GW1-2022-07130_Well Construction - GW1_20220804

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,Print Form�_._�
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name
60 ft. 70 it. i
3568A
NC Well Contractor Certification Number 15.,OUTER CASING'(Or criscil'wels OR LINER'if a' lfcable
Gpm Pumps& Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft• 60 ft• 1.25 ln' sch 40 PVC
Company Name
16.INNER CASING OR TUBING(eother mal closed-lot
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): t't. ft. in.
17.SCREEN a"
Water Supply Well: ,
FROM TO DIAMETER SLOT SIZE THICKNESS hATERIAL
Agricultural Municipal/Public 60 ft, 70 ft. 1.25 1°' 0.010 sch 40 pvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft.
Industrial/Coniniercial OResidential Water Supply(shared) 18.GROUT
kri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20 ft. hole plug poured 150 Ibs
Monitoring DRecovery
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAN;ELIPACK if a 'licable
Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENT dIETHOD
Aquifer Test OStormwater Drainage 60 ft. 70 ft- concrete sand poured
Experimental Technology E3 Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20 DRILLING LOG(attach additional sheets'If necess—
Geothermal(Heating/Cooling Return) '__i Other(explain under#21 Remarks) FROM To DESCRIPTION(color,hardness,sollfrock type,grain size,etc.)
0 ft. 2 ft. Topsoil , R.
r— 2 ,t
ft. rt. "
4.Date Well 7/21/2022 s)Completed: Well]D# 2 4 clay
Sa.Well Location:
e ft. 39 ft. Sand AUG 0' - 2022
Cenida 39 ft. 48 ft, Sand/shell Rr1_;=C41=g
Facility/Owner Name Facility ID#(if applicable) 48 ft' Ba ft. clay {]ViQ190G
122 Gables Place Moyock 27958 60 ft 70 ft Sand
Physical Address,City,and Zip
Currituck REIMARKse
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) 22.Certifica' 1: 1
36 29 59.3 N 076 07 54.4 W
31/2022
6.Is(are)the well(s) Permanent or Temporary Signature of Certified Well Contactor Date
By signing this form,I herebv certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or_E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Nell Consrnrctimt Standards and that a
Ifthis is a repair,Jill 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 forur.
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 GWA 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: 70 (ft.) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdiJjerent(example-3@200'mid 2@100') construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
tfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
5 7/8"
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
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.) J
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 Suauly&Iniection!Wells: In addition to sending the form to
the address(es) above, also submit due copy of this form within 30 days of
13b.Disinfection type: hth Amount: 6 oz completion of well construction tot the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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