GW1-2023-01764_Well Construction - GW1_20230223

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: •I
Kevin White 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
2973 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells OR LINER if a licable)
FROM TO DIAMETER
THICKNESS r MATERIAL
Parratt-Wolff, Inc. ft. ;, lin.
Company Name 16.INNER CASING OR TUBING(geothermal closed400 f•
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n/a 0 ft. 3 tt. 2 in. sch40 PVC
List all applicable well permits(i.e.County,Stale,Variance.Injection.etc.) in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft. 15 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) it. ft. in:,
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 er. 2 ft• Portland Cem Tremie
Non-Water Supply Well: ft. ft.
EMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Rernediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
2 ft• 15 ft #2 Sand Tremie
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soitlmck type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
rt. rt.
4.Date Well 12-14-22 MW-46s)Completed: Well ID# ft. ft, i
5a.Well Location:
Kinder Morgan LLC River Road ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
2023
3340 River Road, Wilmington 28412 ft. ft.
Physical Address,City,and Zip 21 REMARKS rt,..� v• - ra
New Hanover R06400-001-003-000
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
34.179227 N -77.951974 W !: 1 i -oL 3
Signature of Cert ed Well Contractor Date
6.Is(are)the well(s): OPermanent or ❑Temporary 11
By signing this firm,1 hereby certify that the well(s)was(n•ere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAG 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ©No copy ofthis record has been provided to the well owner.
If this is a repair,_fll out known well construction in/ormation and explain the nature of the
repair under 021 remarks section or on the back ofthis form. 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the.sane construction,rou can
submit onejbrm. 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
For multiple wells list all depths ifdiJferent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing• 6 (ft.) Division of Water Resources,Information Processing Unit,
!!water level is above casing.use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 8 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Auger 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following: ; f
(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(gpin) Method of test:
24c.For Water Supply&Injection(Wells:
, ,
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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