GW1--06961_Well Construction - GW1_20231027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr 14.WATER ZONES . ;;� . ,,, .
Well Contractor Name FROM TO DESCRIPTION
48 ft. 70 ft.
3568A ft. • ft.
NC Well Contractor Certification Number IS.OUTER•CASING'(for multi-eased
`wells)OR LINER(if np livable} „ ''^"
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
Company Name +1 ft. 60 ft. 2 in* sch40 Pvc
;MANNER CASING-ORTu)BING(geothermal dosed--loop) -,,A,
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): ft. ft. in.
Water Supply Well: I7.SCREEN"• •. „
FROM _ TO DIAMETER SLOT SIZE THICKNESS MATERIAL
O Agricultural Municipal/Public 60 ft. 70 ft. 2 in. 0.010 40 Pvc
it Geothermal(Heating/Cooling Supply) Ell Residential Water Supply(single) ft. ft. in.
ilndustrial/Commercial OResidential Water Supply(shared) 78.GROUT.
X;[Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 25 ft• Benseal Poured/Pack
(Monitoring ��..Recovery .ft. ft.
Injection Well: "
ft. I ft.
NI Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL•PACK.(if applicable) ., _
jrIAquifer Storage and Recovery C3Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
*Aquifer Test DStormwater Drainage 50 ft. 70 ft• Fllpro Poured
11 Experimental Technology DSubsidence Control ft. ft.
*Geothermal(Closed Loop) DTracer 20.DRILLING LOG(attach additional sheets if necessary)-::. :<.:
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) mother(explain under#21 Remarks) 0 ft. 2 ft. Topsoil
4.Date Well(s)Completed:9/28/2023 Well ID# 2 ft. 7 ft. Clay
5a.Well Location: 7 ft. 35 ft. Sand -*, r;, <,
Russ Corker 35 ft. 50 ft. Clay . ..--. ...0 R..: V; C.: .,�;,
4
Facility/Owner Name Facility ID#(if applicable) 50 ft. 70 ft. Sand/Shell OCT(O 2 7 .7n23
115 W King St Edenton 27932 ft. ft.
1i l,vril r_.,•...1 il:•..:--3.3'.NWT', titist
Physical Address,City,and Zip ft. ft. DWC,,.r c
13
Chowan
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 2 ertification:
36 03 29,6 N -76 36 37.9 W
10/20/23
6.Is(are)the well(s)Jx Permanent or OTemporary Signature f Certified Well 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: OYes .or EiNo - - with 1SA NCAC 02C.0100 or 1SA 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 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 1 GW-1 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,forin within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: 01 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+.r 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 5 7/8 in (in.) 24b.For injection 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(gpns) 25 Method of test: pump 24c.For Water Supply&Injection 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: 16 OZ completion of well construction toi the county health department of the county
where constructed.
Pr—t:W-1 TTnrth Carolina Ilenartment of Envirnnmental Clunlity-nivicinn of Water Recnnrcec Revised 7-72-7016