GW1--06819_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: ' - —
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Oliver,John Pederson . .a4magR:zong.monimmwsw.c..gimmi,;:m. ,. .,,,
FROM TO ' DESCRIPTION
Well Contractor Name : ' ' • ''. ,
.4481-A'.- . • . •
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NC Well Contractor Certification Number . : ' • . :?.•'450111,Eite.ASINGIftifiiiiittkiiidiiiIIWORitINEMItiiP lienble)MW:W:i.WX.N
Cascade Drilling . • .',' .
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ft. ft. DIAMETER THICKNESS MATERIAL in.
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Company Name , .• '. I
•.:::'1163NNERVASING.()It TORINGY(gitithiiiiiiiVCIOSifi4iiiiiiM'AMR,Ni;nW:*!•!AM
I Well Construction Permit#: VVM04014745, ,FROM TO DIAMETER THICKNESS • MATERIAL
1 List all applicable well construction permits(I.e.111C;County,,Slate Variance,etc.) ' . . '' ft. ft. in.
3.Well Use(check well nse):. ' .•
ft. ft.,
IgitliSCREENORMW1i:e1Ngt!.!!,Me.;MW!'!iNg;%MK*KRi.::0.1:m.f.„!.,w,:;,,,..
Water Supply Well:; ' FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural ' . 1:Municipal/Public' r ft. ft. in. •
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OGeothermal(Heating/Cooling Supply) ,OResidential Water Supply(single)' ' ft. .
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Olndustrial/Comniercial OResidential Water Supply(shared)i -;:,o,i;,,:ot.otill,,monom.mangsaii,moli.mmooNtiVW.-firi&O,PA'AO--. .
0 Irrigation. . . . OWells.>100,000 GPD , .FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 1;' 0 ft. 1 ft. Concrete Cap
Injection Well:
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OMonitoring ORecovery ., •: ' i ,'- , 1 ft* 33 ft• Neat Cement-Tremmi Pipe
[Aquifer Recharge , . , „, ADOroundwnterReniediation . ft. ft.
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I ';4K:SitiV01.GRANEZIARCK(Itif011eitbleiMM,'NWA:CR:f0]-60VOMMIM
OAquifer Storage al('Recovery ,, ; 'OS•alinity Barrier ' . .'FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test • '0 Stormwater Drainage ft. ft. 1 '
dExperimental Technology; 0 Subsidence Control ; . ft. ft.
pGeothermal(Closed Loop) . Eltracer • 410AIRILLINGIDOBlitiehlidtiltrottibilientiftiiiiiiiitrYPWMMMIA.;-,Mn,,
0Geothenrial(Heating/Cooling Return) XOther'(explainiunder#21 Remarks) FROM TO DESCRIPTION(color,hardness,soliFrock type,grain size,etc.)
0 ft' 29 ft. Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed: 8/15/23 ' 'Neuthit VAP-B2-02 ' !: 29 ft• 33 it. Bedrock - Dark Gray
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5a.Well Location:• . .
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DOW CorninclCorp. ' . • : . . . •
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Facility/Owner Name • Facility 1D#(if applicable) OCT 2 `,1 '2023
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2914 Patterson Street, GreensbOro',:NC 27407 I !,' !!' ft. ft. ?
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Physical Address,City,and Zip . : ' 1 •! , ' •[ ft. ft. L ,
DWQ.:80i3
Guilford . ,.. . 1 : . ., . • , — ‘ '• 12.t ItgyfAusMpw,VRMMAVAMKORPRI'VARgi.WSRggglir :
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County' . '' . , .. '. Parcel Identifies tion No.(PIN) ,; .I' 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/Iong is suffibient)1 • '
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2.Certification:
11 ° 5" 4 7050'50" y ' 2-----e--F; 11 --•
8/15/23
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6.Is(are)the Well(s)r,OPermanent! or cOTemp ::.orari 14
• 'Signature of Certified Well Contractor Date
INSTALLED
'. By signing this forni,I hereby cert( that the well(s)was(were)constructed in accordance with
7.Is this a repair,to an existing well: 1 ElYei or AN() :• , ' l'iSA NCAC 02C.0100 or 15A NCAC 02C:0200 Well Construction Standards and that a copy
If this is a repair;fill pittknownWell construction:information and explain the nature of thei i ,IK this record has been provided to the well owner.
repair under'#Viremarld section or on the back of thielform.,;
23.Site diagram or additional well details:
8.For Geoornbe/DP'E or deed-Loop Geothermal Wells haviiig the same .,, 'You may use .the back of this page to provide additional
well construction info
construction,only 1 OW-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 I
9.Total well depth helow land surface:. ' ' 33' (ft.)
For multipleSubmit this GW-1 within 30 days of well completion per the following:
wells list all dePthsi f diOrent(example-3®200'and 20100) I '
10.Static water leve6telo top ofcnsing: '. il' . „. I,' 24a. For All Wells: Original form to Division of Water Resources (DWR),
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If water level is above casing,use"+" . '' !Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
II.Borehole diameter:; , , .,,i,', I
, '.:0 n ' ", .,•(i i ' '' f24b.For Injection Wells:Copy ki DWR,Underground Injection Control(IUC)
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'Program,1636 MSC,Raleigh,NC 27699-1636 1,
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12.Well construction Method:.•.:: 'Sbnic Drilling .• 124c.For Water Supply and Open,Loop Geothermal Return Wells:Copy to the
auger,retar);;Ical*?le,&eat ins,ii,ete)l' :' ' ,,1 ,: '
': county environmental health department of the county where installed
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FOR WATEICMXIlli, r„.LNONt,vi li . il p!I .1 1 .
.1,, . ...,, . 1 .• 1 , , r .i4d.For Water Wells producing over 100,000 GPD:Copy.to DWR,CCPCUA
, ,,, i. 1 'I 1 !,,1 :' ,,' , , tql,, ! . ' '': Pernik Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpiny''', ' I I .i I ,!.; :.;014hod Ofient: . . , 1! • I i`
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13b.Disinfection ripe:!. I . • .., Aniinint: • 1,
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Form GW-1 1 ' i . 'l ''''. ! ' 1rtli&rolinaDepartin, ent of EnvirenIntlaliQuality-Division of Water Resources! 1 Revised 6-6-2018
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