GW1-2023-01766_Well Construction - GW1_20230223

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WELL CONSTRUCTION RECORD r
For In[emal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kevin \A/hate 14..WATERZONES p
V V FROM TO DESCRIPTION
Well Contractor Name
2973
NC Well Contractor Certification Number M OUTER CASING(for multi-cased wells)OR LINER if a
FROM TO DIAIIMETER THICKNESS licable MATERIAL.
Parratt-Wolff, Inc. ft. ft. ; I in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: n/a 0 ft' 25 ft- 2 ' in. sch40 PVC
List all applicable ivell permits r.e.County,Slate,Variance.Injection,etc.) ft. ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 25 1- 30 ft. 2 in. .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
❑Uri ation 0 fr. 19 et. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery 19 ft. 22 ft- Hole Plug Tremie
Injection Well: 19 It. 22 ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 22 it" 30 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,son/mck type,gmin size,etc.)
[]Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 1 2-13-22 Well ID#MW-48
ft, ft.
5a.Well Location:
Kinder Morgan LLC River Road ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft. ft.
3340 River Road, Wilmington 28412
Physical Address,City,and Zip .'': QG
21.REMARKS
New Hanover R06400-001-003-000 a
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)
34.178860 N —77.951916 W
Sib ature of Certified Well Contra''? Date
6.Is(are)the well(s): OPermanent or ❑Temporary
By signing this form,I hereby certify that the wells)was(mere)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 II'ell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record hasbeen provided to the well owner.
If this is a repair,'ll out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this forms. 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 injection or non-water supply wells ONLY with the same construction,You can
submit ate form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this"fomt within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1001 construction to the following:
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10.Static water level below top of casing• 8 (ft.) 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: 8 (in.) 24b.For infection Wells ONLY: (]nladdition to sending the form to the address in
Auger 24a above, also submit a copy of his form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger•rotary,cable,direct push,etc.) j
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centi r,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test:
24c.For Water Supply&ih,jection1'Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection,type: Amount: well construction to the county healt}i department of the county where
constructed. p III
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resolurces Revised August 2013
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