GW1--02651_Well Construction - GW1_20240501

. Print Form 1
WELL CONSTRUCTION RECORD(GW-1) ' For Internal Use Only: '
1.Well Contractor Information:
. . Ken.Diediker . . . . . 14.WATER ZONES
WellContiac[orName FROM TO DESCRIPTION
n/a (federal employee) ft ft.
ft ft. •I.
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 DIAMETERI THICKNESS• 1 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.U/C,County,State,Variance,etc.) - 0 ft 20 ft 0,75'! in. SCH 40 PVC '
• •3.Well Use(check well use): ft. ft. . in.
Water Supply Well: 17.SCREEN
_ FROM TO DIAMETER SLOT SIZE THICIGSIESS MATERIAL_ _
Agricultural • ®Municipal/Pu61ic 20 :ft- 30 ft- 0.75 i..n'• 0.010 SCH 40 PVC
• Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial . Residential Water Supply(shared) 18.GROUT '
Irrigation FROM TO . MATERIAL EMPLACEMENT METHOD&AMOUNT
' Non-Water•Supply Well: ' ' .. 0 ft 20 ft. Bentonite - poured and tamped from surface
X Monitoring . . 0Recovery.. ' ' ft. ft.
Injection Well:
-ft. ft.
Aquifer Recharge - I©Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
Aquifer Storage and Recovery 'OSalinity Barrier" - •' FROM ' TO' ' MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage 20 . ft 30 ft sand - poured and tamped from surface
Experimental Technology, ©Subsidenc a Control ' • _.ft. . ft. .
Geothermal(Closed Loop) ' IOTracer 20:DRILLING LOG(attach additional sheets if necessary) •
under#21.Remarks) FROM To DESCRIPTION(color,hardness,soil/rock type,grain size.etc.)
Geothermal(Heating/Cooling Return) I Other(explain
0 ft 7 ft. SM
4.Date Well(s)Completed:10/03/2023 Well ID# I SS.-T(Si/-0( 7 ft 14 ft' ..Sp . ' . .
5a.Well Location: 14 it. 16 ft. 'Sc .
• Ft. Liberty 16 ft 30 ft. SP �... -•.
• . Facility/Owner Name • Facility ID#(if applicable) ft. ft. i V •"
. Watson St.'and Log'Base Charlie Rd, Fort Liberty, 28307 ft ft. ' •
toy -. - (1
. Physical Address,City,and Zip 74
St ft. `�t r
Cumberland 21.REMARKS ' ' Irf.,`:':r^a. .0, .)r-^. .-.,su'1� . . .
G`i-1 ta;.:30G
County ' Parcel Identification No.(PIN)' .
• . 1
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one_lat/long is sufficient) (]�+ �1 �1 . ' 22.Certification:
• 35.1458246. • -78.96542 17 • DIEDIKER.KENNETH.D.160 as+w•m^,
N W 7p5984 „,' p;a.,; 04/23/2024 •
6.Is(are)the well(s)IDIPermanent or Temporary Signature of Certified Well Contractor Date
By signing-this form,1 hereby cert fy that the wells)was(were)constructed in accordance
- 7.Is this a repair to an existing well: ®Yes . or XoNo . : 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 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:I 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 different(example-3@200'and 2@100') construction to the following: ' .
10.Static water level below top of casing:26'7 • (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 Injection Wells: In addition to sending the form to the address in 24a
DlreCt Push ' 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) Method of test: ' 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: 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
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