GW1-2021-00329_Well Construction - GW1_20210312

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
COREY FUTRAL lW4VWAUWZbNk9
FROM TO DESCRIPTION
Well Contractor Name
4330-B
NC Well Contractor Certification Number f1S(iNNERC.>AS7NG'ORT[7BTGr eo her'�'°,nall'eted loo
FROM I TO DIAMETER TMCKNESS I MATERIAL
CATLIN Engineers and Scientists oft.oft.1 Oft. 2 id Sch.40 1 PVC
Company Name IRT6 TfER formnt""`""Tr cam"'de .wills ORhT11�ER if:a it e
FROM TO DIAMETER THICFTESS MATERIAL
2.Well Construction Permit#: N/A a a in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. (t.
3.Well Use(check well use):
6�:fsciiEFa
Water Supply Well: FROM TO DIAMETER I SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 0 ft. 15 rt. 2 in. SIOt.010 I Sch.40 1 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. Ic. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 68CGR0+�r
FROM TO MATERIAL ENIPLACEMENTMETHOD&AIv10UNT
❑Irrigation
ft. a.
Non-Water Supply Well:
®Monitoring ❑Recovery ft. ft.
injection Well: rt. rt.
❑Aquifer Recharge ❑GroundmvaterRemediation 1f19�SAN1l'GitASET�FP CK3ifa amble
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 0 n. 15 rt. Natural Baekfill
IF201DRI11LI1VGIAG'alle addTional she""ets'tf nee
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soilhock tvpe,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 021 Remarks) a. ft.
4.Date Well(s)Completed: 03/04/21 Well ID#: TMW-01 rt. ft. e -
5a.Well Location: rt. rt. S �O «�
Paula Nethercutt
NCDOT R-2303 D Paula Nethercutt �.,do
Facility/Owner Name Facility iD#(if applicable) fc.
5951 ROSEBORO HWY,CLINTON,NC 28328
Physical Address,City,and Zip ft. ft
#211rRE1NAltiCS
SAMPSON
County Parcel identification No.(PIN) = -
51b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
34.973711499 N -78.42659006 W 3/8/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or M Temporary Hv signing this form.I hereby certify that the well(s)was(were)constructed in accordance with
IAA MAC 02C.0100 or 15.4 NCAC 02(".0200 Well Construction Standards and that a cow of
7.Is this a repair to an existing well: ❑Yes or ®No this record has been provided to the well owner.
lfihis is a repair,ill out known well construction information and explain the nature of
the repair under+21 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection ur non-water supply wells ONLY with the same construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15 (g,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3@200'and 2@100J construction to the following:
10.Static water level below top of casing: 6.0 (ft.) Division of Water Resources,Information Processing Unit,
If water keel is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2 (in.) 24b.For Infection Wells ONLY: In addition to sending the fonn to the
address in 24a above,also submit a copy of this form within 30 days of
12.Well construction method: DPT completion of well construction to the following:
(i.e.auger,rotaty,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 Sv'auly&Infection Wells:
Also submit one copy of this form within 30 days of completion of well
13b.Disinfection type: Amount: construction to the county health department of the county where constructed.
Adapted from Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

WELL LOG CATLIN
Engineers and Scientists
220211 SHEET 1 OF 1
PROJECT NO.: 220211 STATE: NC COUNTY: SAMPSON LOCATION: CLINTON
PROJECT: NCDOT R-2303D PAULA LOGGED BY: COREY FUTRAL WELL ID:
NETHERCU17 DRILLER: PATRICK MCCAIN TMW-01
NORTHING: 445920 1 EASTING: 2171853 CREW: TREVOR MIZELLE
SYSTEM: NCSP NAD 83 USft BORING LOCATION: —13'OFF ROSEBORO HWY T.O.C.ELEV.:
DRILL MACHINE: Power Probe METHOD: DPT 10 HOUR DTW: 6.0 TOTAL DEPTH: 15.0
START DATE: 3/4/21 END DATE: 3/4/21 124 HOUR DTW: N/A WELL DEPTH: 15.0
DEPTH BLOW COUNT OVA LA8 o a SOIL AND ROCK WELL
0.5tt 0.5ft 0.5ft 0.5tt (PPM) s G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 0.5 (SM)-Brown,Silty TOPSOIL 0.0 a
1.0 (CH)-Tan with orange and red mottling,Sandy highly
plastic CLAY (n
Direct N M D (SC)-Brown with gray grading to tan,Clayey F.SAND N
Push -
4.0
4.5
(CH)-Gray with orange,red,and purple mottling, -
highly plastic CLAY
Direct NM D
Push
o>
0-
6
in=
8.0
Direct N M M -
Push
12.0 -
Direct N M M
Push -
15.0 15.0 15.0 _ 15.0
BORING TERMINATED AT DEPTH 15.0 ft
Native Backfill