GW1-2023-01699_Well Construction - GW1_20230213

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
14."'ATER ZONES
D.T. Chalmers, JR To I DFSCRIP„ON
Well Contractor Name it. n.
4146A ft. r`
NC Well Contractor Certification Number IS.INNER CASING OR TUBING eothermal closed loo
FROM DIAMETER 111 r'RVESS MATERIAL
CATLIN Engineers and Scientists 0 ft. TO 5 rt. 2 Sch.40 PVC
Company Name 16.OI1TER CASING for multi-cased wells OR LINER if a iaable
FROM To Dl.aVMETER TIIICK\TSS MATERIAL
2.Well Construction Permit#: N/A ft. ft. in.
List all applicable well permits(i.e.County,Stare, Variance,Injection,etc.)
ft. ft. n.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 5 ft. 20 n. 2 m Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FRO%I TO MATERIAL EAIPLACErIE1vThIETHOD&ANIOUNr
❑lni ation
0 Mt. 1 n. Concrete Surface Pour
Non-Water Supply Well: I-
0Monitoring ❑Recovery 1 ft. 3 rt. Bent.Pellets Surface Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a tlicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO FRIA[ I EPIPLACENIENT IMTHOD
rt.
❑Aquifer Test ❑Stormwater Drainage 3 ft. 22 Torpedo Sand-
❑Experimental Technology ❑Subsidence Control It. A.
20.DRILL G LOG attach additional sheets if net
❑Geothermal(Closed Loop) ❑Tracer FRom To I DFSCRIPTIO% ­Io, i,:,rd-,
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it. ft. -_
4.Date Well(s)Completed: 02/01/23 Well ID#: MW-6
Sa.Well Location: -
n.NCDEQ-HAIL'S STORE 00-0-00009410 -1 1;
It. . _
Facility/Owner Name Facility ID#(if applicable) rsli
1,I t.
9830 HIGH HOUSE RD,SALEMBURG,28385
Physical Address,City,and Zip -
2 1.REMARKS -
SAMPSON 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) 7 7
35.11382 N -78.53745 W � 2/3/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary
By signing this form,(hereby scud fi•That the well(s)may(were)canstnrc led m u<cordunce wvdr
1 SA AK.A(-02C.0100 or 15A MAC'02C.0100 Well Construction Siarulards and that a copy of
7.Is this a repair to an existing well: OYes or ®No this record has been provided to the well owner.
If this is a repair,f ll out known well construction information and explain the nature of
the repair under#21 remarks section or on the back of this 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: construction details. You may also attach additional pages if necessary.
For multiple tryection or non-water supply wells ONLY with the saw consbffedon,you SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 20.0 (g,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in dtjjerent(example-3@200'and 2@1009 construction to the following:
10.Static water level below top of casing: 17.92 (g,) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (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: HSA completion of well 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
13a.Yield(gpm) Method of test: 24c.For Water SvDDIv&Infection 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 Glk'-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL CATLIN
GEOTECHNICAL
A41-gtm,Raleigh,Washrgtw.
Charleston Engineers and Scientists
WELL LOG 220284 SHEET 1 OF 1
PROJECT NO.: 220284 1 STATE: NC I COUNTY: SAMPSON LOCATION: SALEMBURG
PROJECT: 220284 LOGGED BY. C. Black WELL ID:
DRILLER: D. T. Chalmers JR MW_6
NORTHING: 496675 1 EASTING: 2138324 CREW: L. Hamilton
SYSTEM: NCSP NAD 83 USft BORING LOCATION: West of former 2,000-Gal.Gasoline UST T.O.C.ELEV.: 99.49
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 18.1 TOTAL DEPTH: 22.0
START DATE: 2/1/23 END DATE: 2/1/23 24 HOUR DTW: 17.9 WELL DEPTH: 20.0
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPM) LAB. Is G DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 99.5 0.0
0.0 (SM)-Brown,Silty SAND with tr.gravel 0.0
a -
° 5 0.1 M r - 1.0
5
r >
a
0
• 1 v
3.0 96.5 3.0
(CL)-Brown,Slightly plastic CLAY with tr.sand N
5.0
5.0
2 2
2 0.3 M
3
10.0
2
' 2 1.4 M
a
oV
oa
00
13.0 86.5 t
(SW)-Lt.brown,F.to Med.SAND. Slight HCO from n
"? 15.0-17.0'BLS
'! Tr.gravel from 20.0-22.0'BLS
15.0 2 .:.:
5 8 20.2 W :,•;r
9
IC
20.0 " - zo.o
:,a jr
4 "^ !
5 5 0.2 Sat.
8 ;; r
22.0 22.0 77.5 22.0
BORING TERMINATED AT ELEVATION 77.5 ft in F.to
Med.SAND
EjPortland Cement Bentonite Pellets El#2 Medium Sand