GW1-2021-06683_Well Construction - GW1_20211007

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
1 14.WATER ZONES
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Contractor Name �"" ft. It.
4146A C� Q 1 TIN ft. ft. C
NC Well Contractor Certification Number
O t,�(� 15.INNER CASING OR TUBING(geothermal closed-loop)
ess FROM TO I DIAMETER THICKNESS I MATERIAL
CATLIN Engineers and Scientists r� c��or 0 rL 15 rL 2 in. Sch.40 PVC
Company Name \�`� � QL
16.OUTER CASING for multi-cased�wells OR LINER ifa licable
FROM TO DIAMETER THCA"NESS MATERIAL
2.Well Construction Permit#: N/A ft. rt. 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 TFQCKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 ft. 25 ft. 2 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. R. in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 fL 1 ft. Portland Cement Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 1 fL 13 fL Bent.Pellets Surface Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATE RIAL EMPLACEMENT METHOD
13 ft. 26.6# Medium Sand Torpedo Sa d
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft. rt.
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.soillrock type,jaain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL fL
4.Date Well(s)Completed: 08/05/21 Well ID#: MW-12 n. ft.
n. a. �O
5a.Well Location: �H
NCDEQ-Linda Blalock Carter's Grocery rL rL
rL PA
Facility/Owner Name Facility DO(if applicable)
tt.
101 RAND RD.,GARNER,NC 27603
rt. rt.
Physical Address,City,and Zip
21.REMARKS
WAKE
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
35.649383 N -78.650465 W 9/2/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or OTemporary Bvsigning this form.I hereby cent ,that the well(s)was(were)constructed in accordance with
I.A N(:AC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copt,of
7.Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
If this is it repair,fill out known well construction information and explain the nature of
the repair under 421 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%veil
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 INSTRUCTIONS
can.submit one form.
9.Total well depth below land surface: 25 (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: 2 0.0 (B,) Division of Water Resources,Information Processing Unit,
lfwaterlevel 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 W ater 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 SvvDly&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 ofthe county where constructed.
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Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

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WELL LOG CATLIN
Engineers and Scientists
zzgz9a SHEET 1 OF 2
PROJECT NO.: 220294 STATE: NC COUNTY: WAKE LOCATION: GARNER
PROJECT: CARTER's GROCERY LOGGED BY: O. DAYNES WELL ID:
DRILLER: D.T. CHALMERS JR. MW-12
NORTHING: 30693114 1 EASTING: 31487277 CREW: K. SWAIN
SYSTEM: NCSP NAD 83 USft BORING LOCATION: SW of MW-1 T.O.C.ELEV.:
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 20.0 TOTAL DEPTH: 26.2
START DATE: 8/5/21 END DATE: 8/5/21 124 HOUR DTW: N/A WELL DEPTH: 25.0
DEPTH BLOW COUNT OVA LAB M a SOIL AND ROCK WELL
o.sn o.sn o.srt o.sft (PPm) s G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (SC)-Red SAND wlclay 0.0 —
Pieces of concrete and asphalt at 4.6'BLS — 1.0
D Brown and red from 9.6-19.6'BLS
HCO from 9.6-24.6'BLS
4.6
4
1
3 D
2
U
0-
la
N
N
9.6
e
e D
14
19
13.0
14.6 16.0
4
17 D
6
19.6 a
se -
4 n t
8 W N�
10 VV
14
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aPortland Cement Bentonite Pellets !E]#2 Medium Sand

WELL LOG CATLIN
Engineers and Scientists
220z94 SHEET 2 OF 2
PROJECT NO.: 220294 1 STATE: NC I COUNTY: WAKE LOCATION: GARNER
PROJECT: CARTER's GROCERY LOGGED BY: O. DAYNES WELL ID:
DRILLER: D.T. CHALMERS JR. MW-12
NORTHING: 30693114 1 EASTING: 31487277 CREW: K. SWAIN
SYSTEM: NCSP NAD 83 USft BORING LOCATION: SW of MW-1 T.O.C.ELEV.:
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 20.0 TOTAL DEPTH: 26.2
START DATE: 8/5/21 END DATE: 8/5/21 124 HOUR DTW: N/A WELL DEPTH: 25.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft �PPm) s G DEPTH DESCRIPTION DETAIL
(SC)-Red SAND w/clay
Pieces of concrete and asphalt at 4.6'BLS
Brown and red from 9.6-19.6'BLS
HCO from 9.6-24.6'BLS(continued)
24.6 24.6
(CH)-Gray with purple and yellow mottling,highly 25.0
4 t plastic CLAY. HCO
3 W
8 26.2
26.2 26.6 (SC)-Red,well graded SAND w/clay and pebbles. 26.6
HCO
BORING TERMINATED AT DEPTH 26.2 ft in well
graded SAND w/clay
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Portland Cement Bentonite Pellets 10#2 Medium Sand