GW1--03310_Well Construction - GW1_20230512

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr "'UMATER10 'S z
Well Contractor Name FROM TO DESCRIPTION
3568A 28 ft. 138 ft.
tt. tt. ,
NC Well
mContractor
mCertificatioQn Number Inc :OUTER CASING: for„multr=cased Sells OR LINER iGn licatile: ,
Gp m Pumps & Irrigation 1 1 FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. 128 ft. 1 1.25 in 40 PVC
,16,ANNER;CASING_0R TUBINCy; 'e"btbkrmai:ctosed.l6o .., ,
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: :.I7:"SCREEN ""
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 28 ft. 38 ff• 1.25 in' 0.010 40 PVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
i Industrial/Commercial DResidential Water Supply(shared)
X=Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0 ft• 25 ft• Benseal poured
Monitoring ORecovery
Injection Well:
Aquifer Recharge DGroundwater Remediation
I,19.SAND/GRAVEL:PACK if applicable
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD M
Aquifer Test Stormwater Drainage 25 ft, 38 ft- filpro poured
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRITLING:LOG attach'additional sheetsifnecessa 7.ni..
FROM TO DESCRIPTION(color,hardness,soil/rock type, rain size,etc.)
'Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft. 2 tt. Topsoil
4.Date Well(s)Completed:5/5/2023" well ID# 2 ft. 6 a. C Lay
5a.Well Location: 6 tt. 38 tt. Sand
Eric Dean ft. tt. 023
tt. ft.
Facility/Owner Name Facility ID#(if applicable) _
803 Broomfield Trail Elizabeth City NC 27909 tt. ft. l„�;r <' �� ;�
rAs 'c;i'�tt
Physical Address,City,and Zip
ft. ft.
Pasquatank ,ZVREMARKS --,- 777
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certification:
36 13 35.8 N -76 07 41 .3 W 5/5/2023
6.Is(are)the well(s) Permanent or (Temporary ifi
xed'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: Owes or DNo with 15A NC'AC 02C.0100 or 15A 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 221 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: 38 (ft.) 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 a 100') construction to the following:
10.Static water level below top of casing:5 (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
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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)40 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: 16 Oz completion of well construction to,the county health department of the county
where constructed.
F.—r.W_t Nnrth Carolina Denartment of Fnvimnmental Ouality-Division of Water Resources Revised 2-22-2016