GW1-2022-10323_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
® 14.WATER ZONES
D.T. CHALMERS, JR. oNt To DESCRIPTION
Well Contractor Name r` p^+ fL IL
4146A NOV j 1 2012 It.
NC Well Contractor Certification Number F5.INNERCASINGORTUBING eolhernmlclosed-loo
IftfOi'fi aUn, p + Otvf TO DIA1vfETER THICKNESS MATERIAL
CATLIN Engineers and Scientists t]mlp'oc 0 ft. 0 ft.1 1 itrl Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A fL rL 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
El Agricultural ❑Municipal/Public Ott. 5 tl 1 in. Slot.010 SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. a. - in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL I EMPLACE1,IENTMETHOD&AMOUNT
❑Irrigation
fL fL
Non-Water Supply Well:
®Monitoring ❑Recovery it. fL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
fL fL
❑Aquifer Test ❑Stor water Drainage
❑Experimental Technology ❑Subsidence Control 0 n. 5 fL Natural Backflll
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM To I DESCRIPTION color,hardness,soil/rock type,wain sire etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R. ft.
rt.
4.Date Well(s)Completed: 10/26/22 Well ID#: TMW-04-2 ft
5a.Well Location:
NCDEQ-MIDWAY MARINA N/A ft. fL
fL
Facility/Owner Name Facility IIA(if applicable)
fL
157 COINJOCK DEVELOPMENT RD.,COINJOCK,NC 27923
Physical Address,City,and Zip fL
21.RE\fAItR KS
CURRITUCK N/A
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)
36.3513135 N -75.94796889 W 11/8/2022
Signature of Certified well Contractor Date
6.Is(are)the well(s): ❑Permanent or ®Temporary
By signing This form,/hereby cer0,that the u•ell(s)was(were)constructed in accordance with
1.iA 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: ❑Yes or ®No this record has been provided to the well owner.
Ijthis it a repair,full out known well construction information and explain the nature of
the repair under 421 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 or non-water supply wells ONLY with the scone construction,yott SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 5.0 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in diffcrent(example-3 a200'and 2@I00J construction to the following:
10.Static water level below top of casing: 1.1 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 4.25 (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: HSA completion ofwell 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 Svpplv&Iniection 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 Enviromnent and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
WIrnington,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LOG 220223 SHEET 1 OF 1
PROJECT NO.: 220223 STATE: NC COUNTY: CURRITUCK LOCATION: COINJOCK
PROJECT: LOGGED BY: T. PARK WELL ID:
MIDWAY MARINA DRILLER: D.T. CHALMERS JR.
NORTHING: 960611 FASTING: 2898716 CREW: N. NEWMNA TMW-04-2
SYSTEM: NCSP NAD 83 USft BORING LOCATION: In location of previous TMW-04 T.O.C.ELEV.: NM
DRILL MACHINE: Diedrich D-25 METHOD: HSA 10 HOUR DTW: 1.1 TOTAL DEPTH: 5.0
START DATE: 10/26/22 END DATE: 10/26/22 124 HOUR DTW: NM WELL DEPTH: 5.0
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH 0.5tt 0.5tt o.5n 0.5ft (PPm) LAB. I G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE _ 0.0
0.0 (SM)-Brown,Silty SAND ao a
2 p
NM M t _ -
U
pU
o d
2.5 o v
3.0 (SP)-Brown to tan,F.SAND
t -
' , NM Sat. -
5.0 5.0 5.0 5.0
BORING TERMINATED AT DEPTH 5.0 ft in f.SAND
Native Backfill