GW1-2022-05684_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD For InternalU, 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 ft
NC Well Contractor Certification Number IS.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERLll.
CATLIN Engineers and Scientists 0 ft. 4 ft. 2 irt.I Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: NSA ft. ft. ;n.
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 4fr 19ft. 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 MET1IOD&AMOUNT
❑Irrigation 0 rr. 0.5 It. Portland Cement Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.5 ft. 3 It. Bent.Pellets Surface Pour
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 ❑Stotmwater Drainage 3 ft. 20;0 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 rmc,grain size,etc.
❑Geothermnal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 04/11/22 Well ID#: MW-02 ft. ft.
ft. ft.
5a.Well Location:
ft ft
NCDEQ-Tackett Residence NA
ft.
Facility/Owner Name Facility ID#(if applicable)
ft.
13117 N. ROXBORO ST,ROUGEMONT,NC 27572
ft. IT
Physical Address,City,and Zip
21.REMARKS
WAKE NA
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/longis sufficient)
36.221198 N -78.927688 w C 4125/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(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 ifnecessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 19.0 (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: 3.85 (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
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,rotanv,cable,directpush,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 comity 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

CATLIN
WELL LOG Engineers and Scientists
zztosz SHEET 1 OF 1
PROJECT NO.: 221052 STATE: NC COUNTY: WAKE LOCATION: ROUGEMONT
PROJECT: TACKETT RESIDENCE LOGGED BY: OLIVIA DAYNES WELL ID:
DRILLER: D.T. CHALMERS, JR. MW-02
NORTHING: 2021331 EASTING: 899431 CREW: TREVOR MIZELLE
SYSTEM: NCSP NAD 83 USft BORING LOCATION: South of former UST basin T.O.C.ELEV.: 100.00
DRILL MACHINE: CME 45B TRACK METHOD: HSA 0 HOUR DTW: 18.3 TOTAL DEPTH: 20.0
START DATE: 4/11/22 END DATE: 4/11/22 24 HOUR DTW: 3.9 WELL DEPTH: 19.0
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 100.0 0.0
0.0 (FILL)-Silty FILL 0.0 - 0.5
a
6 3 3.0 M 1.0 99.0
s (MH)-Orange,highly elastic SILT 0
a
in
3.0 97.0 N 3.0
(ML)-Orange slightly elastic SILT
Brown at 6.0'BLS and mod. HCO 4.0
5.0
3 3 336.7 Mw-o2 M
5 (6-8')
10.0
z
3 5 s 1334 W OIL
s�
12.0 88.0
(WR)-Lt.brown,WEATHERED ROCK N�
Mod. HCO
Ll
LL
15.0
s0i
LL
.4 84.7 D =
19.0
20.0 20.0 80.0 20.0
BORING TERMINATED AT ELEVATION 80.0 ft in
WEATHERED ROCK
EjPortland Cement EM Bentonite Pellets El#2 Medium Sand

G
s N
V'
f r �O
O
'PO
- - - MW-01
y
MW-02
MW-03
WSW-6
P
LEGEND
® Monitoring Well
(Type II) `
y s
O Active Potable it
Water Supply Well
Approximate Location
of Former UST Basin P
U Parcel Boundary
Source: Esri,Maxar, GeoEye, Earthstar Geographies, ONES/AirbL4 DS,
USDA, USGS,AeroGRID, IGN,and the GiS User Community
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 30 15 0 30 60
Feet
PROJECT TITLE
FIGURE
TACKETT RESIDENCE
ATLIN 13117 US HWY 501 SITE MAP
CROUGEMONT, NC
Engineers and Scientists
INCIDENT NO. JOB N0. DATE SCALE DRAWN BY/CHECKED BY
13145 221052 MAY 2022 AS SHOWN KMC/SJO