GW1-2021-07209_Well Construction - GW1_20211006

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
James Robertson 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4482 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. I ft. I in.
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER i"• THICKNESS MATERIAL
2.Well Construction Permit#: N/A SCh40 PVC
List all applicable w Cell permits(i.e. o nn(v•S 0 tr. 5 ft. 4 late. Variance.Injection,etc.) fit. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft' 15 fit 4 in. .010 sch40 PVC
❑Geothermal(Heating/CoolingSupply) ❑Residential Water Supply(single) f. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 3 e. Bentonite Chil Poured
Non-Water Supply Well:
fr. fit.
OMonitoring ❑Recovery
Injection Well: fit. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinitv Barrier MATERIAL EMPLACEMENT METHOD
FROM TO
3 fit 15 fit• #1 Sand Poured
❑Aquifer Test ❑Stormwater Drainage
fit. fit.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it nece'ssa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiurock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 10-13-20s)Completed: Well[D#VMW-1 ft. fit
fit. fit.
5a.Well Location: fit ft
Kinder Morgan Terminals LLC NONCD0001697 ft• ft. Px
n9U �ti
Facility/Owner Name Facility ID#(ifapplicable)
3340 River Road, Wilmington, 28412 fit. fit.
D
Physical Address.City,and Zip 21.REMARKS
New Hanover R06400-001-003-000 2,CConcrete Pad
County Parcel Identification No.(PIN) 5.0 Stick up with 9ft
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient)
34.179070 N -77.951313 W. o„„ 11/10/20210
S ature of Certified Well Contractor Date
6.Is(are)the well(s): [OPermanent or ❑Temporary /3v signing this form, /herehv cergfv drat the well(s)was(were)constructed in accordance
wt6 15A NC'AC 02C.011/0 or 15A NC'AC 02C.0200 Well C'onsiruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy of this record has been provided to the well owner.
If ilus is a repair,fill out knout well construction information and explain the nature of the
repair under=21 remarks section or on the hack of this firm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
l•or multiple injection or non-water supply wells ONLY with the.vame construction,you can
submitoneforin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
1•or multiple e,ells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: None (fit) Division of Water Resources,Information Processing Unit,
if water level is above casing,use•• " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 1 1 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Hollow Stem Auger 24aabove. also submit a copy of,this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger.rotary,cable.direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013