GW1--06821_Well Construction - GW1_20231023

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Oliver John Pederson 14iwATER!zONEs d,:
Well Contractor Name FROM TO DESCRIPTION
ft, ft. i
4481-A it. it. -
NC Well Contractor Certification Number '.
X5:'OIITERCAS1NGIformultkitaedwelliVOICLINEIt fli 'livable
Cascade Drilling FROM TO DIAMETER THICKNESS MATERIAL
. ft it. in.
Company Name .
16 INNERiCASENG:OR TIJBING'(geothermal closed joop) ;::
2.Well Construction Permit#: WM04014745 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft, ft. i in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17 SCREEN, - ,::,_ 0 , ' : `..
FROM TO DIAMETER SLOT SIZE_ THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. -
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. it. .in.
❑Industrial/Commercial ❑Residential Water Supply(shared)
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 it. Concrete Cap
❑Monitoring ❑Recovery 1 it' 63 ft
Injection Well: Neat Cement- Tremmi Pipe
❑Aquifer Recharge • ❑Groundwater Remediation ft. ft I
❑Aquifer Storage and Recovery 0 Salini Barri 19"14ANACGRAVEL PACIG(lf.epplicable) <>: :,,.:, ,: :,,;; ,. ,._,:
ty er FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stonnwater Drainage ft. ft. '
❑Experimental Technology ' ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ❑Tracer .:2O:TI1tIL1JING.I;OG:(attach.additional slieets=ifnecesearv)'
❑Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,soli/rock type grain she,etc.)
0 ft' 45 fb Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed: 7/27/23 Well m# VAP-B 1-13 45 ft• 57 rt. PWR - Dark Gray
5a.Well Location: • 57 ft. 63 n• Bedrock-,-,Dark.Gra _y
DOW Corning Corp. ft. ft. `t;�k�; �, : ,r 1-,-._-_
Facility/Owner Name . Facility ID#(if applicable) ft. it ! r
2914 Patterson Street Greensboro, NC 27407 ft. ft OCT 2023
Physical Address,City,and Zip ft. ft. I rtfOri"F.t;iv n Pr;.?. � r.t i� •
Guilford 21 REMATtifs'i.'.' m e ;R y ."
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
(ifwell.field,one lat/long is sufficient).. 22.Certification:
36°3'26" N 79°50'46" W r�2______
NO WELL �'"�` 7/27/23
6.Is(at e)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor;' Date
INSTALLED 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: ❑Yes or XNo 15A NCAC 02C.0100 or 15A 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:
8.For.Geoprolie/DPT or`Closed-Loop Geother• mal Wells having the same You may use the back of this page to provide additional well construction info
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'Iand surface: 63' (ft.)
For multiple wells list all depths if different(example,-3©200'and 2@100� Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top of casing: 7' (fL) 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
24b.For Injection Wells: Cop)/to.DWR,Underground Injection Control(JUC)11.Borehole diameter: 6 (in;)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: Sonic Drilling
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) • county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) Method of.test:
13b.Disinfection type: • Amount: " '
•
Form GW-1 , ' North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018