GW1-2022-06424_Well Construction - GW1_20220706

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
i
Paul Lacher Sr 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3568A 68 ft_ 80 ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased{wells OR LINER'If a Ifcable
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 70 rt 1.25 � SCh40 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
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.
3.Well Use(check well use): ft• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural 13Municipal/Public 70 ft. 80 ft' 1.25 im 0.010 SC Pvc
Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft. ft. in]
:)Industrial/commercial EIResidential Water Supply(shared) '
18.GROUT
x Irrigation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 30 ft- Hole Plug poured
Monitoring Dj Recovery ft. ft.
Injection Well: ft
Aquifer Recharge Groundwater Remediation
19'SAND/GRAVEI:PACK'if a (feeble
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage 65 It. 80 ft- concrete sand poured
Experimental Technology OI Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG'attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks) I
FROM TO DESCRIPTION(color,hardness,soiVrock e,gmin size,etc.
0 ft. 2 ft. Topsoil
4.Date Well(s)Completed:5/23/2022 Well ID# 2 ft. 6 ft. Clay .�
5a.Well Location: 6 ft 38 ft• Sand
-
Michell Barrows 38 ft- 68 ft- Clay i
2022
Facility/Owner Name Facility ID#(if applicable) 68 ft. 80 ft- Sand/shell
100 Preserve Court Moyock 27958 ft. ft. InforrAaVon Pr.�ft uI
ft
Physical Address,City,and Zip
ft. ft.
Currltuck 121.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if'well field,one lattlong is sufficient) 2.Cc6ation:
362702.3 N -760447.5W
6/28/2022
6.Is(are)the well(s)oPermanent or Oj Temporary gatuon ctor 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: []Yes or EJNo 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 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: 80 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following: i
10.Static water level below top of casing:5 (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
RotO above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry
.e.auger,rot construction to the following:
('r ,g rotary,cable,direct push,etc.)
Division of Water Resources„Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service tenter,Raleigh,NC 27699-1636
13a.Yield(gpm)40 Method of test:pump 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also subdiit:one copy of this form within 30 days of
13b.Disinfection type: HTH Amount; 16 oz completion of well construction to the county health department of the county
where constructed. `
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resource Is Revised 2-22-2016