GW1--06606_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.WATER ZONES --- .
Well Contractor Name FROM -TO. :DESCRIPTION
ft. '. ft. ..
4481-A . -
NC Well Contractor Certification Number .15.OUTER CASING(for mniti-cased wells).OR LINER(If a llcable)
.. Cascade Drilling FROM ... TO .. DIAMETER,n THICKNESS MATERIAL
ft.. it.. i • .. .
Company Name - 'r 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. ft in.
3.Well Use(cheek well use): .. - ft. ft. I in._ -
Water Supply Well:
17:SCREEN
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)-
16:GROUT•"
❑Irrigation ❑Wells>.100,000 GPD FROM • TO - MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply:Well: : 0: - ft' 1 I' :Concrete.Cap
.
❑Monitoring: - - ❑Recovery _ ... 1 ft. 33 n- --Neat Cement- Tremmi Pipe
Injection Well: - •
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ft. ft. .
❑Aquifer Recharge ❑Groundwater Remediation 19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM: :. : TO _.: : MATERIAL . EMPLACEMENT METHOD . .
❑Aquifer.Test ❑Stormwater Drainage. - _ . _ft.:_ ft.
❑Experimental Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) - ❑Tracer- - . . =20.DRILLING LOG(attach additional sheets if necessary),. -
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❑Geothermal(Heating/Cooling Return) -Other(explain.under#21 Remarks) FROM -
. 0. ft. TO 23 it. soWrock type,grain size,etc.)
Silty Sandy.DESCRIPTION(color,Clay hardness, Dark Brown
4.Date Well(s)Completed: 9/7/23 - Well ID# VAP-B3-12 23 ft. 28 ft. PWR - Dark Gray
5a.Well Location: -- - - 28 ft. . 33 ft. Bedrock- Dark Gray
:ft. ft. E f" , ,�. ,rF-'�-",\
. DOW Corning:Corp. . .. .: E 7- c .. 'I d F� '
Facility/Owner Name - Facility ID#(if applicable) ft.- ft
2914 Patterson Street, -Greensboro, NO27407 ft. ft- OCT 0 u 2023
Physical Address,City,and Zipft. ft. .... .r.,. r,:.' rTh-, , ..
Ys� tY, 1f3f"v,l�i+.'.,i1 �... ., t•r,'! l:i:
:. " 21.REMARKS-w.-.. ,: L., .."� -
Guilford Boring was used:for soil samplingand water
County Parcel Identification No.(PIN) g
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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: c
36°3'22"• N 79°50'56" �,: JL-- 9/7/23
6.Is(are)the well(s): ❑Permanent or . ❑TemporaryNO WELL Signature of Certified Well Contractor Date
INSTALLED
By signing this form,I hereby certi:0 that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or )(No ISA NCAC 02C.0100 or 1SA 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 additional well details:
You may use the back p
of this page,to provide additional well construction info
8.For Geoprobe/DPT or.Closed-Loop.Geothermal Wells having the same..
(add Oyer'in Remarks only. 1 GW-1 is needed..Indicate TOTAL NUMBER of wells dd'S O.. s Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 33r (ft.) . Submit this GW-1 within 30:days of well completion per the following:
For multiple wells list all depths if dierent(example-3@200'and 2®100) ' ' '
10.Static water level below top'of casing: 1 O' („ 24a. For All Wells: Original form tO Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter 6 • (in.)-: 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,"1636 MSC,Raleigh,NO21,,699-1636
12.Well construction method:— -Sonic Drl Iling : _ 24c.For Water Supply and 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: 24d.•For Water Wells producing over 100;000 GPD: Copy to DWR,CCPCUA
13a.Yield(gpm)= Method of test: ' • Permit Program;1611 MSC;Raleigh,INC 27699-1611 - -
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