GW1--02653_Well Construction - GW1_20240501

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
. Jack Kulaga, . . 14.WATER ZONES. '
WellContractorName FROM TO , DESCRIPTION
• n/a (federal employee) ft. ft.
• ft. ft. l
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if ap licable)
p US Army Cor of Engineers, Savannah District FROM TO DIAMETER THICKNESS 1 MATERIAL
ft.. ft.' L • 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• 40 ft• 1 in* SCH 40' PVC
3.Well Use(check well use): ft. ft. in.
-Water Supply Well: 17.SCREEN
FROM TO. DIAMETER SLOT SIZE THICKNESS MATERIAL .
*Agricultural DMunicipaUPublic 40 ft• 50-. ft• 1 in, 0.010 SCH 40 PVC
A Geothermal(Heating/Cooling Supply) ElResidential Water Supply(single) - ft. ft. . in.
UllndustriaUCommercial IlResidential Water Supply(shared) 18.GROUT
Ili Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 38 ft• Bentonite poured and tamped from surface
MiIMonitoring (Recovery . ft. ft.. '
Injection Well: .
ft. ft.
*Aquifer Recharge OGroundwater Remediation
19.SAND/GRAVEL PACK(if applicable)
*Aquifer Storage and Recovery OSalinity Barrier FROM TO. MATERIAL EMPLACEMENT METHOD
)))DiAquifer Test - . JStormwater Drainage 38 • ft. 50 ft•. sand poured and tamped from surface
I Experimental Technology Subsidence Control ft. ft.
•
"'Geothermal(Closed Loop) t jTracer 20.DRILLING LOG(attach additional sheets if necessary)' -
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
*Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks)
0 ft• .20 ft• Top:Soil
4.Date Well(s)Completed:10/24/2023 well ID# Ce.FT1312O!OL( 0.20 ft. 1.30 .11. SP ,
5a.Well Location: 1.30 ft. 7 00 ft. SC
Ft. Liberty . . 7.00 ft. 12.00 ft. SP-SM . :.- :• ,�;
•
� �c=:: '-
Facility/Owner Name Facility ID#(if applicable) 12.00 ft• 15.5 ft. SP
Gruber and Merill Street, Fort Liberty;.28307 15e. 50 ft• CH ' MAY 'tl. I thin
Physical ft. ft. IrtfoiI;TriI1.Fi:P.:r.,^ 7 ..�I1;i.qe
Cumberland• . '2 • G''ic
1.REMARKS' . - - (:"?t•"i:3 .
County - Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: .- . . - -
(if well field,one lat/long is sufficient)• 22.Certification: .
35.1230718947 -79.0031191507•
Nw ER.KENNETH.D.160 mi 04+ry o,w. 04/15/2024
723598
7235964 ; Date'.2424041510-020L61:0
6.Is(are)the well(s)01Permanent or EiTemporary Signature of Certified Well Contractor, Date
• By signing this form,I hereby cert(that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or EjNo 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 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:1() SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50 (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:14.1 (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:2.25 n.
(i ) 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: 1
(i.e.auger,rotary,cable,direct push,etc.) ! •
Division of Water Resourcesi 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. I
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
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