GW1--07158_Well Construction - GW1_20231101

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: ; •
1.Well Contractor Information: •
1
Oliver John Pederson I4,:WATERzt#NES,. _f; ,„„,: ,
Well Contractor Name FROM TO DESCRIPTION
I' ft. ft.
4481-A . • • . rt. ft
NC Well Contractor Certification Number' 1VOULER CASING ii iinldt ciliai Wellif,01 L1NEIt{if ap itiablel
• Cascade Drilling FROM TO DIAMETER THICKNESS MATERIAL
' ft. ft. in. ,
Company Name' •
I6‘''INNER'C ASINGoR TIJBING(geotheri al cloyed Ioep) x
2.Well Construction Permit#: W0401474 M 5 FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
t Water Supply.Well: - I :17s=SCREEN J;, ::, ;,_
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public , ft. ft. . in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)• ft. ft. • in.
•
❑Industrial/Commercial ❑Residential Water Supply(shared)' ivoitotf i
❑Irrigation ' ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ; 0 ft. 1 ft' Concrete Cap
❑Monitoring ❑Recovery 1 ft 43 rt. Neat Cement - Tremmi Pipe
Injection Well: . .
ft. ft. 1
❑Aquifer Recharge . .! ; ❑Giroundwater Remediation
19i'SANDW/GR vEL.PACK(ifhpplicable) a "<
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test • • ❑Stormwater.Drainage . ft. ft
DExperimental Technology: , ❑Subsidence Control ft. ft.
OGeothermal(Closed Loop) ' ❑Tracer 20:::I)LULL 1116i .dGi fatliebli ltliti6iant siieets'if necessary)
❑Geothermal(Heating/Cooling FROM TO DESCRIPTION(color,hardness,soil/rock type,grain size,etc.)
g Return) Remarks)_ 0 ft' 33 ft• Silty Sandy Clay - Dark Brown
•
4.Date Well(s)Completed: 8/2/23 Wellm# VAP-B1-15 . 33 ft• 38 ft PWR - Dark Gray
5a.Well Location: .. ' 38 ft. 43 ft• Bedrock - Dark Gray
DOW Corning Corp. ft. ft. ^;r-- in _,, ,
F t:- r: :ir11'a
Facility/Owner Name ft. ft - ,,`z`"e @.�7' ty ji ,-r1'
Y Facility ID#(if applicable)
2914 Patterson Street, Greensboro, NC 27407 ' • , ft ft ; NOV I) 1 2023
Physical Address,City,and Zip: : . ft. ft.
R
Guilford ! ,21REMARKSO . ,- „ A < .:m� t : l :�.
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
(if well field,one lat/long is sufficient) , I 22.Certification: �� c II
' ' '36°3'25" N • : • I' 79,b50'48" v (52L —'�
• ! "`�`'�~ 8/2/23
NO WELL Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary' ' " LLED'
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,' ISA NCAC 02C.0100 or ISA 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 cr on the back of this form.,
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal 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: 0 , • 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: , 43' (ft.)
For multiple wells list all depths if different(example-3@200'and 2@I00' Submit this GW-1 within 30 days of well completion per the following:
0 ' 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: . 7. (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above;casing,use''+" •I 1 I, :I 1 •
11.Borehole diameter: 6 (in.) 24b.For Injection Wells:Copy(to DWR,Underground Injection-Control(TUC).
• i I'; • Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction'met od: • , Sonic Drilling '
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,directpush,etc.) ' I j I, .j 11 :1'. county environmental health department of the county where installed
. ,ii' . it Ir ; !
FOR WATERSi)PPLY WELLS ONLY: ' I ! ! 1' 11k
I 1 � I ; 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
'?! I I. 1, Permit Program,1611 MSC,Raleigh,NC 27699-1611
13a.Yield(gpm) 1 ' ' ; Method of test,',. I
13b.Disinfection type: ! ' Amount:! . • i I
Form GW-I North'Caroll a Department of Environmental Quality-Division of Water Resources Revised 6-6-2018