GW1--06818_Well Construction - GW1_20231023

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WELL CONSTRUCTION RECORD(GW-1) • For Internal Use Only: •
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1.Well Contractor Information: .1 . ._•.]
Oliver John Pederson, ' , r • .ia3VATEIt7ANES_.,: FRA s,, ,.. :.: .:..
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
4481-A .' [t ft.
NC Well Contractor Certification Number YS OLITER-.CASTNCs{for mii[N-cased wells):OR INNER. f s "livable
Cascade Drilling FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name 16'11NNER:tCAS1NG QRTUBING:"(geotkerrtial eloeedleop)
2.Well Construction Permit#: WM04014745 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIt.County,State,'Variance,etc.) [t, ft in.
3.Well Use,,(check well use): 11, ft, ft. in.
Water Supply Well: 17-SCREEN-�`•s ,.. ,_. _
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
:Agricultural ' ; I •, ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in. ,
❑Industrial/Commercial •• • ❑Residential Water Supply(shared) ,1800gOUT .,
❑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" 21 ft• Neat Cement - Tremmi Pipe
Injection Well: [t. ft.
❑Aquifer Recharge' I ; I,oGroundwater Remediation �'
r19'SAND/GRAVEL PACK(ifappllcable) -?.
❑Aquifer Storage and Recovery '❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test in Stormwater Drainage ft. ft.
❑Experimental Technology '❑Subsidence Control ft. ft. ; •
❑Geothermal(Closed Loop) ❑Tracer . , , • , .2D.DRILtING'Y,OG7(attack.adi itlonaLsheets ifneesseO). . „ .<
FROM TO DESCRIPTION(color,hardness,son/rock OGeothermal(Heating/Cooling Return) KOther(explainiunder#21 Remarks) 0 type,grain size,etc.
ft* 10 fb Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed; 9/14/23 ' well ID#:VAP-B2-03 ' 10 ft• 13 ft• PWR - Dark Gray
Sa.Well Location: 13 ft• 21 ft' Bedrock - park,Gray,.-
DOW Corning Corp. • . • , I [t. ft. t: y.d�, ,= i; °�i%A, ,
:
Facility/Owner Name _ Facility Lai/(if applicable) ft, ft n T 9 r� n n
2914 Patterson',Street,l•' •Green'sboio,'!I ,C 27407 ' I!' ft. ft. � c3
Physical Address,City,and Zip II 1 :I I I, I I I' I ft ft. Ill�i i fl �F,i
I Guilford) 1, ? I 1 II tj '., I il., ,I 1 hill, III , 21.IREMARKS; -;' ;.,...- r''.'.-' i �i.
County 11 :�s; ; � ii; 1• 1' i PacelIdent;fieB ionNo.(PlN): , Boring was used for soil sampling and water -
i'' i sampling - Boring:was grouted upon completion
56.Latitude and longitude in degrees/minutes/sl conds or decimal degrees:
(if well field,'on lat%long,is sufficient) 1
i� •l. In ��� II +' 1 �i ;'Z2.Certification: r---
1 .I I! l I6°3; 5111�1i 11 'I I L' i1:.1I. • ;'J I1,9°50'49,, . j I ,
6.Is(are)the.11!weli(s)d'. ❑Permanent. ,or. ;IbTemporary'NO WELL !S•ignature of Certified Well Contractor Date
1: ' II I ' . I ?_: 'INSTALLED 1 I ;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: 1 ❑Yes I Or: .*No !')SA NCAC 02C.0100 or 1 SA NCAC.02C.0200 Well Construction Standards and that a copy
If this is a repair;fill outknown:IweIl construction inforinatibn and explain the nature of the '1of this record has been provided to the well owner.
repair under#211 remarks section or on:the bock of thus form.' i
1 I ; ; , 123.Site diagram or additional well details:
e ll I 1 ° i'I• 'You mayuse the back of this page to pr li
ovide For GeoprobetDPT or:Closed'•-Loop Geothermal Wells having the same p g p ovide additional well construction info
construction,only I 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: 2:1' I (ft.) '
For multiple wells list all depths if different(example-3Qa 200'and 2®100l Submit this GW-1 within 30 days of well completion per the following:
.24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 7i (ft•) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6. tn, . 24b.For Infection Wells:Copy to DWR,Underground Injection Control(IUC)
I , , ( �I1) 11; 1I :I Pro ram,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: SOI11C . ri11111 124cgFor Water Supplyg I
(i.e.auger,rotary),cablb,direct hush,eta f;,I I and Open-Loop Geothermal Return Wells:Copy to the
I, Ill . • ,i .I ! ,, county environmental health department of the county where installed
FOR�VATE�`�SUltI'�LY 4VELLI OS fA' , 1'
i II: I�;I ,1i,I, 1 I�l, „ I24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
, +1, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield.(gent) I :Me.'hod of test: '; . ` I6 I
13b.Disinfection type: Amount: I• I, 1 I, ir
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Form GW-1 I '' ' I •i Nbrth Carolina pep ment of Environs en al Quality-Division of Water Resources Revised 6-6-2018
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