GW1--07160_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD(GW.1) For Internal Use Only:
1.Well Contractor Information:
•
.
.Oliver John Pederson , 4-14.yvATltRzoNts
We1lContractorName FROM TO DESCRIPTION
' ft. ft. 1
14481-AI!I1 , dl i H I ; ; ft. ft.
NC Well Contrac:6i' ertificatiotl Number , I
I ,II I IS OY1TE>Y-Czi$Il�1lI{for`Snniticeged rovellsj OR I.INER(if'applicable)
Cascade Dril inlg ! 1 ! I I I FROM I TO DIAMETER THICKNESS MATERIAL r
Coro an Name' I I ' ft ft. m
i !
p ;y
I j,. I 1 i6 INNER CASING OR<TUBING:'(geothermal closed too )
2.Well Con Itrnction Permmit# '! WM 0.401:: 745' FROM TO DIAMETER THICKNESS MATERIAL
List all applicablefwelJ const' coon permits(i.e.UIC,'Coa'nty,Sfbte,Van'nce,etc.) i ft. ft. . in.
I I_11.I I !.G II P
3.Well Use(c eck well u e): I ft• fa in•
h 1 u 11
❑Ater Supply Well: I' ' ! ' 1'/.SCRIIEN
Ii ' I FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
grioultural: II1. .' blic
I, p ft. ft. in.
❑Geothertnal I. II
(Heating/Cooling Supp y) ❑Reslldenti'al Water Supply(singl )
1, 1!1 I I ; I ft ft in.
I ❑Industrial/Co mercial: • .f + ❑ est enti WI are Supply(shared),.
❑Irrigation 'I . •I 1 ; ❑. el s>lt,0,000 PD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ' ' 0 ft. 1 ft. Concrete Cap
❑Monitoring ORecovery • 1 ft. 13 ft. Neat Cement - Tremmi Pipe-
Injection Well: . •
❑A uifer Recharge ft ft
4 ❑GroundwateiRemediation :Ir
I::. 19.°SAIIINGRAVEL?AGIC(if atiplicable)s _
❑Aquifer Storage'and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD 1
❑Aquifer Test . ❑StormwaterDrainage ft. ft.
❑Experimental Technology' ' DI Subsidence Control ft. ft.
0 Geothermal(Closed Loop? OTracer 20:DRILLINGZOG(attach kdditloi litilibets�ifnecegsary7
❑Geothermal FROM TO DESCRIPTION(color,hardness,soll/rock type,grain size,etc.
(Heating/Cooling Return) Other(explain under#21 Remarks)•
0 ft' 3 't• Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed::.'9/14/23 Well m#,,VAP-B2-08 3 ft• 6 ft• PWR - Dark Gray
5a.Well Location: • ' 6 ft• 13 ft. Bedrock - Dark Gray
DOW Corning'Corp. I rt. rt.
Facility/Owner Name ' Facility ID#(if applicable) ft. ft. `,0'd:.a„„ j;;'9 n'0
2914 Patterson!,;Street,l Greensboro, INC 27407'I• ' ' ft. ft. 1 NOV I) T 20
Physical Address,City,and Zip• ! ' ft. ft.
Guilford 21••RE h'
1VIARI45 x s
,7
County Parcel•Identification No.(PIN) Boring was used for soil samplin and water
Sb.Latitude andllongitude in degrees/minutes/econds ,r deci' al degrees: sampling - Boring was grouted upon completion
(if well field,one 1atI'l ong is'su1 i cient). ' il I I I. 22.Certification: r^
I f!36?3' 4" lv a li!i I y 79'fj 50'49" c1 _--
I'w 1II: O ELL Si ature of Certified Well Contractor Date
6.Is(are)the vie 1(s: 0,P1'1 manei t ,•or .❑Telu ora NSTALLED
By signing this form,I hereby cert�that the well(s)was(were)constructed in accordance with
f
7.Is this a repairlito an ex sting wWell Oyes ;o'r .+ o ! I 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repaii,ifill o'tit known I eft c nstruction inform lion)and•I'lain 1 e nature of the'I of this record has been provided'to the well owner.
' ,repair under,,#21i((remdrks sectlo o,.on the'b)ick of this I iiiri II ' I
I f III L' ' 11 23.Site diagram or additional well details:
8.For Geoprobe PT or C osedi oo Geotherma We I' avin_the same You may use the back of this page to provide additional well construction info
construction,o ly;l'GW-1-t need. j dicate TOE! BER of wells , (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
' 'drille1: I 1 •!I I. III"I. I. I ', 24.SUBMITTALS INSTRUCTIONS
I 11 1 t rfa
y To 0'well dep�beloved nd s ac 1. ii1 1, I1.1 3 :1 (f,) L 11 1
For to lr pie ell J+JI'eJlldeptlis' come r 1( •ample 3(a�20 'an boo' 1 Submit this GW-1 within 30 days of well completion per the following:
lO.IStatic water IjTel belq to i of ca11'1 .l ng: I �,, 1 .,I+ (t. , ,24a. For All Wells: Original form to Division of Water Resources (DWR),
•If water level is abo a casing,e I I' I • ,I 1 )• Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
I �� t
1L Borehole diatine�er: I I� ;16 i in) f 24b.For Injection Wells:Copy to DWR,Underground Injection Control(WC)
I I1II !:I I ', I I Program,1636 MSC,Raleigh,NC 27699-1636
12.Well constrlui on metffiid !I : Sonic D.'rllli f ''I •
(i.e.au'geq ro '' 1 fi g 24c.For Water Supply and OpeniLoop Geothermal Return Wells:Copy to the
Lary,calle directlpus ,etc) ; ,,. I • ,,• I, I Ii..I 1 I county environmental health department of the county where installed
II '
I FOR WATElf SLIjPPLY LgiO�t�,' l '''
• I I i I 1 I I I ! ' [ .,I !, ! 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
(gP � • I I!, ' v:. ' Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield m I I I I •Met od,of;test:'I I I ' !it: ;
• :, 1 l i if! ;
13b.Disinfection type: I I 1 Amount:• , '
I , , I I'I I ' I 11 .
, I . I I
I 1 I f� II
1 Form GW=1 •• I • 1 ,1 I , I :r I Nort i.Carolin1 Departs Tent of Environmental Quality-Division of Water Resources .' , Revised 6-6-2018