GW1-2022-09964_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD ntemd u oNLv
The form can be used for single m mukWit wells
1.Well Contractor Information: -- -- -
14.WATERZONFS
D.T. CHALMERS,JR. ROM o DEs TION
Well Contractor Name n. R
4146A n. tt.
NC Well Contractor Certification Number 15.INNER CMG OR TUBING Y do W4
FROM TO DI.4\ Vi TM('RNE55 xuklhai L
CATLIN Engineers and Scientists 0 n. 4 n. 2 Sch.40 1 PVC
Company Name I&OUTER CASING for mvni-cued wdle OR LLYER if• iotle
FROM TO 111k'Wl R TIIICA\E55 MATERIAL
2.Well Construction Permit H: N/A
4
List all icaNe w U rmtfs/i e Cove n. n.
rtppl pre ry,Gate, Ponrme,/yection,etc.)
n. f
3.Well Use(check well use):
n.SCREEN
Water SupplylYell: txuM I TO Dla%!Enli I SWTS121 I TwCETEss %"T Ri>1
❑Agricultural ❑Mumcipal/Public 4 n. 14 f, 2 Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) R n.
❑Industrial/Commercial ❑Residential Water Supply(shmed) 1a GROUT 'a
FROM TO NLITERIAL AWNT
❑Irrigation 0.0 n. 0.5 R. Concrete Surface Pour
Non-Water Supph P ell:
®Monitoring ❑Recovery 0,5 n. 2 n. Bent.Pellets Surface POUT
Injection ell: it, R
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL RICK ifa is
❑Aquifer Storage and Recovery ❑Salinity Bartier M011 tit NurewAL ENPL{(EXIEN7N1ETFIOD
2 n. 14 R.1#2 Medium Sand Surface Pour
❑Aquifer Test ❑Stomreencr Drainage
❑Experimental Technology ❑Subsidence Control n. R
20.DRILLING LOG attach additimal sheets ifneemsa
❑Geothelmd(Closed Loop) ❑Tracer FROM To [IF SC RIP nnm cdo,IarJnrx.vn1-
❑Geothermal(Heatin Cool ing Reim) ❑Other(explain under N21 Remarks) R n. !r
4.Date Welds)Completed: 10125122 Wen IDM: IMW-04 n it
M1 n. G
Sa.Well Location: -
n. A
NDEQ-US1 00-0-0000001670 n
COUNTRY STORE
Facility/Owner Name Facility IDN(if applicable) /- - y L.
R
1383 US HWY 17 SOUTH,ELIZABETH CITY,27909
R tt.
Physical Address,City,and Zip
21.REMARKS NI IV tki
PASQUOTANK N/A
_ 1
County Parcel Identification No (PUN) 1n;p;A+F
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: t
(if well field,one lat(long is sufficient)
36.26986483 N -76.30256044 W ! 11/1/2022
Sigradme of Candied well Contractor T Date
6.Is(are)the welds): ®Permanent or OTemporary gs..stgmng thafnn l heretic renafs that thr uell(.s/wa+Fwere/atvtnrtrdtn w.,dumr wuh
15A MAC 02C.0100 or 15A At ACO2C.0200 Well Conr1rua n tilamhrds a d dint a ropy of
7.Is this a repay toaoexictingwefl: Ores or ®No th,,.dhwbeenp ,dedtofhe,«dlfmner
if fhfs a o repair,ill and bxnsn well c rriuxum informansm mil explain the"are of
the repair tinder Ql remarks section or on the hack of dos Jorm. 23.Site diagram or additional well details:
You may we the back of this page to pros ide additional well site details or well
8.Number of wells constructed' 1 construction details. You may also attach additional pages if necessary.
Far muln#e oyetnon or mst carer supply wells ONLY with the same mnstrucdon.you
oat.ntbmif ore form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 14.0 (R.) 24a.For AM Wells: Submit this form within 30 days of completion of well
Fin,m multiple"it,hit all depths in differem(example-3@M'rmd 2Q100% construction to the following:
10.Static water level below top of casing: 4.54 (B-) Division of Water Resources,Information Processing Unit,
9"warer level is ahsne 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
11.Well cmtruction method: HSA completion of well construction to the following.
(i e.auger,rotary,;idle.dtreo push etc.) Division of Water Resources,I'nderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13s.Yield(gpm) Method of test: 24c.For Water Svooh�A Infection Wells:
Also submit one cope of this form within 30 days of completion of well
13b.Disinfection type: Amouut: 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 ENV RONMENTAL GEOTECHNICAL
en
�.ReIM.wpm CATLIN
Engineer and Scientists
220209 SHEET 1 OF 1
PROJECT NO.: 220209 STATE: NC COUNTY: PASQUOTANK LOCATION: ELIZABETH CITY
PROJECT: US 17 COUNTRY STORE LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. MW-04
NORTHING: 924302 EAsnNG: 2795233 1 CREW: N. NEWMAN
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Near former DiSpenser Island in front of store T.O.C.ELEV.: 100.07
DRILL MACHINE: DiediriCh D-25 METHOD: HSA 0 HOUR DTW: 5.6 TOTAL DEPTH: 14.0
START DATE: 10/25/22 END DATE: 10/25/22 124 HOUR DTW: 4.5 WELL DEPTH: 14.0
DEPTH BLOW COUNT OVA LAB o L SOIL AND ROCK WELL
0.5R 0.Sfl 0.5fl 0.511 (PPm) a DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 100.1 0.0
0.0 (SP)-Tan to brwm,F.SAND with It.day 0.0 % os
NM
NM NM NNI M ;
NM j
a
2.0
in
Y 3.0 97.1 N
(CL)-Dark broA ,Sandy CLAY
4.0 96.1 4.0
(SC)-elue to green,Clayey F.SAND
5.0
2
4 4 106.8 M
4
8.0 92.1
(SP)-Gray,F.SAND o ui
0
oe
Nr ;
�N
10.0
5
' 5 5 38.0 Sat. ::
14.0 14.0 e5.1 14.0 14.0
BORING TERMINATED AT ELEVATION 86.1 Itin F.
SAND
Concrete Bentonde Pellets #2 Medium Sand

5 N
�1
J 2;OGAL
MW-01 KER�O�..►►SENE
�uaT
DISPENS RS ;
v
OSENE
M SPENSE=k
LEGEND
/ F• ME
/ Monitoring
r �___ T ® Well (Type II)
Vent(s)
y // /, /%%//////// �• Assumed Supply
Lines
Assumed Supply Lines
(Abandoned in Place)
10,000-GAL //��..- ./ Y DISPENSER•
DIESEL US_T UST System Electrical
Component
Vent Lines(Removed)
/ W ,
10,000-GAL MW�03
.MW-02 , / Telephone Lines
GASOLINE
UST .y ' /j ; / Unknown Lines
6,000-GAL '�.� Excavation Limits
..1 L ,,
GASOLINE ' Approximate Location
UST 2 000-GALJDIESEL UST 10,000-GAL Q
(ABANDONED IN PLACE) DIESEL UST of UST System
DIESEL Approximate Location
1111k*L DISPENSERS of Former UST System
Q Parcel Boundary
Source:Esn,Maxar,Ea star Geographics, andt
NOTE: UST system components and utility locations provided by
SEPI Geohpysical Investigation (2021)and are approximate. 30 15 0 30 60
Feet
Wt CT mlE
CATLIN COUNTRY STORE 13 FIGURE
1383 US HWY 17 SOUTH SITE MAP
ELIZABETH CITY, NC
Engineers and Scientists
XlgpExr NO. xIB NO. MiE SCMf pUWN BVFXECNEU By
38813 220209 NOV 2022 AS SHOWN MC/BJA