GW1--00260_Well Construction - GW1_20240105

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr 14.WATER ZONES
Well Contractor Name FROM 10 DtaCltu'rum
3568A 110 ft• 135 ft
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap)licable)
GPMPumps & Irrigation FROM 10 DIAMETER THICKNESS MATERIAL
0 ft• 125 ft• 2 in. 40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER 1 IIICKNESS 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: �h.SCREEN
FROM TO DIAMETER SLOT SIZE TII ICKS ESS NI:'TL.RI:\I.
Agricultural °Municipal/Public 125 ft. 135 ft• 1.25 in' 0.010 40 pvc
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial ()Residential Water Supply(shared)
IS.GROUT
x Irrigation FROM TO MATERIAL EMPLACEMENT:METHOD&A1101..'I
Non-Water Supply Well: ' 0 ft• 40 ft• benseal poured/tapped
Monitoring °Recovery tt. ft.
Injection Well: rt. rt.
Aquifer Recharge DGroundwater Remediation --
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery ©I Salinity Barrier FROM -TO MATERIAL. TM PLACEMENT METHOD
Aquifer Test 0 Stormwater Drainage 115 ft• 135 ft• filpro 2 poured
Experimental Technology 0 Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
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:1 1/18/2023 Well m# 2 ft. 12 ft. Clay ;._ ---:.
5a.Well Location: 12 ft• 35 ft• Sand '`"t ('' -1...)
Larry Anderson 35 ft• 40 ft• Wood _ JAN 0 5 2024
Facility/Owner Name Facility ID#(if applicable) 40 ft• 57 ft. Sand Gray
302 Sandpiper Dr Hertford NC 27944 57 ft. 110 ft. cosy _ Di l'O.l.IG '
Physical Address,City,and Zip 110 ft• 135 ft. Sand
Peequimans 21,REMARKS
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.Certi . ion:
36 06 16.5 N -76 12 28.0 W
_ 12/22/2023
6.Is(are)the well(s)D Permanent or Temporary Signs of Certlhed Well Contrac or Date
By signing this form,I hereby certf that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: E)Yes or ®No with/SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,Jill 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:
S.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: 135 (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:10 (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 7/8 (ill.) 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(gpm) 30 Method of test: pump 24c.For Water Slimily&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 to the county health department of the county
where constructed.
Pnrm GW-1 North Carolina Denartment of Environmental Oualitv-Division of Water Resources Revised 2-22-2016