GW1--07166_Well Construction - GW1_20231101

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: . . 1 i
Oliver John Pederson, . , .14.wA'r>;R;7.pNEs .,- , o _� . . . ��.; ..
Well Contractor Nam_a FROM TO DESCRIPTION
ft, ft.
NC Well Contractor Certification ft. ft
4481-A
anon Number V;OI11'ER ICASINatiniiiiiilikiiiialiellaYDItLINEktiriiiilliaibleMgMn
Cascade Drilling FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. • in.
Company Name ,
m 16 INNER CASING O1t;;TCTBI1�tC(geothermal closed)nop)
2.Well Construction PermitV M#: 040.14745 1 FROM • TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,1Variance,etc.) ft. ft. in,
3.Well Use(checkwell use): ft. ft. in.
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Water Supply Well:. 1t SCREEN "
�Agricuhural' ❑Munlel aUPublic . FROM TO DIAMETER SLOT SIZE THICKNESS MATERNAL
P ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. • ft. in. I--
❑Industrial/Commercial; ' ❑Residential Water Supply(shared)
..18.;G1tOLT'Tmomvx 4,'".:a;,?w?r_.,.-: ,kmakva s b_.
❑Irrigation • D Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: . ! • 0 ft. 1 ft. Concrete Cap
❑Monitoring • ❑Recovery 1 .
Injection Well: ft 56 ft Neat Cement- Tremmi Pipe—
ft ft.
❑Aquifer Recharge ! OGroundwatdr Remediation •
❑Aquifer Storage and Recovery El Salinity Barrier : {FROM' C P.AC1G(ifATERI ble)� ;--
ty FROM TO • MATERIAL EMPLACEMENT METHOD
:Aquifer Test ❑Stormwater•Drainage ft. ft.
DExperimental Technology: • ❑Subsidence Control ft. ft. '
OGeothermal(Closed Loop) ,OTracer a0 11RILLTNG,`LCiG.(ettiach dildittoanl aheets`if aecas's"ery) M
FROM TO DESCRIPTION(color,hardness,soli/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) Other(explainunder#21 Remarks) 0 ft. 46 ft. Silty Sandy Clay - Dark Brown
4.Date Well(s)Completed: '9/11/23 Well m ,VAP-B3-03 ; 46 ft. 51 rt• PWR - Dark Gray
5a.Well Location:' 51 r`' 56 ft. Bedrock - Dark Gray
DOW Corning Corp. ft. ft.
Facility/Owner Name ' FacilstylD#(if applicable) ft, ft, k•�. 4�}/'i:..�: ;a�;�,i,
G>-..is la a__ ,i g
2914 Patterson:Street, Greensboro,NC 27407i! ft. ft.
Physical Address,City,and Zip , . • j ft. ft. ''" ' ±- L l�L J
• Ti REMARKsi+ ��.. . r�, _. , 44.Guilford . • , .
County . 'Parcel Identification No.(PIN) Boring was used for soil sampling°aid water:
5b.Latitude andlongitudeie degrees/minutes/seconds or decimal degrees: sampling - Boring was grouted upon completion
(if well field,one lat/long is sufficient) 22.Certification:
. I36°3' " ! 1 , ! III 79950'56" vv., C71---- 9/11/23
' ' ' ,NO WELL
' 6.Is(are)the well(s): ❑Permanent or ❑Temporary Signature of Certified Well Contractor Date
:INSTALLED • By signing this form,Thereby certf that the well(s)was(were)constructed in accordance with
7.Is this a repair'to an existing well: ❑Yes. or XNo ' • 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fit out/mown well construction information and explain the nature of the: • of this record has been provided to the well owner.
repair under,#2I remarks section or on the back of this form. 1 1 •
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:. 56' (ft.)
For multiple wells list all depths f dt/ferent(example-3Q200'and 2®100) Submit this GW-1 within 30 days;of well completion per the following:
t I 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below'tpp of casing: i:. I U .. (ft)
If water level is above casing,use"+^ i ' • 1!! Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: I . 6 (in.)I ; • 24b.For Injection Wells:Copy to DWR,Underground Injection Control(IUC)
I' ! Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction methot�: 'Sonic Drilling
(i.e,auger,rotary,cal?e,directlpus}y eta) ; ! , I i ! i . 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
1 ;. I I I I I ! county environmental health department of the county where installed
FOR WATER SUPPLY VhEY,LS`ONL�': ! 'I I �I! I it f�
'j ! ; 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gp`m)' Method of test:, i Permit Program,1611 MSC,Raleigh,NC 27699-1611
131%Disinfectttiii type: . I Amount:, :i
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Form GW-1 I • 1, , • • ; ; i N firth•Caroliila;Department of Environmental Quality-Division of Water Resources Revised 6-6-2018