GW1-2021-05910_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr14:}YAE&7o>9 �
Well Contractor Name FROM TO DESCRIPTION
3568A 25 ft• 35 ft•
ft ft '
NC Well Contractor Certification Number
VA5''OUTER CASING,fur.'innlh cC>iseda'well x,OR G'... lieable
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft 25 ft. 2 1O PR200 PVC
363536 '�iis:�•1NNER;CASIZS'i�01tSTNG<
2.Well Construction Permit#: FROM 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.
N 17.SCREEN"«i�ii:i v�c I P a ,.0
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic 25 ft. 35 ft. 1.25 in. 0.010 SCh40 PVC
Geothermal(Heating/Cooling Supply) xi Residential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared) F I8.;GROUTu�'.
lrrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 «• 25 ft• DF Grout Pumped
Monitoring DRecovery ft. ft.
Injection Well:
ft ft.
Aquifer Recharge DGroundwater Remediation
Ji
19 SA1VD/GRAYE1ACif"f3a1c81ile '� .. a. ,e,
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)StormwaterDrainage 25 ft• 35 ft• Filpro Poured
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer "120:"DRIL`)sING10"G ilactiddrhairL'si,eets;if:nece�sa
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) 0 ft. 2 ft. Topsoil
4.Date Well(s)Completed: 1 O/2O/2021 Well ID# 2 ft- 8 ft. Clay
5a.Well Location: 8 ft. 21 ft• Sand
Janessa Lockwood 21 ft• 35 ft• shell
Facility/Owner Name Facility ID#(if applicable) ft. ft.
146 White Horse Dr Shawboro NC 27973 ft. ft.
Physical Address,City,and Zip
ft. ft. 5
Currituck
County Parcel Identification No.(PIN)
tbn Proce .�
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: D
(if well field,one lat/long is sufficient) 2.'& tifica on:
36 22 26.0 N -76 06 35.4 W
10/20/2021
6.Is(are)the well(s) Permanent or Temporary Signature 3f C rtified 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: E3Yes or JqNo with 15A NCAC 02C.0/00 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#2l 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: 35 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiflerent(example-3Ca 200'and 2@a 100') construction to the following:
10.Static water level below top of casing:8 (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 Infection Wells: In addition to sending the form to the address in 24a
rotory 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 C inter,Raleigh,NC 27699-1636
13a.Yield(gpm) 35 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: huh Amount: 320Z completion of well construction to,the county health department of the county
where constructed.
North Carolina Department of Environmental Oualitv-Division of Water Resources Revised 2-22-2016