GW1-2022-03463_Well Construction - GW1_20220325

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
JACOB MESSICK 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft.
A - 4252
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) 0.0 It. 10.0 It. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ff ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10.0 ft' 45.0 ft' 2.0 in. .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) B ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 ft. 4.0 ft. PORTLANDBENTONnE SLURRY
OMonitoring ❑Recovery 4.0 ft' 8.0 IL BENTONITEPELLTs SURFACE POUR
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 8.0 ft 45.0 tt• 20-40 FINE SILICA SAND
❑Experimental Technology El Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness,soiltrock e,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 It. 1.0 It. CONCRETE/STONE
4.Date Well(s)Completed: 03/11/22 Well ID# MW-1 1.0 ft 20.0 ft BROWN SILTY CLAY
5a.Well Location: 20.0 tf 45.0 tf BROWN SILT
BENJAMIN BROWN PROPERTY Unknown ft. ff
Facility/Owner Name Facility ID#(if applicable) ff ff
1225 NORTH LIBERTY STREET WINSTON SALEM 27101
Physical Address,City,and Zip ft. ft.
FO RSYTH NA 2L REMARKS
County Parcel Identification No.(PIN) BENTONITE SEAL-4.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwellfield,one lat/long is sufficient) 22.Certification:
360 06' 37.25" N 800 14' 04.38" W /'0" ` '' 03/15/22
6.Is(are)the well(s): IN Permanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or IFNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
Ifthis is a repair,fill out known well construction information and explain the nature ofthe of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45.0 (ft.)
For multiple wells list all depths if different(example-3@200'and 2@I00') Submit this GW-1 within 30 days of well completion per the following:
20.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft*) Information Processing Unit, 1617 MSC,Raleigh,NC 2769 9-1 6 1 7
Ifwater level is above casing,use "+"
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD: Copy to DWR,CCPCUA
Permit Program, 1611 MSC,Raleigh,NC 27699-16 1 1
13a.Yield(gpm) Method of test:
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

220 Old Dairy Road
CATLIN Wilmington, NC 28405
45
[phone]-5861
Engineers and Scientists
www.CatlinUSA.com
March 25, 2022
North Carolina Department of Environmental Quality
Division of Water Quality
Information Processing
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: North Carolina Well Construction
Benjamin Brown Property
1225 N. Liberty St.
Winston-Salem, North Carolina 27101
Incident No.: 48161
CATLIN Project No.: 222013
To Whom it May Concern,
CATLIN Engineers and Scientists (CATLIN) recently constructed one (1) monitoring well
at the above referenced site. Attached to this letter is the completed North Carolina
Well Construction Record with associated Attachments for the site in Winston-Salem,
North Carolina.
If you have any questions or require additional information, please feel free to contact
us at [phone].
Sincerely,
Benjamin J. Ashba P.G. Corey D. Futral, CWC
Project Manager Project Geologist
Enclosures
Well Construction Record, Well Log, and Site Map
ENVIRONMENTAL CIVIL GEOTECHNICAL
Wilmington, NC I Raleigh, NC Washington, NC I Atlanta, GA I Charleston, SC

CATLIN
WELL LOG Engineers and Scientists
zzzol3 SHEET 1 OF 1
PROJECT NO.: 222013 STATE: NC COUNTY: FORSYTH LOCATION: WINSTON-SALEM
PROJECT: BENJAMIN BROWN PROPERTY LOGGED BY: Thomas Parks WELL ID:
DRILLER: Jacob Messick MW-1
NORTHING: 1635322 EASTING: 861300 CREW: Geologic Exploration
SYSTEM: NCSP NAD 83 USft BORING LOCATION: South of building in concrete T.O.C.ELEV.: NM
DRILL MACHINE: D-50 METHOD: HSA 0 HOUR DTW: 20.0 TOTAL DEPTH: 45.0
START DATE: 3/11/22 END DATE: 3/11/22 24 HOUR DTW: NM WELL DEPTH: 45.0
DEPTH BLOW COUNT OVA LAB 0 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 -
U
4.0 z a — 4.0
z MW-1 M �
1 1 (4-g)
U
(V
8.0
10.0
10.0 2
1 M
z
4
13.0 2
4 M
4
7
(SM)-Various browns and tans,Sandy SILT
18.0
3 M
4
5
23.0 4
3 M
3
12
oU
oa
28.0 4
s M NU)
12
13
33.0 2
3 M
4
3
38.0 5
10 W
13
12
c. 43.0 3
11 18 W .. ,e 45.0 45.0 45.0
45.0 45
BORING TERMINATED AT DEPTH 45.0 ft in Sandy
SILT
LL
ElPortland Cement Em Bentonite Pellets El#2 Medium Sand

� f N
J ►r _ _
z
co
MW�1 ti
/174
LEGEND -
® Proposed Monitoring
Well (Type II)
Parcel Boundaryuse
,
ce: E r,Ge Eye, E G- gr p ics,CNE rebus DS,
NOTE: Well locations were obtained from previous reports
prepared by other consultants and are approximate. 40 20 0 40 80
Feet
PROJECT
B TITLE
ENJAMIN BROWN
FIGURE
ATLIN PROPERTY SITE MAP
1225 N LIBERTY ST
WINSTON-SALEM, NC
Engineers and Scientists
INCIDENT NO I JOB N0. DATE SCALE DRAWN BY/CHECKED BY
48161 222013 MAR 2022 AS SHOWN KMC/SJO