GW1--06588_Well Construction - GW1_20231006

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 ,
4481-A . ft. ft . ! : '
NC Well Contractor Certification Number "_IS.OUTER CASING-(for multi-cared wells).OR LINER(If pp llcable)
- - FROM TO DIAMETER THICKNESS MATERIAL
Cascade Drilling : .. . .
ft. ft.: in.
Company Name -16.INNER CASING OR TUBING'(geothermal'closed-loop)
2.Well Construction Permit#: . V V I V t 04 014745 -. . FROM - . TO - DIAMETER , THICKNESS MATERIAL
List all applicable Well'constructionpermits(i.e.UIC,,County,State,;Variance,etc,)_: : ft. ft. i, in. : .
- . ft. :.. ... ft I in.
3.Well Use(check well use):
Water Supply Well: •
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural - OMunicipal/Public . . ft ft. in.
❑Geothermal(Heating/Cooling Supply) DResidential 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-Water Supply Well: . .0: ft. ..:. 1 it .Concrete.Cap :
❑Monitoring ...DRecovery: .-,_ •.. , . 1_ ft. ... .21 ft :"Neat Cement- Tremmi Pipe
Injection Well:
ft. ft.
DAquifer Recharge OGroundwater Remediation 19:SAND/GRAVEL PACK(if applicable) -.
❑Aquifer Storage and Recovery ❑Salinity Barrier .. : FROM: _ TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage. ft. : ft.
DExperimental Technology ❑Subsidence Control ft.- ft.:
DGeothermal(Closed Loop) :. ❑Tracer• 20.DRILLING LOG(attach additional sheets if necessary). . ' . ..
FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
DGeothermal(Heating/Cooling Return) . Other(explain under#21.Remarks)
0. ft. :. 1.0 it Silty Sandy:Clay ; Dark Brown
4.Date Well(S)completed: '9/14/23 Well m# VAP-B2-03 • .10 ft. 1.3 ft PWR'- Dark Gray
5a.Well Location: 1.3 ft• . 21 ft Bedrock- Dark Gray
D01N..Corn ing::Corp. •ft. rt- - ° ,� .
-ft. ft, " '' I
Facility/Owner Name Facility ID#(if applicable) ,
2914 Patterson-Street; Greensboro, NC 27407 ft' "= �� i G 2023
Physical City; - ,ys' , and Zip . .. ft. ft. f3;71
Guilford • - 21:REMARKS': - 'nY•• ,,_Pr.---,-,,,..-:,� .,, -.....
County Parcel Identification No.(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 1at/long is sufficient) 22.Certification: •
36°325" N • . : 79°50'49" W; 0- �-�-_ 9/14/23
• NO WELL Signature of Certified Well Contractor , Date
6.Is(are)the well(s): ❑Permanent or ..❑Temporary)N$TALLED
-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: _❑Yes or (No- 15A 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 additional'well details:
• 8.For Geo robe/DPT'Or:Closed-L(44i 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
9.Total well depth below land surface: 21' (ft.) Submit this.GW-1 within 30 days,of well-completion per the following: .
For multiple wells list:all depths if different(example-3Qa 200'and'2(g100)
10.Static water level below top of casing: 7' (fL) 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,NC 27699-1636
12.Well construction method: . " Sonic Drilling • • �• "
• 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:
13b.Disinfection type: Amount: ' :. - - - f
Form GW-1 •' North Carolina Department of Environmental Quality-Division of Water Resources - - Revised 6-6-2018