GW1-2021-00364_Well Construction - GW1_20210315

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher
FROM TO DESCRIPTION
Well Contractor Name
20 rt. 30 rt.
3568A
NC Well Contractor Certification Number f •_
-- 5.OUTERGAS1N�b fd"e„multt�e'd���OR1NE12 if li�Ute. ...
Gpm Pumps 8c Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 u• 20 tt• i.2' Sch 40 PVC
Company Name
16 ><' Tt�Gifi511�CORRT1VGs 1�'i,mello" d=3o5
2.Well Construction Permit#: FROM I TO DIAMETER I 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: FROM RE I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural . ❑Municipal/Public 20 ft' 30 ft' 1.25 "' 0.010 Sch40 Pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 20 it. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18GR0tiT
InIrrl ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 tt• 20 ft. Hole plug Poured 200 Ibs
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
• �I�:SA'1VD%�It����R1P,i1`�" lika licab�:
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 20 tt• 30 tt. Filpro Poured
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20RI17LING Q aIchadBill oniil s6i9°afai
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
0 ft. 3 ft. Topsoil
4.Date Well(s)Completed: 23 Feb 2021 Well ID# 3 It- 30 ft- Sand
Sa.Well Location:
Matt Neal
n. ft. �-
Facility/Owner Name Facility ID#(if applicable) RECEIVED
211 Ocean Blvd, Kitty Hawk NC 27949
Physical Address,City,and Zip ft. ft.
MAK
Dare 21REIVI�R`fZS
1r:#clina Ion Pro, a t
County Parcel Identification No.(PIN) i
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cer'
36 07 48.4 N 075 43 41.3 W 2/23/2021
6.Is(are)the well(s): nPermanent or ❑Temporary ignature o ertifi Well CoNractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or nNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the 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 construction info
construction,only 1 GW=1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths i(dierent(example-3@200'and 2@100')
10.Static water level below top of casing: 3 (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
if water level is above casing,use"+"
11.Borehole diameter: 5 7/8 (in.) 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Rotory
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
p Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 40 Method of test: Pump -
13b.Disinfection type: hth Amount: 8oZ
Fnrm rw-1 - Nnrth Csrnlinn Denartment of Environmental Ouality-Division of Water Resources Revised 6-6-2018