GW1--02650_Well Construction - GW1_20240501

.
t Print Form-,1
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: i
I
Ken Dledlker . 14.WATER ZONES ' . • ' '
Well Contractor Name FROM TO DESCRIPTION
rt. ft. I I •
n/a (federal employee) f I I . ..rt. 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 1 MATERIAL
• ft. • . ft. i I 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.UIC,County,State,Variance,etc.) 0 ft 30 ft.. '0.75 ! in. SCH 40 PVC
3.Well Use(check well use): ft ft. in. •
17.
Water Supply Well: FROM SCREENTO _ DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural OMunieipal/Public 30 ft. 40 ft. 0.75. in 0.010 . SCH 40 PVC
•
Geothermal(Heating/CoolingSupply) OResidential 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• 30 ft• Bentdnite . poured and tamped from surface
Ix Monitoring ID Recovery ft. ft.
Injection Well:
ft. ft.
Aquifer Recharge El Groundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery D Salinity Barrier •• FROM _ TO MATERIAL EMPLACEMENT METHOD
Aquifer Test • 0 Stormwater Drainage 30 ft. 40 ft. sand poured and tamped from surface
Experimental Technology: OSubsidence Control ft. ft. •
'
Geothermal(Closed Loop) OTracer 20.DRILLING LOG(attach additional sheets if necessary) .
eXFROM TO DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return). OGther(explain under#21 Remarks)•
i,Sp-fiw-01 0 ft' '1.5 ft• Asphalt, GP.
4.Date Well(s)Completed:10/04/2023 Well ID# i�0 -TN-nZ 1.5 ft. 17.5 ft. SM ,; .
5a.Well Location: 17.5 it 38 ft: SP
Ft. Liberty . 38 ft. 40 ft. CL , _ : ,.
Facility/Owner Name Facility ID#(if applicable)
fi. ft. a 4'd•.,L.;L.f aE �',�,�.,,.
• Aberdeen Training Facility, Fort Liberty; -28307 : ft.' ft. MAY u t i024
• Physical Address,City,and Zip • . . ft. ft. . . .
Cumberland . • . : %...,, ,,
21:REMARKS . . ll..r;,:v=xa,2,• �.;>,q[ :4'✓...i . .
VA'Qt.1' mil)
County . . Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latt//llong is sufficient) AA -n} r}�-n1 22.Certification: •
35.1201961 -79.3653356 • DIEDIKER.KENNETH.D,1fi0 Qu.ro•c.m
N W : 7235954 „ig.;re A„o;;, ° " 04/23/2024
6.Is(are)the well(s)IDPermanent or Temporary •
Signature of Certified Well Contractor Date
By signing this form,I hereby cert fy that the well(s)was(were)constructed in accordance
7,Is this a repair to an existing well: DYes or ONo with iSA NCAC 02C.0100 or%SA 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:2 ' SUBMITTAL 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'and 2@I00') . construction to the following:
10.Static water level below top of casing:37'9 (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:2.25 (in;) 24b.For Infection Wells: In addition to sending the form to the address in 24a'
Direct Push • • above,also submit one copy of tliis form within 30 days of completion of well
12.Well construction method: construction to the following: i(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 '
A
13a.Yield(gpm) Method of test: . . 24e. For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit lone 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 GW-1 - North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
I