GW1-2021-01686_Well Construction - GW1_20210429

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 A TERZONES
o� DESCRIPTION
Well Contractor Name
4146A
NC Well Contractor Certification Number 15 INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER TI-IIC[CNESS MATERIAL
CATLIN Engineers and Scientists 0«. 2 ft. 2 in.1 Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a icable
FROM TO DIAMETER THICKNESS N1ATEPJAL
2.Well Construction Permit#: N/A ft. rt. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. u.
3.Well Use(check well use): 17 SCREEN -
Water Supply Well: FROM 10 5I,v7=Eiz I M Slzl-_ rI y1\II R1 yi
❑Agricultural ❑Municipal/Public 2 ft. 12 n. 2 Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rt. it. - i..
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT _
FROM TO \I:11 t:t1.\L EMPLACEMENT METHOD R A.NIOUNT
❑Irrigation 0 ft. 0.5 ft. Portland Cement Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.5 ft. 1 ft. Bent.Pellets Surface Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENFNIETHOD
1 ft. 12# Medium Sand Torpedo Sa d
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. ft.
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness so&rock type,wam size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 02/26/21 Well ID#: MW-01 ft. ft. `ft
ft. ft. 0 5a.Well Location: 6��e
Facility/Owner Name Facility m#(if applicable) -
n.
157 COINJOCK DEVELOPMENT RD.,COINJOCK,NC
Physical Address,City,and Zip -
21.REMARKS _
CURRITUCK
County Parcel Identification No.(PIN) cesstl Unft
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 1. I SeC310n
(if well field,one lat/long is sufficient) ( crtiticatiun; P pWR
36.351193331 N -75.948289314 W y(/ j�7 3/8/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 0 Permanent or ❑Temporary By signing this_jorm,I hereby certify that the well(t)was(were)constructed in accordance with
1 SA NC AC 02C.0100 or 15A NCAC 02C.0200 Well Consiruction 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.
I(this is a repair,fill out known well construction information and explain the nature of
the repair render 921 remarks section or on the back ofthi's 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: 12 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3W00'and 2@I00) construction to the following:
10.Static water level below top of casing: 4.32 (g) Division of Water Resources,Information Processing Unit,
/(water level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•25 (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 SvaDly&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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

�` CATLIN
WELL LOG Engineers and Scientists
zzozz3 SHEET 1 OF 1
PROJECT NO.: 220223 STATE: NC COUNTY: CURRITUCK LOCATION: COINJOCK
PROJECT: MIDWAY MARINA LOGGED BY: COREY FUTRAL WELL ID:
DRILLER: D.T. CHALMERS JR. MW-01
NORTHING: 960625 1 EASTING: 2898726 CREW: TREVOR MIZELLE
SYSTEM: NCSP NAD 83 USft BORING LOCATION: NEAR DOCKS AND ICW T.O.C.ELEV.:
DRILL MACHINE: CME 550 METHOD: HSA 0 HOUR DTW: 4.3 TOTAL DEPTH: 12.0
START DATE: 2/26/21 END DATE: 2/26/21 124 HOUR DTW: N/A WELL DEPTH: 12.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (PPm) s G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 :; (SW)-Brown to tan with orange mottling,F.SAND 0.00
4 a
3 MW-01 { v 1.0
3 0.6 (12) M c
3 cn
a' 2.0 ry
5
5.0 ` .0
(SC/SM)-Dark gray,Silty and Clayey,F.SAND
(MUCK)
WOH WOH WOH 4.0 Sat. .
WOH o c>
Da
oa
yt
V U)
10.0
WOH WOH WOH 2.6 Sat. •.
WOH
12.0 12.0 _ 12.0 12.0
BORING TERMINATED AT DEP--H 12.0 ft
Portland Cement Bentonite Pellets #2 Medium Sand