GW1-2023-02779_Well Construction - GW1_20230417

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 ,
4146A a. rt. :.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermal closed-moo
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0.3 rt 5 rt 2 Sch.40 '. PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable)
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft ft in:
List all applicable well permits(i.e.County,State, Variance,Injection,etc.) ..
it ft in.
3.Well Use(check well use): n.SCREEN
Water Supply Well:. FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 tt. 15 rt. 2 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0.3'tt 1 ft. Concrete Surface Pour
Non-Water Supply Well:
99Monitoring ❑Recovery 1 ft. 3 ft. Bent.Pellets Surface Pour
Injection Well: ft u.
❑Aquifer Recharge. ❑Groundwater Remediation 19.SAND/GRAVEL PACK Itapplicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM- To MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 3ft. 15rt. Torpedo Sand Surface Pour
❑Experimental Technology ❑Subsidence Control ft ft
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM T'O DESCRIPTION color.hardness,soilfrock tv e.aain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) ft ft.
4.Date Well(s)Completed: 03/27/23 Well ID#: MW-04 tt: ft.
n. u. �O
5a.Well Location:
rt ft
NCDEQ-Winston Hill and.So 00-0-007507
ns Grocery
ft.Facility/Ownei Name Facility D#(if applicable)
ft. P
1030 SEASHHORE DR,ATLANTIC,28511 n rt APRrY r'QL�
Physical Address,City,and Zip
21.REMARKS
CARTERET N/A
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or,decimal degrees: 22.Certification:
(if Nvell field,one lat/long is sufficient)
-76.337434 ' l
34.88256 N W 4/11/2023
Signature of Certified Well Contractor Date
6.Is,(are)the well(s): 00 Permanent or ❑Temporary By signing this form,ihereby terrify that the uell(s)was(were)conslrucled in accordance with
I SA NCAC 01C,0100 or W NCAC 02C.0100 iVell Construction 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 name of
the repair under it21,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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-wafer supply wells ONLY with the slime construction,you SUBMITTAL INSTRUCTIONS
can submit one form. .
9.Total well depth below land surface: 15.0 (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: (ft.) 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: 8.25 010 24b.For Iniection Wells ONLY: In addition to sending the form to the
address in 24a above,also submit a copy of.this form wlthuT 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 Svoaly&iniection'Wells:
Also submit one copy of this form within 30 days of completion of well-
construction to the county health department of the county where constructed.
13b.Disinfection,type: Amount:
Adapted from Form GW-f North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016
I i
i

EIJVIRCNMENTAL,CNIL
GEOTECHNICAL CATLIN
1Mlmington,Raleigh,Washington, '
Charleston Engineers and Scientists
WELL LO"G . 221160 SHEET 1 OF 1
PROJECT NO.: 221160 STATE: NC COUNTY, CARTERET . LOCATION: ATLANTIC
PROJECT: WINSTON HILL & SONS GROCERY LOGGED BY: C. Stratton WELL ID:
DRILLER: . D. T. Chalmers, JR IUW-04
NORTHING:- 422896 1 EASTING: 2798399 CREW: L. Hamilton
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Eastern portion of propert line T.O.C.ELEV.: 98.05
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: NM TOTAL DEPTH: 15.0
START DATE: 3/27/23 END DATE: 3/27/23 124 HOUR DTW: NM WELL DEPTH: 15.0
BLOW COUNT OVA o o
I SOIL AND ROCK WELL
DEPTH 0.5ft O.Sft 0.5ft O.Sft (ppm) LAB. � DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE, 98A . 0.0 .
0.0 (SM)-Dark to It.brown,Silty F.SAND -0.3 _
1 —
4 3 1813 D - to
3
>
a
v
3.0
U
(V
5.0 s.o
2 2 685 M
2
8.0 .....2._ 90.4
.4
(SW)-Lt.gray and tan,F.and Cse.SAND
•� °t oa
10.0 s
2 3 •�a't N
4 89 VV
.. 6 e'•,
1'3.0
4
e 6 85 Sat.
15.0 15.0 43 15.0 15.0
BORING TERMINATED AT ELEVATION 83.4 ft in F.
and Cse.SAND
Portland Cement Bentonite Pellets #2 Medium Sand