GW1--02652_Well Construction - GW1_20240501

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• I , -, Print Form
•• WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: -
. Ken.Diediker 14.WATERZONES, 1
Well Contractor Name FROM TO DESCRIPTION
n/a (federal employee) fL r�
NC Well Contractor Certification Number
' 15.OUTER CASING.(for multi-cased wells)OR LINER(if ap livable)
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,County,State,Variance,etc) 0 : ft. 34.15 ft. 1 tn• SCH 40 PVC
3.Well Use(check well use): • ft ft. �• .
17.
Water Supply Well: FROM
REE TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural tiMunicipal/Public 34.15 ft. 44.15ft• 1 . in. 0.010 . SCH 40 PVC.
Geothermal(Heating/Cooling Supply) ([Residential 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. 32.15 ft• Bentonite poured and tamped from surface
x Monitoring [Recovery . ft. ft.
Injection Well: ft. ft.
Aquifer Recharge IDGroundwater Remediation . •
19.•SAND/GRAVEL PACK(if applicable) -
Aquifer Storage and Recovery 'I0Salinity Barrier' • FROM , TO MATERIAL EMPLACEMENT METHOD'
Aquifer Test 0Storrnwater Drainage 32.15 ft. 44.15 ft. sand . poured and tamped from surface-
Experimental Technology ()Subsidence Control ft. ft.
Geothermal(Closed Loop) E3Tracer 20.DRILLING LOG(attach additional sheets if necessary) '
Geothermal(Heating/Cooling Return). 'l Other(explain under 421.Remarks)' FROM TO. DESCRIPTION(color,hardness,soil/rock type,¢rain size etc.)
0 ft. .80 ft• Top Soil, SM.
02/22/2024 C£-FT3�131v��. 0.80 ft. 14.60 ft. SC
4.Date Well(s)Completed: Well ID#
5a.Well Location: 14.60 ft. 22.0 ft. SP
Ft. Liberty 22.0 ft- 22.8 ft. CL I�-:- ;'- f,.-. -
.. �.1.,...Ya.--I... i 4. 1._.,v�P .
Facility/Owner Name Facility ID#(if applicable) 22.8 ft. 45 ft. SP
Rock Merritt Ave. and Letterman Street, Fort Liberty, 28307 ft. ft. • MAY• i 1 LOL4
PhysicalAddress,Ci mid Zi ft. ., ft. ,
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Cumberland 21.REMARKS _ i
c•., 7.
County Parcel Identification No.(PIN) '
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: •
(dwell field,one lat/long is sufficient) 22.Certification:
35.1547996199 -78.9989618703
N . W
DIEDIKERKENNETH.D.150 gtooM
sz �' 04/16/202472359a4 1.m a.5E .
.
6.Is(are)the well(s)lPermanent or xiITemporary Signature of Certified Well Contractor Date
' By signing this form,I hereby certt&that'the well(s)was(were)constructed in accordance
. 7.Is this a repair to an existing well: DYes or EliNo 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#21 remarks section or on the back of this fonn.
. • 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:18 SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45 _ (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:23.32 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter:2.25 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Direct 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.) i I
• Division of Water Resources,Underground Injection Control Program,
• FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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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 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016