GW1-2022-01454_Well Construction - GW1_20220120

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 ft. a.
4146A Id
rt.
NC Well Contractor Certification Number 15.INNER CASQdG OR TUBING eothermal ehnedl
FROM TO DIAMETER TMCKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 3 ft. 2 Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a ieable
FROM TO DIANIFITR TMCKNFSS MATERim
2.Well Construction Permit#: N/A rl. rt. in.
List all applicable well permits(i.e.County, gate, Variance,byedion,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DI vMt II K sru1SIzl IMCICNESS MATERIAL
❑Agricultural ❑Municipal/Public 3 ft. 13 ft. 2 in. Slot.010 I SCh.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM1I TO MATERIAL ENLACEMENT
❑irrigation
0 n. 0.5 n. Concrete Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.5 it. 1.5 t. Bent.Pellets Surface Pour
Injection Well: It. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FR(111I TO MATERIAL EnIPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage 1.5 it. 13# Medium Sand Torpedo d
❑Experimental Technology ❑Subsidence Control ft. It.
20.DRILLING LOG tattach additional sheds if mecessa
❑Geothermal(Closed Loop) ❑Tracer FKI t\I TOI DESCRIPTION color,hardness soil rock v,Pe,gram sire etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
4.Date Well(s)Completed: 01/10122 Well ID#: MW-07 f`
It. ft. e-001
O
5a.Well Location: GN
NCDEQ- Four Point Grocery N/A it. I'd 010
f t.
Facility/Owner Name Facility ID#(if applicable) -
I i.
5830 GOLDSBORO RD.,WADE,NC 28395
n. n.
Physical Address,City,and Zip
21.REMARKS
CUMBERLAND N/A 22
County Parcel Identification No (PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: �:17n2ttOtl F�roceSS1r1
(if well field,one lat/long is sufficient) w gctlOrl
35.133127 N -78.695578 W 1/18/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or ❑Temporary By signing this form.I hereb-certify that the uell(s)was(were)constructed in accordance with
ISA NCAC 02C.0100 or 1 SA MCAC 02C.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: 0 Yes or O 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 hack 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: 1 construction details. You may also attach additional pages if necessary.
For midtiple injection or non-warer supply wells ONLY with the same construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 13.0 (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@1007 construction to the following:
10.Static water level below top of casing: 7.5 (ft.) Division of Water Resources,Information Processing Unit,
Ifwafer 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: H SA 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 SvuDly&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 from Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

CATLIN
ENIneers and Scientists
WELL LOG zzo3lz SHEET 1 OF 1
PROJECT NO.: 220312 STATE: NC CouNTY: CUMBERLAND LOCATION: WADE
PROJECT: LOGGED BY: O DAYNES WELL ID:
Four Point Grocery DRILLER: D.T. CHALMERS, JR.
NORTHING: 30709580 EASTING: 31674907 CREW: C STRATTION MNV'07
SYSTEM: NCSP NAD 83 USft BORING LOCATION: in proposed location,next to the powerpole T.O.C.ELEV.: NM
DRILL MACHINE: CME 45B TRACK METHOD: HSA 1 0 HOUR DTW: 7.5 TOTAL DEPTH: 13.0
START DATE: 1/10/22 END DATE: 1/10/22 124 HOUR DTW: NM WELL DEPTH: 13.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft o.5n 0.5ft 0.5ft (PPm) Is G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (SP)-Brown Med.SAND w/Silt,Poorly Graded = 0.5
2 U
0.0 M a'
2 a 1.5
fV
3.0 3.0
(SC)-Tan CLAYEY SAND to SAND w/CLAY
5.0
3
3 4 0.0 M
3
o j _
8.0
(SP)-Dark Gray F.to Med.SAND
tV�
10.0
z 3 6 e 481.0 Sat. "'0
(SP)-Color Change to L.Gray,HCO
13.0 13.0 13.0 13.0
BORING TERMINATED AT DEPTH 13.0 ft in F.to
MED.SAND
Portland Cement Bentonite Pellets El#2 Medium Sand

4-
4
I
a
VV
I
SB-01 MW-5
MW-3
-
o�
C� P
MW-07
MW-4
LEGEND
♦ Soil Boring
® Monitoring Well
(Type II)
OMonitoring Well
(Type III)
Active Potable
Water Supply Well
Approximate Location
of Former USTs
(filled with concrete)
Parcel Boundary S S•u :E x• c . - e,Earthslar Geographics, CNES/Airbus®S,
SDA,USc er• RID, IGN,and the GIS User Community
NOTE: Well and UST locations were obtained from previous
reports prepared by other consultants and are approximate. 40 20 o ao 80
I I Feet
PROJECT TITLE FIGURE
FOUR POINT GROCERY
ATLIN 5830 GOLDSBORO ROAD SITE MAP
CWADE, NC 1
Engineers and Scientists
INCIDENT N0. JOB NO DATE SCALE I DRAWN BY/CHECKED BY
11660 220312 JAN 2022 AS SHOWN KMC/BJA