GW1--06610_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. 1
4481-A ft. . ft 1
NC Well Contractor Certification Number 15.OUTER CASING(for multi,cased wells)OR LINER.(if op &able) . ' -
Cascade Drilling . . . FROM ', ' TO -- DIAMETER- THICKNESS MATERIAL
ft: ft: in.
Company Name • .
16.INNER CASING OR TUBING(geothermal dosed-loop) •'
2.Well Construction Permit#: '' WM 0401 4745 : FROM TO DIAMETER . THICKNESS MATERIAL
List all a licable well construction permits(i.e.UIC,County,State,,Variance,etc.' ft. :• ft. in. ._ .
PP J::. . .
3.Will Use(check well use): .: . '' ft. ft. :. .... '. in;- ." .
17.SCREEN
Water Supply Well: •
,. FROM TO .' DIAMETER SLOT SIZE THICKNESS MATERIAL .
❑Agricultural . . . - ❑Municipal/Public. . it ft. . in.
PP y) ent _ Supply( g ) .it ft.. . in. . ..
❑Geotherlal(Heating/CoolingSu 1 ❑Residential Water (single)
❑Industrial/Commercial : ❑Residential Water Supply(shared) : .18.GROUT
'❑InigatioIl . . .. ❑Wells>-100,000 GPD- - FROM - TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply-Well: •
:0: ft* :1 ft; :Concrete Cap .
❑Monitoring __ ❑Recovery ,. ... .. 1. [t. 75 ft Neat Cement -Tremmi Pipe
Injection Well:•. • •..
ft. ft •
❑Aquifer Recharge • " OGroundwater 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- ft.. ft
❑Geothermal(Closed Loop) • ❑Tracer.- .. 20.DRILLING LOG(attach additional sheets if necessary) --. . .
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) .•ilOther(explain.under#21 Remarks) 0.
ft• 65 ft Silty'Sandy Clay-.Dark Brown
4.Date Well(s)Completed: "8/11/23 Well iD#.VAP-B2-04 :65 ft• 70 ft PWR - Dark Gray
5a.WellLocation: 70 ft• - 75 ft Bedrock - Dark Gray
ft. ft_ -r r..,
DOW Corning:Corp. .: "� .,. ,,
Facility/Owner Name : Facility ID#(if applicable) "' : ft.:• • .ft:
ft... fr.- OCT 0 u 2123
2914 Patterson Street,' Greensboro. NC 27407 : -
Physical Address,City,and Zip : ... ft. ft I r'.tcr F z n Pr-• .5Adt`:I u:'-
. '-.. • - t ;';.ate`_;`:Nj. :.
Guilford 2L REMARKS
County ParcelldentificationNo.(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°3'29" N - -I- 79950'59" W. -^ 8/11/23
6.Is(are)the well(s): ❑Permanent or .❑TemporaryN NO WELL Signature of Certified Well Contractor ; • Date
_. . . INSTALLED •
Bysigning 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 X1No 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 detaiLsi
8.For Geoprobe/DPT Or Closed-Loop.Geothermal Wells having the same.. You may the the batik 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: " 75'' (ft.)
For multiple wells list all depths iifd(t erenr(example=3(a3z00'and 2(a3700) Submit this GW-1 within 30-days of well.completion per.the following: -
10.Static water level below top of casing: 7' (fL) 24a. For All Wells: Original:form,to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+'• .
11.Borehole diameter: .. 6 (in.) _ 24b.For.Infection Wells:Copy to DWR,Underground Injection Control(IUC)
Program;11636 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: -- '
.
I •
. . Form GW-1 -. - North Carolina Department of Environmental Quality-Division of Water Resources - Revised 6-6-2018