GW1-2022-01373_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
James D. Barker 14-WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 21 ft' 22 ft• Tan PWR
3106-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a bk
FROM TO DIAMETER THICKNESS MATERIAL
Quantex, Inc. ft. ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: NA 0 ft. 10 ft• 2" in. Sch 40 PVC
List all applicable well construction permits(i.e.County,State,1'ariance,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 10 tt. 25 ft. 2" in, 0.010 Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 6 ft- Neat Cement Poured- 140 lbs.
Non-Water Supply Well:
g rt. g ft- Bentonite Poured 3/8"Pellets-30 tbs.
oMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. It.
8 25 #2 silica sand pour
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,roil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. Top Soil
4.Date Well(s)Completed: 1/13/22 MW-9 1 ft.
16 ft- Tan/Brown Silty Sands
16 ft. 25 ft• Tan PWR
5.Well Location: ft. ft.
NCDEQ US158 SR1138 Orphan Tank ft. ft. '
Facility/Owner Name Facility IDu(if applicable) ft. ft.
1218 NC Highway 158, Berea, NC 27565
Physical Address,City,and Zip 21.REMARKS
Granville NA
County Parcel Identification No (PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Ccrti cation:
(if well field,one latilong is sufficient)
36.313327 78.735625 W �, �, 1/14/22
Signature f Certified Well Contractor Date
6.Is(are)the well(s): 2Permanent or ❑Temporary By siguir this form.i herebv certify that the well(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ElNo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fell out known well construction information and explain the nature of the
repair under#11 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: 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 can
submit oneform. 24.Submittal Instructions:
s
9.Total well depth below land surface: 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3C200'and 1C100') construction to the following:
10.Static water level below top of casing: na (ft•) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 61t (in.) 24b.For Injection Wells: in addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Auger construction to the following:
(i.e.auger.rotary,cable,direct push,etc)
Division of Water Quality,Underground Injection Control Program,
13.FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection e• Amount: completion of well construction to the county health department of the county
type: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

CATLIN
WELL LOG Engineers and Scientists
Zz,oaa SHEET 1 OF 1
PROJECT NO.: 221044 STATE: NC COUNTY: GRANVILLE LOCATION: Berea
PROJECT: US158-SR1138 Orphan UST LOGGED BY: M. Au erle WELL ID:
p DRILLER: JD Barker
NORTHING: 30714022 1 EASTING: 31245178 CREW: Quantex —
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Across Culberth Rd N of big tree T.O.C.ELEV.: 97.69
DRILL MACHINE: Geo robe 7822DT METHOD: S.S. Auger/Air Rotary 0 HOUR DTW: NM TOTAL DEPTH: 25.0
START DATE: 1/12/22 END DATE: 1/22/22 74 HOUR DTW: 20.5 WELL DEPTH: 25.0
BLOW COUNT OVA M o SOIL AND ROCK WELL
DEPTH o.sn o.sft 0.sft 0.sft (PPM) LAB. s G DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 97.7 0 0
0.0
0.0
Organic and black
Direct Push 0.0 +r 1.0 _ 96.7
(SM)-Tan to brown,Silty SAND A
Refusal at 12.0'BLS. Switched to Air Rotary
AV
U
4.0 a A
0
Direct �Push 0.1
:�
;
6.0
tV
8.0
10.0
Direct
Push
12.0 0.2
15.0 Direct
Push 0•2 16.0 81.7
(ML)-Tan powdery SILT
pU
oa
oe
rn c
�N
20.0
Direct 8 0
Push
22.0
Direct 17 3
Push
25.0 25.0 7z.7 2s.o .: 2s.o
BORING TERMINATED AT ELEVATION 72.7 ft in
powdery SILT
�a.r Concrete El Bentonite Pellets 0#2 Medium Sand

i
N
�P
• t
�- ® MW-4
® MW-3 US Hryy.
�S
MW`-6 ® MW-1 �3 r MW 8
I
P WSW-31 , MW-09*
r
MW-2
j
LEGEND `
<Z
® Monitoring Well " p�
(Type II) n
Z
© Active Potable po
Water Supply Well
❑ ONO-
Approximate Location
of Former UST
❑ Parcel Boundary •' ,t^r
,0Sou-e:E='sri,Maxar.GeoEye. EarthstarGeogr phics. EIS/ rbus S.ao
USDA.USGS,AeroGRID, IGN,and the GIS Use C«o m Wily
NOTES:
1. Well and tank locations were obtained from previous reports 50 25 0 50 100
prepared by other consultants and are approximate.
2. " =Well installed on 01/12/2022 Feet
PROJECT TITLE FIGURE
BEREA MINI-MART
ATLIN 1218 US HWY 158 SITE MAP
CBEREA, NC 1
Engineers and Scientists NCIDENT NO JOB NO DATE SCALE I DRAWN BY/CHECKED BY
26130 220212 JAN 2022 AS SHOWN KMC/SJO