GW1-2022-09302_Well Construction - GW1_20221006

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr 14�!:iTiRfi(SIYI
WellContractor Name FROM TO DESCRIPTION
3568A 20 ft. 30 ft.
ft ft.
NC Well Contractor Certification Number 'I5 Ul7TEIz GASIIVG formultisV=w�11 URIN,ERrf , lia61
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 20 ft. 1.25 1 in' 40 1 pvc
#16:INi,FAE NSING)UR IIlBINO ARl' maIVJ6"MWWPI 10)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.(11C,County,State,Variance,etc.) et. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: I ;PSCREEN III . . I
FROM TO DIAMETER SLOT SIZE I THICKNESS MATERIAL
Agricultural E3Municipal/Public 20 ft- 30 et• 1 1.25 i"L 10.010 140 pvc
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single)
Industrial/Commercial DResidential Water Supply(shared) 18 GROUTS
X(lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: o rt• 20 rt• hole plug poured 150lbs
Monitoring DRecovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19�iSA°iVD/GRA1;EIA�GiZY if liable
Aquifer Storage and Recovery Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 20 ft• 30 rr• concrete sand poured
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20�'DRILLINr OG a h' dditidJ I h is iT-nW a. ,,s
Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft. 2 ft. topsoil
4.Date Well(s)Completed:09/14/22 well ID# 2 ft. 8 ft. cla _ -- <4
l� 7
5a.Well Location: g ft. 30 ft. sand
Rozar rt. it.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
123 Kings Way Moyock 27958
Physical Address,City,and Zip
Currltuck
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certifi !� l
3631 12.0 N 76 13 41 .0 W
10/2/2022
6.Is(are)the well(s) X Permanent or [3Temporary Signature of1te I d Well 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: [3Yes or IgNo 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 in%rination 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 1his.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: 30 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:6 tfc•) 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.) I
24b.For Iniection 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.
1
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 18 Method of test: pump 24c.For Water Supply& Iniection 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: $Oz completion of well construction to the county health department of the county
where constructed.
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