GW1-2022-01462_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
zo
Austin Fowler FxoM TO DESCRIPTION
Well Contractor Name ft. n.
4366A r� t
NC Well Contractor Certification Number 2 2Q??, OR TUBING aseher,aal dirt' t
FROM T'O DI:1611'"f, IIIME11 VL-A11 R1M
CATLIN Engineers and Scientists 0 ft.1 1 n. 1 m.1 Sch. 40 PVC
Company Name 16.OUTERCASING for multi-eased wdls OR LINER if a icable
FROM TO DLAAIF11'R IIII(KNFSs VI:%]I R1k1.
2.Well Construction Permit#: N/A t' a. ft. in.
List all applicable well permits(i.e.('onnlr,.G,nr, I arlance,Injection,eta) -
tt. ft. in.
3.Well Use(check well use):
n.SCREEN
Water Supply Well: FROM To N v%n II i .1 or,1a Tlu(K\rss \rAn RI v1
❑Agricultural ❑Municipal/Public 1 It. 18 it. 1 in. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. n.
❑industrial/Commercial ❑Residential Water Supply(shared) IL
GROUr
FRO\I TO M",IT RL\I I MPLACEMEKIMETHOD d AMOUNT
❑Irri ation
n. e.
Non-Water Supply Well: -
MMonitoring ❑Recovery 1 ft. 2 ft. Bent Pellets Surface Pour
Injection Well: ft. ft.
❑Aquifer Recharge 0Groundwater Remediation 19.SAND/GRAVEL PACK Jif aM icable
•Aquifer Storage and Recovery ❑Salinity Barrier FROM rD 11I:\11RIU EMPLACEMENTMETHOD
❑Aquifer Test ❑StormwaterDrainage 2 it. 18*2 Medium Sand Torpedo Sa d
❑Experimental Technology ❑Subsidence Control ft. fc
20.DRILLING LOG attach additional sheet if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DFSCRII'i10\ ­1,,r h:,rdncs,.od-1,t, .a,see ct,
❑Geothermal(Heating/Cooling(Heating/Cooling Return 1 ❑Other(explain under#21 Remarks) n. rt. -_
4.Date Well(s)Completed: 12/14/21 Well ID#: P-1
u. ft. -In �O
5a.Well Location: GN
ft. . P
NCDEQ-Ed's Village Oven Air Market N/A '
1i.
Facility/Owner Name Facility ID#(if applicable) 1
rt.
103 W.Jackson Blvd.,Erwin,NC,ERWIN,NC 28339
e. n.
Physical Address,City,and Zip -
21.REMARKS _
HARNETT
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)
35.331746 N -78.677143 W �'f��G 1/12/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): O Permanent or ®Temporary By signing thisform,I hereby certify that the well(s)was(were)constructed in accordance with
ISA A AC 01C.0100 or I5A NCAC 01C'.0100 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
Ifthis is a repair,ill out known well construction information and explain the nature ql'
the repair under -21 remarks section or on the back of this form. 23.She 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-wager supply wells ONLY with the same construction,you
can submit one.form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 18.0 (g,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells Its tall depths indifferent(example-3@ 2(V and 2@100) construction to the following:
10.Static water level below top of casing: 12.95 (g,) Division of Water Resources,Information Processing Unit,
1j water level is above caving use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (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,ratary,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 Svpoly&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 of the county where constructed.
Adapted from Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

CATLIN
WELL LOG Engineers and Scientists
z2°zz7 SHEET 1 OF 1
PROJECT NO.: 220227 STATE: NC COUNTY: HARNETT LOCATION: ERWIN
PROJECT: EUS VILLAGE OPEN AIR MARKET LOGGED BY: O. Da nes WELL ID:
DRILLER: Austin Fowler P-1
NORTHING: 30703031 EASTING: 31600546 CREW: D.T. Chalmers
SYSTEM: NCSP NAD 83 USft BORING LOCATION: -11 feet west of former UST basin T.O.C.ELEV.: 100.19
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 13.0 TOTAL DEPTH: 17.0
START DATE: 12/14/21 END DATE: 12/14/21 124 HOUR DTw: NM WELL DEPTH: 18.0
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPm) LAB. s G DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 100.2 0.0
0.5 11
0.5 ASPHALT 99.7 0.60.
!
(SM)-Brown SILTY SAND 1.Oa
e 2 1.5 98.7 ai
3 2 29.5 D (CL)-Brown CLAY w/Med.Plasticity,HCO 2.0
5.0 5.0 95.2
(CL)-SAA w/Red and Gray Mottling,HCO
2
4 6 61.0 P1(10-12) D
7
o�
oa
oa
10.0 10.0 90.2
(CL)-w/SAND. Faint HCO
3
3 3 58.0 M
4
15.0 4 2 3 16.7 W 15.5 84.7
15.5 4
,r (SW)-L.Tan Well Graded SAND
2.5 Sat.
17.0 17.0 83.2
BORING TERMINATED AT ELEVATION 83.2 It in well
graded SAND 18.0 18.0
Bentonite Pellets E]#2 Medium Sand