GW1-2022-10404_Well Construction - GW1_20221116

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Contractor Name rL fl
4146A ft.1 rt.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loo
FROM I TO "'TER THICKNESS I MATERIAL
CATLIN Engineers and Scientists 0 rt. 5 rt. I in. Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A fL ft. in.
List all applicable well permits(i.e.County,Slate, Variance,Injection,etc.)
fL fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5ft. 15 It. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. rt. _in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL ENIPLACEMENT METHOD R:Ah10UNr
❑Irrigation
ft. ft.
Non-Water Supply Well:
®Monitoring ❑Recovery ft. fL
Injection Well:
❑Aquifer Recharge ❑Groundwater Renlediation 19.SAND/GRAVEL PACK if a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stomnvater Drainage fL It.
❑Experimental Technology ❑Subsidence Control 0 ff. 15 It. Natural Backfill
20.DRILLING LOG attach additional sheets it necessary)
❑Geothermal(Closed Loop) ❑Tracer Fkw TO DESCRIPTION color,hardness.soiltrock type,gain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) It. ft.
4.Date Well(s)Completed: 11/01/22 Well ID#: TMW-05 fL fL ��-
fL
5a.Well Location:
N/A ft.
NCDEQ-Tackett Residence
ft.
Facility/Owner Name Facility ID#(if applicable) PON
tt.
13117 N.ROXBORO ST,ROLIGEMONT,27572 ft. rt. pj,- f
Physical Address,City,and Zip
21.REMARKS
WAKE N/A I 1
County Parcel Identification No.(PIN) ` `
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 10orrmation Pra za.4 ,.g Unit:
(if well field,one lat/long is sufficient) 22.Certification: f3'Va"210G
36.22146888 N -78.92783392 w L11/8/2022
Signature of( tified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or O Temporary By signing this form,I hereby cerrifi,that the wells)was(were)constructed in accordance with
I5A NCAC 01C.0100 or 15A NCAC 02C.0200 11'ell Cotuiruction Siandardr and that a copy of
7.Is this a repair to an existing well: Oyes 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 at-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 mahiple injection or non-water supply wells ONLY with the saitte construction,you
can submit one fonn. 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 imiltiple wells list all depths in different(example-3 a200'and 2@1009 construction to the following:
10.Static water level below top of casing: 8.44 (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: 4.25 (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,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 submit one cop),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

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
Wlnhngton,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LOG 221052 SHEET 1 OF 1
PROJECT NO.: 221052 1 STATE: NC I COUNTY: WAKE LOCATION: ROUGEMONT
PROJECT: LOGGED BY: T. PARK WELL ID:
TACKETT RESIDENCE DRILLER: D.T. CHALMERS JR.
NORTHING: 899529 EASTING: 2021288 CREW: C. BLACK TMV11-05
SYSTEM: NCSP NAD 83 USft BORING LOCATION: —45 feet North of TMW-04 T.O.C.ELEV.: NM
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: N/A TOTAL DEPTH: 15.0
START DATE: 11/1/22 END DATE: 11/1/22 124 HOUR DM3.4 Dry WELL DEPTH: 15.0
BLOW COUNT OVA o L SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPm) LAB. Is G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (CL)-Brown,Clayey TOPSOIL o.o _
2 1 3 0.0 M (CL)-Orange grading to tan,CLAY
4
EL
0
v -
t
5.0 s.o
2 -
1 2 0.0 M
6
oa
10.0 a
,n -
2 4 0.0 D =
5 -
12.0 _
(ML)-Tan to green,Clayey SILT
13.0 =
s '
LL
14 16 0.0 D
18
15.0 15.0 15.0 15.0
BORING TERMINATED AT DEPTH 15.0 ft in Clayey
SILT
LL
Native Backfill