GW1-2021-07645_Well Construction - GW1_20211214

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor information:
14.WATER ZONES
DT CHALMERS FROM TO DESCRUMON
Well Contractor Name ft. ft.
4146-A ft. ft.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermal closed-1
FROM TO DIAMETER THICF:NESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 3 rt. 2 i..1 SCh.40 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a icable
IRO V TO DI-V,11IIR T1RKNESS MAIIRIAI.
2.Well Construction Permit#: N/A ft, in.
List all applicable well permits(i.e.County,State, Variance.Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROV TO DI.AXII II R SI OT 1;1/1 1 THICI:NI %I:\I I RI\I
❑Agricultural ❑Municipal/Public 3 ft. 13 ft. 2 n. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) IR GROUT
FROM TO A1A1 ILI:V. I,VI'LACEMENr METHOD I.A.AIOUNT
❑Irrigation 0 ft. 1 ft. Concrete Surface Pour
Non-Water Supply Well: -
1 ft. 2 it. Bunt Pellets Surface Pour
EMonitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK fif audicabliel
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
2 rt. 13 s2 Medium Sand Surface pour
❑Aquifer Test ❑Stornwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attack atiNtional abeed if necessaryl
❑Geothermal(Closed Loop) ❑Tracer FROM To DIiSCRu'Tto],­1„ t,.,,n, :<_ ,1-1,nr, n size et
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) n. It.
ft. It. G`
4.Date Well(s)Completed: 11/01/21 Well ID#: MW06 C+
5a.Well Location: GH
NCDEQ JENNIFER'S SUBDIVISION N/A
PFacility/Owner Name Facility IDH(if applicable)
3198 MT MISERY ROAD LELAND,NC,LELAND,NC
Physical Address,City,and Zip
21.REMARKS
BRUNSWICK
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
34.304128 N -78.076529 W 9Y1CT�1-nVl 12/10/2021
SigrtatureofCertified Well Contractor Date
6.Is(are)the well(s): M Permanent or OTemporary By signing this form 1 hereby certify that the wells)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
Ifihis is a repair,fill ow known well construction information and explain the nature of
the repair under=2I 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.
1`4 multiple injection or non-water supply wells ONLY with the same construction,you SUBMITTAL INSTRUCTIONS
can.submit one form.
9.Total well depth below land surface: 13.0 (ft,) 24a.For All Wells: Submit this form within 30 days of completion of well
Pitr multiple wells list all depths in different(example-3WOO'and 2@100) construction to the following:
10.Static water level below top of casing: 10.2 (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: 8.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the
address in 24a above,also submit a copy of this form within 30 days of
12.Well construction method: HStA(456) completion of well 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
24c.For Water SvDDIV&Infection Wells:
13a.Yield(gpm) Method of test:
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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

CATLIN
Engineers and Scientists
WELL LOG 220201 SHEET 1 OF 1
PROJECT NO.: 220201 STATE: NC COUNTY: BRUNSWICK LOCATION: LELAND
PROJECT: JENNIFER'S SUBDIVISION LOGGED BY: O DAYNES WELL ID:
DRILLER: T CHALMEERS MW06
NORTHING:30528263 EASTING:31979296 CREW: E. SWAIN
SYSTEM: NCSP NAD 83 ft BORING LOCATION: SE corner of building T.O.C.ELEV.:
DRILL MACHINE: CME-45B METHOD: HSA 0 HOUR DTW: 10.2 TOTAL DEPTH: 13.0
START DATE: 11/1/21 END DATE: 11/1/21 24 HOUR DTW: N/A WELL DEPTH: 13.0
BLOW COUNT OVA M L SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPM) LAB. s G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (SP)-Tan F.SAND,Poorly Graded(0.0-0.5 Artificial 0.0
8 4 Fill) > t 1.0
4 2.2 D
3
2.0
iv
}}} 3.0
(CL-CH)-Tan to Gray CLAY w/SAND,Medium
Plasticity
5.0
3 " , 1.1 D
s
o�
oa
oe
rn c
�U
N
10.0
10.5
3 t3 9 12 74.4 Sat. (SP)-Tan to White F.to Med.SAND,Poorly Graded,
Saturated(Sulphur odor?)
13.0 13.0 13.0 .; 13.0
BORING TERMINATED IN SAND AT DEPTH 13.0 ft
°4.: Concrete Bentonite Pellets #2 Medium Sand