GW1-2022-09303_Well Construction - GW1_20221006

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
I
Paul A Lacher Sr I4WiTERLOlVY3$
Well Contractor Name FROM TO DESCRIPTION
3568A 68 rt. 80 rt.
ft ft.
NC Well Contractor Certification Number 0,151COUTERGASINGf fo�ruulh cased'`ells`,OR LINER,if€ri libl ,
Gpm Pumps & Irrigation Inc FROM TO DIAMETER I THICKNESS MATERIAL
Company Name
0 ft 70 ft. 1 2 pr 200 pvc
G. lYN 1NG th�ma"Y c1o"�`ced=1�`o
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well constnrction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft, in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural E)Municipal/Public 70 ft- 80 ft' 125 h"•I 0.010 40 pvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. tt. in.l
Industrial/Commercial Residential Water Supply(shared) ,A'8 GROUT
Xi Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 35 ft hole plug poured 225 lb
Monitoring .Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation ft ft.
19.�c,SA1VD/GRA�Y;Elf=P,AGK",fka!ic'�6°lc _
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 60 ft- 80 rc. concrete sand poured
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer `20 DRILLING,1OG,aifacYiaadBitionIsheefsatisa f`,.
�,.
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks)
0 ft. 2 ft. topsoil ,
4.Date Well(s)Completed:09/30/22 well ID# 2 ft. 9 ft. clay
5a.Well Location: 9 ft 38 f`' sand ^
Tom Hurley 38 ft 52 clay
Facility/Owner Name Facility ID#(if applicable) 52 ft 68 ff Sand fine shl9fl'"'
110 Sligo Way Moyock 27958 68 80 ft Sand heavy shell V
Physical Address,City,and Zip
Currituck r271"9 EMAR Xs'fflffl91- 5: � ,.1 ,.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one IatAong is sufficient) 22.Certil Tiow
36 27 0.01 N 76 04 0.44 W 10/2/2022
6.Is(are)the well(s) x Permanent or Temporary Signature o hfied Mll Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constnicted in accordance
7.Is this a repair to an existing well: [3Yes or JqNo 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 constnrction information and explain the nature ofthe 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-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may alsoattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: $0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iit'dii ferent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing:8 (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 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 75 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: 12 oZ completion of well construction to the county health department of the county
where constructed.
Fnnn(;W_l North Carolina nenartment of Fnvirnnmenml f)uality-r)ivicinn of Water Recnnrnec Revised 9_99_9l116