GW1--06811_Well Construction - GW1_20231023

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: '
Oliver John Pederson • , 14;WATER'zONES.. = ,.: . ..
WellContrac[orName FROM TO DESCRIPTION
ft. ft. '
4481-A ft. ft.
NC Well Contractor Certification Number
X5:OUTBI ECASING(for rnnlH-caged welliiIDI''LINER(It'applienble)
Cascade Drilling • . FROM TO DIAMETER THICKNESS I MATERIAL
ft. ft. in.
Company Name
• s GINNEII CASING'.OR=TUBINGIgeothermai elosed=loop) :
2.Well Construction Permit#: • .WM04014745, FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun));State,:Variance,etc.) ft. . ft. in.
3.Well Use(check'well use): t ft. ft in.
• •17 SCREEN .`+V :.
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft, ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial • ❑Residential Water Supply(shared) 18:`:GROITF ;.
❑Irrigation , • . . ❑Wells>100,000 GPD ' FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: , ' 0 ft. 1 ft' Concrete Cap
❑Monitoring ,, ,I , ❑Recovery , 1 ft. 48 ft- Neat Cement - Tremmi Pipe
Injection Well:
1 ft. ft.
❑Aquifer Recharge • . I ❑GroundwaterIRemediation
19rSAND/GRAVEI:PACK(ifiapplicrthle)"`..:._.
❑Aquifer Storage and Recovery : ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
DAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology' ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer ,20 DRILtING`LOG attach additional sheets if necessa '
❑Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,tic.)
0 ft' 38 ft. Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed:; 9/6/23 well ID#•VAP-B3-14 38 ft• 43 ft. PWR - Dark Gray
5a.Well Location:, 43 ft• 48 ft Bedrock - D,ark7.G:ray- tT—r,-.
DOW Corning Corp. ft. ft. . v. _°„_•li,.u.,;: V L;I.)
Facility/Owner Name Facility ID#.(ifapplicable) • ft. ft. ^n2.I
OCT2 r2
2914 Patterson:IStreet; Greensboro, NC 27407 ft. ft. I /1' t,
.,.✓....,N w:F. i
Physical Address,City,and Zip ft. ft. . fit::,�„3•`
Guilford . , n1:REIVIARKS , t„ .,. z..,
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 held,one lat/leng is sufficient) , 22.Certification: c
I36°3� 3" i I I ,, '.11 ! ,79i°50'56":w. •i1 ._./ _.
9/6/23
• NO'WELL Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑TemporarylNSTALLED
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: DYes ,or XNo • 15A 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:
S.For Geoprebe/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: 48' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3Q200'and 2()a 1007
' t 1 24a. For All Wells: Original form to Division of Water Resources (D'WR),
10.Static water level below top of casing:' ., r . . I I ru (ft•) iInformation Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" , i 1
11.Borehole diameter: . i• '6 (in,)i • `I t ' I •24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Sonic D.rillin '• i
(i.e.auger,rotary•,:cablb,direct push,etc:) ' I';' i, !' g •
! I 124e.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
I I county environmental health department of the county where installed
' FOR WATERS 1PLY' EILL t�INJ(1 1 I I III I I 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
i ; I ;Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gptn)' '1'• •;Method of test: I; I ,
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13b.Disinfection.type: i : ' ' I ..Amount: i! I
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Form GW-1 I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018
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