GW1-2023-01770_Well Construction - GW1_20230223

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul, Lacher Sr
FROM TO I DESCRIPTION
Well Contractor Name 40 50
3568A
NC Well Contractor Certification Number 1,15.,OUTER CASING:(for in ul .OR-LINER ifiaviilka blel
G p m Pumps & Irrigation Inc FROM I TO DIAMETER THICKNESS MATERIAL
Company Name 0 ft. J 40 ft' 4 in. SDR26 PVC
�16.",MM,CASIN11 GDT,TUBING(i6thermal,closed-too
0
2.Well Construction Permit#:381648 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): ft. ft. in.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
_ Agricultural
�"A tur.1 DMunicipal/Public 40 ft- 50 1" 2 in' 0.010 SCH 40 PVC
NGeothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.,
Industrial/Commercial DResidential Water Supply(shared)
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water
Supply Well: 0 30 Hole Plug Poured
_I Monitoring EIRecovery
Injection Well:
Aquifer Recharge OGroundwater Remediation
PACK ffappliiable),",'�
Aquifer Storage and Recovery DSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test OStorinwater Drainage 30 ft- 50 ft- Filpro#2 poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) OTracer ,,20.­DRILLI GXOG(atfich
Geothermal(Heating/Cooling Return) :Other(explain under#21 Remarks) I FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 ft- 2 ft- Topsoil
4.Date Well(s)Completed:1 1/10/2022 Well ID# 2 ft- 17 ft. ay
5a.Well Location: 17 ft- 50 ft' Sand C 0 k In
Bryon Morris ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft. FEB 2 S 2023'
132 Long Branch Court Hertford 27944 Pra1w%,T..0 UM
Physical Address,City,and Zip ft. ft.
Perquimans 1`21"REMARKS,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) rtiricati
36 08 33.9 N -76 18 37.4 W ��5� 1 10/15/22
6.Is(are)the well(s)oPe.rmanent or OTemporary Signature of rtifie ell 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 ivell: DYis or [KDNo with 15YI ArCAC 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#21 remarks section or on the back ofthisfirm. 23.Site diagram or additional well details:
having the same 8.For Geoprobe/DPT or Closed-Loop Geothermal Wells"
You may use the back of this page to provide additional well site details or well
- I
construction,only I GWA is needed. Indicate TOTAL NUMBER ofwells construction details. You may also,attach additional pages ifnecessary.
drilled: SUBMITTAL INSTRUCTIONS:
9.Total well depth below land surface: 50
A) '24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths it different(example-3@200'and 2@100') construction to the following:
7
10.Static water level below top of casing: 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: 8 (in.) 24b.For Infection Wells: In addliti6n to sending the form to the address in 24a
rotary above, also submit one copy of th.is,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 C eii ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 60 Method of test:air 24c.For Water Supply&Ineect!o I
Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Hth Amount: 64oz completion'of well construction to the county health department of the county
where constructed.
F.—r:w-1 Nnrth Carolina Denartment of Environmental Oualitv-Division of Water Resources Revised 2-22-2016