GW1-2023-01698_Well Construction - GW1_20230213

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 F WATER ZONES
FROM To DFscRu>[ION
Well Contractor Name ft. ft.
4146A ft. ft.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eolheRmal dined 1
FRO\I TO D14Stf,rF THICKNESST MATERIAL
CATLIN Engineers and Scientists 0 ft.1 5 ft. 2 i..1 Sch.40 1 PVC
Company Name 16.OUTER CASING 1for multi-cased wells OR LINER if a icable
FRMI TO DI4VIFTFR TI11f KNFSS M6ATERI:AL
2.Well Construction Permit#: N/A n. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
n.scREEN
Water Supply Well: FROM TO DIANTETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 5 a. 20 n 2 irt. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT _
FROM TO MIA111ou IA II'LACENIENT METHOD&.i,Uul S1
❑Irrigation
0 a. 1 n. Concrete Surface Pour
Non-Water Supply Well: —
1 Sent.Pellets Surface Pour
3Monitoring ❑Recovery
Injection Well:
0 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ira dkable
FROM TO A TI R1At EM1IPLACENIENTMETHOD
❑Aquifer Storage and Recovery D Salinity Barrier —
❑Aquifer Test O Stortnwater Drainage 4 n. 20 n. Torpedo Sand
—
❑Experimental Technology ❑Subsidence Control u. ft.
20.DRE LLING LOG attach additional sheets if necessary)
0Geothermal(Closed Loop) ❑Tracer FROM TO ha'dn's soivrod t'f e gain s­.etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n. n. —
4.Date Wells)Completed: 02/01/23 Well ID#: MW-7 It. n. -1 ` O rt.
Sa.Well Location: —
NCDEQ-HALL S STORE 00-0-00009410
I.. P
Facility/Owner Name Facility ID#(if applicable)
rt.
9830 HIGH HOUSE RD,SALEMBURG,28385
n. n.
Physical Address,City,and Zip —
21.REMARKS _
SAMPSON 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)
35.11382 N -78.53753 W '�/ 2/3/2023
Signature of Certified Well Contractor Date
6.is(are)the well(s): ®Permanent or ❑Temporary
By signing this jorvn,/hereby tern fi-that the well(s)was(were)conslnrcled m acconkmce with
I9A MAC 02C.0100 or 15A NCAC 02C.0100 Well Cowiruetion Standards and that a copy of
7.Is this a repair to an existing well: Oyes or ®No this record has been provided to the well owner.
If this is a repair,fill out known well construction information anti explain the nature of
the repair wider s2I 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 njectron or non-water supply wells ONLY with the same eonsducdon,you SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 20.0 (g,) 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'antd 2@I001 construction to the following:
10.Static water level below top of casing: 13.42 (g,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•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,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
13a.Yield(gpm) Method of test: 24c.For Water SvoDly&Infection 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL CATLIN
GEOTECHNICAL
Wnmglon,Raleigh,Washington,
cbmustonWELL LOG Engineers and Scientists
220282oz64 SHEET 1 OF 1
PROJECT NO.: 220284 STATE: NC COUNTY: SAMPSON LOCATION: SALEMBURG
PROJECT: 220284 LOGGED BY: C. Black WELL ID:
DRILLER: D. T. Chalmers JR MW_7
NORTHING: 496674 1 EASTING: 2138301 CREW: L. Hamilton
SYSTEM: NCSP NAD 83 USft BORING LOCATION: South of MW-2 T.O.C.ELEV.: 99.96
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HHOUR DTW: 18.6 TOTAL DEPTH: 20.0
START DATE: 2/1/23 END DATE: 2/1/23 124 HOUR DTW: 13.4 WELL DEPTH: 20.0
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPM) LAB. Is c DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 100.0 0.0
0.0 (SP)-Gray to dark gray,F.SAND 0.0
5 6 6 NM M = 1.0
6 U
a
v
3.0 J97.0 n
(CH)-Brown to white,Silty highly plastic CLAY. Slight N
HCO from 10.0-1 3.0'BLS 4.0
5.0
5.0
5
NM M
4
10.0
2
5 5 NM M
8
oQ>
oa
60
13.0 87.0 �t
; (SW)-Orangish brown,F.to Cse.SAND with IT.silt
•' from 18.0-20.0'BLS.
15.0 j
3 •�•}t
4 4 N M W a
s
18.0 ;
4 6
5 3 ;a•t
20.0 20.0 80.0 20.0 20.0
BORING TERMINATED AT ELEVATION 80.0 ft in Med.
to Cse.SAND w/IT.silt
Portland Cement Bentonite Pellets El#2 Medium Sand

nnw-a V N
0
ED
-. u a t.
Od
MW-3
3
MW-1
FORMER 2,000-GAL.
j'GASOLINE USTS
FORMER 500-GAL.
KEROSENE UST MW-5 MW=6 r FORMER
1�—�500-GAL.UST
FORME
DISPENSER \FORMER
ISLAND MW.-2 4,000-GAL.
®MW-7 USTS
LEGEND
® Monitoring Well
(Type II)
Water Line NtGt-,AOvgE RD
Approximate Location
of Former UST System
Parcel Boundary
Source: Esn, Maxar. Earthstar Geographics.and the GIS User Community
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 30 15 0 30 60
Feet
PROJECT TITLE FIGURE
HALL'S STORE
ATLIN 9830 HIGH HOUSE RD SITE MAP
CSALEMBURG, NC 1
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE I DRAWN BYICHECKED By
42022 220284 FEB 2023 AS SHOWN KMC/BJA