GW1-2022-09965_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD For Internal Use ONLY
T.form can be uud fa rinek or m&*wells
1.Well Contractor Information:
14.WAIVER ZONES 71
D.T. CHALMERS, JR. Fltohl I m I DESMPT10N
Well Contractor Name rt n.
4146A A.1 o
NC Well Contractor Certification Number IS.INNER CASING OR T11306 oMessal dased-I
FROM TO DI mo IER lmL'K,�E55 hlATEImAL
CATLIN Engineers and Scientists 0 n. 15 n. 2 i..l Sch.40 1 PVC
Company Name 16.OUTER CASING for wiftELudwdls OR LLNER ira i"bI
FROnI TO DfUff@a I}{I�_K]Eit \HhRIAL
2.WeB Comtruction Permk#: N/A ft'i it
List all applicable well permits(ire,(bunny Stare, Parima e,lnyearori,ek)
(L rL
3.Well Use(check well me): 17 WREEN
Water Supply W ell: MAI I To mA%IMR SLOTSLM MCKIDESS ]L4ME
❑Agricultural DMtmicipal/Public 15 n. 20 n.1 2 i..l Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) (L a n.
❑Industrial/Commercial ❑Residential Water Supply(shared) Ir.GROtrf
MOM To \r r:TRIAL E\WI_iC'Fna\T no-THWBAArol1T
❑Irrigation 0.0n. 0.5 u. Concrete Surface Pour
Non-Water Supply WeB:
®Monitoring ❑Recovery 0.5 n. 13a Bent Pellets Surface Pour
olectmn Well:
❑Aquifer Recharge ❑Grourdwater Remediation 19.SAND/GRAVEL PACx in ir,Nr
D Aquifer Storage and Recovery DSaluuty Barrier rxnnl ro SurEwAL EhIPt_acemenrnnEmou
13 n. 20 n. #2 Medium Sand Surface Pour
' ❑Aquifer Tess ❑Slormwarer Draiooge
❑Experimental Technology ❑Subsidence Control n. ft.
20.DRILLING LOG fintsob addidt al shMs ifnne
❑Geothermal(Closed Loop) ❑Tracer FR0%1 nr DESCnIPnON(, ll,.I.�w,«,.-.1-kn ae rm
❑Geothermal(HeatinWConling Return) DOlher(explain under#21 Remarks) n. n.
4.Date Well(s)Completed: 10/27122 WellIDN: AS-01 r r w Gfl. _O
n. Gsa.Well Location: -
P NCDEOrNanne N/A
wn O'S MART
Facility/Oer Name Facility 07(if applicable)
fl ^M ^Z
6059 NC HWY 43 NORTH,FALKLAND,27827
Physical Address,City,and Zip
21.REINARKS
PITT N/A
County Parcel Identification No (PIN) pr.... ufrd
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (y ;j!a(Qi 30G
22.Certification:
(if well field,one lat/long is sufficient)
36.69883639 N -77.51422483 W Y'"U� 11/1/2022
Signature ofCeN6ed Well Canasta Date
6.ls(are)fbewe11(s): MPenr(ulmt or ❑lemporin Jh signing thtsforrn l herrhP cerr/v that tlwwell(,/war(were).,ru,,edmrucardarwe wah
15A ATAC 02C.0/00 or 15A At At 02C A200 WAl Conanarran Stardoms 1 1 tint a copy of
7.Is this a repair to anesistingwell: ❑Yes or 19No this record has Geenprovrdn/la the well aw•rcr.
lfOus is a repair,fill ou.bmmn well amananoo ngorrmeam ratl explum ahe aravre of
the rep it under=21 remarks section or an the Mc*ofthu form. 23.Site diagram or additional well details:
You may use the back of thus page to provide additional well site details or well
8.Number of wells constructed: 1 corutruction details. You may also amach additional pages dnecessary.
Fw mdlipre uyeetam or mirrwarer.su/yrly welts ONLPwtth the same consbueNon.you SUBMITTAL INSTRUCTIONS
can S'drat one form.
9.Total weB depth below load surface: 20.0 (R,) 24a.For AB Wells: Submit this form within 30 days of completion of well
Par multiple wells fur all dephs in dierem(example-3@X0'and 2®t00J construction to to following:
10.Static water level below top ofcasing: 14.41 (R-) Division of W tiler Resources,Information Processing Unit,
tfwreer lne/is al ne casing.use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: US (m,) 24b.For Injection W'eks 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: Mud Rotary completion of well construction to the following.
(ie auger,rotary cahle,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 Svnnly&Iniection 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 ofthe county where constructed.
Adapted from Form GW-1 Nmd(Carolina Deparmne t of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

WELL LOG ENV RONMENTAL CNIL
riEOTECHNICAL CATLIN.arm.vridm.
Engineersand Scientists
22107e SHEET 1 OF 1
PROJECT NO.: 221076 1 STATE: NC I COUNTY: PITT LOCATION: FALKLAND
PROJECT: PANCHO'S MART LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. AS-01
NORTHING: 712575 1 FASTING: 2441116 cREw: N. NEWMAN
SYSTEM: NCSP NAD 83 USft BORING LOCATION: West of MW-1 near Parcel Bounda T.O.C.ELEV.: 90.18
DRILL MACHINE: Diedrich D-25 METHOD: Mud Rote 0 HOUR DTW: 14.4 TOTAL DEPTH: 20.0
START DATE: 10/27/22 END DATE: 10/27/22 124 HOUR DTW: NM WELL DEPTH: 20.0
DEPTH BLOW COUNT OVA LAB 0 L SOIL AND ROCK WELL
o.5rt o.5rt o.5rt o.srt (PPM) S c DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 99.8 0.0
0.0 ::;' 0.5 ISM-Tan,Gravelly SAND 99.3 0.0 :k 0.8
e e (SP)-Lt.gray to tan,F.SAND with It.day
4 301 M
3
4.0 95.8
(CL)-Tan to orange with green and brown staining,
Sandy CLAY
5.3
2 3
5 2516 M
4
5
N
10.3
2 3
5 2515 M
4
13.0
14.0 85.8
(CL)-Ten to orange and gray,CLAY _
15.0
15.3
66.8 Sat
2 '>
so '
s9
20.0 20.0 79.8 20.0 20.0
BORING TERMINATED AT ELEVATION 79.8It in
CLAY
Concrete ®Bentonite Pellets El#2 Medium Sand

ti� N
Y�
® MW-5 -
i
F
FORMER
DISPENSER
ISLAND
'M
MW-3
MW-7
so
FORMER
UST
® MW-1
ED MW-2 MW 6 AS-01
j
,j
LEGEND
Q. Air Sparge Well
® Monitoring Well
(Type II)
Approximate Location
of Former UST System
Parcel Boundary a
Souroe:Esn,Max arthstar Geographics,and the GIS
NOTE. Well and tank locations were obtained from previous reports
prepared by other consultants and are approximate. 20 10 0 20 40
Feet
4tO CT nTLE
FIGURE
PANCHO'S MART
CATLIN 6059 FA KLAND, NC N SITE MAP
Engineers and Scientists
NO rHiE scue oMwx al"eaeo ar
38424 221076 NOV 2022 AS SHOWN 04CIBJA