GW1--03883_Well Construction - GW1_20240628

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Paul A Lacher 14.WATER ZONES
Well Contractor Name FROM ro DESCRIPTION
3568A 115 ft. 135 ft.
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 I IHCKNLSS MATERIAL
0 ft• 125 ft. 2 it' Pr 200 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
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: 17.SCREEN
ERoNi to DIAMETER SLOT SIZE THICKNESS AlATERIAI.
Agricultural ®Municipal/Public 125 ft• 135 ft. 1.25 "'• 0.010 40
Geothermal(Heating/Cooling Supply) °Residential Water Supply(single) ft. ft. in.
Industrial/Commercial °Residential Water Supply(shared) IS.GROUT
x Irrigation FROM TO y A.TERIAI, E.NtPLACEMLvI.ME:IHOD& s>tot rt
Non-Water Supply Well: 0 ft. 35 ft. Hole Plug Poured Gravity
Monitoring °Recovery It. ft.
Injection Well: ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery °Salinity Barrier FROM TO MATERIAL FAIT tACLMENI.METHOD
Aquifer Test 0Stormwater Drainage 115 ft. 135 ft Concrete Sand#2
Experimental Technology °Subsidence Control ft. ft.
Geothermal(Closed Loop) 0Tracer 20.DRILLING LOG(attach additional sheets if necessary)
FROM TO DESCRIPTION(color.hardness,soil/rock lspe,grain site,etc.)
Geothermal(Heating/Cooling Return) []Other(explain under#21 Remarks) 0 R. 2 ft• topsoil
4.Date Well(s)Completed:6/6/2024 Well ID# 2 ff. 28 it' sand
5a.Well Location: 28 ft. 38 ft'
Silt `�L.:;
Roy Hudgins 38 ft• 68 ft. sand JUN 2 8 2024
Facility/Owner Name Facility ID#(if applicable) 68 ft. 90 ft• Clay
Lot 163 Bald Eagle Pointe Dr Hertford 27944 90 ft. 115 ft. silt Ir ec.rtli'F1 .'-.ram-.Y u>~.
l)'Oir.a S�
Physical Address,City,and Zip 115 ff. 135 ft. Sand course
Perquimans 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one Iat/long is sufficient) C 22•C tification•
36 6 14 N 076 11 58 \ W 6/9/2024
6.Is(are)the well(s) Permanent or Temporary Signa e of Certified Well Co ctor Date
x
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or 13No with ISA 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 l GW-I 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: 140 (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: 1 _ (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 7/5 (in.) 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)40 Method of test: pump 24c. For Water Suaoly&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: 64 oz completion of well construction to the county health department of the county
where constructed.
c.....,nuf_i Tinn6 rnrnlinn flenartment of Fnvimnmenml(l,mIit,,-ilivicinn of Water 12ecnnrnec Revised 2.22.2016