GW1-2022-08977_Well Construction - GW1_20220919

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information: 14.Corey D. Futral FROM WATER ZONES
I DESCRIPTION
Well Contractor Name N ft
4330-B ft. I.
NCWellContractorCertificationNumber 15.INNERCASINGORTUBING eothermalclosed-loo
FROM TO DIAMETER THICKNESS I MATERIAL
CATLIN Engineers and Scientists 0 rL 5 ft. 1in.1 Sch.40. PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER ifa licable
FROM TO DIAMETER I THICHIVESS I MATERIAL
2.Well Construction Permit#: N/A ft ft. in.
List all applicable well permits(1.e.County,State, Variance,Injection,etc.)
M ft. in. -
3.Well Use(check well use): 17 SCREEN
Water Supply Well: - FROM TO _ DIAMETER I SLOT SIZE .THICKNESS I MATERIAL ..
❑Agricultural ❑Municipal/Public 5 rt. 15 ft. 1 in.I slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT -
FROM TO MATERIAL. EMPLACEMENTMETHOD&AMOUNT
❑Irrigation
ft. ft
Non-Water Supply Well:
❑Monitoring ®Recovery ft It.
Injection Well: ft. %
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK if a 'licable
❑Aquifer•Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
El Experimental Technology ❑Subsidence Control 0 ft 16 ra Natural Backfill:
20.DRILL LOG attach additional sheets if necessa -
❑Geothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION color,hardness soiltrock tye,grain size etc.
❑Geothermal'(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft.
4.Date Well(s)Completed: 09/06/22 Well ID#: TMW-01 ft ft O
ft. ft.
5a.Well Location: NW
rt. rt.
NCDEQ-LINDA BLALOCK N/A ft �� � ' a -
Facility/Owner Name Facility ID#(if applicable)
rt.
7995 NC-43,ROCKY MOUNT,ROCKY MOUNT,NC 27801 ft _ 1t
Physical Address,City,and Zip
21.REMARKS I In!
EDGECOMBE N/A IfffuVaic..D�V' GOG
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) l� L
35.855179 N -77.683196 W 9/12/2022.
Signature of Certified Well Contractor Date
6.Is(are)the well(s): O Permanent or M Temporary By signing this form,I hereby certify that the well(s)was(were)•constructed in accordance with-
/SA NCAC O2C.0100 or ISA NCAC 02G:0200 Well Gohstrrction Standards and that 6 copy of
7.Is this a repair to an existing well: .O Yes or ®No this record has been.provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of
the repair under.#21 remarks section or on the back 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 injection or non-wetter supply wells ONLY with the same construction,you SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 15.0 (ft,) 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@1009 construction to the following:
10.Static water level below top of casing: 11.37 (g,) 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: 2.25 (in.) 24b.For Iniection 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: DPT 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
I3a.Yield:(gpm) Method of test: 24c.For Water SvoDly&Iniection Wells:
Also submit one copy of this form within 30 days of completion of well
13:. ,sinfectiomtype: 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

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
1Ml�gton,Raleigh,Washington,
Charleston Englneers and Scientists
WELL LOG 221043 SHEET 1 OF 1
PROJECT NO.: 221043 STATE: NC COUNTY: EDGECOMBE ;LOCATION: ROCKY MOUNT
PROJECT: M&R GROCERY LOGGED BY: C. FUTRAL WELLID:
DRILLER: E. SWAIN TMW 01
NORTHING: 7687701 EASTING: 2300198 CREW:
SYSTEM: NCSP NAD 83 LUSM BORING LOCATION: East of building T.O.C.ELEV.: NM
DRILL MACHINE: Power Probe METHOD: DPT 0 HOUR DTW: 11.4 TOTAL DEPTH: 16.0
START DATE: 9/6/22 END DATE: 9/6/22 124 HOUR DTW: FIAD WELL DEPTH: 15.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.54 0.5ft 0:5ft (PPM) S c DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 '-':. 0.5 (SP)-Brown,Sandy TOPSOIL 0.0 _
Direct Push 0.0 D (SM)-Tan to orange,Silty F.SAND
or _-
2.0 '
0
Direct `L
Push 0.4 D -
4.0
. r
Direct 0 8 D r 5.0
Push
6.0 6.0
(CH)-Tan to orange with red mottling,highly plastic
Direct CLAY
Push 0.7 D Gray with orange and red mottling from 9.0-12.0'BLS
Dark gray with orange and red mottling from 12.0-14.0' -
8.0 BLS -
Direct 0.5 M
Push -
oj -
o n_
10.060
�t -
�U _
Direct 0.1 M
Push -
12.0 -
- . Direct- - •- .. --
Push 0.0 M
14.0
14.0 _
(SW)-Gray with tan and brown,CSE.SAND with tr. -
Direct 0.0 VU ,�, gravel,bricks debris,and clay 15.0 _
Push
16.0 :r 16.0 16.0
BORING TERMINATED AT DEPTH 16.0 ft in CSE.
SAND with tr.gravel,brick,and tr.clay.
i
V PVC well set to 15.0'BLS,Sampled(TMW-01),and
Abandoned
i
ENative Backfill