GW1-2021-02523_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Robin Webb 14.WATER ZONES
FROM TO DESCRH'TION
Well Contractor Name
2418 p ft- 305 ft. naao
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells)O$LINER if a licable
Greene Brothers Well & Pump, WT Inc. FROM TO DIAMETER THICKNESS MATERIAL
p tt. 77 It. 1 61/4 in. SDR21
Company Name
W 121100102838 16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS I MATERIAL
List all applicable well construction permits(i.e. UIC,County,State, Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
pp y FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ®Municipal/Public ft. tt. in.
Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft. iL in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: p tt. 20 tt. Bentonite
Monitoring Recovery
Injection Well:
ft. ft.
Aquifer Recharge ®Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test []Stormwater Drainage
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks FROM TO DESCRiPTTON color,hardness,soiUrock a rain slat,etc.
p ft. 77 ft. Clay
4.Date Well(s)Completed: 06/30/21 Well ID# 77 ft. 305 ft, Granite
5a.Well Location:
Kirk Trowell/Velvet Morning Farms
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
209 McKinney Rd Etowah 28729
Physical Address,City,and Zip
Henderson 9529-83-8275 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. tifica on:
35.327 N 82.590
W 6�� I
06/30/21
6.Is(are)the well(s)oPermanent or Temporary Signature 617Certified Well Contractor f Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: ®Yes or ONo with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:' SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 345 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 50 (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: 6 1/4 (in.) 24b.For Iniection Wells: In adIdition to sending the form to the address in 24a
Rotary above, also submit one copy of this form°within 30 days of completion of well
12.Well construction method: 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) 17 Method of test: 2 hours 24c.For Water Supply&Iniection 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 type: HTH Amount: 63 Tabs completion of well construction ito the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016
t .

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WELL LOG �' CATLIN
Engineers and Scientists
z2oI SHEET 1 OF 1
PROJECT NO.: 220292 STATE: NC COUNTY: RANDOLPH LOCATION: Libert
PROJECT: H&M TIRE SERVICE LOGGED BY: M. Auppi§rle WELL ID:
DRILLER: D.T. CHALMERS JR. MW_04D
NORTHING: EASTING: CREW: CATLI N
SYSTEM: BORING LOCATION: T.O.C.ELEV.: 98.64
DRILL MACHINE: CME 45B TRACK METHOD: HSA/MR 0 HOUR DTW: N/A TOTAL DEPTH: 75.1
START DATE: 06/09/21 END DATE: 06/10/21 24 HOUR DTW: 11.6 WELL DEPTH: 75.1
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.5ft 0.5tt 0.5ft (Ppm) s G DEPTH DESCRIPTION ELEVATION DETAIL
LAND SURFACE
0.0 Contacts inferred between sampled intervals 98.6 0.0
1 o Topsoil ---------------- t:9s 0.0
------- -�97.6
4.0 6 I(GW)=GRAVEL FILL -----J
7 _
a (CL)-Red and orange,CLAY _
10 -_
8.0 2 3
4 -
3 -
12.0 ' 2
2 -
3 -
16.0 ' 2
2
3
21.5 77.1 z =
23.0 3 5 (SC)-Yellow,Clayey SAND with black speckles.
e =�
10 -
_t
U
_ro
28.0 2 5 _
7
10 -
33.0 5 7 z a =
11 0
12
d _
U -
38.0 15 25 N -
26 =
27 -
43.0 16 =
25
49 -
50/ -
.3 -
48.0 31 60/ as.349.3 = as.o
(SC)-Clayey SAND -50.0
(Logged from cuttings)
63.0 35.6
Some Granite in cuttings
68.0
70.0
oa
oQ
75.1 75.1 23.5 75.1
BORING TERMINATED AT ELEVATION 23.5 ft
(Elevation referenced to MW-03 with assumed elevation
of 99.70ft)
Portland Cement M Bentonite Grout #2 Medium Sand
f
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AT �20
Old Dairy Road
NWilmington, NC 28405
Engineers and Scientists [phone]
www.CatlinUSA.com
July 29, 2021
North Carolina Department of Environmental Quality
Division of Water Quality
Information Processing
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: North Carolina Construction and/or Abandonment Record(s)
H&M Tire Service
232 N. Greensboro Street
Lilberty, Randolph County, NC
CATLIN Project No.: 220292
To Whom it May Concern,
CATLIN Engineers and Scientists (CATLIN) recently constructed one (1) monitoring well
at the above referenced site. The completed North Carolina Well Construction Record
and Boring Log are attached.
If you have any questions or require additional information, please feel free to contact
us at [phone].
Sincerely,
Sean O'Neil, PE
Project Manager
Enclosures
CATLIN Letterhead_ILM
ENVIRONMENTAL CIVIL GEOT�EiCHNICAL
i '
Wilmington, NC I Raleigh, NC I Washington, NC I Atlanta, GA I Cha�leston,'SC