GW1--06609_Well Construction - GW1_20231006

WELL CONSTRUCTION RECORD(GW-1)::. . For Internal Use Only:
1.Well Contractor Information: - -
Oliver John Pederson .:. =14:WATEl:ZONES'
Well Contractor Name. FROM :TO - :DESCRIPTION
ft. ft. ` •
4481-A ft. ft. '
NC Well Contractor Certification Number •.IS:OUTER CASING(for-multi=cased wells),OR LINER(if ap liable)Cascade Drilling - " - FROM TO DIAMETER _ THICKNESS MATERIAL
ft. .ft. I i in.
Company Name .: 16.INNER CASING OR TUBING(geothermal elosed-loop) - ,:"
2.Well Construction Permit#: • :- WM040.14745-' : :. FROM - • ' TO - • DIAMETER•- THICKNESS MATERIAL
List all applicable:well construction permits(i.e.UIC,County,State;Variance,etc.):: ft• ft. in.
3.Well Use(check well use): ft, ft. to
Water Supply Well: 17sSCREENr, _
FROM TO .• DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public, ft. ft. . in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) :ft. . it.. in..
❑lndustrial/Commercial ❑Residential Water Supply(shared) • 18;GROUT
❑Irrigation ❑Wells>100,000 GPD FROM ' TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: : 0' ft' 1 ft' :Concrete Cap
.
OMonitoring • ❑Recovery. -_. 1, ft' 13 ft -Neat Cement - Tremmi Pipe
Injection Well: •
ft. ft. •
❑Aquifer Recharge. DGroundwater Remediation ' 19:SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Battier - FROM:.:. . TO MATERIAL . :EMPLACEMENT METHOD
. ❑Aquifer Test . . ❑Stormwater Drainage.. - . . ft, i fL
❑Experimental Technology 0 Subsidence Control , ft.: - ft
❑Geothermal(Closed Loop) - ❑Tracer. 20.DRILLING LOG.(attael'additional sheets if necessary). -.
•FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size,etc.) -
❑Geoihermal:(Heating/Cooling Return) Other(explain.under#21 Remarks)
• :0. ft' : .3. ft Silty;Sandy.Clay ;.Dark Brown .
4.Date Well(s)Completed: 9/14/23 well iD# 'VAP-B2-08 ' 3 ft. 6 ft PWR - Dark Gray . -
5a.Well Location: •' - 6 f` • 13 it Bedrock - Dark Gray
DOW Corning Corp. .. :. :ft. ft T l,_ ;
Facility/Owner Name Facility ID#(if applicable) ft. ft _� �.r 4- �.�,
• 2914 Patterson Street; :Greensboro, NC27407 . -f`: f` (lCT 0 A 2023
ft. ft.
Physical Address,City,and Zip -
,21.REMARKS',::'• ' . . . , . . -. II'o r •, , :' "ri.r 1,%t.
Guilford 1 i.. t.
County . Parcel Identification No.(PIN) :Boring was used'for soil sampling'ardwater
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:'24" N 79950'49" W: -- ___- _ 9/14/23
NO WELL " Signature of Certified Well Contractor Date
6.:Is(are)the well(s): ❑Permanent or ❑Temporary)NSTALLED
• By signing this form,I hereby certify that the well(s).was(were)constructed in accordance with _
7.Is this a repair to an existing well: .CI.Yes or XNo : 15A NCAC 02C.0100 or 15A NCAC mg.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 of this page to provide additional well construction info
8.For Geoprobe/DPT unclosed-Loop Geothermal Wells having the same.. (add'See Over in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
t •
9.Total well depth below land surface: - 3 • (ft.) ..Submit this.GW 1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example:3®200'and 2@I00') " -
10.Static water level below top of casing: -7-1 f( ) 24a.-For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" t Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
-- 11.Borehole diameter:. . _ 24b.For.Injection Wells:Copy toiDWR,Underground Injection Control(IUC)
6 (�') Program,j 1636 MSC,Raleigh,NC 27699-1636.
•12.Well construction method: Sonic Drilling1
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•
:Permit Program;1611 MSC,Raleigh,NC 27699-1611 --•
13a.Yield(gpm). : Method of test: - • I - •
13b.Disinfection type: Amount: - - - - -
f
Form GW-1 - North Carolina Department of Environmental Quality-Division of Water Resources I. Revised 6-6-2018
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