GW1--00476_Well Construction - GW1_20240116

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
Well Contractor Name It. ft.
4366A i_r . _ s 1 ft. ft. -
NC Well Contractor Certification Number JA N 1 6 2024 IS.INNER CASING OR TUBING(Eeothennal closed-loop)
FROM TO DI.\?.IICIFR THICKNESS \I.\TF:RIAL
CATLIN Engineers and Scientists 0.3 ft. 4 rt. 1 in. Sch.40 PVC
Company Name �, 16.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
GV>.if✓ FROM TO DI vME111R TItICKNESS NI.vTFRLvL
2.Well Construction Permit#: N/A e. ft.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
n. n.
3.Well Use(check well use): 17.SCREEN
Water Supply Well FROM TO DI-AMIi!Eft_ll)Isiii nncK\t_sk Ni n1 RI AI.
❑Agricultural ❑Municipal/Public - 4 f. 13.6 ft. 1 in. Slot.010 Sch. 40 PVC
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&:Ulu(\1
❑Irrigation 0 ft. 0.5 rt. Portland Cement Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.5 n. 3 It. Bent.Pellets Surface Pour
Injection Well: ft.[" ft.
0 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM l() M.\I RI:\I. EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 3 rt. 1511. Torpedo Sand Surface Pour
❑Experimental Technology 0 Subsidence Control ft. It.
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) 0 Tracer FR:1V F() DESCRIPTION(color,hardness,soil rock type,dam size,etc)
0 Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) It. ft.
4.Date Well(s)Completed: 12/13/23 Well ID#: MW-01 It li. IC+e ft.
. rt. / �e
Sa.Well Location:
It. tt. was' pkcp
NCDEQ Pk1
It.
Facility/Owner Name Facility EA(if applicable)
a.
220 West Main St.,Rowland,NC 28383
u. It.
Physical Address,City,and Zip
21.REMARKS
ROBESON
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)
34.53822 N -79.29454 w --::-.-21/12/2024
SigtatureofCertified Well Contractor Date
6.Is(are)the well(s): ®Permanent or °Temporary By signing this form,/hereby certify that the well(s)was(were)constructed in accordance with
15A MAC 02('.0/00 or I SA MAC 02('.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#2l remarks section or on the back of this form. 23.Site diagram or additional wen 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 same construction,you SUBMITTAL INSTRUCTIONScan submit one form.
9.Total well depth below land surface: 14.0 (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@l009 construction to the following:
10.Static water level below top of casing: 5.0 (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: 7.25 (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: H.S.AUGERS 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
Method of test: 24c.For Water Svpply&Injection Wells:
13a.Yield
(gpm) 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

WELL I_OG ENE
L.CNIL
CATLIN
2231ashington.
Charleston Engineers and Scientists
zz3tg3.oz SHEET 1 OF 1
1Mlmngton,NC
PROJECT NO.: 223193.02 STATE: NC COUNTY: ROBESON LOCATION: Rowland
PROJECT: The Corner Store (Former Starlite 2) LOGGED BY: C. STRATTON WELL ID:
DRILLER: Austin Fowler MW-01
NORTHING: 287015 EASTING: 911287 CREW: CATLIN
SYSTEM: NCSP NAD 83 (USft) DRILL MACHINE: CAT1303 CME-550 94.5%02/23/2023 T.O.C.ELEV.: 138.37
VERT.DATUM: NAVD88 (USft) METHOD: H.S. AUGERS 0 HOUR DTW: 5.0 TOTAL DEPTH: 15.0
START DATE: 12/13/23 END DATE: 12/13/23 24 HOUR DTW: NM WELL DEPTH: 14.0_
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (PPm) S G DEPTH DESCRIPTION ELEVATION DETAIL
0.0 Land Surface 138.7 o.o
Aid;4 `- _
0.5 4:•a:' 0.5 CONCRETE 138.2 -0.3
0.5
2 (CH)-Gray to dark gray,highly plastic CLAY. Strong1
2 t 357 M % HCO .:.
a ••
o :S
j '•' 3.0
4.0 134.7 4.0 •",
(CL)-Brown,gray,and red,mottled,Silty CLAY with m::
/ trace f.Sand. Strong HCO =:::
5.0 •:•.
ar.
2
2
3 256 W m.•::
EN ::
8.0 130.7 •..
oar•.
(CH)-Orange and gray,mottled,highly plastic CLAY. bap••.;
Slight HCO o m
::
WOH
WOH 42 W p
WOH ::'
12.5 126.2 mi;;
V` (SC)-Orange brown,Clayey,f.to med.SAND. Slight p;
cr.
z 13.0 HCO -::.
6 3 2 • 14.0 .:::
g 4 5 45 W
LL
15.0 A15.0 123.7 15.0
BORING TERMINATED AT ELEVATION 123.7 ft
iT
LL
2
C
w
a
0
z
2
t�
rn
Mry�`{
01
C7
a
i
2
z
C
s
z
P.
7 Portland Cement '.':'::Bentonite Pellets Ej#2 Medium Sand

co
N
z``, r
if
if
•
8,000-GAL. , 411141N1440 110 If
GASOLINE .
4 UST
401
---I?
FORMER 2,000-GAL. 4,000- GAL.
KEROSENE UST MW-01 e GASOLINE
USTS
•
DISPENSER
ISLAND ,4448IL ,
4411111P
LEGEND I O
A Soil Sample
Monitoring Well �-
® (Type II)
0 Approximate Location
of Former AST
❑ Approximate Location
4114111k *1
of UST System It
wM '�El Parcel Boundary 4
/4,
S t1 �`
T Source: Esri,Maxar, Earthstar Geographies,and the c7I,-User Cc--,,,,:n:t,
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 20 10 0 20 40
witwom imilmil mimminli Feet
PROJECT TITLE FIGURE
THE CORNER STORE
CATLIN N ST
ROWLAN I NC SITE MAP
1
Engineers and Scientists
INCIDENT NO. JOB NO. DATE SCALE DRAWN BY/CHECKED BY
29037 223193 JAN 2024 AS SHOWN KMC/SJO