WQ0035809_MW-4, MW-5 & MW-6_20230126

WELL CONSTRUCTION RECORD F-1
1. Well Contractor Information: rLE
Stephen L. Clark
Well Contractor Name
2069A
NC Well Contractor Certification Number
The Clark Group
Company Name NA
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
(Heating/Cooling Supply)
Non -Water Supply Well:
Recharge
Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cool
QMunicipal/Public
Residential Water Supply (single)
Residential Water Supply (shared)
[] Groundwater Remediation
Salinity Barrier
[]Stormwater Drainage
[]Subsidence Control
[] Tracer
under#21
4. Date Well(s) Completed:12/5/18 Well ID# MW4
5a. Well Location:
Stateside Wastewater Plant
Facility/Owner Name Facility ID# (if applicable)
Old North State Water Company
Physical Address, City, and Zip
Stateside Wastewater Plant. Richlands, NC/OnslowCounty 445103308576
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
34-52-47.39 N 77-28-47.09
6. Is(are) the well(s)E)Permanent or []Temporary
14. WATER ZONES
FROM
TO
DESCRIPTION
7 ft-
20 ft.
Surficial Groundwater
ft.
ft.
15. OUTER CASING for multi -cased wells OR LINER if a licable
FROM
TO
of NIETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft-
1.5 ft.
2 '"'
Soh 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
1.5 ft.
19.5 ft-
2 in*
0.010
Soh 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & ANIOFR
0 ft.
0.5 ft-
Neat Cement
In -Place
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1.0 ft-
19.5 ft.
Coarse Sand
Pour
ft.
ft.
20. DRILLING LOG attach additional sheets if necessary)
FRODI
TO
DESCRIPTION color, hardness, soil/rack type, grain sin, etc.
ft.
ft.
Attached
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
W
Signature of0ertified Well Contractor
7. Is this a repair to an existing well: []Yes or []No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back of this forn+.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 19.5
For multiple wells list all depths if different (example- 3 a 200' and 2@100')
10. Static water level below top of casing: 7+/ (ft.)
If water level is above casing, me "+"
11.Borehole diameter: 8•5 (in.)
12. Well construction method: Hollow Stem Auger
(i.e. auger, rotary, cable, direct push, etc.)
12/13/18
vate
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. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
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 Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

P*.\OOODRAFTING\OOODRAFFING\FIGURES TEMPLATESWONITO RING WELLS.dwq, 12/13/2018 11:48:09 AM
MW4
PVC STAND—UP
WELL SHIELD
2.0 FT.
Lu
co
UZI
0.5 FT.
�s
9. 0 FT.
0.5 FT.
ca
1.0 FT.
Z
.6
":c Ln
PVC SLIP CAP
LOCKING WELL CAP
—CONCRETE CROWN
GROUND SURFACE
BENTONITE
Lu
(/) 1.5 FT.
I
2 IN. SCH. 40
PVC RISER
........ ..........
........ ..........
WATER V TABLE
. .......... ..........
cr 18.0 FT.
.. .........
.. .........
Q)
.. .........
SAND PACK
V)
.... ..........
..........
2 IN. SCH. 40 . ..... PVC SCREEN
BOTTOM PLUG
................
AS -BUILT
WELL DETAIL
r
SM-1
9
9 THE CLARK STATESIDE WASTEWATER DRAWN BY:CDH
GROUP DISPOSAL SITE DATE: 12/13/18
4918 WRIGHTSVILLE AVENUE- WILMINGTON NC 28403 RICHLANDS, NC
TELEPHONE [phone] FACSIMILE [phone]
www,clarkgroup.us CLARK PROJECT NO. I I I 1513 NOT TO SCALE
email: [e-mail] I

Print Form
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1. Well Contractor Information:
Stephen L. Clark
Well Contractor Name
2069A
NC Well Contractor Certification Number
The Clark Group
Company Name N
2. Well Construction Permit #: "
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
C]MunicipaVPublic
Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
X Monitoring ©Recovery
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
©Groundwater Remediation
Salinity Barrier
nStormwater Drainage
OSubsidence Control
® Tracer
under #21
12/5/1 8
Well ID# MW5
4. Date Well(s) Completed:
5a. Well Location:
Stateside Wastewater Plant
Facility/Owner Name
Facility ID# (if applicable)
Old North State Water Company
Physical Address, City, and Zip
Stateside Wastemter Plant Richlands, Nclonslow County
445103308576
County
Parcel Identification No. (PIN)
Sb L ft d d l 't d' d /'
t/ d d 'm I d rem
14. WATER ZONES
FROM
TO
DESCRIPTION
7 ft.
20 ft.
Surficial Groundwater
ft.
ft.
15.OUTER CASING for multi -cased wells OR LINER if a livable
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FRONT
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
2.0 ft-
2 in.
Sch 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2.0 ft
20.0 ft-
2 in.
0.010
Sch 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT'
0 ft.
0.5 ft'
Neat Cement
In -Place
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
1.0 ft.
20.0- ft-
Coarse Sand
Pour
ft.
ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION color, hardness, soulrock e, rain size, etc.
ft.
rt.
Attached
ft.
ft.
ft.
ft.
ft,
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
. a g u can ongl It e m egrees m nu es secon s or ecr a
6. Is(are) the well(s)EX Permanent or Temporary Signature of Certified Well Contractor Date
7. Is this a repair to an existing well: QYes or nXNo
If this is a repair, fill out known well construction information and explain the nature oflhe
repair under 921 remarks section or on the back of this fornn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
9. Total well depth below land surface: 20 (ft.)
For nudtiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 7+/
If water level is above casing, use "+"
11. Borehole diameter: 8•5 (in.)
12. Well construction method: Hollow Steal Auger
(i.e. auger, rotary, cable, direct push, etc.)
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 [Yell Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
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 SuoDly & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

P.\OOODRAFTING\OOODRAFFING\FIGURES TEMPLATESWONITOMNG W ELLS.dwq, 12/13/2018 11:50:52 AM
MW5
PVC STAND-UP
WELL SHIELD
PVC SLIP CAP
LOCKING WELL CAP
CL
2.0 FT.
Y
U
CONCRETE CROWN
GROUND SURFACE
J
m
UZI
0.5 FT.
Zw
W
U U
9.0+/- FT.
o 0.5 FT.
o __
8
_ - ' BENTONITE (w,) 2.0 FT.
z
W
o
1.0 FT.
m
Q�
2 IN. SCH. 40
........
:; ;:;, I PVC RISER
......... ,r
1 r I�.'
WATER TABLE
— — — — — — :,,,',---------
18.0 FT.
SAND PACK ,,,,
2 IN. SCH. 40
PVC SCREEN
BOTTOM PLUG
...
AS -BUILT
WELL DETAIL
f
W
0 20.0 FT.
J
9
THE CLARK STATESIDE WASTEWATER DRAWN BY:
19 CDH
GROUP DISPOSAL SITE DATE:
12/13/18
4918 WRIGHTSVILLE AVENUE- WILMINGTON NC 29103 RICHLANDS, NC
TELEPHONE [phone] FACSIMILE [phone]
www.clarkgroup.us CLARK PROJECT NO. 11115B NOT TO SCALE
email: [e-mail]

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Stephen L. Clark
Well Contractor Name
2069A
NC Well Contractor Certification Number
The Clark Group
Company Name NA
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
ter
(Heating/Cooling Supply)
Non -Water Supply Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
4. Date Well(s) Completed: 12/5/1 8
5a. Well Location:
Stateside Wastewater Plant
[]Municipal/Public
©Residential Water Supply (single)
Residential Water Supply (shared)
QGroundwater Remediation
[]Salinity Barrier
[] Stormwater Drainage
Subsidence Control
Tracer
under #21
Well ID# MW6
Facility/Owner Name Facility ID# (if applicable)
Old North State Water Company
Physical Address, City, and Zip
Stateside Wastewater Plant Richlands, NC/Onsim County 445103308576
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one lat/long is sufficient)
34-52-47.39 N 77-28-47.09 W
6. Is(are) the well(s)EX Permanent or Temporary
7. Is this a repair to an existing well: []Yes or E)No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 921 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: 11
For multiple wells list all depths if different (exannple- 3 a 200' and 2@100')
10. Static water level below top of casing: 2+/
If water level is above casing, use "+"
I I. Borehole diameter: 8.5 (in.)
12. Well construction method: Hollow Stern Auger
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
2 ft.
11 ft.
Surficial Groundwater
ft.
ft.
15.OUTER CASING for multi -cased wells OR LINER if a licable
FROM
TO
DIAMETER
THICKNESS
NATERIAL
ft.
I ft.
I in.
16. INNER CASING OR TUBING(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
1.0 ft-
2 in.
Sch 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
NIATERWL
1.0 ft'
11.0 ft'
2 in.
0.010
Sch 40
PVC
ft.
ft.
in.
18. GROUT
FRONI
TO
MATERIAL
ENIPLACENIENT NIETHOD & AIIIOUNT
0 ft-
0.25 ft'
Neat Cement
In -Place
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
ENIPLACEMENT NIETHOD
0.5 ft.
11.0 ft-
Coarse Sand
Pour
ft.
ft.
20. DRILLING LOG attach additional sheets if necessary)
FRONT
TO
DESCRIPTION color, hardness, soil/rock type, grain size, etc.
ft.
ft.
Attached
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
12/13/18
Signature of Certified ell Contractor Date
By signing this form, 1 hereby certify that the wells) was (here) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Constniction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
(ft.) 24a• For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
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 Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

THE CLARK GROUP
BORING LOG
PROJECT NAME: Stateside Wastewater Disposal Site WELL NO. MW6
LOCATION: Richlands, NC DATE: 12/4/18
CLARK PROJECT NO: 11115B LOGGED BY: S. Clark
DEPTH
FROM TO DESCRIPTION
(ft BGS) (ft BGS)
0 1 Brown/black organic SAND, becoming gray
1 6.5 Gray silty SAND, wet at —2 feet
6.5 11 Gray silty SAND
NOTE:
ft BGS REPRESENTS FEET BELOW GROUND SURFACE
THE CLARK GROUP

P:\OOODRAFfING\OOODRAFIING\FIGURES TEMPLATESWONITORING WELLS.dwo. 12/13/201811:54:11 AM
MW6
PVC STAND—UP PVC SLIP CAP
WELL SHIELD
LOCKING WELL CAP
Q_
2.0 FT. Y
U
CONCRETE CROWN
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w
0.25 FT. w
U U
FW— --
---
4.0+/— FT. o
0.25 FT.
BENTONITE (;�
1.0 FT.
z
m --
--
L z
lil ...,:,:.:
:.:,
0W
0. 5 FT. Q ca =........='
W
U2
IN. SCH. 40
';:? PVC RISER
o
•1
CL
0
11.0 FT.
'.
.
;;;;: ?
WATER V TABLE
---- ----
---
_
it� ..
_--- z
cr
10.0 FT.
SAND PACK-•;.;.'
:::_..t cUn
2 IN. SCH. 40
PVC SCREEN
BOTTOM PLUG --`"''
..........................
I Qw
AS -BUILT
WELL DETAIL
19 THE CLARK STATESIDE WASTEWATER DRAWN BY:
CDH
GROUP DISPOSAL SITE DATE:
12/13/18
4918 WRIGHTSVILLE AVENUE. WILMINGTON NC 28403 RICHLANDS, NC
TELEPHONE [phone] FACSIMILE [phone]
www.clarkgroup.us CLARK PROJECT NO. 11115B NOT TO SCALE
email: [e-mail]