GW1--06187_Well Construction - GW1_20230922

C.t, -a
WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES ' .
Austin Fowler FROM TO DESCRIPTION
II
Well Contractor Name ft. ft. I
4366A R• ft
NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 3 ft. ;4 in. .010 PVC
Company Name 16.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft n. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM , TO DIAMETER SLOT SIZE THICKNESS MATERIAL
0 Agricultural ❑Municipal/Public 3 rt. 13 a. 4 , in. Slot.010 .010 PVC
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. : in.
0 Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0.5 ft. 1 rt. Portland Cement Surface Pour
Non-Water Supply Well:
❑Monitoring INRecovery 1 ft. 2 ft. Bent.Pellets Surface Pour
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
0 Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test 0 Stommater Drainage 2 ft. 14 it. #2 Medium Sand Surface Pour
IDExperimental Technology 0 Subsidence Control ft. it.
20.DRILLING LOG(attach additional sheets if necessary)
0 Geothemial(Closed Loop) 0 Tracer FROM TO DESCRIPTION(color.hardness.soil/rock type.main size.etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ft. I'
ft. ft. to-
4.Date Well(s)Completed: 07/28/23 Well ID#: RW-1 ' VO
it. ft. �5a.Well Location: B. rt.NCDEQ Lumberton MobilepkG
ft. �`� 1` F.))i1_--.r
Facility/Owner Name Facility DX(if applicable)
rt.• 5105 Fayetteville Road,Lumberton,NC 28360 rrt ft. SL r 2 2 2023
Physical Address,City,and Zip '
21.-REMARKS Ic'F:.T"`..r:: 7*.-,-.::,.........,,,.,:,
ROBESON i]Va`GrL?+1;l
County Parcel Identification No.(PIN) .
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: c%��
(if well field,onetat/long is sufficient)
34.6720017393 N -79.0080108359 w �� 9/14/2023
Signature of Certified Well Contractor' Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,l 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
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 brick 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the seine construction,you SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 13.0 (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@i002 construction to the following:
10.Static water level below top of casing: 5.89 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Servii a Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10.25 (in.) 24b.For Injection 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 ServiiceiCenter,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Svnnly&Inje1ction Wells:
Also submit one copy of this foram 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 Re oul ces Revised 2-22-2016

3 t 11
ENVIRONMENTAL,CIVIL
INELL 1..OG GEOTECHNICAL CATLIN
W hringtoni,Raleigh,Washington.
2202 Charleston Engineers and Scientists
W20Ito n,NC SHEET 1 OF 1
PROJECT NO.: 220237 STATE: NC COUNTY: ROBESON LOCATION: Lumberton
PROJECT: Lumberton Mobile LOGGED BY: M. Aupperle WELL ID:
• DRILLER: Austin Fowler RW-1 •
NORTHING: 335560 EASTING: 1997591 CREW: R. Gonzalez
SYSTEM: NCSP NAD 83 (USft) DRILL MACHINE: CME 550 ATV I. T.O.C.ELEV.: 99.37
VERT.DATUM: EST. METHOD: HSA 0 HOUR MTV: N/A TOTAL DEPTH: 14.0
START DATE: 07/27/23 END DATE: 07/28/23 24 HOUR DTW: 5.9 WELL DEPTH: 13.0
BLOW COUNT OVA o L SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPm) LAB, S G DEPTH DESCRIPTION i ELEVATION DETAIL
0.0 Land Surface(Concrete), 99.4 0.0
o.o
_ _ 0 to
— E ..'•' 2.0
• 3.0 •S
I .
• I - m:::
i -
...
— —::
5.0 -
5.0 94.4 _
— �
(ML)-Brown with black layering,Clayey SILT •..:
- �:::
z 13 —
z �::,
• :.
3 i �.:•.
o>—::.
o_•::
-.E,
I.
—::.
10.0— .. 10.0 10.0 —
m,• ..
.- •.,/ —(SP-CL)-Gray,fine SAND and dark gray,Sandy CLAY :••:.
6 :;� 1 m
— 7 10.5 1 _
a 12 :� ::
:•:
12.0— —
•�./ 12.0 87.4
' •'
(SP)-Gray and tan,fine SAND ,' — =:• ;•
5 :..
7 _ 13.0 _m •:
—
— 8
• 14.0 :.:- 14.0 85.4 14.0
BORING TERMINATED AT ELEVATION 85.4 ft -
I
_ -
•
_ I _
i -
• -
Li Portland Cement til Bentonite Pellets El#2 Medium Sand