GW1-2022-09967_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Contractor Name ft ft
4146A fL ft. l
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS I MATERIAL.'
CATLIN Engineers and Scientists oft.oft.1 4 fl-I 1 12 in.1 SCh.40 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable)
FROM I TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: N/A ft ftl in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
fL fL in.
3.Well Use(check Well use): 17.SCREEN
Water Supply Well: FROM To I DIAMETER I SLAT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 4 ft. 14 ft. 2 in. Slot.010 I Sch.40 PVC.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACErVENL'METHOD&AMOUNT
❑Irrigation 0.0 ft. 0.5 ft. Concrete Surface Pour
Non-Water Supply Well:
0.51t 2ft. Bent.Pellets Surface Pour
IN Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL.PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EA IPLACEMENTMETHOD
2 ft. 14 ft. #2 Medium Sand Surface Pour
❑Aquifer Test ❑Stomnvater Drainage
❑Experimental Technology ❑Subsidence Control ft ft.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothemlal(Closed Loop) ❑Tracer FROIv[ TO DESCRIPTION color,hardness soillrock tvpe,main sire etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 10/25/22 Well ID#: MW-01 rL rt.
ft. ft. I �O
5a.Well Location: �N
00001670
NDEQ-US 17 COUNTRY STORE 00-0-00 rt.
Facility/Owner Name Facility ID#(if applicable) s
ft.
1383 US HWY 17 SOUTH,ELIZABETH CITY,27909
Physical Address,City,and Zip ft. ft.
21.REMARKS
PA$QUOTANK N/A
r,I
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)
36.25991082 N -76.30238759 W 11/1/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or O Temporary By signing this fonn,I hereby cerify that the wells)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and drat a copy of
7.Is this a repair to an existing well: ❑Yes or ®No this record has been provided to the well mvner.
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-water supply wells ONLY with the saute construction,you SUBMITTAL INSTRUCTIONS
can submit one form.
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9.Total well depth below land surface: 14..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 a200'and 2@1009 construction to the following:
10.Static water level below top of casing: 4.18 (ft.) Division of Water Resources,Information Processing Unit,
Ijwa[er level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•25 (in.) 24b.For Iniectiofi 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: H SA 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 Se i ice Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SyaDly&Injection 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

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ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
Wlrtvigton,Raleigh,Washington,
Ciarlestan Engineers and Scientists
WELL LOG 2zozos SHEET 1 OF 1
PROJECT NO.: 220209 STATE: NC I COUNTY: PASQUOTANK LOCATION: ELIZABETH CITY
PROJECT: US 17 COUNTRY STORE LOGGED BY: G T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. MW-01
NORTHING: 924323 1 EASTING: 2795283 CREW: N. 'NEWMAN
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Near former Kerosene UST T.O.C.ELEV.: 100.00
DRILL MACHINE:,Diedrich D-25 METHOD: HSA 10 HOUR DTW: 4.9 TOTAL DEPTH: - 14.0
START DATE: 10/25/22 END DATE: 10/25/22 124 HOUR DTW: 4.2 WELL DEPTH: 14.0
BLOW COUNT OVA o o SOIL AND ROCK '' WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft ("rn) LAB. S' G DEPTH DESCRIPTION. j ELEVATION DETAIL
� I
0.0 LAND SURFACE 100.0 0.0
0.0 (SP)-Tan,F.SAND with tr.clay 0.0 AQ 0.5
NM
NM NM NM NM M
a
v 2.0
:.
(CL)-Brown to tan,Sandy CLAY
4.0
5.0
WOH WOH WOH 77.1 W
WOH
8.0 ____ 92.0
---------
(SP)-Gray,f.SAND with tr.clay
oa
00
_v
' m t
fV fn
10.0
a ' 7 55.9 Sat. 1
10
LL
14.0 14.0 86.0 14.0 14.0
BORING TERMINATED AT ELEVATION 86.0 ft in F.
SAND with tr.clay
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Rd.:Concrete Bentonite Pellets #2 Medium Sand