GW1--01336_Well Construction - GW1_20240304

1 ..
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul Lacher Sr - r4:,WATER(zONEs ., _ ... ., _ 4.. ' ,A
Well Contractor Name FROM TO DESCRIPTION
3568A 7 ft. 25 ft. 1
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING'(forl,niulti casedwells).OR'LINER(ifs ipplicable), .,., .. _..
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 20 ft. 1.25 in. 40 PVC
Company Name
"a. I
403042INNER CASING-OR TUBING'(geotliermalclosed loop). _ _ i UY % ,
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: .1.7.:SCREEN ,. .. ".' . 4 :, '4 04 .K, . �_ I .. .14l_ .k.
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
*Agricultural Municipal/Public 20 ft. 24 ft. 1.25 in' 0.010 40 Pvc
*Geothermal(Heating/Cooling Supply) *Residential Water Supply(single) ft. ft. in.
*Industrial/Commercial DResidential'Water Supply(shared)
1$'GROUT :'.;
ill Irrigation FROM TO '_ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 20, ft• Hole.Plug poured ,
*Monitoring .ERecovery ft. ft.
Injection Well: ft. • ft. '
NI Aquifer Recharge OGroundwater Remediation
.49.-SAND/GRAVEL PACK(if applicable),._•. '
*Aquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
•'Aquifer Test DStormwater Drainage 20 ft. 28 ft• filpro poured
$Experimental Technology' OSubsidence Control ft. ft.
*Geothermal(Closed Loop) OTracer r'20.,DRILLING-LOG(attach additionalisheetsifnecessary)',., A;
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
.IGeothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) 0 ft. 2 ft. Topsoil
4.Date Well(s)Completed:) •/23/2024 Well ID# 2 ft. 7 ft. Clay
5a.Well Location: 7 ft. 25 ft. " Sand . P.—., ,,,,,,,7—s, ,t,v,,.,,.
Christopher Simonds . ' 25 ft. 30 ft. Shell with clay "e s®L i i V t u
Facility/Owner Name• Facility ID#(if applicable) ft. . ft. M®R A A ,n 7d
187 C Lake Road Camden NC 27921 ft. ft. - ---. '
Physical Address,City,and Zip ft. ft. h a?r9793eArias in �.o.kf �16Bf
Camden " --
County Parcel Identification No.(PIN) 0 r4G\-)t-to 4 OU us- b L l ' pOr—t. Wu...KO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: A S N"‘ �, P CJQ� `��W V C.)0
(if well field,one lat/long is sufficient) 22.Certifi do : 11.+ r,e.a.'
36 24 38.9 N 076 16 15.2 W 2/22/2024
6.Is(are)the well(s)Ox Permanent or (Temporary Signature of Ce fied Well Contractor �� Date
By signing this form,I hereby certify that the ivell(s)was(were):constructed in accordance
7.Is this a repair to an existing well: DYes, or llNo 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: 24 (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:2 . (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 Injection Wells: In addition to sending the form to the address in 24a
rotary 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) 15 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: 16oz completion of well construction to the county health department of the county
where constructed.