GW1--06608_Well Construction - GW1_20231006

. :WELL CONSTRUCTION RECORD(GW-1) For-Internal Use Only: 1 -
- 1.Well Contractor Information: •
Oliver John Pederson .. 14:WATERZONEs
•
Well Contractor Name FROM TO- :DESCRIPTION - -
. . ft. . ft. C
•
4481-A .- - ft. ft. ' 1 . .
NC Well Contractor Certification Number
15,OUTER CASING(for multi-cased wells)OR LINER.(if op &Able) •
-." FROM� TO -- DIAMETER ' THICKNESS MATERIAL
Cascade Drilling .. ft. ft in.
Company Name -
-16.INNER CASING OR TUBING(geothermal closed-loop) :" '
-2.Well Construction Permit#: - •-IVVM04014745 - FROM TO • "- DIAMETER THICKNESS MATERIAL
List all applicable"wellconstructions permits(i.e.UIC,County,State,-Variance,etc.):: ft. ft. j is .
3.Well Use(check well use): ft ft is
Water Supply Well: -" 17:SCREEN -
FROM TO .. DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural - ..❑Municipal/Pablic. . . - ft. ft. • - in.
❑Geothermal(Heating/Cooling Supply). ❑Residential 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 ft. :Concrete.Cap
•
❑Monitoring -_ • ORecovery. -,.. ,,.1. ft. -.56 ft• -Neat Cement - Tremmi Pipe
Injection Well: " -" -" -
ft. ft
❑Aquifer Recharge. Groundwater Remediation -'- •
19.SAND/GRAVELPACK(if applicable) - ..
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM- • . TO _ . MATERIAL EMPLACEMENT METHOD
❑Aquifer Test . ElStormwater Drainage:. .. _.. . ft. ,ft.'
❑Experimental Technology ❑Subsidence Control ff.: ft.
.❑Geothermal(Closed Loop) -:: ❑Tracer: .. -.- (attach.additional sheets if necessary) '20.DRILLING LOG. - .. .
FROM TO • DESCRIPTION(color,hardness,soWrock type,grain size,etc.)
❑Geothermal.(Heating/Cooling Return) " Other(explain.under#21 Remarks) -
O. ft. :..46 ft. Silty'.Sandy-Clay-=. Dark Brown .
4.Date wells)Completed: 9/11/23 Well ID# VAP-B3-03 :46 ft. 5:1 ft. PWR - Dark Gray
5a.Well Location: - -51 ft. ' 56 ft• Bedrock-- Dark,Gray;-- : r.,..,..,.
DOW.Corning Corp. . ft. ft as t„.? r �..
' Facility/Owner Name Facility ID#(if applicable) .ft..- -ft._ �.
f1CT f, ?n73
• 2914-Patterson Street;" Greensboro NC 27407 ft'" " -
t tt:iJ.,i-: :,i -.•N: 14.
Ph ical Address,Ci •and Zipft. it l3'•. -. .
Guilford 21.REMARKS _ .>
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:'24" N. • 79°50'56" �, • - 9/11/23
NO WELL Signature of Certified Well Contractor - Date
6.Is(ere)the wags): ❑Permanent or ❑Temporary)N STALLE D
By signing this form,-I hereby certi y that the wel(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: :❑Yes or -XN"o• : ISA NCAC 02C.0100 or 15A 1VCAC-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 Geop.robe/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 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: • 56 (ft.) .Submit this.GW, -1 within 30days of well:completion per.the following:
For multiple wells list-all depths if different(example-'3Q200'and 2@100) -
10.Static water level below top of casing: 10' ( ) 24a.-For All Wells: Original;form,to Division of-Water Resources-(DWR),
ft. Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i
11.Borehole.diameter : 6- • (in.) 24b.For Injection Wells:Copy
to DWR,Underground Injection Control(IUC)
Program,1:636 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
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 L Revised 6-6-2018