GW1-2021-02720_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 4CWATER>zONEs
Well Contractor Name FROM TO DESCRIPTION
3568A 75 ft• 95 ft Sand
ft. ft.
NC Well Contractor Certification Number 1'S;'OUTER CASING'fo�'multr cased viells'OR`3 INER if ii"livable
GPMPumps & Irrigation FROM TO DIAMETER THICKNESS MATERIAL
0 fG 85 ft 2 m Pr 200 JPVC
Company Name
"I6JNNMCASING:OR'.TUBING'`eothermal'closed-loo" r,_.
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. b7C,County,State,Variance,etc) ft• ft. in.
3.Well Use(check well use): ft' ft' in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
Agricultural ®Municipal/Public 85 ft. 95 fL 1.25 i1 0.010 SCh 40 JPVC
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared)
18:_GROUT _ I~.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 60 ft Hole;Plug Poured 300 pds
Monitoring 13Recovery ft. ft.
Injection Well:
Aquifer Recharge E3Groundwater Remediation
YJ9.�SAND/GRAVEL,iP.AGK4 if i""liciible
Aquifer Storage and Recovery [3Sallnity Barrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage 60 ft• 95 ft• filpro, poured
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILL,ING'-LOG;At&''sadditiunal A&fiii f necessa" 4
Geothermal(Heating/Cooling Return) E3Other(explain under#21 Remarks) I
FROM TO DESCRIPTION color,hardness,soilfrock tyM grain sae,eta
0 ft- 2 ft• Topsoil
4.Date Well(s)Completed:7/22/2021 Well ID# 2 It- 9 ft' Clay
5a.Well Location: 9 ft 30 ft Sand
Terry Lord 30 ft• 75 ft• Clay 1�
Facility/Owner Name Facility ID#(if applicable) 75 ft• 95 ft' Sand {r
310 Kingswood Blvd Elizabeyh City 27909 ft. M �9
Physical Address,City,and Zip
Pasqutank
11 REMARKS
County Parcel Identification No.(PIN) Q(
5b.Latitude and longitude in degrees/minutes/seconds or decimal d rees:
(ifwell field,one lat/long is sufficient) 22 Certification'
36 14 37.0 N 076 15 42.6 W ! 7/26/2021
6.Is(are)the well(s)oPermanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cerry�that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or R]No with I5A NCAC 02C.0100 or 15A NCAC 02C.0100 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#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 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: 95 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing:$ (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/$ (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;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)40 Method of test:Pumped 24c.For Water SuDDIv& Iniec`tion 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: 12 OZ completion of well construction `to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016