GW1-2022-09406_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr 1,111WXTERZONEs» i';g
Well Contractor Name FROM TO DESCRIPTION
40 ft. 50 ft.
3568A
ft ft.
NC Well Contractor Certification Number
S:Ol1,TER°CASING" of r i;la*caseit well" OReI371, R?i111�"Iic�Ul�.
G p m Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name
p ft. 140 ft- 4 , "n Sdr26 pvc
-
16:�)I1\,'N,>R"�CASII3"G,b 'IB7NG107o#hermalclo"?;Ad»l6o"
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Mariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: Ir �
FROM TO DIAM 11 ETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 40 ft• 50 ft• 2 '"` 0.010 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. to
Industriat/Commercial DResidential Water Supply(shared) y, n �g
w IB GROUT x 6 0V .,,a3
X Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 40 ft• hole plug poured 2501b
Monitoring ORecovery R. ft.
Injection Well:
ft ft.
Aquifer Recharge OGroundwater Remediation
9;�SANI)/GRA�UEIPA�K�f„ii licnb'1i:
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 40 ft• 50 ft• concrete sand poured
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 30-DRILL'llVG3I"OG atchddifioitelisbeeif_n�cSa � y „.
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 tt. 2 ft. tOpS011
4.Date Well(s)Completed:09/01/22 Well ID# 2 ft• 22 ft• clay
5a.Well Location: 22 tt. 40 tt. fine sand
Jake Branch 40 ft- 50 ft- coarse sand
Facility/Owner Name Facility ID#(if applicable)
218 Long Branch Lane Hertford 27944 ft. rt.
Physical Address,City,and Zip
Perquimans m211,RZ41ARIKSg 6ii „
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 rtifreatio .
3608 0.13 N 7618 0.31 W 10/2/2022
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: Yes or xO'No with 15A NCAC 02C.0100 or 13A NCAC 02C.0200 Well Construction Standards and that a
If this 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 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: 51 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di,/ferent(example-3@200'and 2 a 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 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) 20 Method of test: pump 24c. For Water Supply& Iniectl'on 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.