GW1--07165_Well Construction - GW1_20231101

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WELL CoNSTRIICTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: • . 1
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•Oliver John Pederson . . • *-14mATER•zonsw..,..mwmom -J,g,N%-,m5-k-P'0,,,,,z1 , --;.,Y.v;,
. . FROM TO DESCRIPTION
Well Contractor Name '
, • ft. ft. I
4481-A . . ft. ft. !
NC Well Contractor Certification Number $154:01111:ERVASINGIffittiiiillkitindiiiill#OWLINERTititii lietibleff:•• ::24..!••••i'' 'i':
Cascade Drilling . FROM TO DIAMETER THICKNESS MATERIAL
• I ft. ft. .in.
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Company Name , I. •
i A6i,INEIC:CASINOD N IC:rMiligO(Ontheriitatitaid;10-iiidNWW:aktKV :'4;.**
'2.Well Conitruction Permit#: WM 04014745 FROM TO DIAMETER THICKNESS MATERIAL -
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List all applicable well construction permits(i.e.UN,County,State,'Variance,etc.) ft. ft. in.
3.Well Use(check well use: •, . , • ft. ft. in.
' 417:1SCREEW44.5'1001:MglIM14.1WMP.Wa1DMV,WZ,VMM:AW:iil:
Water Supply Well:
FROM TO DIAMETER -SLOT SIZE THICKNESS MATERIAL
OAgricultural OMUnicipal/Public ft. ft. in.
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OGeothennal(Heating/Cooling Supply) OResidential Water Supply(single) ft. ft. in.
0 Industrial/Commercial • • OResidential Water Supply(shared) Atk:OROUVWZMAIRMUMAMM„' Re•Mf•Mit .V,,.5i:•:•'?••,,,.•';:\.;t,.,i.,,:,:'),•,,a';
OIrrigation • ' . ! , OWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:•• • 0 ft. ft* Concrete Cap
OMonitoring •Injection Well: ORecovery . 1 ft' 75 ft. Neat Cement - Tremmi Pipe-
: •
ft.OAquifer Recharge 1 OGroundwaterRemediation ft.
. . g:19i'SAND/GRAMPAtIC(Itiiiiiilietilile)- 41.:RA;Viaa.ZOMMO00??..;.,W.eW.9i.
OAquifer Storage and Recovery : 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
OAquifer Test 0 Stormwater Drainage ' ft. ft.
°Experimental Technology : ' • 0 Subsidence Control ft. ft.
OGeothermai(Closed Loop): ; OTracer „ • 40iiiiMMINOZOGIiiitilehlidaltiniiiiratienhiittiiiiiiiiiiil*MWNMIn:i-17-
FROM TO DESCRIPTION(color,hardness,soil/rock type,groin size,etc.)
OGeothermal(Heating/Coolitig Return) Other(explain under#21 Remarks)
0 ft' 65 ft• Silty Sandy Clay- Dark Brown
4.Date Well(s)!Completed: 8/11/23 Well ID#•VAP-B2-04 65 it 70 ft• PWR - Dark Gray •
5a..Well Location: • 70 ft. 75 ft. Bedrock -Dark Gray
_L . 1, ft. ft. ' r•, .;. -i 't_.
DOW Cornind Corp. . ' ' -..::.i,.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
I •• ft. ft. NOV t) 1 2023
29t4 Patterson.Street, Greentboro,'NC 27407:. '
Physical Addreis,City,and Zip 1 ft. ft. , In>c ;c-r:71: 1a pr.:--,-„,,,„:._ -.1.-:-.:2, 1,;r:)‘
3132E1WARKSW:MilIMP:kiMg=gallt*P;i4.4-4.=.-.WWW&OEK'M
Guilford '1 .. • .. . . . .
County ' ! " Parcel Identification No.(PIN) Boring was used for soil sampling and water
, •5b.Latitude an4 longitude in degrees/minutes/seconds or decimal degrees: sampling - Boring was grouted upon completion
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(if well field,one lat/long is sufficient) , 22.Certification: c T .....)
i • " 791650'59" N,'' ; '
N : ' ., . :I • I:, ' ! X......._1/......4----.......,___
8/11/23
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' NONVELL
6.Is(are)the well(s): OPerrnanent or EITemporarY i Signature of Certified Well Contractor Date
, . • • INSTALLED '
, .. . By signing this form,Thereby cern),that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: 01(es .or XNo , 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repaii,fill put 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 tbls form:
23.Site diagram or additional well details: ,
You may use the back of this page to provide additional well construction info
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
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: : .75' (ft.)
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) Submit this GW-1 within 30 days of well completion per the following:
t .
„ s 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: 17 I • (L
1 I. t)- Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+" ! I ' ' 1
11 ,
Borehole diameter 6
tin)
ri• 24b.For Injection Wells:Copy'to DWR,Underground Injection Control(1UC)
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i . . • • „! ., Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction megiod: 'Sonic Drilling . I, 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directIijusli,etc.) I I I : I 1 i I I t
1 II: . • •I . • 1 I I I!! L I ; county environmental health department of the county w—liere installed
• FOR WATER SUPpLY WELLS!ONLY: •: ;i I I I! 1 1 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
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: 1.1• •i; I . !ill l' • ,: '' • Permit Program, 1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm)'I• I'' I ' • Method Wiest :1 ., . I
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131):Disinfection type: ':Amount:
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Fonn GW-1 1 : ! , t ,, 'North arolhie Department of Envirodrnental Quality-Division of Water Resources Revised 6-6-2018