GW1--06813_Well Construction - GW1_20231023

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
L
Oliver John Pederson ' m:xWATrgitzoNEs
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4481-A ft. ft.
NC Well Contractor Certification Number
25.;UTITERVASIN (for'molti-ca ediwells OR LINEI Oin IIcable) '
, Cascade'Drilling '• FROM ft. TO ft. DIAMETER in. THICKNESS MATERIAL
Company Name ,
I6;INNERVCASING OR TUBING?(geothermal closedsloop) ,v'!,
2.Well Construction Permit#: WM 04014745 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable,well construction permits(i.e.IBC,County,State,Variance,etc.) ft, ft. in,
ft. ft
3.Well Use(check well.use): in.
f7<SCREEN 1
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural • ❑Municipal/Public ft. ft. in.
❑Geothermal'(Heating/Cooling Supply) . ❑Residential Water Supply(single) ' ft ft. in. •
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❑Industrial/Commercial, , ❑Residential Water.Supply(shared)' „ratite Uy1 .,.".. „, ::, ;.:, ,:.. ,.-;.
❑Irrigation '. ' ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 1 ft' Concrete Cap
❑Monitoring ❑Recovery : , 1 ft' 58 ft Neat Cement - Tremmi Pipe
Injection Well: • ft. ft.
❑Aquifer Recharge , • , • 'OGroundwater Remediation
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• 19.-SAND/GRA llIt1ACIC(if.applicable) V;•' j.;..: .:m."., ,
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test' ' " ' .' ❑Storinwater Drainage ft. ft. '
❑Experimental,Technology ❑Subsidence Control ft. ft.
❑Geothermal(Closed Loop) ❑Tracer • ,.20.:DRIFT:INGI;OG`(ittuirhadditlonnlsheetsiflaeccesory) ;M1
0 Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness sowrack type,grain size eic.)
0 ft. 48 ft Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed: 9/8/23 Well ID# VAP-B3-07 48 ft 53 ft PWR - Dark Gray
5a.Well Location: 53 ft 58 ft• Bedrock - Dar,.-IcGrayy, - _
DOW Corning Corp. ft. ft. ', .-,---..,1.=s; 'I;,i
Facility/Owner Name Facility ID#(if applicable) ft. ft. • ill:
i;•1 `-' n
ft, ft. l' J
2914 Patterson Street, Greensboro;, NC 27407 ;, '
t1iC•it:: :: 71 Pr,;,nc,IN
Physical Address,co,and Zip I i t t L ,
Guilford. .'. .1 ,• ' 1 :•i.1 IVIARxs; . ... .K . . ...:�. . . . .. ....
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21:I r . ,
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County Parcel Identification No.(PIN) Boring was used for soil sampling and water
, F. i d :1 • I 'f 1 'I : ' : sampling - Boringiwas grouted upon completion
5b.Latitude and longitude;in degrees/minntes/seconds of decimal degrees: .,
(if well field,one lat/long is sufficient) r .I 22.Certification:
.,;36°3'2 " N . ;t79 50'56" ;w. ( -
9/8/23
6.Is are the wells: OPermanent or ❑Tem ora NO;WELL Signature of Certified Well Contractor Date
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Is(
) p SIN STALLED , By signing this form,Thereby certify that the well(s)was(were)constructed in accordance with.
7.Is this a repair to an existing well: ' ❑Yes or XNO „ ' •15A NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a copy.
If this Ira repair,fill out known well construction information and expjain(he 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. •,,1 I • 23.Site diagram or additional well details:
8.For Geoprobe/DPT or.Closed-Loop Geothermal Wells.)iavi!}g 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: 58 (ft) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2®100) ,
i 24a. For All Wells: Original'form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft") !Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above,casing,use"+" •
11.Borehole diameter 6 (in.)i: l�'I
24b.For Injection Wells:Copy to DWR,Underground Injection ControUC)
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;Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Sonic Drilling 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy zo 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
i Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of test: _ _
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13b.Disinfection;type: . • Amount:
Form OW-1 ' ' • North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018