Well ID# 2 ft, 8 ft. Clay
5a.Well Location: $ ft' 45 ft' Sand k''„+��,.__ G 'i
Jeff Peters 45 ft, 60 ft- Clay
2022
Facility/Owner Name Facility ID#(if applicable) 60 ft. 70 f` Sand J^ I
118 Mooreland Way Moyock 27958 70 ft- 87 ft- Clay Irl 3,-
Physical Address,City,and Zip 87 ft- 110 ft- Sand
CurrltuCk 21.REINIARKS= >„
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:
3631 07.9 N -76 10 25.2 NV 8/29/2022
6.Is(are)the well(s) Permanent or OTemporary Signature of Certifie ell -on ractor Date
By signing this form,I hereby certify that tine well(s)was(were)constructed ill accordance
7.Is this a repair to an existing well: OYes or kNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out Iarown well construction information and explain the nature ofthe copy ofthis 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-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: 110 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For•multiple wells list all depths iJ'dierent(erample-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 7 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater 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) 12 Method oftest: Pump 24c.For Water Supply& 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: 8Oz 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