GW1-2021-01139_Well Construction - GW1_20210215

i
WELL CONSTRUCTION RECORD For Internal U ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Contractor Name
4146A
NC Well Contractor Certification Number ' 'I
FROM TOO DIAMETER I TIiICKNESS I MATERIAL
CATLIN Engineers and Scientists 0 rt. 10 a. 1 2 in.i Sch.40 PVC
Company Name 0630 G 0'i"W I"U'R1 f i? i
FROM TO DIAMETER i THICKNESS MATERIAL
2.Well Construction Permit#: NSA ft n in
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft, ft.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public 10 ft. 20 ft. 2 in. Slot.010 Sch.40 PVC
O Geothermal(Heating/Cooling Supply) O Residential Water Supply(single) R. R. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) MrSTGRl)tl'
FROM TO MATERIAL ENLACEMENT METHOD&AMOUNT
OIrrigation Non-Water Supply Well: O a. 1 ft.. Concrete Surface Pour
®Monitoring ❑Recovery 1 rt. 7 ft. Bent.Pellets Surface Pour
Injection Well: n. a.
•Aquifer Recharge ❑Groundwater Rentediation "7GR`VEIIfPAt.ifa idle
❑Aquifer Storage and Recovery O Salinity Barrier FROM I TO MATERIAL IEMPLACEMENT METHOD
❑Aquifer Test O Stomtwater Drainage
7 ft. 200. Medium Sand Torpedo Sa d
1l!2r):>iD12t1311rNGyL�O`G.a tac�tu`dilil'i
❑Experimental Technology ❑Subsidence Control rt. tr.
�_� it"a"s'llah"e�e n�ft IUn
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION Jcolor,hardness soiVrock tyve,wain size etc.
❑Geothermal(Heating/Cooling Return) O Other(explain under#21 Remarks) ft. ft. %
4.Date Well(s)Completed: 01/21121 Well II#: MW-01 n. rt.
5a.Well Location:
Bruce and Debra P.Locklear Glenn's Quick Stop
ft. �
Facility/Owner Name Facility ID#(if applicable)
a. �
101 E.Railroad St.,PEMBROKE,NC 28372 a rt
Physical Address,City,and Zip
I�Et�RF1NAlttfS'
ROBESON
County Parcel Identification No,(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: j
(if well field,one lat/long is sufficient) 2ertification:
r e,��°e,a ? I
34.681328607 N -79.191169425 ,1VW 1/27/2021
^081 atureofCertiHedWellContractor Date
6.Is(are)the well(s): ®Permanent or OTemporary 1 ` 4
L� BYSIgqlj7g,,r,����((�•farm./herehr cerlifi hut the arc/t(t)was(were)consuvered in accordance with
0100 or 154 MAC 02C 0200'*,41 Con.,tntclion Standurdr and that a copy of
n
7.Is this a repair to an existing well: •Yes or ®No Sh,rP�„{,.+.rlir.c record has neon pro,+fled u,rhe;well owner;
'
!/'this is a repair,,frl1 out known well construction inlormution and erplpirL(ye3 cy(G,U+{;�'.� '
the repair under 21 remarks•section or on the buck of'this•,form. J�,TJ " ;��"� 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 construcfion,you
can submit one formn. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (ft.) 24a.For All Wells: SubmitI is form within 30 days of completion of well
For multiple wells list all depths in cl!1krew(exumple-3@200'and 2 et 100) construction to the following!
10.Static water level below top of casing: 7.27 (ft.) Division of Water Resource ,Information Processing Unit,
lfwuicr level is uhove casing,use" 1617 Mail Se- gre 9 Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (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
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 Svoaly&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.
j
Adapted from Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

CATLIN
Englnkis and Scientists
zzozseWELL LOG
SHEET 1 OF 1
PROJECT NO.: 220238 STATE: NC COUNTY: ROBESON LOCATION: PEMBROKE
PROJECT NAME: LOGGED BY: COREY FUTRAL WELL ID:
Glenn's Quick Stop DRILLER: D.T. CHALMERS� JR.
NORTHING: 339010 FASTING: 1942528 CREW: TREVOR MIZELLE ��
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Parking Sot Near East Railroad St. T.O.C.ELEV.:
DRILL MACHINE: CME 45B TRACK METHOD: HSA 0 HOUR DTW: 9.6 TOTAL DEPTH: 20.0
START DATE: 1/21/21 END DATE: 1/21/21 124 HOUR'DTW: ! 7.3 WELL DEPTH: 20.0
DEPTH BLOW COUNT OVA LAB. 0 o SOIL AND ROCK I' WELL
o.sn o.srt o.srt o.sn (pPm) Is DEPTH DESCRIPTION + DETAIL
0.0 LAND SURFACE 0.0
ASPHALT 0.0 =
(CH)-Dark gray,Sandy and Silty highly plastic CLAY — 1.0
3.0 3.0
(SP)-Tan with gray Silty F.to Cse.SAND. Slight HCO
2 Mw-o1 from 3.0-5.0'BLS and Strong HCO from'5.0-8.0'BLS
3.1 (51) M ! >
a
1 a
tV
I f
i
7.0
8.0
(CH)-Gray with orange mottling grading to gray,highly
Mw-01 plastic CLAY. Strong HCO
1,858 ($') W
10.0 % 10.0
(SC)-Gray with orange mottling,Clayey F.SAND.
Strong HCO from 10.0-13.0'BLS and moderate HCO
from 13.0-15.0'BLS
I
13.0
r
z 2 113.3 W
4 pU
oa
oa
N t
N N
18.0
woH woH z 64.2 Sat. .;';: 19.0
2 ,"X I (SVV)-Lt.gray,F.SAND
20.0 "i 20.0 I 20.0 20.0
BORING TERMINATED AT DEPTH 2O.0 ft in Clayey F.
SAND
Portland Cement RM Bentonite Pellets' El#2 Medium Sand
� II