GW1-2022-10318_Well Construction - GW1_20221114

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 TO DESCRIPTION
Well Contractor Name � � R. fL
4146A I-O F uV ft. n.
NC Well Contractor Certification Number \' ` 7 15.INNER CASING OR TUBING thermal closed-loo
Nov " '-0220�( TO DIAI�TER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 fL 5 ft. 2 Sch.40 PVC
Company Name p C VtO�t 16.OUTER CASING for multi-cased wells OR LINER if a licable
2.Well Construction Permit#: N/A �i1* v�J'D4z!CVa'0C FROM ft TO fL DIAMETER in. THICKNESS IvfATERIAL
List all applicable ivell 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 TtuclwEss MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 ft 1 2 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL I ErIPLACEr IENTMETHOD&AMOUNf
❑Irrigation 0 ft. 1 ft. Portland Cement Surface Pour
Non-Water Supply Well:
1 rt. 3 rt. Bent.Pellets Surface Pour
®Monitoring ❑Recovery
Injection Well: rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
-FROM TO MATERIAL EhIPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
3 ft. 22 fL Torpedo Sand
❑ nv
Aquifer Test ❑Stomater Drainage
❑Experimental Technology ❑Subsidence Control a• R.
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/rock tvpe,grain sire etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) o. R
n ft
4.Date Well(s)Completed: 11/02/22 Well ID#: MW-02
fL fL
Sa.Well Location:
it. n. t
NCDEQ-Foodmart#8
n. �� 1
Facility/Owner Name Facility ID#(if applicable)
rt.
12924 N.ROXBORO ST.,NC,ROUGEMONT,NC 27572
rL rL
Physical Address,City,and Zip
21.REMARKS
DURHAM
County Parcel Identification No.(PIM
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
36.21818039 N -78.92600522 W L-(6o;;r3 11/9/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby cerrii,that the units)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15.4 NCAC 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 ivell owner.
If this is a repair,fill out known well construction infonnation and explain the nature of
the repair under 421 remarks section or on the back ofthis 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 sane construction,you
SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 20.0 (ft,) 24a.For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3@200'and 2@I009 construction to the following:
10.Static water level below top of casing- 7.71 (ft.) Division of Water Resources,Information Processing Unit,
Ifivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the
address in 24a above,also subunit a copy of this form within 30 days of
12.Well construction method: HSA 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 Svpply&Iniection Wells:
Also subunit 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 Fom1 GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
VNlrnington,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LOG zzlosl SHEET 1 OF 1
PROJECT NO.: 221051 STATE: NC COUNTY: DURHAM LOCATION: ROUGEMONT
PROJECT: FOODMART#8 LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. MW-02
NORTHING: 898333 1 EASTING: 2021828 CREW: C. BLACK
SYSTEM: NCSP NAD 83 USft BORING LOCATION: NORTHWEST OF DISPENSER ISLANDS T.O.C.ELEV.: 99.19
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: DrY TOTAL DEPTH: 22.0
START DATE: 11/2/22 END DATE: 11/2/22 124 HOUR DTW: 7.7 WELL DEPTH: 20.0
BLOW COUNT OVA o L SOIL AND ROCK WELL
DEPTH o.5tt a.5tt o.5ft a.5n (PPM) LAB. s G DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 99.2 0.0
0.5 0 5 (GW)-ASPHALT and GRAVEL mic 98.7 0.0
5 7 (CLG)-Orange,Gravelly CLAY(FILL) — 1.0
6 6 51.5 M o 2.0-----------------------97.z a
(CL)-Gray,Sandy CLAY a
3.0
95.2
(ML)-Tan to orange Wth green,SILT With IT.sand
5.0 (SAPROLITE) 5.0
16 51 49/ 1881 M 5 02 D
.4
10.0
21
45
55/' 1675 D
.4 0
oa
o v
�t
tV�
15.0
4 4
6 3000 M
16
20.0
20.0
20 16
24 1876 D
76
22.0 22.0 77.2 22.0
BORING TERMINATED AT ELEVATION 77.2 ft IN SILT
With tr.sand(SAPROLITE
Ll
Portland Cement Bentonite Pellets #2 Medium Sand