GW1-2021-05909_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD (GW-1) For Intemal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr I4'-WAfiTERZpN s,l,' s,Q, _ .. .
Well Contractor Name FROM TO DESCRIPTION
3568A 50 ft. 60 ft.
ft. ft.
NC Well Contractor Certification Number url5 OUTER;CASING,fo%multi xa'sed Hells -OR'LINER if li""lira"'ble P
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 50 ft. 4 in- SDR 26 PVC
Company Name 016'31NNER"GA SING,ORkT1M1NG_eotlteittialilo ed lao%; i�r,..r e „«
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.i/IC,County,,rate, Mariance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
�'I7i;SQREEN,„,,, ,,, s. r. ..:. .... ....c ,,. �.
Water Supply Well: �'" "
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural []Municipal/Public 50 ft. 60 ft' 2.0 in' 0.010 sch40 PVC
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
_h r
X;Irri ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 35 ft. Hole Plug Poured
Monitoring 13Recovery
Injection Well:
Aquifer Recharge 13Groundwater Remediation
I9.$0D/QRAV%,VPAC-J if a 'liesble
Aquifer Storage and Recovery Osalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 35 ft• 60 ft• Concrete Sand Poured
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRIliDING 1 OG:attach'additionlheefs if'riecessa s �;„
FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM
rt- 2 ft- Topsoil
4.Date Well(s)Completed:10/08/2021 well ID# 2 ft. 5 ft, Clay
5a.Well Location: 5 ft- 41 ft, Sand,
Gary Hart 41 ft. 60 ft. Course Sand
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
147 Sanderson Court Moyock NC 27958
Physical Address,City,and Zip ft. ft. SIn9 Un
Currituck
=11.REMARKS.
County Parcel Identification No.(PIN) D
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifiicatio .
36 28 21 N -76 01 42
2021
6.Is(are)the well(s) Permanent or Temporary Signature ofCert ed Well Contractor Date
x
By signing this form,I hereby certify that the well(.e)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes 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 k21 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-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: 60 (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if diJjerwu(example-3@200'and 1@100') construction t0 the following:
10.Static water level below top of casing:7 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 Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 30 Method of test: pump 24c.For Water SUDDIV&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: 16oz completion of well construction to the county health department of the county
where constructed.
(`n Iina r)eoor nt of Fnuir nmPntn1 rinality-r)ivi6nn of Water Resources Revised 2-22-2016