GW1--06607_Well Construction - GW1_20231006

i
WELL CONSTRUCTION RECORD(GW-1) •
For Internal Use Only: . . •
1.Well Contractor Information: • •
Oliver John Pederson .:. 14 WATERZONEs
Well Contractor FROM TO •DESCRIPTION - '
ft. ft. . 1
4481-A ft. ft. . . -1 i
NC Well Contractor Certification Number 15:OUTERCASING(for multi-cased wells)OR LINER(if ap lletble)
. Cascade Drilling - .: .. .. . FROM - TO _ .. DIAMETER THICKNESS MATERIAL
ft.' :ft.. [ I' in. .
.Company Name
16.INNER-CASING OR TUBING'(geothermal closed-loop), _ . ,
2.Well Construction Permit#: WM04014745. :' . . : FROM - . TO , DIAMETER - THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,:Variance,etc.): - ft. • ft is
3:Well Use(check well use): • • ft. • ft. 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)= :18.GROUT
.❑lrrigation.: . .. ❑Wells>:100,000 GPD: :., FROM • TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply-Well: ft
: •0: ' ft•1 ' :Concrete.Cap
❑Monitoring . , DRecovery:. ..
-"' ' 1 ft' :. •58 " Neat Cement - Tremmi Pipe
Injection Well: -
tt. ft. ,
❑Aquifer Recharge DGroundwater 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 fi.: - ft.
❑Geothermal(Closed Loop) .. . ❑Tracer :. -- - ^20.DRILLING LOG(attach additlos al sheets if.necesaary): .,'"" '
FROM TO DESCRIPTION(color,hardness,sotUrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) .. Other(explain.under#21 Remarks)
. .0- ft' .48 it Silty'Sandy Clay= Dark Brown
4.Date Wells)Completed: 9/8/23 Well ID# VAP-B3-07 .48 ft 53 it PWR - Dark Gray
5a.Well Location: 53 ft - 58 ft Bedrock - Dark,Grayr-..
'
DOW Corning Corp. ft.• ft. '. rV r.6,,,1. 'i,., , r:
Facility/Owner Name Facility ID#(if applicable) ft.- ft .- .
ft.,, ft. v tl2J
2914 Patterson Street, Greensboro, NC•27407 •
-
PhysicalAddress,City,andZip ft. _ „ ft .. .. ; If!iii,M. ,,?^i1 ;)r-;..,' i I
21.REMARKS'.S;
Guilford
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:
36°3'22" N 79°50'56" �,: - ; �-- - 9/8/23
. . NO WELL
6.Is(are)the well(s): ❑Permanent or ..❑Temporary Signature of Certified Well Contractor Date
INSTALLED By signing this form,•I hereby cert fy that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: :❑Yes or )(No - I SA 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 thisform.
23.Site diagram or additional well 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 OW-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: 58' • (fh) .Submit this.GW 1 within 30:days of well:completion Per the following
For multiple wells list all depths if d�erent(example-3Q200'and 2@100')
.
10.Static water level below top of casing: 10' (ft.) 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
6 (n•) -
11.Borehole diameter - 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: • - . -. . ••
Form GW-1 - - - North Carolina Department of Environmental Quality-Division of Water Resources • Revised 6-6-2018