GW1-2021-07208_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: , 9
James Robertson �i FROM
WATER ZONES
�� FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4482 QC� 6 e5s�r9� ft. ft.
NC Well Contractor Certification Number �CQo �Qn 15.OUTER CASING for multi cased wells OR LINER:if s "icable
Parratt-Wolff, Inc. `Q��`:�0� J�Q FROM TO DIAMETER THICKNESS MATERIAL
l fr. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A 0 ft' 5 ft. 4 in. sch40 pvc
List all applicable svel/permits(i.e.(b11)7111,S'lale, Variance,loleciiiin,WC.)
R. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply I Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft- 15 ft' 4 tn' .010 SCh40 pvc
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18-GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 3 ft- Bentonite Chil Poured
Non-Water Supply Well: ft. ft.
Monitoring ❑Recovery
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL,PACK(if it "Gca`ble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stone Aater Drainage 3 ft. 15 ft #1 Sand Poured
tt. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG"attach additiodal•sheets if oece'ssary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillmck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well 10-14-20 VMW-3 ft. ft.
$)Completed: Well ID# fr. ft.
5a.Well Location: ft. ft.
Kinder Morgan Terminals LLC NONCD0001697 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
3340 River Road, Wilmington, 28412 ft. ft.
Physical Address.City,and Zip
2 L REMARIHS
New Hanover R06400-001-003-000 24 Concrete Pad
County Parcel Identification No.(PIN) 5.0 Stick up with 90s
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient)
34.179136 N -77.951510 W 11/10/202D
ature of Certified Well Contractor Date
6.Is(are)the well(s): 21'ermanent or ❑Temporary By signing ihis form, 1 herehv cerlifi%that the well(s)was(were)constructed in accordance
wilh 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well C'onsimcuon Standards and Thal a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provides(to the well owner.
if this is a repair,fill out known well construction information anti explain the nature of die
repair corder�21 remarks section or on the hack of this 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: 1 construction details. You may also attach additional pages if necessary.
For multiple oyeclion or non-eater supply wells fJNLY wish the same constriicdon,van can
submit one fibrin. SUBMITTAL 1NSTUCTIONS
9.Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
/in•mu/rip/e wells list a//depths fdifferem(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: None (ft) Division of Water Resources,Information Processing Unit,
{fwaier level is above casing,use" " 1617 Mail Service Center,Raleigh,NC 27699-16I7
11.Borehole diameter: 1 1 (in.) 24b. For Infection Wells ONLY: In addition to sending the form to the address in
Hollow Stem 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:
(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(gpm) 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-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013