GW1-2022-10489_Well Construction - GW1_20221118

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4146A ft. rL
NC Well Contractor Certification Number 15.INNER CASING OR TUBING geothermal closed-loo
FROM TO DIAMETER THicKrmSS I MATERIAL
CATLIN Engineers and Scientists 0 ft.1 2 ft.1 1 in.1 Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A rL ft. in.
List all applicable ivell permits(i.e.County,Stale, Variance,Injection,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMEMR SLOT SIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL rt.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well:
®Monitoring ❑Recovery ft. R.
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO I,IAI RIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery El Salinity Barrier
rt. B.
❑Aquifer Test ❑Stomlwater Drainage
❑Experimental Technology ❑Subsidence Control 0 ft. 12 ft. Natural Backfill
20.DRILLING LOG attach addifional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness soillrock Wpe,grain sire etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. n.
4.Date Well(s)Completed: 11/10/22 Well ID#: TMW-01 rL rt. �� O
R. ft.
Sa.Well Location:
N/A ft. rf. �`
NCDEQ-VERA HOWARD ` r - �- `` ' � "} •
Facility/Owner Name Facility ID#(if applicable) rt.
R.
22545 US HWY 17 N.,HAMPSTEAD,28443 NOV LU
ft ft i i7 LL
Physical Address,City,and Zip
�l.REMARKSPENDER N/A t '-:.: .-. . .,_
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
34.4502129 N -77.6170441 W 11/10/2022
Signature ofCertified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or O Temporary Bvsigning this form,l hereby certtfv that the u-ell(s)ryas(here)conslnicted in accordance x,ifh
ISA N(AC 02C.0100 or 15A NCIC 02C.0200{Veil Consiniction 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.
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 ntaltiple injection or non-seater supply wells ONLY with the sane construction,votr SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 12.0 (ft,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3@200'and 2@1009 construction to the following:
10.Static water level below top of casing: 4.1 (ft,) Division of Water Resources,Information Processing Unit,
Ifwaler level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 2.25 (in.) 24b.For Iniection 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: DIRECT PUSH completion ofwell 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
24c.For Water Svauly&Iniection Wells:
13a.Yield(gpm) Method of test:
Also submit one cop)'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

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
WELL LOGWilmington,Raleigh,Washington,
Charleston Engineers and Scientists
z2z,ss SHEET 1 OF 1
PROJECT NO.: 222183 STATE: NC I COUNTY: PENDER LOCATION: HAMPSTEAD
PROJECT: NCDEQ VERA HOWARD LOGGED BY: C. FUTRAL WELL ID:
DRILLER: D.T. CHALMERS JR. TMW-01
NORTHING: 257748 1 EASTING: 2416922 CREW:
SYSTEM: NCSP NAD 83 USft BORING LOCATION: 5 feet off of Edge of Pavement in Grass T.O.C.ELEV.:
DRILL MACHINE: POWER PROBE METHOD: DIRECT PUSH 0 HOUR Elm: 4.1 TOTAL DEPTH: 12.0
START DATE: 11/10/22 END DATE: 11/10/22 24 HOUR DTW: FIAD WELL DEPTH: 12.0
BLOW COUNT OVA M a SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPm) LAB. s G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (SP)-Brown and tan with grading to gray,F.SAND 0.0s:) _
a -
0
IREC 4.3 D
PUSH L
U
(n -
2.0 2.0- -
IREC PUSH 6,3 TMW-01 M _
(3')
4.0 -
IREC
PUSH 3.9 Sat.
6.0 0 0 -
oa
IREC PUSH 8.0 Sat. 55
t
U -
8.0 -
IREC PUSH 6.7 Sat.
10.0 1 o.a
(SC) Dark gray,Clayey F.SAND
IREC PUSH 7.3 Sat. -
12.0 12.0 12.0 12.0
BORING TERMINATED AT DEPTH 12.0 ft in Clayey F.
SAND
Native Backfill