GW1-2022-08259_Well Construction - GW1_20220907

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr VNFROMT0,
� ESM y,
Well Contractor Name DESCRIPTION
3568A ft- ft- sand course
NC Well Contractor Certification Number
Gpm Pumps & Irrigation Inc DIAMETER I THICKNESS MATERIAL
Company Name 0 ft. 40 ft- 2 in. Sch 40 PVC
,000 NER149AS OR ,,BIND, i6tV di-omMMINWAMMOMM
2.Well Construction Permit#: FROM TO DIAMETER I THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, ilariance,etc.) ft, ft, in.
3.Well Use(check well use):
Water Supply Well: I7VSOREEI, _ . .,
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public 40 ft- 50 ft' 1.25 'j' 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft.
Industrial/Commercial 13Residential Water Supply(shared) x
18 GROU!T
X.Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply WeII: 0 ft• 35 ft• Hole Plug Poured
Monitoring EIRecovery
Injection Well: ft. ft.
Aquifer Recharge 13Groundwater Remediation
lIS3dif3VD1GRVY P,�iCIfiI' fid 'tic'�ll4Sand4
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIALAquifer Test OStormwater Drainage 35 ft• 50 ft• Concrete
Experimental Technology Subsidence Control ft. ft. i
Geothermal(Closed Loop) 13Tracer ;204DRILLING4200"aitaeh
Geothermal(Heating/Cooling Return)
TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.) :Other(explain under#21 Remarks) 0 ft. 2 ft. TOP SOII
4.Date Well(s)Completed: Well ID# 2 ft- 7 ft. Clay
5a.Well Location: 7 ft. 28 rt. Sand ,4 .
John Corprew 28 ft• 35 ft• Clay
Facility/Owner Name Facility ID#(if applicable) 35 ft• 50 ft• Gravel SNP SEP Q
101 River Dr Hertford 27944
UniI
Physical Address,City,and Zip ft. ft. r�tl0I1�(
Perquimans
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one ladlong is sufficient) 22.Certif,ation•
36 11 35.9 N -76 27 18.4 W
8/29/2022
6.Is(are)the well(s) X Permanent or Temporary Signature of CerNfied Well Co tractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair t0 an existing well: Yes or _X®_,'No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If ihis 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 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 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: 50 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a//depths if different(example-3 a 100'and 2@100') construction to the following:
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10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
If water 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
Rotary 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.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 100 Method of test: Pump 24c.For Water SunDly& Inje'ction 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 constructiont to the county health department of the county
where constructed. C
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Fonn GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016