GW1-2021-03145_Well Construction - GW1_20210625

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: p
1.Well Contractor Information: j
Paul Lacher k,lawATERzoNs.,a,
Well Contractor Name FROM TO DESCRIPTION
3568A 24 rt. 34 ft.
rc. rt.
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NC Well Contractor Certification Number ,WOUTE11"SINO for:;ii uhi:�FQ7—% 1 0WMNER,ifii"""licable
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 rt. 24 ft- 2 in. SCh 40 PVC
Company Name
16 llV1VER CASIt�1G`IOR rUB1Nt a therm l=clof'd=Coo i �w. >b ,.. .
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. fQ in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN ^` ..,,c € .: 1 •,_ „ .- W .
pP y FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural [)Municipal/Public 24 ft- 34 fc 1.25 '"' 0.010 40 JPVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) R. ft. ;n•
Industrial/Commercial DResidential Water Supply(shared) it 9,.'GR0T)T
X Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply\Nell: 0 ft 24 ft Hole Flug poured
Monitoring Recovery
Injection Well:
ft. rc.
Aquifer Recharge Groundwater Remediation
_ Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD__
Aquifer Test OStormwater Drainage 24 ft 34 ft mpro poured
Experimental Technology OSubsidence Control
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Geothermal(Closed Loop) Tracer 20.`DRILLING^I' Cs ta sOttact lAditi
Geothermal(Heating/Cooling Return) rJOther(explain under#21 Remarks)
FROM TO DESCRIPTION color,hardness,soillrock type,grain size,etc.
p fr. 2 it• Topsoil
4.Date Well(s)Completed-6/24/ZO21 Well ID# 2 ft- 8 ft' Clay.!
5a.Well Location: 8 ft' 35 ft' Sand
115 Eagle Lane ft. ft. an•
Facility/Owner Name Facility ID#(if applicable) ft. ft.
Jay Robinson ft. rc. Unit
Physical Address,City,and Zip ` ft rt I�JI11� 9l Cps,On
115 Eagle Lane Elizabeth City 27909
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.Certifica on:
36 19 4108 N -76 14 38.9
6/27/2021
6.ls(are)the well(s) x'.Permanent or OTemporary Signature of erti ell Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance-
7.Is this a repair to an existing well: Oyes or nNo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
Ifthis 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'-'21 remarks section or on the back of this fornh.
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 l GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: 34 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing:6 (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,'iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) 25 Method of test: pump 24c. For Water Suably& Iniection Wells: In addition to sending the form to
the address(es) above, also submit i one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form CW-h Nnrih Carolina Denartment of RnvironmentA Ouality-Division of Water Resnurces Revised 2-22-2016