GW1-2021-02648_Well Construction - GW1_20210811

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
D.T. Chalmers FROM TO DESCRIPTION
Well Contractor Name n. R.
4146A
NC Well Contractor Certification Number 15.INNER CASING OR TUBING geothermal closed-too
FROM TO DIAMETER TILII LESS MATERIAL
CATLIN Engineers and Scientists 0 ft.1 12 ft.1 2 iml SCh.40 1 PVC
Company Name 16.OUTER"CASING fo�multi-casedwelis ORCINERIifa licable
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: N/A
fL 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 ❑Municipal/Public 12 It. 27 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 TO MATERIAL EN[PLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well:
®Monitoring ❑Recovery 0.5 It. 10 ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stomwater Drainage 10 It. 27 ft. #2 Medium Sand #2 Medium Sand
❑Experimental Technology ❑Subsidence Control ft' ft.
20.DRILLING LOG attach additiod`al sheets ifnecessary)
❑Geothemlal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soiltrock type,wain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain tinder#21 Remarks)
4.Date Well(s)Completed: 07/14/21 Well ID#: MW-04
Sa.Well Location: N
fl fl P
NCDEQ CA
��
n.
Facility/Owner Name Facility ID#(if applicable)
ft.
12127 Hwy 42 W,Fuguay-Varina,NC ft. B. `
Physical Address,City,and Zip 21.REMARKS f i'
HARNETT P s5�n
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)
35.5628652581 N -78.8717486587 W 7/30/2021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or ❑Temporary By signing thisform.I herebv certifi,that the well(s)was(were)constnrcied in accordance with
iSA MAC 01C.0100 or 15.4 MAC 02C.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 onner.
If thts is a repair,ill out known well construction information and explain the nature of
the repair under 921 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 mulliple injection or non-water supply wells ONLY with the same construction,You
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 27 (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 a l00J construction to the following:
10.Static water level below top of casing: 18.54 (B.) Division of Water Resources,Information Processing Unit,
Ifwater level 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: 4.25' H.S.Auger completion of well construction to the following:
(i.e.auger,rotary,cable,direci 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 SvvDly&Infection Wells:
Also submit one cop),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 Fonn GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

WELL LOG CATLIN
Engineers and scientists
220229 SHEET 1 OF 2
PROJECT NO.: 220229 STATE. NC COUNTY: HARNETT LOCATION: Fu ua -Varina
PROJECT: LOGGED BY:M. Au erle/ L. Pugh WELL ID:
Hobby Store DRILLER: D.T. Chalmers
NORTHING: 659808 EASTING: 2038142 CREW: O. DAYNES INVU'04
SYSTEM: NCSP NAD 83 USft BORING LOCATION: North corner of building off Cokesbury Rd T.O.C.ELEV.:
DRILL MACHINE: CME-550 METHOD: 4.25' H.S. Auger 0 HOUR DTW: 18.5 TOTAL DEPTH: 27.0
START DATE: 7/14/21 END DATE: 7/14/21 24 HOUR DTW: N/A WELL DEPTH: 27.0
BLOW COUNT OVA o L 0 SOIL AND ROCK WELL
DEPTH 0.5rc 0.5tt 0.5tt o.5tt (ppm) s c DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.5 (GP)-AGGREGATE 0.0
(SC) Brown,clayey,f.to cse.SAND
4.5
9 U
14 16.7 1100
1 a
7
v
L
U
N
N
9.5
10.0
8
10 13 0.8 1145 M
17
12.0
14.0
14.5 (SP-SM)-Light brown,f.POORLY GRADED SAND to
white,silty,f.SAND at 15.9'BLS.
5
9 9 0.8 W
7
16.3
(ML)-white,sandy,SILT
pU
oa
o�
fn t
N N
C
Bentonite Pellets #2 Medium Sand
e

—' ' CATLIN
WELL LOG Engineers and Scientists
zz I SHEET 2 OF 2
PROJECT NO.: 220229 STATE: NC I COUNTY: HARNETT LOCATION: Fu ua -Varina
PROJECT: Hobby Store LOGGED BY:M. Au erle/ L. Pugh WELL ID:
DRILLER: D.T. Chalmers MW-04
NORTHING: 659808 1 EASTING: 2038142 CREW: O.'DAYNES
SYSTEM: NCSP NAD 83 USft BORING LOCATION: North corner of buildinc I off Cokesbury Rd T.O.C.ELEV.:
DRILL MACHINE: CME-550 METHOD: 4.25' H.S. Auger 0 HOUR DTW: 18.5 TOTAL DEPTH: 27.0
START DATE: 7/14/21 END DATE: 7/14/21 24 HOUR DTW: N/A WELL DEPTH: 27.0
DEPTH BLOW COUNT OVA LAB M a SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (PPm) s G DEPTH DESCRIPTION DETAIL
(ML)-white,sandy,SILT(continued)
27.0 27.0 27.0 27.0
BORING TERMINATED AT DEPTH 27.0 ft
i
Bentonite Pellets El
#2 Medium Sand