GW1-2022-06669_Well Construction - GW1_20220708

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr l'4}waTER-z(SNS¢?, .£�,y „ �J14 'ai .• ,
Well Contractor Name FROM TO DESCRIPTION
3568A 80 ft- 100 ft•
ft. ft.
NC Well Contractor Certification Number '"&OUTEXCASING forrinuld cis it �ellt°ORTT7NERi ifa'►i ble '
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 fr 90 ft. 1 2.0 In Pr2OO PVC
Company Name
„1`6 INNE12 CA51NG b12 TUBINGt' 6,11 rrialelosed',l'o'rf ", „ .,. z
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): tt. ft. in.
Water Supply Well 17.,SCCFT a". <e, €,t .;'0 �i.V .*.� .�. ,43 �w
FROM I TO I DIAMETER I SLOT SIZE I THICKNESS MATERIAL
Agricultural [3Municipal/Public 90 ft. 100 ft' 2.0 ins 0.010 Sch40 Pvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) tt ft. W
Industrial/Commercial Residential Water Supply(shared) 18:-GROI3T s,-
X Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: O ft• 35 ft• Hole Plug poured
_Monitoring 13Recovery
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
=�19,k$ANI)1GR:A��LL`��GK:.
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test []Stormwater Drainage 80 ft• 100 ft• concrete sand poured
Experimental Technology 13Subsidence Control
Geothermal(Closed Loop) Tracer 24.'DRILLINGL"OG.attailiadd,tionat'she'eis'if-necessa.` .°
FROM TO DESCRIPTION color,hardness,soil/rock type, rain size,etc.
B Geothermal(Heating/Cooling Return) ;Other(explain under#21 Remarks)
0 ft- 2 ft- Topsoil
4.Date Well(s)Completed:6/21/2022 well ID# 2 ft• 42 ft- Sand
5a.Well Location: 42 ft. 75 ft- Clay
Gina Gillikin 75 ft- 80 ft- Sand r{
Facility/Owner Name Facility ID#(if applicable) 80 ft• 100 ft- Shell/Sand
1367 US HWY 17 South Elizabeth City 27909 tt. tt. JOE
Physical Address,City,and Zip ft. ft. � Pri`.,&emg fAl
Pasguotank21:R1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) �22. lficatioj�: �
3615 39.4 N -76 18 01 .7 W 7/5/2022
6.Is(are)the well(s) 'Permanent'. or Temporary lfkafore of Cert' e I 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: [3Yes or E)No 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 N21 remarks section or on the hack 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 OW-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: 100 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths;(different(example-3@200'and 2@a 100') construction to the following:
10.Static water level below top of casing: 10 (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 Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 20 Method of test: pump 24c. For Water Supply&Infection 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: 16 oz completion of well construction to the county health department of the county
where constructed.