GW1--04826_Well Construction - GW1_20240814

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 14.WATERZONES
Well Contractor Name FROM TO DESCRIPTION
3568A 75 ft. 90 ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Gpm pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 80 ft. 2 pr200 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
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:6l7.SCREEN
ppy FROM lt) DI:AAIE FER SLOT SIZE IIIICKNESS MATERIAL
Agricultural �Municipal/Public 80 ft. 90 ft. 1.25 ill' 0.010 40 pvc
[Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial ()Residential Water Supply(shared) 18.GROUT
Irrigation FROM ro NI:crERl,tl. e�IPL:�cF:MENi MH:THOD .-s.�lorN I
Non-Water Supply Well: 0 ft. 25 It Benseal pourd 175 Ibs
Monitoring [Recovery I
ft. R.
Injection Well: it ft
[Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
[AquiferStorageandRecovery [Salinity Barrier FROM TO MATERIAL. EM I'LACEMENI METHOD
0 Aquifer Test [Stormwater Drainage 80 ft. 90 ft• concrete sand poured
[Experimental Technology [Subsidence Control ft. ft.
()Geothermal(Closed Loop) [Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM 10 DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
OGeothermal(Heating/Cooling Return) [Other(explain under#21 Remarks) 0 ft. 2 ft. tOpSO l
4.Date Well(s)Completed:7/3/2024 Well ID# 2 it 8 ft. sand
5a.Well Location: 8 rt. 18 ft. clay '-- ' Vt 1=i l)
Chris Suber 18 ft• 30 ft. fsand i'i06 1 4
Facility/Owner Name Facility ID#(if applicable) 30 ft• 75 ft. clay 2024
119 Ranch Drive Elizabeth City 27909 75 ft. 90 ft. sand fir : ,
lKli
Physical Address,City,and Zip ft. ft. L i
Pasqutank 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) , e tificati
36 17 10.6 N 76 15 01 .0 W
4/2024
6.Is(are)the well(s)Ox Permanent or []/I cntporary Signature o C 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 XONo 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 construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#11 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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 90 (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: 17 (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 7/5 (in.) 24b.For Injection 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) 30 Method of test: pump 24c.For Water Supply& Injection 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.
Feints Mkt-I North Carolina Department of Environmental Oualitv-Division of Water Resources Revised 2-22-2016