GW1-2021-02651_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
4146A
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermal closed-ioo
FROM TO DIAMETER TMCKNESS MATERIAL
CATLIN Engineers and Scientists Off.Off.1 12 a. 2 Sch.40 1 PVC
Company Name 16.OUTER CASING ffor mulii-casett'wells OR LINER f if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. in.
List all applicable well permits(i.e.County,State, Variance,lnlection,etc.)
ft. ft. in.
3.Well Use(check well use): 17 SCREEN li
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12 ft. 27 ft. 2 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irrigation
ft. rc
Non-Water Supply Well:
N Monitoring ❑Recovery 0.5 re 10 rt.
Injection Well: n. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if armlichble
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 10 R. 27 ft. #2 Medium Sand #2 Medium Sand
❑Experimental Technology ❑Subsidence Control
R. ft
20.DRILLING LOG(attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness.soil/rock type.grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 07/14/21 Well ID#: MW-04 ft. a. �_
ft. R. tO
Sa.Well Location: ft. fL P
NCDEQ
rt. �N
Facility/Owner Name Facility iD#(if applicable)
tt.
12127 Hwy 42 W,Fuguay-Varina,NC
Physical Address,City,and Zip n. tr.
21.REMARKS �- 1
HARNETT P c9�n
County Parcel identification No.(PIN) P Jt�O
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t;OtC '
22.Certification:
(if well field,one]at/long is sufficient)
35.5628652581 N -78.8717486587 W 7/30/2021
Signature ofCertifled Well Contractor Date
6.Is(are)the well(s): M Permanent or ❑Temporary By signing this form.1 hereby cerlifi,that the well(s)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15.4 NC.'AC 02C.'.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: ❑Yes or ®No this record has been provided to the well owner
if this is a repair,fill out known well construction information and explain the nature of
the repair under m21 remarks section or on the buck 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 SUBMITTAL INSTRUCTIONS
can submit one form.
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-3t200'and 2 a l00) construction to the following:
10.Static water level below top of casing: 18.54 (ft.) Division of Water Resources,Information Processing Unit,
If water level is uhcme 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,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 SvaDly&Injection 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

i
WELL LOG �. CATLIN
Engineers and Scientists
zzoI SHEET 1 OF 2
PROJECT NO.: 220229 STATE: NC COUNTY: HARNETT LOCATION: Fu ua -Varina
PROJECT: Hobby Store LOGGED BY:M. AupperleV L. Pu h 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 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 o SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft o.5ft o.5ft (ppm) LAB. s G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
C. 0.5 (GP)-AGGREGATE 0.0
(SC)-Brown,clayey,f.to cse.SAND
4.5
s 11 14 16.7 1100
a
17 0
v
U
fN
tV
9.5
10.0
a
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
s 9 0.8 W
7
16.3
(ML)-white,sandy,SILT
of
oa
o�
�t
fV�
1
Bentonite Pellets El#2 Medium Sand

WELL LOG Jam' CATLIN
Engineers and Scientists
zzoiI SHEET 2 OF 2
PROJECT NO.: 220229 STATE: NC COUNTY: HARNETT LOCATION: Fu ua -Varina
PROJECT: Hobby Store LOGGED BY:M. Au erle/ L. Pugh WELL ID:
DRILLER: D.T. Chalmers MVW_04
NORTHING: 659808 1 EASTING: 2038142 CREW: 0. bAYNES
SYSTEM: NCSP NAD 83 USft BORING LOCATION: North corner of building off Colkesbury 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 o SOIL AND ROCK WELL
o.sft o.sft o.sft o.sft (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
w
I
Bentonite Pellets El
#2 Medium Sand