GW1-2022-10324_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:
D.T. CHALMERS, JR. FRO�ATERZONES DEscRrnnoN
Well Contractor Name ft. fL
4146A �� / rt. a
NC Well Contractor Certification Number �rj FROM
INNER CASING OR TUBING eolhermal closed-moo t
NNN+��� ''FROM TO DIAMETER THIC[QQESS MATERIAL
CATLIN Engineers and Scientists Nov/ � � 0 ft. 0 IL 1 iml Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: N/A 1f1OfPl':s 1�1 fir,:^{35y:19 U7t
R. ft. in.
List all applicable well permits(i.e.County,State, Variance,injection?,` b.
fL ft in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 0 ft. 5 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. _in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL ErvlPLACEmEN r mETHOD&AMOUNT
❑Irrigation
ft. ft.
Non-Water Supply Well:
®Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.S.AND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL Eh1PLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage tL tL
❑Experimental Technology ❑Subsidence Control 0 ft. 5 ft. Natural Backflll
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock tvpe,min size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL ft.
4.Date Well(s)Completed: 10/26/22 Well ID#: TMW-01-2 rt. rt. `,w��
5a.Well Location: �N
rL �r P
NCDEQ-MIDWAY MARINA N/A ft.ft.
Facility/Owner Name Facility D#(ifapplicable)
fL
157 COINJOCK DEVELOPMENT RD.,COINJOCK,NC 27923
fL IL
Physical Address,City,and Zip
21.REMARKS
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)
36.35165127 N -75.94801091 W 11/8/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or O Temporary By signing this fonn,1 herebv certify that the well(s)was(were)constructed in accordance with
ISA NCAC 02C.0100 or 15A NCAC 02C.0200(Fell Consinrctlon Standards and that a copy of
7.Is this a repair to an existing well: ❑Yes or ®No this retard 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 921 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 same construction,you 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 d�erent(example-3(200'and 2 a 100) construction to the following:
10.Static water level below top of casing: 1.2 (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 of well construction to the following:
(i.e.auger,rolary,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
13a.Yield(gpm) Method of test: 24c.For Water Svpplv&Iniection Wells:
Also submit one cop),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-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL
GEOTECHNICAL Wlmi CATLIN
nglon,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LOG 220223 SHEET 1 OF 1
PROJECT NO.: 220223 STATE: NC COUNTY: CURRITUCK LOCATION: COINJOCK
PROJECT: MIDWAY MARINA LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. TMW-01-2
NORTHING: 960733 1 EASTING: 2898700 CREW: N. NEWMNA
-SYSTEM: NCSP NAD 83 USft BORING LOCATION: In location of previous TMW-01 T.O.C.ELEV.: NM
DRILL MACHINE: Diedrich D-25 METHOD: HSA 0 HOUR DTW: 1.2 TOTAL DEPTH: 5.0
START DATE: 10/26/22 END DATE: 10/26/22 24 HOUR DTW: NM WELL DEPTH: 5.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.5ft 0.51t 0.5ft (pPm) Is c DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (MLG)-Brown to tan,Sandy Gravelly SILT a0 a
e 7 5 NM M
5 �
oU
o
2.5 a6 ov
3.0 (SP)-Tan to brown,F.SAND e
z
NM Sat.
5.0 :•: 5.0 5.0 - 5.0
BORING TERMINATED AT DEPTH 5.0 ft in f.SAND
Native Backfill