GW1--06963_Well Construction - GW1_20231027

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr
Well Contractor Name FROM TO DESCRIPTION
48 ft. 70 ft,
3568A .ft. ft.
NC Well Contractor Certification Number ,15:OUTER'CASING.(for multt cased wells),OR-LINER(if ap licable); r,. ..
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
+1 ft, 60 ft. 2 ! in. sch40 Pvc
Company Name
'16t-INNER-CASING;OR TUBING•(geotbermal closed-loop), I ':_ '
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,Stale, Variance,etc) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: ';17..SGREEN 3 ", .? o.. .,, �.z
Munlct al/Public FROM ft. TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ip g,
-- 70 2 in. 0.010 40 Pvc
__Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
_-Industrial/Commercial DResidential Water Supply(shared) A.,1S.'GROUT "
x Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 30 ft. Benseal Poured/Pack
Monitoring ORecovery _ ft, - ft.
Injection Well: ft. ft.
Aquifer Recharge 0Groundwater Remediation
-19.SAND/GRAVEL PACK(if applicable)'.,
Aquifer Storage and Recovery DSalinity Barrier FROM i TO MATERIAL EMPLACEMENT METHOD
Aquifer Test DStorinwater Drainage 50 . ft. 70 ft. Filpro Poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) DTracer 20.DRILLING LOG,(attach additional sheets`ifnecessary)"-=- '-,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft. 2 ft. Topsoil
4.Date Well(s)Completed:9/2$/2023 Well ID# 2 ft, 7 ft, Clay
5a.Well Location: 7 ft. 35 ft• Sand
St Ann Catholic Church 35 ft•• 50 ' •ft• -clay ' • . - , L: n: 'V 'v
Facility/Owner Name • FacilitylD#(ifapplicable) 50 ft.• 70 ft' Sand/Shell OCT 2 7 2023
207•N Broad St Edenton 27932
Physical Address,City,and Zip ft. _ ft. s ,,_•,•:a P..•: „'zng 4.,!51:1
Ir.,a•r
Chowan .21.,REMARKS <, IC : '''•.« ", ^
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.C teat n•
36 03 45.1 N -76 36 30.3 w 10/20/23
6.Is(are)the well(s) Permanent or fiTemporary Signa re of 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 DiNo - with 15A NCAC 02C..0100 or ISA 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-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: 70 (ft) 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 level below top of casing:1 0 (ft.) 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 7/5 in (in.) ' 24b.For Iniection Wells: In addition to sending the form to the address in 24a
rotO above, also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry 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) 30 Method of test: pump '24c. For Water Supply&Iniectil n 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 to the county health department of the county
where constructed.
Fnrn,rw-1 Unrrh f�rnlinn Tlrnarrmnnt nF Gn,irnnn,Pnr�l!l„�I:w-Tli.d,,;,,,of Worn.A>en,,...-� De..:..e,1 0 00 ont