GW1-2022-10396_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr '.K,,WATER,ZONES
Well Contractor Name FROM TO DESCRIPTION
3568A 65 fr. 80 rt.
fr. rt.
NC Well Contractor Certification Number 15.°OUT,E&CASING for;mulfi=ci sedlivclls'OR'LINER if:a licablc
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 70 rt. 2 in. SCh 40 PVC
'�16.INNERCASING'0RTUBING. eothermalelosed-loop)'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well consiniction permits(i.e. UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 47.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 70 ft- 80 ft. 1.25 in. 0.010 SCh 40 PVC
,Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
DIndustrial/Commercial Residential Water Supply(shared) 18.:GROIIT '�.
X Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 30 ft- Hole Plug Poured
Monitoring Recovery
njectifn Well:IAquoeRecha rge roundwater RemediationG ft. ft.
19.SAND/GRAVEL PACK if a licabl'c
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
F—lAquifer Test E3Stormwater Drainage 65 ft. 80 ft. Fllpro 2 Poured
Experimental Technology [3Subsidence Control
Geothermal(Closed Loop) ElTracer 20.DRILLING LOG attach additioaalisheetsN if necessar
FROM ft. TO ft. DESCRIPTION color,hardness,sou Urock type, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 2 Topsoil
4.Date Well(s)Completed: 11/04/2022 Well ID# 2 ft- 7 ft* Sand
5a.Well Location: 7 ft. 25 ft- Clay
Robert Manzer 25 ft- 35 ft- Gray SandNoll
Facility/Owner Name Facility ID#(if applicable) 35 ft- 65 ft' CIa
y
133 Main St Hertford NC 27944 65 ft. 80 ft. Sand shell horf,'wan PrM�!� 110
Physical Address,City,and Zip
ft. ft.
PergUlnlanS °21:REMARKS
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. titication•
36 1309.1 N -76 27 59.8
11/6/2022
6.Is(are)the well(s)oPermanent or OTemporary Signatu ertified Well Contr r Date
By signing this farm,1 hereby certify that the ivell(s)was(were)constnicted in accordance
7.Is this a repair to an existing well: Yes or nXNo with i5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
ifthis is a repair,fill out known well consiniction information and explain the nature ofihe copy of this record has been provided to the well owner.
repair under 921 reinarks section or on the back of ibis 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 ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 80 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a 200'and 2Ca 100') Construction to the following:
10.Static water level below top of casing: 1 1 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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) 60 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: 160Z 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