GW1-2023-01571_Well Construction - GW1_20230209

WELL CONSTRUCTION RECORD For Internal ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES -
D.T.Chalmers, A r-ROM FO DEY Hill110
Well Contractor Name ft. n.
4146A fit. n.
E�„_�,,,.� y j„ 15.INNER CASING OR TLBING,eothermal
NC Well Contractor Certification Number closed-loo
FRo�I ro DL�tl nx nu(ti�Ess %I-tn RIAL
CATLIN Engineers and Scientists p, o 0 ft. 3 ft. 2 Sch. 40 PVC
Company Name 16.OUTER CASING for multkased wells OR LINER if a icable
FROM ro DLSnmTtiR nn(RNl ss nfaTEalAt
2.Well Construction Permit#: N/Alnfi�"T �`i= r " l;
List all applicable well permits(i.e.County,State, Vari me j brut,etc.)
ft. ft.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DUNIMETER SLOT SIZE TFUCKNESS NIATERI,u
❑Agricultural ❑Municipal/Public 3 n. 10 ft. 2 i.. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL ENWLACEh(E\7\IEniOD&AAIOIJIT
❑Irrigation
0 n. 1 fit. Concrete Surface Pour
Non-Water Supply Well: -
MMonitoring ❑Recovery 1 ft. 2 u. Bent.Pellets Surface Pour
Injection Well: ft. fit.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if a icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FRONT rO Nl,%IrRIAL EM1�LACEMENTIv1ETHOD
❑Aquifer Test ❑Stolmwater Drainage2 it. 13 ft. Torpedo Sand
❑Experimental Technology ❑Subsidence Control °' It
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DI-S(Rn'nO\i i,,,. Ata�ess.so ut« v 5,�_et.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. It. -
4.Date Well(s)Completed: 02/02/23 Well ID#: MW-4
tN�G
Sa.Well Location: -
ft.
NCDEQ-Bowden Grocery and Grill 0-017636
Facility/Owner Name Facility ID#(if applicable)
u.
6879 US HWY 401 SOUTH,BUNNLEVEL,28323
Physical Address,City,and Zip -
21.REMARKS -
HARN ETT N/A
County Parcel Identification No.(PIN)
Latitude and Longitude c degrees/minutes/seconds or decimal degrees: 22.Certification:
(if
(if well field,one IaUlong is sufficient)
35.307193 N -78.781482 W 2/3/2023
Signature of Certified Well Contractor Date
6.Is(are)the well(s): O Permanent or ❑Temporary By signing ihisform,I berebv certifi chat the u ellts)was(were)constructed in accwr h nce,nth
1 SA M-AC 01C.0100 or ISA NCA('02C.0200 WeU Construction Standards and thug a copy of
7.Is this a repair to an existing well: ❑Yes or ®No this record has been provided to the well owner.
1f 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 provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,You
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13.0 (g,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of casing: 6.23 (g,) Division of Water Resources,Information Processing Unit,
lfwater level is ahme casing,use " 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b.For infection 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 SvoDly&Infection 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 from Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL CATLIN
GEOTECHNICAL
WELL LOGMmu4m,RaWo,WasWr4m.
Ctwles 0" Engineers and Scientists
zzozzs SHEET 1 OF 1
PROJECT NO.: 220226 STATE: NC COUNTY: HARNETT LOCATION: BUNNLEVEL
PROJECT: BOWDEN GROCERY AND GRILL LOGGED BY: C. Black WELL ID:
DRILLER: D. T. Chalmers JR MW-4
NORTHING: 5668011 EASTING: 2065193 CREW: L. Hamilton
SYSTEM: NCSP NAD 83 USft BORING LOCATION: SW corner of Former UST-2 T.O.C.ELEV.: 100.24
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 6.2 TOTAL DEPTH: 13.0
START DATE: 2/2/23 END DATE: 2/2/23 124 HOUR DTW: NM WELL DEPTH: 13.0
BLOW COUNT OVA M SOIL AND ROCK WELL
DEPTH 0 stt 0.sn 0.5tt 0.stt (PPm) LAB. s G DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 100.2 0.0
0.0 (SP)-Tan,CSE.SAND 0.0
a - 1.0
0
0
t
2.0
tV
3.0
6.0 94.2
of° N M Sat.
(SC)-Brown to gray,Clayey CSE.SAND
uthng Tan to orange,Clayey F.to CSE SAND from 10-13'BLS
Strong HCO
oU
oa
o�
NL
tV N
9..13.0 13.0 87.2 13.0 13.0
BORING TERMINATED AT ELEVATION 87.2 ft in
Clayey F.to CSE.SAND
IL
Portland Cement Bentonite Pellets El#2 Medium Sand

N
}
3
x
j 9
Cn
t .
rt .s
POSSIBLE
ORPHAN UST
i MW-2
I
MW-1 R
® MW-3 — ..... . ....�.a j
MW-4
FORMER FORMER
UST-2 UST4-
LEGEND
Monitoring Well
(Type II)
Approximate Location
of ASTs
DApproximate Location _
of USTs
Parcel Boundary ;
Source: Esri, Maxar, Earthstar Geographics,and the GIS User Community,
NOTE: MW-1 and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 40 20 0 40 80
Feet
PROJECT � � FIGURE
BOWDEN
C6879ATLIN GROCERY & GRILL SITE MAP
US H WY 401 S
Engineers and Scientists BUNNLEVEL, NC 3
INCIDENT NO I JOB NO. DATE SCALE I DRAWN BYICHECKED BY
21800 220226 MARCH 2O23 AS SHOWN KMC/SJO