GW1--00262_Well Construction - GW1_20240105

I
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher Sr 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
3568A 30 ft. 40 ft•
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
GPMPumps & Irrigation „ROMDIASIF;I I) _ „ICK.NESS MSTE1tIA1.
0 ft. 40 ft. 2 40 pvc
Company Name
lb.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: t ltl)>1 to DiASlETFR "r HICK NESS - SI.-vFERI-u.
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: l7.SCREEN
I host TO DIASIEI FR "-SLOT SIZE THICKNESS VISTERI.-SI.
Agricultural
7s. ft• 40 ft 1.25 'IL0.010 40 pvc
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) rt. rt. in.Industrial/Commercial Residential Water Supply(shared) ttt�t;t
Irrigation Item ro �I:�reRIII. - e.�IrL:�cenleNTMETIIoD& sstou.N"r
Non-Water Supply Well: 0 It. 30 ft. benseal poured/tapped
°Monitoring pRecovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge oGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Et Aquifer Storage and Recovery oSalinity Barrier mom To MATERIAL EMPLACEMENT METHOD
[Aquifer Test QStormwaterDrainage 30 ft. 40 ft• filpro 2 poured
Experimental Technology OSubsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soil/rock t}pe,grain size.etc.)
©Geothermal(Heating/Cooling Return) nOther(explain under#21 Remarks)
0 ft. 2 ft. Topsoil
4.Date Well(s)Completed:1 0/20/2023 Well ID# 2 rt. 7 ft. Clay
5a.Well Location: tt. 40 ft. Sand F•, t
Patel ft. ft. _ • (-,.L i/ r
Facility/Owner Name Facility ID#(if applicable) ft. ft. - 1,'Y 0 J 2024
150 Pelican Pointe Elizabeth City 27909 It. ft.
Physical Address,City,and Zip ft. ft. OtSi
Pasqutank _'_I.REMARKS _
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/loug is sufficient) 22.Certifte •
36 165 18.4 N -76 11 03.2 W
11/08/2023
6.Is(are)the well(s)WIx Permanent or DTenlpor ary Signature o tfied Well Contractor Date
�-�1 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: [J Yes or QNo 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 G W-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SIIIIMITTAL INSTRUCTIONS
9.Total well depth below land surface: 40 (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',nu/2@l00') construction to the following:
10.Static water level below top of casing:7 (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) 60 Method of test: pump 21e. 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 to the county health department of the county
where constructed.
P,,r...(W-1 North Carolina Ilenartment of Fnvirnnmental Duality-Division of Water Resources Revised 2-22-2016