GW1-2021-01788_Well Construction - GW1_20210429

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 De6Cfa l'II(,]
Well Contractor Name e. a.
4146A Q ,�021 rt. n.
NC Well Contractor Certification Number (� 2 v 15.INNER CASING OR TUBING eothermal closed-loo
Sg`��v0k FROM TO DIAMETER I TFUCKNESS \I\III21.\L
CATLIN Engineers and Scientists „pcoc. 0 ft. 2 ft. 2 Sch.40 PVC
Company Name �l'+i�tC�D N?Sg 16.OUTER CASING for multi-cased wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS \1\11 R1\I.
2.Well Construction Permit#: NSA ft. R. in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DI.\\II 1TR SLOTSIZF 11 IICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 2 n. 12 n. 2_ Slot 010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT _
FROM TO \t.\I I IAL EMPLACEME\T METI IOD&AMOUNT
❑Irrigation 0 ft. 0.5 a. Concrete Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.5 rt. 1.5 ft. Bent.Pellets Surface Pour
Injection Well: n. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier I ROM TO MATERIAL EMPL4CEMENrMETHOD
❑Aquifer Test ❑Stormwater Drainage 1.5 e. 12# Medium Sand Torpedo Sa d
❑Experimental Technology ❑Subsidence Control e. ft.
20.DRILLING LOG attach additional sheets if necessan
❑Geothem7al(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hanlne...soilro:krcpe,i7ainsize etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 01/21/21 Well ID#: MW-01 (t. 00 Jr
C=�
�'`
ft. ft.
Sa.Well Location: G�
Facility/Owner Name Facility ID#(if applicable) -
rt.
8268 NC 27 West,LILLINGTON,NC 27546
n. e.
Physical Address,City,and Zip
21.REMARKS
HARNETT
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)
35.344498 N -78.93823 W �yj' 1/2712021
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance with
1 JA MAC 02C.0100 or 1 JA N(AC 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 well owner.
If 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 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,your
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 12 (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 a�00'and 2@100) construction to the following:
10.Static water level below top of casing: 2.70 (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 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,directpush,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 Svpaly&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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

WELL LOG CATLIN
Engineers and Scientists
zzozss SHEET 1 OF 1
PROJECT NO.: 220239 STATE: NC COUNTY: HARNETT LOCATION: LILLINGTON
PROJECT NAME: WOMACK GROCERY LOGGED BY: COREY FUTRAL WELL ID:
DRILLER: D.T. CHALMERS JR. MW-01
NORTHING: 580318 1 FASTING: 2018361 CREW: TREVOR MIZELLE
SYSTEM: NCSP NAD 83 USft BORING LOCATION: -20'on East side of Buill ing Near Diesel AST T.O.C.ELEV.:
DRILL MACHINE: CME 45B TRACK METHOD: HSA 0 HOUR DTW: 2.7 TOTAL DEPTH: 12.0
START DATE: 1/21/21 END DATE: 1/21/21 124 HOUR DTW: N/A WELL DEPTH: 12.0
BLOW COUNT OVA o
DEPTH LAB. 0 SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (PPM) SI G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE _ 0.0
ASPHALT 0.Oa = 0.5
►': (GW)-ABC STONE with F.SAND Q
+'f (SW)-Tan with orange.F.SAND 1.5
2.0 2.01
(CL)-Tan to gray with orange,Sandy moderatley plastic
CLAY
3.0
2
2 2 z 1.4 "5.�1 M
o>
oa
oa
N t
fV U
N
8.0
8
13 16 to 0.3 W 9.0
(SM)-Red to orange,Silty F.SAND
10.0
:a (SW)-Tan and orange,F.SAND
12.0 12.0 12.0 12.0
BORING TERMINATED AT DEPTH 12.0 ft in F. SAND
Portland Cement Bentonite Pellets #2 Medium Sand

Post Office Box 10279
Wilmington, North Carolina 28404-0279
CAIN
�� TL Telephone: [phone]
Engineers and Scientists Fax: [phone]
www.catlinusa.com
April 13, 2021
North Carolina Department of Environmental Quality
Division of Water Quality
Information Processing
1617 Mail Service Center
Raleigh, North Carolina 27699-1617
Re: North Carolina Well Construction Record and Boring Log
Womack Grocery
8268 NC 27 W, Lillington, NC 27546
Incident Number: 15452
CATLIN Project No.: 220239
To Whom it May Concern,
CATLIN Engineers and Scientists (CATLIN) recently constructed one (1) monitoring well
at the above referenced site. The completed North Carolina Well Construction Record
and Boring Log are attached.
If you have any questions or require additional information, please feel free to contact
us at [phone].
Sincerely,
n
Sean O'Neil, PE
Project Manager
Enclosures
Boring Log and Well Construction Record
I