GW1--00261_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 FRO.�l TO DESCRIPTION
3568A 57 ft. 70 ft.
ft. ft.
NC Well Contractor Certification Number IS.OUTER CASING(for multi-cased wells)OR LINER(Hap Beetle)
GPMPumps & Irrigation FROM TO DIAVFFER THICKNESS NEvE RIA1.
0 ft. 70 ft. 2 40 pvc
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAJIET ER 1 HICKNESS MA I ERE\1.
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. n.
Water Supply Well: 17.SCREEN
1 RO,I TO DI',METER SLOT SIZE THICKNESS MA FERKsL
Agricultural ()Municipal/Public 60 ft. 70 ft. 1.25 in. 3.010 40 pvc
Geothermal(Heating/Cooling Supply) ()Residential Water Supply(single) ft. ft. in.
Industrial/Commercial ()Residential Water Supply(shared) 13.GROUT
x Irrigation FROM TO NIA-1ERIAL EMPLACEMENT AtETt1OD&.AJIOLNI
Non-Water Supply Well: 0 ft. 25 ft. benseal poured/tapped
Monitoring ORecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ()Groundwater Remediation
19.SAND/GIL-WEL PACK(if applies ilc)
Aquifer Storage and Recovery ()Salinity Barrier FROJI ro MATER!AI. EJ1T'LACE:AIEN1 >IE:THOD
Aquifer Test ()StormwaterDrainage 57 ft. 70 ft. filpro 2 poured
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) ()Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROSt TO DESCRIPTION(color.hardness,soil/rock Icpe,grain size.etc.)_.
Geothermal(Heating/Cooling Return) ()Other(explain under 021 Remarks) 0 ft. 2 ft. Topsoil
4.Date Well(s)Completed:1 0/20/2023 Well ID# 2 ft. 23 ft. sand
5a.Well Location: 23 ft. 37 ft. Clay _-
Schriefer 37 ft. 70 ft. Sand .
ft. ft. 1A f�„ t 'U24
Facility/Owner Name Facility ID#(if applicable) (j
199 Beech Point Dr Hertford 27944 ft. ft.
Physical Address,City,and Zip ft. ft. 1:F�
Perquimans 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iatllong is sufficient) 22.Certificati n:
36 0512.8 N -76 24 28.2 W
11/08/2023
6.Is(are)the well(s)Dx Permanent or ()Temporary Signature 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: Wes or ()No with 15A NCAC 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 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 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:9 (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 (in.) 24b.For Infection 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 1 lcthod of test:pump 24c.For Water Suaaly&Infection 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.
Form GW_1 North Carolina Department of Rnvironmental Onality-Division of Water Resources Revised 2-22-2016