GW1-2022-05688_Well Construction - GW1_20220426

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, JR. FROM I TO DESCRIPTION
Well Contractor Name ft. ft
4146A ft. rr
NC Well Contractor Certification Number IS.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER T1llCKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 5 ft. 2 in.I SCh.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable
FROM TO DIAMETER TIUCRNESS MATERIAL
2.Well Construction Permit#: NSA ft. �. ;n.
List all applicable well permits 6.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 TIRCKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5fr. 15ft. 2 in. SIOt.olo SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ff fr. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METIIOD&AMOUNT
❑Irrigation 0 ft. 0.5 It. Portland Cement Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.5fr. 3.51t. Bent.Pellets Surface POUT
Injection Well: rt. rt.
❑Aquifer Recharge ❑Groundwater Rcmcdiation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stonnwater Drainage 3.5 ft. 15#t Medium Sand Torpedo Said
❑Experimental Technology ❑Subsidence Control ft. ft.
20.DRILLING LOG attach additional sheets if necessar
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION"color,hardness soil/rock rype,grainsizc,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
4.Date Well(s)Completed: 04/19/22 Well ID#: MW-04 fr. fr. -
ft. ft.
5a.Well Location:
ft. ft.
Khaled Elmawy M&M GRILL ft
Facility/Owner Name Facility ID#(if applicable)
ft.
217 E.South Main Street,LITTLETON,NC 27850
ft. IT
Physical Address,City,and Zip
21.REMARKS
HALIFAX
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/longis sufficient)
36.435857 N -77.909146 w C -� 4126/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the welf(s)was(were)constructed in accordance with
15ANCAC 02C.0100 or 15ANCAC 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#21 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 pro-ride additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages ifnccessary.
For multiple injection or non-wader supply we11s ONLYwith the same construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 15.0 (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@1009 construction to the following:
10.Static water level below top of casing: 7.15 (ft.) Division of Water Resources,Information Processing Unit,
Ifwate-level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b.For Injection 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 ofwell 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 Svuuly&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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

WELL LOG CATLIN
Engineers and Scientists
221233 SHEET 1 OF 1
PROJECT NO.: 221233 STATE: NC COUNTY: HALI FAX LOCATION: LITTLETON
PROJECT: M&M GRILL LOGGED BY: T. Park WELL ID:
DRILLER: D.T. CHALMERS, JR. MW-04
NORTHING: 2320924 EASTING: 979339 CREW: E. SWAI
SYSTEM: NCSP NAD 83 USft BORING LOCATION: -10'west of Former UST Basin T.O.C.ELEV.: 99.60
DRILL MACHINE: CME 45B TRACK METHOD: HSA 0 HOUR DTW: 8.5 TOTAL DEPTH: 15.0
START DATE: 4/19/22 END DATE: 4/19/22 24 HOUR DTW: 7.2 WELL DEPTH: 15.0
DEPTH BLOW COUNT OVA LAB o a SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (ppm) s G DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 99.6 0.0
0.5 Asphalt 99.1 0.0 — 0.5
10 s 2.7 M (SC)-Brown to red,Clayey SAND
'�
4
a
0
v
3.0 96.6
(ML)-Green with black and brown,SILT with tr.sand. N 3.5
HCO
5.0 5.0
woh
2 3 415 W
2
8.0 91.6
(ML)-Tan to gray,SILT
o�
oa
10.0
N L
(V U
1 N
woh 1 1,707 W
1
15.0 15.0 84.6 15.0 15.0
BORING TERMINATED AT ELEVATION 84.6 ft in SILT
EjPortland Cement Bentonite Pellets El#2 Medium Sand