GW1--06816_Well Construction - GW1_20231023

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
,
1.Well Contractor Information:
Oliver John: Pederson .ia:wA'r ::uksigs r. .
Well ContractorNarrie FROM TO DESCRIPTION
i ft. ft
4481-A ft. ft.
NC Well Contractor;Certification Number •
' • -I5.OUTERCASING(for multi cased Svelte}OR'LINER(It,applicable)
Cascade Drilling •
FROM TO
ft. ft. DIAMETER THICKNESS I MATERIAL
in.
Company Name i .
16:INNERCCASING`,.OR'rTUBINGI(geotherinal.closed•loop)
2.Well Construction Permit#: • WM 04014745 • FROM 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.
• M7.5CRZ;EN t t? f .: :,:
Water Supply Well: . 1FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural' ❑Municipal/Public: ft. ft. in.
0 Geothermal(Heating/Cooling"Supply) ❑Residential Watec•Supply(singl) ! ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Ie.:GROUT i<`. ' ,, s..;;
❑irrigation ❑Wells>100;000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: .1 • 0 ft' 1•f' Concrete Cap
•
❑Monitoring , ❑Recovery 1 ft' 13 ft Neat Cement - Tremmi Pipe
Injection Well: • •
ft. ft.
❑Aquifer Recharge , ;I:1 i . : ❑GroundwatertRemediation
191:SAND/GRAYEI2 PACIC(1f.applicableX
: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 I 20:I)RILIiING`LOC:(attacb,edillilonal sheets<itneceseery) ''
t
❑Geothermal(Heating/Cooling Return) XOther(explain,under#21 Remarks) FROM TO DESCRIPTION(color,hardness,solUrock type,grain size,etc.
0 ft' 3 ft' Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed: :9/14/23 . weii m# VAP-B2-08 3 ft. 6 ft PWR - Dark Gray •
5a.Well Location: 6 ft. 13 ft Bedrock - Dam Gray
DOW Coming Corp, ' ft. ft. �C.t 5 ;-Z� L
g p. , z. 0 a` 'a.> ��'ii
Facility/Owner Nanie • Facility ID#(if applicable) ft. ft
2914 Patterson Street, 'Gre"ensborb NC 27407 .i ft. ft. 2
Physical Address,City,and Zip, , , ft. ft. i R mz.:'c n 'r:- r,-.�r,�(.311N.
Guilford
It-REMARKS` } . ;: ..t i;..: vS x
County Parcel Identification No.•
(PIN) Boring was used for soil sampling and water
• I•
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),
,, , .i 22.Certification:
1 I li I'l 613f ii" 1. ii !1' 111 i 1 '' �I' 1,17911r50'49" W' ; '..4--- ~
I `- 9/14/23
NO;WELL Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or "❑Temporaryl INSTALLED
By signing this form,I hereby certify that the well(s)was(were)constructed in accordanm with
7.Is this a repair to an existing well: ❑Yes or XNo •ISA NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a copy
tf this is a repair;fihl'out known well construction:inforrpation'and a plain the nature of the : :of this record has been provided to the well owner.
repair under#21i remarks section Or on the 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.nfo
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: 13' (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths'if different(esample-3@.200'and 2®100)
10.Static wafer level bet:.; top of casing: I]',: ; I ft i124a. For All Wells: Original(form to Division of Water Resources (DWR),
limiter level is above casing,use"+' I I( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
1
II.Borehole diameter: ' 6 . (i q!.) . i 'i ; • , ;24b.For Injection Wells:Copy to DWR,Underground Injection Control CUC)
,• II ;!:! , : ,I,+ ki! I I . i • (Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction'method: n:i Sonio rillinq i
(i.e,auger,ro 1 i � 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy�the
tary,Icable,direct qus�,04; I 1 I 11 i I county environmental health department of the county where installed
i , ..i ! . :i I I:I 1 i,; , I
FOR A' EIS S JlyP1LY 'E L''d I. iI 1 : 1
w i 1 j i1� r 4 �' /4d.For Water Wells producing'over 100,000 GPD:Copy to DWR,CCPCUA
II ''' '! (I ! '', ' •••i : 1: 1 ..! Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) •'I ' :Method of;test: I I.
13b.Disinfection type: . • ••
Amount:
Form GW-1 , I i North Carolintv Department of Environmental Quality-Division of Water Resources Revised 6-6.2018