GW1--06591_Well Construction - GW1_20231006

WELL"CONSTRUCTION RECORD (GW-1).- For Internal Use Only: -
1.Well Contractor Information: •
1
Oliver John Pederson 14.WATER ZONES -- '
Well.Contractor Name FROM -TO •DESCRIPTION-
ft. ft.
4481-A .: ft. - ft. -
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(If ap Sable)
FROM - TO - ' - DIAMETER THICKNESS MATERIAL
Cascade Drilling , . —
Company Name 16.1NNER CASING OR TUBING(geotherinal dosed-loop) -:-.'
2.Well Construction Permit#: WM 04014745. FROM TO DIAMETER THICKNESS MATERIAL --
List all applicable well construction permits(i.e.UIC,County,State,-Variance,etc.)' _:. • ft. -." • ft. r.-, ! in.
3.Well Use(check well use):. - - - •:- ft. : • • ft. : .- . i in. - -
Water Supply Well•
FROM TO . DIAMETER ' SLOT SIZE THICKNESS MATERIAL
❑Agricultural . . OMunicipal/Public. . ft• ft. in.
❑Geothermal(Heating/Cooling Supply):, ❑Residential Water Supply(single) ft. ft,_ in., •
"❑industrial/Commereial ` ❑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. 43 ft• Neat Cement- Tremmi Pipe
Injection Well: -
" ft. ft.
DAquifer Recharge. OGroundwater Remediation - 19:$AND/GRAVEL PACK(if applicable)
DAquifer.Storage and Recovery ❑Salinity Barrier :.:. : FROM:.: : TO - . . MATERIAL : EMPLACEMENT METHOD
DAquifer Test .-.. ❑Stormwater Drainage:. . ft.. . ft.
. ❑Experimental Technology ❑Subsidence Control . ft.: = ft. '
DGeothermal(Closed Loop) ❑Tracer • . . • • 20:DRILLING LOG{attach additional sheets if necessary) . . .. .-
.FROM TO . DESCRIPTION(color,hardness,soUUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) . .XOther(explain under#21:Remarks) •
. .... .0: ft' 33 ft- Silty Sandy Clay - Dark Brown .
4.Date wells)Completed: 8/2/23 "weu ID# VAP-B 1-15 33 ft• 38 ft. PWR - Dark Gray 1 .
5a.Well Location: 38 ft• - 43 fA Bedrock Dark Gray
DOW Corning..Corp. : .. . . :. ft. ft..
:,� .---, -•
,
Facility/Owner Name -Facility ID#(if applicable) - ft. ft. .� - ' ,ri,.,, iJ' i::, yi
2914 Patterson Street, Greensboro, NC-27407 ft' ft. OCT 0 6 7n23 •
Physical Address,City,and Zip : ft. ft.
21:REMARKS:; `, }A, r:
.Guilford . . . eti1iJ
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 lat/long is sufficient) :... , 22.Certification: - c
- 36°3'25" N . 79°50'48" w.: _ 8/2/23
NO WELL Signature of Certified Well Contractor Date
6.:Is(are)the well(s): ❑Permanent or ❑Temporary
INSTALLED
•'By signing this form,-I hereby certfy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: - -❑Yes or :XNo• ISA NCAC 02C.0100 or 15A 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 Geoprobe/DPT or Closed-Loop Geothermal Wells having the same. ' You may rite 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: 43' (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: _ ' 7' •• • .- (fL) 24a.•For All Wells: Original:-form to Division of Water Resources•(DWR),
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 to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 2,7699-1636
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 fiver 100;000 GPD:Copy to DWR,'CCPCUA
13a.Yield(gpm) Method of test: -Permit Program;1611 MSC;Raleigh,NC 27699-1611- -
•
13b.Disinfection type:_ - - - • Amount: - - -
Form GW-1- - • - North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018