GW1--06815_Well Construction - GW1_20231023

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Oliver John Pederson 414<WAICERZONES ,,_ -.
Well Contractor Name FROM TO DESCRIPTION
ft. ft. '
4481-A ft. ft.
NC Well Contractor Certification Number
•154011TERiCASING{for multi-is ed.wllie OR LINER(If ap !Cable) .,
Cascade Drilling FROM TO DIAMETER THICKNESS q MATERIAL
ft. ft. 1 in.
Company Name '
I6,INNERiCASING:OReT[IBIN.G.i(geothermal closed+loop) N_:<_
2.Well Construction Permit#: :WM04014745 PROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check,well use): • ; ft. ft. in.
Water Supply Well: 176CREEN."; S..;;.:. :,...;: ;:
• 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/Comalercial ❑Residential Water Supply(shared) ,15'GROIIT ; . ,7„ -:' x c.,,;
❑Irrigation • OWells>100;000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' 0 ft' 1 ft' Concrete Cap
❑Monitoring ❑Recovery 1 ft. 23 ." Neat Cement- Tremmi Pipe
Injection Well: ft. ft
❑Aquifer Recharge . . : ❑Groundwater Remediation •
;i ', ' .19:-SAND/GRAVEL PACK(ie.applicable) • ..ir.;.
❑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:DRlL/G.xOG7ettacli:&iidl8tinaIsheetsatnecessary) s _ :: -,
FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc,
OGeothermal(Heating/Cooling Return) XOther(explain'under#21 Remarks) 0
ft. 14 ft. Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed: 9/13/23 Well ID# VAP-B2-09, 14 ft' 18 ft. PWR - Dark Gray
5a.Well Location: 18 ft. 23 ft. Bedrock-:-2.Dark;Gray ___
ft ft. ,, �i-L' .DOW Corning Corp. I 3,a_.Facility/Owner Name Facility ID#(if applicable) • ft. ft. n(.T 2 s
2914 Patterson Street, Greensboro, NC 27407 st. I lt. „tll`rRn `�2J '
Physical Address,'City,and Zip" . Ri 4 l l;a
Guilford • 21 REivimuc' :. n.
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: � r
' I I!: 'II? ','16P3fZ4" 4 ll Iyll i�' •)11. i:'l i II I79e50'49u �;1,Ir l2I Cj2---' ''/Z--_'---,
9/13/23
NO WELL Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent' or' ❑TemporarylNSTALLED
By signing this form,I hereby certifi that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yea or XNo 15A NCAC 02C.0100 or 1SA 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:
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or:Closed-Loop Geothermal Wells having the same
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: 23, (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 1(41100)
, 24a. For All Wells: Original!form to Division of Water Resources (DWR),10.Static water level below top of casing: ; ;+ :7 'L '(ft.) 'Information Processing Unit,16'17 MSC,Raleigh,NC 27699-1617
If water level is above casing,fuse'+ : • I I I j
11.Borehole diameter 6 (ip,) !I I • ,24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
. ;1 I , .• I • . ' 'Program,1636 MSC,Raleigh,Nq27699-1636
12.Well construction method: . sonic Drillin9 !
24c.For Water Supply and O I en-Loop Geothermal Return Wells:Copy to the
' (i.e.auger,rotary,lcali('e,diree pusf i,efe?j ''I I 'I ' '1 1 I 1'
l ' .!county environmental health department of the county where installed
I FOR IYAt'Et S PITYr'ELPIdsll t t pp I I LL' PI IZ4d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
r Ii!: `j I :?I ; •: I 'I •,. ` !Permit Program,1611 MSC,Raleigh,NC 27699-1611
1!3a.Yield(gpm)!I Me hod of test:
13b.Disinfection type: ; Amount: I i
•
Form GW-1 , , ,: , : I Nbrtti Carolina'I)epaikinent of Environmental Quality-Division of Water Resources Revised 6-6-2018