GW1--06814_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: - '
1.Well Contractor Information: • '
•
Oliver.John Pederson • : �1o,wATEItons
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4481-A, ft. ft.
•
NC Weil Contractor Certification Number '15.OTITERCASING'(for multi=cemed tiells)'OR LINER'(if ii-liable
Cascade Drilling •
FROM TO DIAMETER THICKNESS MATERIAL
ft, ft. in.
Company Name ', ,
i 161NNER'CASING;ORMUBING'•(geotbermal closed;loopj ...,+s .,
2.Well Construction Permit#: WM04014745, FROM TO DIAMETER THICKNESS MATERIAL 1
List all applicable well construction permits(i.e.UIC,County;State,Variance,etc.) ft. It in,
3.Well Use(check•well use): ft. ft. in.
Water Supply Well: i7 aiCREEN ?- °;: r
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
❑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. 56 ft. Neat Cement - Tremmi Pipe
Injection Well: ' • • ft. ft.
DAquifer Recharge ❑Groundwater Remediation
19lSAND/GR'AVEL<P.ACK(it applicableW• ti. -..;,+ .
❑Aquifer Storage.and Recovery • ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test • ❑Stormwater Drainage ft. ft. ,
❑Experimental Technology ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer ,,IODRIIIINGI1UG`(attachiidditionrtislieetsifriecessiry)W::..:.:
FROM TO DESCRIPTION(color,hardness,soWrock type,grain size,eta)
❑Geothermal(Heating/Cooling Return) XOther(explain under#21 Remarks) 0 ft, 46 ft' Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed: 9/11/2.3 Well ID# VAP-B3-03 46 ft. 51 it. PVVR - Dark Gray '
5a.Well Location:, _ 51 It' 56 ft. Bedrock -,Dark Gray
DOW Corning.Corp. it. ft. r \ r"r':,�
Facility/Owner Name Facility ID#(if applicable) ft, ft.
2914 Patterson'IStreet, iG.reensboro, NC 27407 : !' ft. ft. ,
Physical Address,City,and Zip ! 1 ft. ft. I11;;:i;;:,..,' :;l fir^. .neoxq kilt
Guilford.
, 21:-REIGIARKs '..w. N.;T. . 1.tv,i ,.vkl s s:
County Parcel Identification No.(PIN) Boring was used for soil sampling and water
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: sampling - Boring was grouted upon completion
(if well field,one lat/long is sufficient) ,, ' 1 22.Certification: c
I3663r24r' :N; ! •. 'c I. I i ,i I. 11 7,9°50'56"1w i �/�------ "`�"`'' -.- 9/11/23
_ . , NO;WELL
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or '❑Temporary)NSTALLED
By signing this form,I hereby certj that the well(s)was(were)constructed in accordarce 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 is a repairkfill.olut kpown we'll construction information and explain the nature of the , of this record has been provided to the well owner.
repair tinder,,#21;renl arks section Or on(he!back of this form:. ' .
• 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
• (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 24.SUBMITTAL INSTRUCTIONS
i
9.Total well.depth below land surface: • 66 ; (ft.)
For multiple wells list all depths if different(example-3@200'and 201,00� •Submit this GW-1 within 30 days of well completion per the following:
li i.. '' • i l I 1 .I. i I i, i 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water levelbelo Op of casing:., 1! ., I !1 Ili' (fti) Information Processing Unit,1617,MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" i ,1 ''
' i • ! 'i : ' . , ;24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
1 i 1.Borehole diameter: 6 (in.)I I• I Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construcllonmethod: . • Sonic Drilling '! i • , 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,;cable,direct P 1 usi,etc.) j ' I I ; ounty environmental health department of the county where installed
!I l
FOR WATER!Si 'P,,Y V1bE L5'0 1LY!,I:I1 !I I1I i —1 j ,I f' 44d.For Water Wells producing over 100,000 GPD: Copy to DWR,CO2CUA
i I , ; I ,, I, .I I..,,I ;I I „I Permit Program,1611 MSC,Raleigh,NC 27699-1611
,
13a.Yield(gpm)1. 1 ! 'Method of:test: !I I ;! 1 11
I
13b.Disinfection type: • ' ; ° Amount: . •
Form GW-I I " North CarolinaiI iepartment of Environmental Quality-Division of Water Resources Revised 6-6-2018