GW1-2022-10321_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.D.T. CHALMERS, JR. (. IV 0 FROM ER ZONES
FROM TO DESCRtPTON
Well Contractor Name t - 2�Z2 ft. ft.
4146A ft. fL
NC Well Contractor Certification Number ,+, rA 15.INNER CASING OR TUBING eothermatclosed-too
ttlr`i1ftN�ii�Z)i1 Pr FROM TO DIANETER THICIQ ss I MATERIAL
CATLIN Engineers and Scientists G / 0 ft. 2.5 ft. 2 i..J Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER TFECKNESS MATERIAL
2.Well Construction Permit#: N/A ft. ft. in.
List all applicable well permits(i.e.(.'ounty,State, Variance,injection,etc.)
tt ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAIvE ER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2.5 ft. 12.5 IL 2 in. Slot.o10 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) rL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTMETHOD&AMOUNT
❑Irri ation 0 rl. 0.5 ft. Portland Cement Surface Pour
Non-Water Supply Well: -
XMonitoring ❑Recovery 0.5 rL 2 ft. Bent.Pellets Surface Pour
Injection Well: rL a.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stomrwater Drainage 2 ft. 12.5 R #2 Medium Sand Surface Pour
❑Experimental Technology ❑Subsidence Control ft. tL
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tmcer FROM TO DESCRIPTION color.hardness soillrock tvpe.grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I. ft.
4.Date Well(s)Completed: 11/03/22 Well ID#: MW-01 ft ft. q��
ft. ft.
5a.Well Location:
rt. rt.
NCDEQ-Foodmart#8 tL
Facility/Owner Name Facility ID#(if applicable)
tL
12924 N.ROXBORO ST.,NC,ROUGEMONT,NC 27572
rL rL
Physical Address,City,and Zip
21.REMARKS
DURHAM
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
36.21823835 N -78.92574751 W L11/9/2022
Signatw'e ofCcitified Well Contractor Date
6.Is(are)the well(s): O Permanent or ❑Temporary By signing this form,I herebv certifi,that the irell(s)was(were)consavcued in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C'.0200 Nell Consiniction 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,ill out knit well construction information 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-ivater supply wells ONLY with the same construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12.5 (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: 2.35 (ft.) Division of Water Resources,Information Processing Unit,
Ifwater 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 submit a copy of this form within 30 days of
12.Well construction method: HSA completion of well construction to the following:
(i.e.auger,rolwy,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 Sv'aply&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 of the county where constructed.
Adapted front Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
Wlminglon,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LO,G 221051 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_01
NORTHING: 898354 1 EASTING: 2021904 CREW: C. BLACK
SYSTEM: NCSP NAD 83 USft BORING LOCATION: NEAR LISTS NORTH OF BUILDING T.O.C.ELEV.: 100.00
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: D TOTAL DEPTH: 12.5
START DATE: 11/3/22 END DATE: 11/3/22 124 HOUR D1W: 2.4 WELL DEPTH: 12.5
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PP►n) LAB. s B DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 100.0 0.0
0.5 0 5 (GW )-ASPHALT and GRAVEL mix ss.5 O.O> 0.5
2 MW-01 (MLG)-Tan with brown and green,Gravelly Clayey
2 0.0 (0.5-2') M o SILT(FILL) 2.0
2.5 N -
0
4.0-----------------------96.0
(ML)-Tan to green SILT with gravel(FILL)
5.0
WOH WOH WOH 25.0 VV
WOH
7.0 93.0 cj
oa
0
8.0 92.0 t
Hard Drilling N
Auger Refusal at 12.5'BLS
12.5 12.5 87.5 12.5 12.6
BORING TERMINATED BY AUGER REFUSAL AT
ELEVATION 87.5 ft
Portland Cement Bentonite Pellets #2 Medium Sand