GW1--07161_Well Construction - GW1_20231101

1 .I. I11 1.:I ! ! !I 1,1I! , 1111. I1,II d ,
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
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1.Well Contractor Information: I
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Oliver John Pederson . . 14„WAIEI . UNES . <t
Well Contractor Name FROM • TO DESCRIPTION
ft. ft.
4481-A ft. ft.
NC Well Contractor Certification Number
15.OIFfl1JIt:CA'SING{fo`r mnli i ed welliWOR G1r1 IMInp kiiiile) ,.
Cascade Drilling FROM TO DIAMETER THICKNESS MATERIAL '
ft. ft. in.
Company Name '
IE INNER'CASING OR ll311l11IG(geothefinal cloSed=loop) '
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. in.
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3.Well Use(check well use):'
ft. ft. • in.
Water Supply Well: , : I , I7 SCREEi�i :,; r
:FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft, in.
OGeothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) '
ft it. in.
❑Industrial/Commercial ' ❑Residential Water Supply(shared) , I8.-G4R1ittr . P "
❑irrigation • . ❑Wells>100,000 GPD • FROM TO MATERIAL EMPLACEMENT METHOD ds AMOUNT
Non-Water Supply Well: 0 ft. 1 fa Concrete Cap
❑Monitoring • - ' ❑Recovery . 1 ft. 63 ft. Neat Cement - Tremmi Pipe
Injection Well: '
ft ft.
❑Aquifer Recharge OGroundwater,Remediation I
19.-S D/GRACE.,PACK I1aop1a'cable), ;`.
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ' ❑StormwaterDrainage ft. ft. '
❑Experimental Technology, ' ❑Subsidencg Control ft. ft.
❑Geothetmal(ClosedLoop) 0 Tracer Z( DRRLEINGILOCr.(attaeli dititluualsheetiiifnecessaty) +g_.::>, '❑Geothermal(Close g/Cobling Return) Other(explain under#21 Remarks) 'FROM TO DESCRIPTION(color,hardness,solUrock type,Rrain sixe etc.)
0 ft. 45 ft. Silty Sandy Clay - Dark.Brown
4.Date Well(s)Completed:;' 7/27/23 Well IS'VAP-B1-13, . 45 'ft• 57 ft. PWR - Dark Gray
Sa.Well Location: . . i 57 ft• 63 ft. Bedrock - Dark Gray
DOW Corning'Corp. ft. ft. ' :�,,, ;---., —
Facility/Owner Name. , Facility ID#(if applicable) ' ' ' ft. ft. '�•' =;,,,s-., +V i.,,, :i
2914 Patterson Street 'Greenshor,o; NC 27407' ' ft. ft. NOV ,) 1 2023
Physical Address,City,and Zip. ft. ft. i
Guilford 21'REIVIARKS: `
. ,F` � c F
County ' Parcel IdentificationNo.(PIN) Boring was used for soil sampling and water
•Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees: sampling - Boring was grouted upon completion
(if well field,one lat/long is sufficient) 22.Certification:
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� -`— 7/27/23
I N'O WELL . ''
6.Is(are)the Well(s); OPernjanent' or '❑Temporary' '(+ Signature of Certified Well Contractor Date
I `INSTALLED j 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 XNoI I 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 an4 explain the nature ofthe••1 of this record has been provided to the well owner.
repair under#2I iremarks section or on the back of this form.'
23.Site diagram or additional well details:
8.For Geoprobe/DPTor Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info •
(add'See Over'in Remarks Box).You may also attach additional pages if necessary.
construction,only 1'GW-1 is needed. Indicate TOTAL NUMB�ER.of wells
drilled: I •
24.SUBMITTAL INSTRUCTIONS
9.Total well depth below.land surface: : 63 (fL) i' •
For multiple'wells list all depths if different(example-3(a}200'and 2_QI00) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below'top of casing: 7'' ft. 24a. For All Wells: Original form to Division of Water Resources (DWR),
If water level is above casing,use"+" 1 , ) Information Processing Unit,1617'MSC,Raleigh,NC 27699-1617
I1.Borehole diameter: 6 (in.) .'' : !! 24b.For Injection Wells:Copy,to,:DWR,Underground Injection Control(IUC)
-. ; II I I it I.! ' Program,1636 MSC,Raleigh,NC 27699-1636
12.Well'con'struchon metlioi: : .Sonic D!rllllr I , !I ! I
}},, g 24c.For Water Supply and Open-Loop Geothermal Return Wells:Co to the
(i.e.auger,rotary,icablet d`irectiius,,etc.) • ' _, 1 I 1: .I 'I' Copy
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• county environmental health department of the county where installed
FOR WAT R S I'PIL,Y` ELLS O Y: ,f i ( f
�,• ,f,. i I f'• , I ' ! II i 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
I i f j • I I I Permit Program,1611 MSC,Raleigh;NC 27699-1611 '
13a.Yield(gpm) :Method t�i teat: I k is IIf ,, '
13b.Disinfection type: !'''' , Amount:1 i I'
Form GW-1
North CarollmaiDepartment of Environmental Quality-Division of Water Resources Revised 6-6-2018