GW1--06602_Well Construction - GW1_20231006

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WELL CONSTRUCTION RECORD(GW-1) . For Internal Use:Only: ! - .
1.Well Contractor Information:
Oliver John Pederson 14:'WATERZONES =
Well Contractor Name FROM TO DESCRIPTION -
ft. ft I ,
4481-A : s ft. ft.
NC Well Contractor Certification Number • 15:OUTER CASING(for multi-cased wells)OR LINER(if ap Stable) '
. .. . ... FROM .... TO .••• DIAMETER THICKNESS MATERIAL
Cascade Drilling
ft:- ft.- in.
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Company Name 16.INNER CASING OR TUBING.(geothermal closed-loop) ..' . -
2.Well Construction Permit#: • : WMO4O 14745. :. FROM - -. TO - - ' DIAMETER. , THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,- etc.) ft. it in.
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3.Well Use(check well use): it. ft. in,
Water Supply Well:
FROM TO .. DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public . - ft, ft. . in.' •
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.. . ft... . in. . .
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT
❑Irrigation . :. .. ❑Wells>100,000 GPD '. FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-WaterSupply_Well: 0: ft. 1 ft' .Concrete.Cap . .
.
DMonitoring _- . . .DRecovtry' -., • ,- , 1- ft. :. ..23 sr. Neat Cement - Tremmi Pipe
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery Li Salinity Barrier FROM :: : TO .. MATERIAL .EMPLACEMENT METHOD
❑Aquifer Test . ❑Stormwater Drainage. ft. .. ft.
❑Experimental Technology z ❑Subsidence Control • ft.: ft.
❑Geothermal(Closed Loop) ❑Tracer.. 20.DRILLING'LOG.(attach.additional sheets if necessary)':' . - - . -. . .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
0 Geothermal(Heating/Cooling Return) ..-XOther(explain.under#21 Remarks)
' .0. ft. • 14 It Silty Sandy Clay- Dark Brown
4.Date Wells)Completed: 9/13/23 we ID# VAP-B2-09 14 ft• 18 ft PWR - Dark Gray
5a.WellLocation: . . 18 ft' - 23 It Bedrock - Dark_Gray
rt.: - t{ :.: r'h':
DOW Corning:`Corp. - t...
Facility/Olvne Name Facility loll(if applicable) ft' ft.: OCT 0 O 23
2914 Patterson Street,- Greensboro, NC 27407 - ft` .fti
Physical Addrese City,and Zip ..: ft. ft .... , Ir}i: rr.•:;;.^1%'':a�. 7,t,',3.Iii x'! -
21:REMARKS.-- ,.." '-.�,v y v
Guilford
County ParcelldentificationNo.(PIN) -Boring was used for soil sampling and water
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:, sampling - Boring was grouted upon completion
(if well field,one lat/long is sufficient) 22.Certification: . .
36°3'24" N . . 79°50'49" W:- —"�-'—1 - 9/13/23
NO WELL Signature of Certified Well Contractor ; Date
6.IS(are)the well(s): OPermanent or .❑Temporary-INSTALLED
••By signing this form,I hereby certi;fy that`the wells)was(were)constructed in accordance with
7.Is this a repair to an existing well: :❑Yes or XNo- • ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature:of the 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 atiditional'wep 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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells • - (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: '' 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: - 23' • • • (ft.) •
Submit this GW-1 within 30.days of well completion per the following:
For multiple wells list all depths if different(example-3 a@200'and 2Q100)
- 24a.-For All Wells: Original-.for to Division of Water Resources (DWR),
10.Static water level below top of casing: 7' - (ft.)
If water level is above casing,use"+'If Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter:: - 6 (in.) . • 24b.For-Injection Wells:Copy toI:DWR,Underground Injection Control(IUC)
Program 1636 MSC,Raleigh,NC 27699-1636 :
12.Well construction method: Sonic DrillingP
24c.For Water Snppl,Land Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) - county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24(1:For Water-Wells producing over 100,000 GPD:'Copy to DWR,CCPCUA
Permit Program;11611 MSC,Raleigh,NC 27699-1611.
13a.Yield(gpm). . Method of test: . -
13b.Disinfection type: _ -Amount: :
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Form GW-1 - . . North Carolina Department of Environmental Quality-Division of Water Resources + Revised 6-6-2018