GW1-2023-01700_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:
D.T. Chalmers, JR FROM TO DESCRIPTION
Well Contractor Name rL rt
4146A
NC Well Contractor Certification Number 15.INNER CASING OR TUBING I geoth etm al Closed too
FRONT TO DIAN1111 R n11CKNESS N14TERIAL
CATLIN Engineers and Scientists 0 ft. 5 ft.1 2 itt I Sch. 40 PVC
Company Name 16.OUTER CASING for multi-cased welts OR LINER if a ieable
FROM I TO DIANWILR TI1I('RNESS MATERIAL
2.Well Construction Permit#: N/A rt. ft. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
fl. rt. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIANII:TFR SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 ft. ? in. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt• n.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
I IMA[ TO NG\TERIAL ENPLACENIENT METHOD K moi AT
❑irrigation 0 ft. 1 ft. Concrete Surface Pour
Non-Water Supply Well: -
®Monitoring ❑Recovery 1 ft. 3 ft. Bent.Pellets Surface Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK its icable
❑Aquifer Storage and Recovery ❑Salinity Barner FROM TO NIAII RIA1 I ENPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage3 ft. 20 ft, Torpedo Sand
-
❑Experimental Technology ❑Subsidence Control ft. ft,
20.DRILLING LOG attach additional sheets if nee
❑Geothermal(Closed Loop) ❑Tracer FROM To DFscwF n > ,.,i:, hardness.soiurmk t.to vain size etc
❑Geothemral(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft, -_
4.Date Well(s)Completed: 02/01/23 Well ID#: MW-5 n. n. -� V� O
0` N�
Ss.Well Location: ltd
NCDEQ-HALL'S STORE 00-0-00009410
P
It.
Facility/Owner Name Facility ID#(if applicable)
tl. L v ZO 11'
9830 HIGH HOUSE RD,SALEMBURG,28385
n. a.
Physical Address,City,and Zip
zI.REM1fARKS _
SAMPSON N/A
County Parcel identification No.(PK
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
35.11376 N -78.53747 W 2/3/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or ❑1 emlwrary Br signing thisform,i hereby certA.,that the well(s)was(were)consintcied to accorckrnce with
1SA MAC 02C.0100 or iSA MCAC 02C.0200 Well Construction Standards 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,fill 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 injection or non-water supply wells ONLY with the smite consrucdoe,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 different(example-3@200'and 2@1009 construction to the following:
10.Static water level below top of casing: 18.21 (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 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: 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 GW-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CNIL CATLIN
GEOTECHNICAL
A41- w,Raleigh.Washi gtm,
G WELL LOG Engineers and Scientists
2zo2e4 SHEET 1 OF 1
PROJECT NO.: 220284 STATE: NC coLINTY: SAMPSON LOCATION: SALEMBURG
PROJECT: 220284 LOGGED BY: C. Black WELL ID:
DRILLER: D. T. Chalmers JR MW-5
NORTHING: 496653 EASTING: 2138319 CREW: L. Hamilton
SYSTEM: NCSP NAD 83 USft BORING LOCATION: South of former kerosene LIST T.O.C.ELEV.: 99.87
DRILL MACHINE: Diedrich D-50 METHOD: HSA 1 0 HOUR DTW: 18.8 TOTAL DEPTH: 20.0
START DATE: 2/1/23 END DATE: 2/1/23 124 HOUR DTW: 18.2 WELL DEPTH: 20.0
DEPTH BLOW COUNT OVA LAB M L SOIL AND ROCK WELL
0.5ft 1 0.5ft 0.5ft o.5ft (PPM) s c DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 99.9 0.0
0.0 (CL)-Brown,Silty slightly plastic CLAY. 0.0 -
a a 3 0.1 M HCO from 5-8'BLS = 1.0
a
CL
c
u 3.0
rn
(V
5.0 s.o
a
10
10.3 M
12
8.0 91.9
(ML)-Brown,Sandy SILT. Slight HCO
10.0
3
5 34.6 M 11.0 88.9
6 7 (CL)-Whitish brown,Silty moderately plastic CLAY.
Slight HCO o j
oa
-6
13.0 86.9 mt
• (V U
(SW)-Lt.brown to orange,F.to Cse.SAND. Moderate in
HCO
15.0
5 r
5 7 6.5 W ';t•.jr
9
1 8.0 :a•'yr
3 8 ~^ r -
10 3.2 •.=.'.
3 ;� e
20.0 Sat. 20.0 79.9 20.0 20.0
BORING TERMINATED AT ELEVATION 79.9 ft in F.to
Cse.SAND
ElPortland Cement Bentonite Pellets El#2 Medium Sand