GW1-2022-05389_Well Construction - GW1 Attachment_20220609 (2)

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WELL CONSTRUCTION RECORD (GW-1 )
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Form GW-1 Well Construction Electronic Form
North Carolina Department of Environmental Quality
Division of Water Resources
November1
Submission ID#
GW 1-2022-05389
Are you submitting a scanned form?* Yes
• No
CONTACT INFORMATION
.......................................................................................................................
Contact Name* Email Address*
Chris Lacko [e-mail]
Is this a revision to the form you have previously submitted?*
Yes No
WELL CONSTRUCTION INFORMATION
........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
Owner Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
3516 A CHRISTOPHER LACKO Directional Technologies
2.Well Construction Permit#:
W10800548
List all applicable well construction permits(i.e.Monitoring Wells,UIC-Underground Injection Control,CCPCUA-Central Coastal Plain Capacity Use Area,County,
etc.)
What type of well is this?* Injection Well Non-Water Supply Well
Water Supply Well(includes irrigation wells)
3.Injection Well* Aquifer Recharge Aquifer Storage and Recovery
Aquifer Test Experimental Technology
Geothermal (Closed Loop) Geothermal (Heating/Cooling Return)
Groundwater Remediation Salinity Barrier
Stormwater Drainage Subsidence Control
Tracer Other Sparge Well
4.Date well was completed and ID#
......................................

Date Well Completed* Well ID# Well Yield
5/18/2022 HAS-4 na
(gallons per minute)"
5.Well Location
Facility/Owner Name*
Kinder Morgan Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
New Hanover
Physical Address* Street Address
3340 River Road
Address Line 2
City State/Province/Region
Wilmington NC
Postal/Zip Code Country
28412-6242 us
Latitude* 34.1790080000 Longitude*-77.9507320000
Decimal degrees Decimal degrees
........ ................ ........ ....................... ........................... ......... ......... ......... .....
6.Is(are)the well(s):* Permanent Temporary
7.Is this a repair to an existing well:* Yes • No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface: (ft.) 9a.What is the depth of the casing from ground
28 surface?
For multiple wells list all depths if different 28
(example-3@200'and 2@100') in feet
10.Static water level below top of casing: (ft.) 11.Borehole diameter:
NA 6
If water level is above casing,use"+" in inches
12.Well construction method:
Auger Air Rotary Cable Tool
Direct Push Mud Rotary Rotosonic
Other
Directional Mud Rotary
14.WATER BEARING/FRACTURE ZONES
From To Description
in feet in feet Horizontal well

15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 180.00 3.00 SDR11 HDPE
in feet in feet in inches
17.SCREEN
.............................
From To Diameter Thickness Material
180.00 380.00 3.00 SDR11 HDPE
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 27.00 Portland Cement Grout Tremmie pipe 18811bs
in feet in feet
19. SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
in feet in feet
20. DRILLING LOG
From To Description(color, hardness,soil/rock type,grain size,etc.)
0.00 28.00 Brown Sand
in feet in feet
21. Remarks
Casing and Screen Measurements are length of pipe.Other measurements are below ground surface.
22.Site diagram or additional well details:
You may upload additional well construction information here.
as built HAS-4.pdf 355.53KB
pdf only
CERTIFICATION INFORMATION
* By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C.0100 or
15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to the well owner.
23.Certification
&4W al O
Signature of Certified Well Contractor