GW1-2023-01768_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 44"
Well Contractor Name FROM TO I.DESCRIPTION
3568A 45 ft- 65 ft. heavy Shell
11
ft. ft. i
NC Well Contractor Certification Number OUTER-CASING(fo r Hs,,FO�ffLM�E iMa e
FROM 0 M6�
Gpm Pumps & Irrigation Inc E1_1_M ET-1 THICKNESS
NES9
Company Name U ft. 150 ft. 4 in' I SDR 26 PVC
2.Well Construction Permit#: FROM TO DIAMETERI THICKNESS J MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. lin.
3.Well Use(check well use): ft. ft. :in.
Water Supply Well:
FROM TO DIAMETER! SLOT SIZE THICKNESS MATERIAL
Agricultural nMunicipaYPublic 50 ft- 65 f" 2 in.. 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) E]Residential Water Supply(single) ft. ft. in:"
Industrial,/Commercial [DResidential Water Supply(shared) I. ,
GROUT"'11
X,I ri igtip FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 30 ft Benseal Poured
LiMon-itorin. DRecovery—.
Injection Well:
Aquifer fer Recharge Groundwater Rcmediation 19:SAND/GRAVEL PACK if applicablef
DAquifer Storage and Recovery [3Salinity Barrier FROM TO MATERIAL EMPLACEMENT,I I METHOD
Aquifer Test. OSt6rmwater Drainage 50' ft- '65 ft- Concrete Sand poured
Experimental Technology Subsidence Control ft. ft.
HGeothermal(Closed Loop) OTracer 120:,DRILLI G",LOG'(attAclf-hddit!6nils'ht6ts,if
Geothermal(Heating/Coo(ing Return) MOther(explain under#21 Remarks) FROM TO DESCRIPTION color,hardness,soiltrock type,grain size,etc.)
0 ft. 2 ft- Topsoil
4.Date Well(s)Completed:02/131/2023 Well ID# 2 ft- 6 ft. t
ay L77 1"1 ;F;—M
5a.Well Location: 6 ft. 25 ft-. sand i6—
'
K&L Farms 25 ft- '45 ft- shell i FEB 2 S3 2023
Facility/Owner Name Facility IDU(if applicable) 45 ft- 65 f` Heavy Shell and sand
987 Gherry,Glade Rd Elizabeth City 27909
Physical Address,City,and Zip ft.
Pasqutank
0�
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient)
3616 59.9 -76 22 47.0
N W
1 2/15/2023
6.Is(are)the well(s)oPermanent or 13Temporary Signature o iLied IContractor Date
- By signing this form,I hereby certify that the wells)was(were)constructed in accordance
7.Is this a repair to an existing well: E]Yes or [9No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill on[known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair wider#21 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 having0 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: 65
A) 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:
10.Static water water level below top of casing: Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+ 1617 Mail Service Cetiter,Raleigh,NC 27699-1617
,11.Borehole diameter: 8 (in.) 24b.For Inicetion Wells: Ir ;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 i enter,Raleigh,NC27699-1636
13a.Yield(gpm) 115 Method of test:pump 24c.For Water Supply k ln*ec io I ells: In addition to sending the form to
the address(es) above, also subini I it lone copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 32oz completion of well construction to the county health department of the county
where constructed.