GW1-2022-10384_Well Construction - GW1_20221115

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well ContractorInf rm i n•o at o .
Paul A Lacher Sr 14:wATER'zONE8
FROM TO DESCRIPTION
Well Contractor Name 3568A 20 ft. 30 ft.
ft. ft.
NC Well Contractor Certification Number 15 OUTER.CASING=for multi-cased wells OR LINER-if:u" licable
Gp m Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 25 rt. 2 '° Sch 40 pvc
Company Name I6,INNER'CASING OR;TIJBING, eothermal'elased too < I'
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) in.
3.Well Use(check well use): ft. ft. in.
17r.SCREENs'
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Municipal/Public 25 ft• 30 ft- 1.25 in. 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
Industrial/Commercial Residential Water Supply(shared)
X Irrl atlon FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rt• 25 rt• Hole Plug Poured
Monitoring Recovery
Injection Well:
Aquifer Recharge DGroundwater Remediation —
19:SANDIGRAYEL=PACK;'if a "'licable
E„
Aquifer Storage and Recovery E3Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage 25 ft- 30 ft- Filpro 2 Poured
Experimental Technology �,,,�,,,�Subsidence Control
Geothermal(Closed Loop) DTracer 20:DRILLING'LOG;attach'additionalslneets ifnecessa
FROM TO DESCRIPTION color,hardness,soil/rock e, rain size,etc.
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) 0 ft- 2 ft- Topsoil
4.Date Well(s)Completed:10/06/2022 well ID# 2 ft. 6 ft, Clay
5a.Well Location: 6 ft, 27 ft' Yellow Sand
Steven McDyer 27 ft- 30 ft- Gray Sand
Facility/Owner Name Facility ID#(ifapplicable)
214 Campus Dr Moyock NC 27958
a.
Physical Address,City,and Zip ft. ft.
Currltuck �;
1
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: intor iWian ProczWng I l6h
(ifwell field,one latllong is sufficient) 22.Cer cation•
36 30 56.8 N -76 08 8.0 W 11/6/2022
6.Is(are)the well(s)ox Permanent or OTemporary Si ature of Ce e l 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: []Yes or [9No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,full out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 921 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 also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@/00') construction to the following:
10.Static water level below top of casing:5 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 Iniection 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) 60 Method of test: pump 24c.For Water Supply&Iniection 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: S OZ 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