GW1--04346_Well Construction - GW1_20240722

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Eddie Swain FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4632B rt. ft
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermal dweddoo
PROM I TO DIANIFIIER I TMCKNESS 114TERIA1
CATLIN Engineers and Scientists 0 ft. 4 ft. 2 Sch. 40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable)
I ROM I TO I DIA11L'7ER I THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. 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
❑Agricultural ❑MunicipaUPublic 4 ft. 14 ft. 2 in. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
I'ROM TO .AI:AIEKLAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 ft. 1 Ic Concrete Surface Pour
Non-Water Supply Well:
MMonitoring ❑Recovery 1 n. 3 it Bent.Pellets
Injection Well: h. it.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To NL I ERI:\I. EMPLACEMENT N1ET}fOD
❑Aquifer Test ❑StormwaterDrainage 3tt. 14n #2 Medium Sand Surface Pour
❑Experimental Technology ❑Subsidence Control n• ft
20.DRELLING LOG attach additional sheets if nec
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRII TION(color hardness,sclLrockrype,gmn sae etc
❑Geothermal(HeatingtCooling Return) ❑Other(explain under#21 Remarks) It. n.4.Date Well(s)Completed: 05/28/24 Well ID#: MW-01 ft. tt�i' n. --�e�n.
Sa.Well Location: -
tt PNCDEQ NCDEQ Bio John's Food Mart
rf. `
Facility/Owner Name Facility ID#(if applicable)
n.
6203 Chadbourn Hwy,Chadbourn. NC 28431,Chadbourn, NC 28431
n. n.
Physical Address,City,and Zip -
21.REMARKS
COLUMBUS
Count Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Cc leation• `
34.32521 N -78.81017 W ~ 6/25/2024
Signature of Certified Well Contractor Date
6.Is(are)the well(S): ®Pci manent or ❑temporary Bvsigning thisform,I herehv certify that the mell(s)war(were)consiructedin accordance with
ISA NCAC 01C.0100 or 15A NCAC 01C.0100 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.
1f this is a repair,ill out known well construction information and explain the nature of
the repair tinder=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 same construction,you SUBMITTAL INSTRUCTIONS
can 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@100) construction to the following:
10.Static water level below top of casing: 10.1 (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: 4.25 (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: HStA► 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 Suaaly&Inieetion 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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL.CIVIL
GEOTECHNICAL CATLIN
WELL LOGWilmington.Raleigh,Washington.
Charleston Engineers and Scientists
224105 SHEET 1 OF 1
PROJECT NO.: 224105 STATE: NC I COUNTY: COLUMBUS LOCATION: Chadbourn
PROJECT: NCDEQ Big John's Food Mart LOGGED BY: Ashley Jessen WELL ID:
DRILLER: Eddie Swain MW-01
NORTHING: 34 EASTING: -79 CREW: Andrew Dunivan
SYSTEM: NCSP NAD 83 m DRILL MACHINE: CAT1303 CME-550 93% 03/05/2024 T.O.C.ELEV.:
VERT.DATUM: NAVD88 USff METHOD: HSA 0 HOUR DTW: 10.8 TOTAL DEPTH: 14.0
START DATE: 5/28/24 END DATE: 5/28/24 24 HOUR DTW: 10.1 WELL DEPTH: 14.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft o.5ft 0.5ft 0.5ft (PPM) s G DEPTH DESCRIPTION DETAIL
0.0 Land Surface 0.0
0.0 (SM)-Dark to light gray,Silty,fine SAND. 0.0 -
3 —
s 7 0.0 D - 1.0
5 >
a
0
0
t
U
3.0
4.0
5.0
4
e 4 0.0 M
4
9.0
o�
oa
(ML)-Orange-brown,fine Sandy SILT N
VU)
10.0
2 _
0.0 M
12.0
0.0 M
z
14.0 14.0 1a.o 14.0
BORING TERMINATED AT DEPTH 14.0 ft
Portland Cement Bentonite Pellets [:]#2 Medium Sand