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Home My WebLink AboutGW1--02649_Well Construction - GW1_20240501 •. . , • • . . . . • - • . Print Form • . . - -- • . WELL CONSTRUCTION RECORD(GW-1) . For Internal Use Only: , . • . 1.Well Contractor Information:. . . . . • ! " • Ken. Diediker . . . . 14.WATER ZONES I . . " . . FROM TO . DESCRIPTION Well Contractor Name. ' ft. •- . I I - . . • n/a (federal employee) • ft. . . . . ft. . . . . .. . . NC Well Contractor Certification Number 15:OUTER CASING(for multi-cased wells)OR LINER(if ap licable) . • US Army Corp of Engineers; Savannah District FROM TO DIAMETER' . THICKNESS MATERIAL .ft. , ft. ' .in. .. • 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.U1C,Coun6i,-State,Variance;etc.) - 0 . ft 15.5 ft. 2 . In• SCH'40' PVC • •.. , ft. ft. : • , • 3.Well Use(check well use): : in. • • . • • ' • " 17.SC . . • - , • Water Supply Well: . . . . REEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL . :. . Agricultural" • • ' • ' ElMunicipal/Public ' • 15.5:ft.• 25.6 it 2 i!'. 0.010 SOH 40 PVC Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single). •ft.. .• ft.. in. - . . Industrial/Commercial . . OResidential Water Supply.(shared) 18.GROUT • • . • • • irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water.Supply Well: " .• • .' • " • • " 0. ft. .15.5 ft Bentonite poured and tamped from surface X Monitoring - . I jRecovery . . . • . . - . ft. . ft. . Injection Well: • ft.- ft. - . . ' • • . • Aquifer Recharge 0 Groundwater Remediation I - •• . • 19.SAND/GRAVEL PACK(if applicable) Aquifer Storage and Recovery- .0 Sal inity Barrier-. - - FROM TO ' MATERIAL - EMPLACEMENT METHOD - - Aquifer Test - . Et Stormwater Drainage. - . 15.5 ft. 25.5 ft. sand ; - • poured and tamped from surface • : : • ' Experimental Technology, DSubsidence'Control . • fr.. . ft. . • , . . . • Geothermal(Closed Loop) ' ' OTracer 20.DRILLING LOG(attach additional sheets if necessary) FROM . TO DESCRIPTION(color,hardness,soil/rock type,grain sire,etc.) Geothermal(Heating/Cooling:Return). 'n Other(explain under#21 Remarks)' . . 0. ft ...60 ft. Concrete . • . . • 4.Date Well(s)Completed:.02/28/2024 Well ID#C-8727A-RW-5R2 0.60 ft .25.5 ft SM • . . . . . • ft. • ft. ' 5a.Well Location: Ft. Liberty . • . • • - ft • ft. •• 5* t,.......- N.....,*1,.•,_...-1,' v' " ,.....",,,,.).,,.' ' ' • . . Facility/Owner Name - Facility ID#(if applicable). ft. ft. • • .MAY Vi-1 211%4 407th BSB Motor Pool, off'Yorktown Victor Rd, Fort Liberty,28307 - .. ft. - ft. . •• . . . . Physical Address,City,and Zip• . • •• • • . ft. • ft. . •i11017-r•A•:. -1-,i1 P•r,cr.. ;-,4:,.),: l . D- • .• .,7,.......-k'',IX.--;.',.h.i • Cumberland • • . 21.REMARKS • - - - • • • . County . Parcel Identification No.(PIN) . . . . 5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: . • (if well field,one Igt/long is sufficient) 22.Certification: 35.124101 • -79 025590 . . . N • • _ W .ff2h:n.KENNETH.D.16o4itszviewzg.. . 04/23/2024 • . . 6.Is(are)the well(s)CIPermanent or [ Temporary Signature of Certified Well Contractor , Date ' By signing this forth,I hereby certt&that the well(s)Was(were)constructed in accordance- • 7.Is this a repair to an existing well: 10 Yes or IDNo . - ' 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 thistorm. - • •. . . 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 necesary. drilled:1 ' • SUBMITTAL INSTRUCTIONS' •5 ' • •. • 9.-Total well depth below land surface:.25. - . (ft.) 24a: For All Wells: Submit this form within 30 days of'completion of well For multiple wells list all depths tf different(example-3@200'and 2@100') • construction to the following: • • • 71 - • • • . i . 10.Static water level below top of casing: - • . (ft.) " Division of Water Resources,Information Processing Unit, If water level is above casing,usc"+"- . .1617 Mail Service Center,Raleigh,NC 27699-1617 .' . 11.Borehole diameter:4.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a ' ' . above,also submit one copy of this',form within 30 days of completion of well 12.Well construction method::Auger •• . . - construction-to the following: • (i.e.auger,rotary,'cable,direct push,etc.) • : ' . . • I 1 . ' . Division of Water Resources,Underground Injection Control Program, . ' FOR WATER SUPPLY WELLS ONLY: . 1636 Mail Service Center,Raleigh,NC 27699-1636 • 1 : . ' . 13a.Yield(gpm) • Method of test: 24c.For Water Supply&iniectinn 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: . Amount: • completion of well construction to the county health department of the county • where constructed. • Form OW-.1 . North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016 ' • II ' • • ' ' . '