GW1-2021-06293_Well Construction - GW1_20210915

17
l�lz�
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
I.Well Contractor information:
Robert Teague lu.WATERz0%
FROM ! TO DF,cCRIPTTON
\Yell Contractor Name V- ft. ft.
All
B& K Well Drilling Inc Q re �,\n� S S
NC tVell Contractor Cenilieatiun\timber ✓„" 15.OUTER CASING for mahi-eamd Welk)OR LfNER if a licabk)
2857-A r3�'°�Rye D FROM ft Tn ft ILihtFTER to THICKNESS MATERIAL
AL
118 SDR-21 PVC
Company Namc 16.INNER C.+aS1NG OR TUBING tesbermril closed-
' 4 . FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit M: ft- ft. i^•
Lrst, .
ill ,ell runsrn,cron pc•nnit(el.u.f7('.Cbunn'.Sta,u, fariwuc.cn.l
' ft. rt. in.
3.Well Use(check well use):
17.SCREEN
Water Supply Vi ell: FROM TO DIAMETER SLOT SIZE THICKNESS M4TER14L
Agricuitural
Municipal Public ft. ft. in.
Geothermal(ilcating.Cooliog Supµlyl Residential Water Supply(sin tcj ft. ft. in.
IndustrialiContalercial Residential Water Supply(shared) 18.GROUT
FROM To y1.1TERL\L F(v1Pi.ACEMENT!itF.TFIUD X-4MU[T7T
Irrigation t,, it.
Non-Water Supply Well:
:)monitoring, nRecoterl ti ft'
injection Well: tt. ft.
Aquifer uifer Rechar,e ❑<rroundwarer Relmcdiation
) r 19,SANDlGR4VEL PACK(if Applicable)
Aquifer Sum lge and RecOlery �Saliniry Aa+Tier FROM TO MATERIAL EMPLACEMENTMEIHOD
ft. ft.
Aquifer Test [:)Stor nwatcr Drainage
Experimental Technology
Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if aecessery
FRON1 TO DESCRIPTION cobr.hard as.soll,roak n rein W.C.ctd
Geothermal(HeatinniCooling Return) n0ther tex lain under 421 Remark;) ft.
1
' Well ID#' L (t• StL i
4.Date Well(s) e
s)Completed: �i �� -
Well Location: L
o�,� d S�cam, jJr c i nl t cY. ft- ft.
Facility ID=ttfapplicablet
Faeiliry tOwncr Name
ft.
Lf `A\Ll�
fr. ft.
Physical Address.City.and Zip
ll.REDiARKS
{ vJ Parcel ldeulife:nion Na IPIN,
County
5b.'Latitude and longitude in degrees/minutesiseconds or decimal degrees:
fit Hell field,one IaGlong ii iufftcicml 22.Cgrti Ic ion:
Stcnaturc of Ccrnftcd WCii C• actor Datc
Br 1 ht•rt•.n'
6.19(are)tbew'ell(s)Ex Permanent or Temporary' cernli'that the nruiro wm tK'cre)rnnamicred in accn,dancr
_ .st signing this!a'm.
7.Is this a repair to an existing well: [3 ti es Or-ONO :vh 1:^.\CAC 02C'.0100 w'1 i.A tiC.{C 02C.0200 will C umtructiur Siandards and that a
ll nut known Hell ennsmicr+nn n+hnnatinn an .rplain Me rehire of Ih,� cnJn'"!,hi.,rermd ha;been prm,ided m d+.•well mr,o'r.
i!the a a repair,fi
epair and„';=21 r,'rrrark,s,•ni:n ur,,Jar 6,n'k„f thi,,G„'n,. 23.Site diagram or additional well details-
you mad'use the back of this page to pro%ide additional well site details or%tell
b.For Geoprobe,DPT or Closed-Loop Geothermal Wells hat ing the same constnlcton details. you may also attach additional pages if necessary.
constntction.only I GW-l is needed. Indicate TOTAL NUMBER of wells
drilled: SUBAIIT'hAL INSTRUCTIONS
9.Total well depth bEloN land surface: (ft-) 24a. For All Wells: Submit, this form within 30 days of completion of well
for r+mltiple it'll.(lt,t all delnhi i/dr/)error,,:rnny>Ir-_'a Yl0',,n ,a;l tl0', construction to the followin^:
10.Static water level below top of casing:40 (ft.) Division of Water Resources,Information Processing Unit,
10.Static
iste,lei, a er level
el below
o 1617 Mail Service Center,Raleigh,NC 27699-1617
i i.Borehole diameter: 6 118 (in.) 24b.For filiection Wells: in addition to sending the Torn to the address in '_-la
Air Rotary above.also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
I 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
l/ Nlethod of test: Air Flow 24c.For Water SuoDly&Iniection q ells: b,addition to sending the fonn to
13a.Yield(gpm) the address(es) above, also submit one copy of this form within 30 days of
Chlor Tabs Amount 1 1/2 Cbs completion of well construction to the county health department of the county
13b.Disinfection typc: whcre constructcd.
Fonn 0Y,'-i North Carolina Department of Em ironuuntal Quahry-Division of Water Resource.
Revised 2-32-201 ti

r
WELL CONSTRUCTION
. • RECORD
• . , $
NORTH CPR(XING
Form GW1 Well
�wr,",.�a Q••rin
Construction Electronic
North - • Department of • Quality
DkAsion of Water Resources
April 1.2021_
Submission ID#
G W 1-2021-01197
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
Contact Name* Email Address*
Jimmy Morris [e-mail]
Is this a revision to the form you have previously submitted?
r Yes r No
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
....................._._...
Certiticate# Cert Level First Name Last Name Company Name
4193 A JIMMY MORRIS MAGETTE WELL&PUMP COMPANY,
INC.
2.Weil Construction Permit#:
PWS2021-100637
List all applicable well construction permits(i.e Nbriaoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
IT Water Supply Well(includes irrigation wells)
IV'*)
3.Water Supply Well* $',Geothermal(Heating/Cooling Supply) r Industrial/Commercial
i Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

8/17/2021 60
(gallons per minute)'
5.Well Location
Facility/Owner Name
Kevin Rawls Facility ID#
(Required) (If applicable)
County*
Beaufort
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity L/se Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No.(PIN)
Physical Address* Street Address
5282 Clarks Neck Rd
Address Line 2
City State/Province I Region
Washington NC
Postal/Zip Code Country
27889 USA
Latitude* 35.5850460000 Longitude*77151469.0000000000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r, Temporary
7. Is this a repair to an existing well:* (7 Yes P No
If this is a repair,fill out known well construction information and e)#ain the nature of the
repair under#21 remarks section or on the back of this form
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
175 surface?
For multiple wells list all depths if different 143
(example-3@200'and 2@100� in feet
10. Static water level below top of casing:(ft.) 11.Borehole diameter:
8 9.875
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:

8/17/2021 60
(gallons per minute)"
5.Well Location
Facility/Owner Name
Kevin Rawls Facility ID#
(Required) (If applicable)
County*
Beaufort
The selected county is within the Central Coastal Plain Capacity lase Area. Please reference your Capacity Ltse Water
Withdrawal Permit IJumber(CL&xxx)In Section 2.above.
Parcel Identification No.(PIN)
Physical Address* Street Address
5282 Clarks Neck Rd
Address Line 2
City State/ProWnce/Region
Washington NC
Postal 17jp Code Country
27889 USA
Latitude* 35.5850460000 Longitude*-77151469.0000000000
Decimal degrees Decimal degrees
6.Is(are)the well(s):* r Permanent r Temporary
7.Is this a repair to an existing well:* C Yes t% No
If this is a repair,fill out known well construction information and e)lain the nature of the
repair under#21 remarks section or on the back of this form
For multiple GeoprobelDPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
Ba.Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
175 surface?
For multiple wells list ail depths if different 143
(e)ample-3@200'and 2Qa 1001 in feet
10.Static water level below top of casing:(ft.) 11.Borehole diameter:
8 9.875
Kwater le%el is above casing,use'+" in inches
12.Well construction method:
r, Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:

13a.Yield(gpm)
60 13a.Method of test:
if applicable Air Lift
13b.Disinfection type:* 13b.Amount:*
12%Sodium Hypochlorite 2 Gallons
14.WATER BEARING/FRACTURE ZONES
From To Description
143 175 fine black sand with some course quarts sand
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
143.00 175.00 4.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 120.00 Bentonite Tremie
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Empiacment Method
120.00 178.00 SP#2 Tremie
in feet in feet
20.DRILLING LOG
From To Description(color,hardness,soil/rock type,grain size,etc.)
0.00 14.00 Sand
in feet in feet
14.00 33.00 Gray clay and shells
in feet in feet
33.00 42.00 Limestone
in feet in feet
42.00 60.00 Limestone,white clay with black sand
in feet in feet
60.00 65.00 limestone
in feet in feet
65.00 72.00 Gray clay, black sand,shells
in feet in feet

72.00 77.00 shells,gray clay with black sand
in feet in feet
77.00 81.00 sand
in feet in feet
81.00 83.00 limestone
in feet in feet
83.00 94.00 stiff black gray clay
in feet in feet
94.00 95.00 rock
in feet in feet
95.00 118.00 stiff black gray clay
in feet in feet
118.00 119.00 rock
in feet in feet
119.00 136.00 gray clay
in feet in feet
136.00 142.00 green sandy clay
in feet in feet
142.00 178.00 fine black sand with medium course quarts sand
in feet in feet
178.00 182.00 gray clay
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
"only
CERTIFICATION INFORMATION
*p By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
J4"/ MWei
Signature of Certified Well Contractor
Submittal Date 9/2/2021

' 72.00 77.00 shells,gray clay with black sand
in feet in feet
77.00 81.00 sand
in feet In feet
81.00 83.00 limestone
in feet in feet
83.00 94.00 stiff black gray clay
in feet in feet
94.00 95.00 rock
in feet in feet
95.00 118.00 stiff black gray clay
in feet in feet
118.00 119.00 rock
in feet in feet
119.00 136.00 gray clay
In feet in feet
136.00 142.00 green sandy clay
in feet in feet
142.00 178.00 fine black sand with medium course quarts sand
in feet in feet
178.00 182.00 gray clay
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You may upload additional well oonstnx:tion information here.
pdf only
CERTIFICATION INFORMATION
*p By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
'TA"l Awea
Signature of Certified Well Contractor
Submittal Date 9/2/2021

CZ
NORTH CAROLiNA
WELL CONSTRUCTION RECORD (GW-1)
EmtmwwM•1 Q•dtry
•rm GW-1 Mll Construction Electronic •
North • Department of •
DkAsion
April 1,2021
Submission ID#
G W 1-2021-01198
Are you submitting a printed form?* r Yes
r No
CONTACT INFORMATION
Contact Name* Email Address*
Jimmy Morris [e-mail]
Is this a revision to the form you have previously submitted?*
r Yes r No
WELL CONSTRUCTION INFORMATION
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name last Name Company Name
4193 A JIMMY MORRIS MAGETTE WELL&PUMP COMPANY,
INC.
2.Well Construction Permit#:
PWS2021-100638
List all applicable well construction permits(i.e.Nbiritoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
r Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
C Irrigation r Municipal/Public/Community
IT Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4.Date well was completed and ID#
Date Well Completed* Well ID# Well Yield

i
8/20/2021 60
(gallons per minute)"
5.Well Location
Facility/Owner Name
Kevin Rawls Facility ID#
(Required) (If applicable)
County*
Beaufort
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No.(PIN)
Physical Address* Street Address
5282 Clarks Neck Road
Address Line 2
City State/ProHnce/Region
Washington NC
Postal/Zip Code County
27889 us
Latitude* 35.5848890000 Longitude*77.1514690000
Decimal degrees Decimal degrees
6.Is(are)the weil(s):* r Permanent r Temporary
7.Is this a repair to an existing well:* r Yes r No
ff this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a.Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
174 surface?
For multiple wells list all depths if different 142
(example-3@200'and 2@1001 in feet
10.Static water level below top of casing:(ft.) 11.Borehole diameter:
8 9.875
If water level is abme casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:

8/20/2021 60
(gallons per minute)"
5.Well Location
Facility/Owner Name
Kevin Rawls Facility ID#
(Required) (If applicable)
County*
Beaufort
The selected county is within the Central Coastal Plain Capacity Use Area. Please reference your Capacity Use Water
Withdrawal Permit Number(CUxxxx)in Section 2.above.
Parcel Identification No.(PIN)
Physical Address* Street Address
5282 Clarks Neck Road
Address Line 2
City State/Pro\ince/Region
Washington NC
Postal/Zip Code Country
27889 us
Latitude* 35.5848890000 Longitude*77.1514690000
Decimal degrees Decimal degrees
6.Is(are)the well(s):* r Permanent r Temporary
7.Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and a>plain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
Ba.Indicate TOTAL NUMBER of wells drilled:
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
174 surface?
For multiple wells list all depths if different 142
(example-3@200'and 2@1001 in feet
10.Static water level below top of casing:(ft.) 11.Borehole diameter:
8 9.875
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13.FOR WATER SUPPLY WELLS ONLY:
L

13a.Yield(gpm)
60 13a.Method of test:
If applicable Air Lift
13b. Disinfection type:* 13b.Amount:*
12%Sodium Hypochlorite 2 Gallons
14.WATER BEARING/FRACTURE ZONES
From To Description
142 174 fine black sand with medium course quarts sand
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
142.00 174.00 4.00 Sch 40 PVC
in feet in feet in inches
18.GROUT
From To Material Emplacment Method&Amount
0.00 120.00 Bentonite Tremie
in feet in feet
19.SANDIGRAVEL PACK(if applicable)
From To Material Emplacment Method
120.00 178.00 SP#2 Tremie
in feet in feet
20.DRILLING LOG
From To Description(color,hardness,soil/rock type,grain size,etc.)
0.00 14.00 Sand
in feet in feet
14.00 33.00 gray clay with shells
in feet in feet
33.00 42.00 limestone
in feet in feet
42.00 60.00 limestone,white clay with black sand
in feet in feet
60.00 65.00 Hard limestone
in feet in feet
65.00 77.00 Gray clay black sand and shells
in feet in feet

77.00 81.00 Sand
in feet in feet
81.00 83.00 Limestone
in feet in feet
83.00 94.00 Stiff black gray clay
in feet in feet
94.00 95.00 Rock
in feet in feet
95.00 118.00 stiff black gray clay
in feet in feet
118.00 119.00 rock
in feet in feet
119.00 136.00 gray clay
in feet in feet
136.00 141.00 green sandy clay
in feet in feet
141.00 178.00 fine black sand with medium course quarts sand
in feet in feet
178.00 182.00 gray clay
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
*W By signing this form, I hereby certify that the wells)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
Signature of Certified Well Contractor
Submittal Date 9/2/2021

77.00 81.00 Sand
in feet in feet
81.00 83.00 Limestone
in feet in feet
83.00 94.00 Stiff black gray clay
in feet in feet
94.00 95.00 Rock
in feet in feet
95.00 11800 stiff black gray clay
in feet in feet
118.00 119.00 rock
in feet in feet
119.00 136.00 gray clay
in feet in feet
136.00 141.00 green sandy clay
in feet in feet
141.00 178.00 fine black sand with medium course quarts sand
in feet in feet
178.00 182.00 gray clay
in feet in feet
21.Remarks
22.Site diagram or additional well details:
You mayupload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
*W By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
Signature of Certified Well Contractor
Submittal Date 9/2/2021
l