GW1--03829_Well Construction - GW1_20240628

I.
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher 14.WATER ZONES
Well Contractor Name FRONT To DESCRIPTION
4 ft. 29 ft.
3568A
ft. ft.
NC Well Contractor Certification Number 15,OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
Gpm Pumps & Irrigation Inc FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 30 ft. 1.25 1n' Sch 40 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FRONI 1() 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: I?.SCREE\
FROM TO DIAMETER SLOT SIZE THICKNESS MA' TRIAL
Agricultural oMunicipal/Public 20 ft. 30 ft. 1.25 in' 0.010 40
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) 18.GROUT
X Irrigation FROM "10 NI:NTERIAL ENIPL%CIENMENT METHOD A AMOUNT
Non-Water Supply Well: 0 ft• 20 it' Hole Plug Poured Gravity
Monitoring DRecovery ft. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL ENII'LACENILN'I NIL HOD
Aquifer Test QStormwater Drainage 20 ft. 30 ft• Concrete Sand#2
Experimental Technology [Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM "10 DESCRIPTION(color,hardness,soil/rock L)pc.grain size,etc.)
Geothermal(Heating/Cooling Return) [Other(explain under#21 Remarks)
0 ft. 2 ft. topsoil
4.Date Well(s)Completed:6/9/2024 Well ID# 2 ft. 4 ft. clay
5a.Well Location: 4 ft. 29 ft. sand
Chris Gibson 29 ft. 38 ft. Heavy Shell , no sand
Facility/Owner Name Facility ID#(if applicable) ft. ft. +
107 Heritage Dr Edenton 27932 ft. ft.
ft. ft. I!I to O 0 ,A
Physical Address,City,and Zip
Chowan 21.REMARKS _
Ir40:ml*. nat'.c. :At
County Parcel Identification No.(PIN) v.,.C, iO
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) Certif loll:
36 01 38 N 076 35 38 W
•
6/9/2024
6.Is(are)the w xell(s) Permanent or DTemporary Si afore of Certified Wel ontracto Date
By s ,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or xONo with 15A NCAC 02C.0100 or 1SA 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 421 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: 30 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dii)jerent(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 Iniection 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) 25 Method of test: pump 24c.For Water Slimly& Iniection 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: 32oz completion of well construction to the county health department of the county
where constructed.
Fnrm GW-I North Carolina Department of Environmental Oualitv-Division of Water Resources Revised 2-22-2016