GW1-2022-03537_Well Construction - GW1_20220324

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr '14.WATER ZONES_
Well Contractor Name FROM I TO DESCRIPTION
3568A 20 ft- 26 ft Sand
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING'foF multPeas' *ells)OR LINER'if a' licah7e
Gpm Pumps & Irrigation Inc FROM TO DIAMETER 1HICIQVESS MATERLIL
Company Name 21 ft 26 ft• 1.25 j i" 40 pvc
16.INNER CASING OR TUBING "eothermal closed-loop)p
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) ft. ft. in.
i
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOIT SUE THICKNESS MATERIAL
Agricultural 13Municipal/Public 21 ft. 26 ft. 1.25 1"' 0.010 40 pvc
71!Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in.
Industrial/Commercial 13Residential Water Supply(shared) 18.GROUT
X Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt. 21 ft hole plug poured
'Monitoring Oi Recovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge E3Groundwater Remediation
.19.SAND/GRAVEI;�P.AGK€tf a"lieelile '
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13 Stormwater Drainage 21 ft- 26 ft. Filpro poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if:neceskibt'
FROM TO DESCRIPTION color,hardness,soil/rack e, rain size,etc.
I Geothermal(Heating/Cooling Return) �Other(explain under#21 Remarks)
3/17/2022 0 ft' 2 ft• topsoil
4.Date Well(s)Completed: Well ID# 2 ft 7 ft clay i
5a.Well Location: 7 ft. 26 ft. sand!yellow
Mark Dickerson ft. ft.
Facility/Owner Name Facility 9D#(if applicable) ft. ft. s
109 Survey Rd Moyock 27958 ft. ft. M
Physical Address,City,and Zip ft. ft
Currituck 21.REMARKS ! ",
County Parcel Identification No.(PN t t rur >
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertifica
36 30 28.9 N -76 09 33.9 W /21/2022
I
6.Is(are)the well(s)oPermanent or Temporary Signature ofCerIffraWell 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 ONo with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
Ifthis is a repair,fill out known well construction information and explain the nature oflhe 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 I
9.Total well depth below land surface: 26 (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 1@100� construction to the following:
10.Static water level below top of casing:5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diamet er:5 7/$ m.
11 ( ) 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
13a.Yield(gpm)40 Method of test:pump 24c.For Water Supply&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: 12oZ 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