GW1--04825_Well Construction - GW1_20240814

.1111/
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
3568A 40 ft. 50 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Gpm pumps & Irrigation Inc FRO.,I TO DI.AIIIETER ' THICKNESS MATERIAL
0 ft. 40 ft. 2 in. pr200 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS NIA 1 ERIAL
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:
17.SCREEN
ppy FROM TO DIAMETER SLOT SIZE THICKNESS NIATERIAL
Agricultural °Municipal/Public 40 ft. 50 ft. 1.25 in. 0.010 40 pvc
Geothermal(Heating/Cooling Supply) }Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
x Irrigation FROM TO NIA I t RIAL L)1PLACE}IENT METHOD&AMOt s I
Non-Water Supply Well: 0 ft• 20 ft• Benseal pourd 150 lbs
Monitoring °Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge °Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM '10 MATERIAL ESIPL.A(E>tEN-r NI TTIIOD
Aquifer Test QStormwater Drainage 40 ft. 50 ft. concrete sand poured
Experimental Technology oSubsidence Control ft. ft.
Geothermal(Closed Loop) °Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft. 2 ft• topsoil
4.Date Well(s)Completed:7/8/2024 Well ID# 2 ft. 28 ft• sand
5a.Well Location: 28 ft• 40 ft' clay .. .
Mellisa Hooper 40 ft• 50 ft• fsand . , .,.., i i;�.
Facility/Owner Name Facility ID#(if applicable) ft. ft. A U G 1 L 2024
121 River Dr Hertford 27944 ft. ft.
Physical Address,City,and Zip ft. ft. IG:. :R•• " t r S� jolt
Perquimans 21.REMARKS Dlrj (,rn3
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) ,.....3..2..Certifieatigp:-.
36 19 42.7 N 76 45 42.5 W '_` z _ _._.---- 7/14/2024
6.Is(are)the well(s)0Permanent or °Temporary C_- fi iature of Certified 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: °Yes or la No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Jfshis 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 u21 remarks section or on the hack 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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50 (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@100') construction to the following:
10.Static water level below top of casing: 10 (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) 20 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: 32 completion of well construction to the county health department of the county
where constructed.
Form t;W-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016