GW1-2022-09059_Well Construction - GW1_20220923

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WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
51-4AWATER ZONES
COREY D. FUTRAL FROM TO DESCRIPTION
Well Contractor Name ,. p < rL ft.
4330E a
NC Well Contractor Certification Number c; t15WWI rGASIN(''0 &G e`othermall'dosedrloo
Sp P J / FROM . TO DIAMETER —CKNESS I MATERIAL
CATLIN Engineers and Scientists 0 rL 10.8 a 1 Sch.40 PVC
Company Name c l 1r167fOUTER?GASINGr(fo—r.m Iti-ta` "s'ed N-'s4'0A1L1lNIf1tTT—aPpi9M4M
Ins•.' ti FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: rL rL in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft ft. in.
3.Well Use(check well use): Mi-71SCREEN
Water Supply Well: .FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 10.8o 15.8iL I 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL R.1in.
❑Industrial/Commercial ❑Residential Water Supply(shared) /I8[GGROl1T
FROM TO I MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation. rL ft.
Non-Water Supply Well:
N Monitoring ❑Recovery fL ft. -
Injection Well: rL IL
❑Aquifer Recharge ❑Groundwater Remediation �9TSAND//GRWVEIf KC-iC7i"fa licatile
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rL a.
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 0 ft. 15.8 ft. Natural Backfill
W0�15—Ta TI.. .... attachXddition`al sheet'sTif,necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock tym wain sve etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) k rL
4.Date Well(s)Completed: 08/30/22 Well ID#: TMW-01 ft n.
fL rL S �O
5a.Well Location:
rL ftNCDOT ROW
N/A P
ft. P
Facility/Owner Name Facility iD#(ifapplicable)
ft
300 East Gold St.,Wilson,NC 27893
ft.Physical Address,City,and Zip rt.
IFUNKEMAR'KS
WILSON 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)
35.727469 Iv -77.90427 W 9/21/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or O Temporary By signing this form,I hereby certij•that the well(T)was(were)constructed in accordance with
ISA NCIC 01C.0/00 or 15A NCIC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
If 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 ofthis 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: 15.8 (R,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in Jim erent(example-3 a200'and 2@1009 construction to the following:
10.Static water level below top of casing: 15.50 (R,) Division of WaterjResources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: —3 (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: HAND AUGER completion of well construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Resoulrces,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 Syaaly&iInfection 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 2-22-2616

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ENVIRONMENTAL,CIVIL CATLIN
GEOTECHNICAL
VUlmington,Raleigh,Washkoon,
Charleston Engineers and Scientists
WELL LOG i z21049 SHEET 1 OF 1
PROJECT NO.: 221049 STATE: NC COUNTY: WILSON ,LOCATION: Wilson
PROJECT: LOGGED BY: W N EWMAN WELL ID:
Quick Stop Mart DRILLER: C UTRAL
NORTHING: 7214911 EASTING: 2325205 CREW: TMW-01
SYSTEM: NCSP NAD 83 USft BORING LOCATION: 3'South of sidewalk across street from MW-04 T.O.C.ELEV.: NM
DRILL MACHINE: HAND AUGER METHOD: HAND AUGER 0 HOUR''DTW: 15.5 TOTAL DEPTH: 15.8
START DATE: 8/30/22 END DATE: 8/30/22 24 HOUR DTW: FIAD WELL DEPTH: 15.8
BLOW COUNT OVA o L SOIL AND ROCK WELL
DEPTH 0.5tt 0.5ft 0.5rt 0.5ft (PPM) LAB. Is c DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 __ (CL)-Sandy slightly plastic CLAY 0.0
a -
o -
u
u1
HAND UGE NM 8.0
(CL)-Gray with red mottling,slighlty plastic CLAY with
tr.sand
10.8 -
11.0 -
yn
(SC)-Gray,Clayey SAND -
o� -
oa
o�
15.8 ,- 15.8 15.8 - 15.8
BORING TERMINATED AT DEPTH 158 ft in Clayey
SAND
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Native Backfill
is