GW1-2022-09407_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr 114 ATzEIVZONES
Well Contractor Name FROM TO DESCRIPTION
3568A 45 fr. 60 fr.
ft. ft.
f
NC Well Contractor Certification Number15.OtJ:TER.CASINGa fur muld�ca'sed wells":ORiis]NER ifi 'li"cUle'
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. 50 ft- 2 in. sch40 pve
6�1VNERtCAS11 Ge, tIBIP1G1 the m Milo „liio ;,�
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List a//applicable well construction permits(i.e.UIC,County,State, iaariance,etc) ft. ft. in,
3.Well Use(check well use): ft. ft. in.
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 50 ft- 60 ft- 1.25 in•� 0.010 40 pvc
Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) ft. ft. in•
Industrial/Commercial Residential Water Supply(shared)
t8;GltUtiT,
X Irrl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 40 ft hole plug poured 2501b
Monitoring DRecovery tr. ft.
Injection Well:
ft ft.
Aquifer Recharge Groundwater Remediation
Aquifer Storage and Recover '))t9ySA.ND7GRA;E P�iCK-rifp—pIii tite
q g y OSalinityBarrier FROM TO MATERIA L EMPLACEMENT METHOD
Aquifer Test E)Stormwater Drainage 40 ft- 60 ft- concrete sand poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 320:;ARILLItVG'tOG, attach""addtdonal heets,ifineb�ssa" £,�, .
FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc.
_ Geothermal(Heating/Cooling Return) ClOther(explain under#21 Remarks) ft. ft.
0 2 topsoil t— --.
4.Date Well(s)Completed:08/30/2022 well ID# 2 ft- g ft. clay ' . v G 1,f'a'z
5a.Well Location: 8 ft- 40 ft. sand.' OCT 10 -
Phil Shulto 40 ft- 45 ft- clay
Facility/Owner Name Facility ID#(if applicable) 45 60 sand shell ,,-,,,-•=•.
104 Yeoman Creek Dr Hertford 27944 it. ft. • ;'t'.0 ,
Physical Address,City,and Zip
ft. ft.
Perquimans
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Cer Ieation:
36 05 30 N 7624 44.0 W
10/2/2022
6.Is(are)the well(s) x,Permanent or Temporary Signature ofterdfied Well Contractor Date
��!1 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 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 ofthe 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may alsoattach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS:
9.Total well depth below land surface: 60 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ereni(example-3@200'and 2 a 100') construction to the following:
10.Static water level below top of casing: 1 1 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
rot0ry above, also submit one copy of this'form within 30 days of completion of well
12.Well construction method: construction to the following: j
(i.e.auger,rotary,cable,direct push,etc.)
i
Division of Water Resources,Underground Injection Control Program,
L13a.
ATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
ld(gpm) 25Method of test: pump 24c. For Water Sunviv&Iniecdon Wells: In addition to sending the form to
the addresses) above, also submit!one copy of this form within 30 days of
sinfection type: hth Amount: 8oz completion of well construction to the county health department of the county
where constructed.
i
Fnnn hW-I North Carolina Denartment of F.nvimnmental nnality-I)ivisinn of Water ResnnrceA Revised 2-22-2016