GW1-2022-01795_Well Construction - GW1_20220214

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for smgle or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Austin Fowler FROM TO DESCRIPTION
Well Contractor Name ft. fc
4366A ft. a
r �"JVED 15.INNER CASING OR TUBING eothermal dosed loo
NC II Contractor Certification Number FROM To DIAn"TTR nuc KNFss ntATTR1.aL
CATLIN Engineers and Scientists -�p� ��1�1 0 rt. 15,,J 2 Sch.40 1 Pv:c::i
Company Name 16.OUTERCASING Ifor multi-casedwells OR LINER ir• icade
FROM TO DIAnIETER Tllll'KNESS MATI'RIAI
Ufa .
2.Well Construction Permit#: N/A 'f00r� rt. n. in.
List all applicable well permits(i.e.Coin n,State, Mri7trtce,!n
ft. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO OI\N11.11;R SLAT SIZE TMCKNESS MA"ITRIAL
❑Agricultural ❑Municipal Public 15 ft. 30 f. 2 in. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. h. _ in.
❑industnal/Commercial ❑Residential Water Supply(shared) 13.GROUT
IRO%1 TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 0.5 ft. Concrete Surface Pour
Non-Water Supply Well:
0.5 rt. 13.5 ft. Sent.Pellets Surface Pour
®Monitoring ❑Recovery
njection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO n1.4TERLAL EMPLACEMENT niIIHOO
❑Aquifer Test ❑Stormwater Drainage 13.5 ft. 32 X Medium Sand Torpedo Sa d
❑Experimental Technology ❑Subsidence Control R. ft.
20.DRILLING LOG attach additional sbeets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM To DscRtPTut�,.,:,� „•:;.o�tr«kt.ts
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n. It. _
4.Date Wells)Completed: 12/15/21 Wep IDN: MW-07 t -16e �O
ft- GN
Sa.Well Location:
n. n.
NCDEQ-Fastwav Food Mart N/A
Facility/Owner Name Facility ID#(if applicable)
n-
217 W.Broad St.,ROCKINGHAM,NC 28379
ft. Ii.
Physical Address,City,and Zip -
N/A 21.REMARKS _
RICHMOND _
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) _
34.936866 N -79.776819 W l G 2/10/2022
Signature of Certified Well Contractor Date
6.Is(are)the Welf(S): M Permanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance wait
iSA NG1C 02C.0100 or 15A NC AC 02C.0200 Well Construction Standards aril that o copy of
7.Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
If this is a repair,fill out known well construction information awl explain the nature of
the repair under ii21 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 uyeaion or non-water supply wells ONLY with the same construction,you SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 30.0 (g,) 24a.For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different(example-3 200'and 2@1009 construction to the following:
10.Static water level below top of casing: 29.1 (g,) Division of Water Resources,Information Processing Unit,
Ifwater level is ahxrve casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.25 (in.) 24b.For Injection 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 SvuDly&Injection 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
WELL LOG Engineers and Scientists
220283 SHEET 1 OF 2
PROJECT NO.: 220283 STATE: NC COUNTY: RICHMOND LOCATION: ROCKINGHAM
PROJECT: FASTWAY FOOD MART LOGGED BY: O. Da nes WELL ID:
DRILLER: Austin Fowler MW-07
NORTHING: 4328631 EA STING: 1767192 CREW: D.T. Chalmers
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Sloped drive behind buil ing T.O.C.ELEV.: 94.71
DRILL MACHINE: Diedrich D-50 METHOD: HSA 10 HOUR DTW: 29.1 TOTAL DEPTH: 32.0
START DATE: 12/15/21 END DATE: 12/15/21 124 HOUR DTW: NM WELL DEPTH: 30.0
BLOW COUNT OVA M o SOIL AND ROCK WELL
DEPTH o.sn o.sn o.sn o.sn (PPm) LAB. s DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 94.7 _ 0.0
0•0 (ML)-Red SILT w/Trace SAND and Med.Plasticity 0.0 — 0.5
2
4 6 1.2 D
8
5.0 5.0 89.7
SAA w/No Plasticity
3
13 is 0.4 D
a
a
t
ti
fV
10.0 10.0 84.7
Gray-Green SILT w/Foliation(Saprolite)
2 12 'driller mentioned vapors from the augers at—13.0'BLS
33 0.9 D
53
13.5
15.0 15.0 79.7 16.0
Strong HCO
11
fio 20 609.6 D
20.0
8 D
51 49 1483
EjPortland Cement Bentonite Pellets #2 Medium Sand

CATLIN
WELL LOG Engineers and Scientists
zzo26s SHEET 2 OF 2
PROJECT NO.: 220283 STATE: NC COUNTY: RICHMOND LOCATION: ROCKINGHAM
PROJECT: FASTWAY FOOD MART LOGGED BY: O. Da nes WELL ID:
DRILLER: Austin Fowler MW-07
NORTHING: 4328631 EASTING: 1767192 CREW: D.T. Chalmers
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Sloped drive behind buildin T.O.C.ELEV.: 94.71
DRILL MACHINE: Diedrich D-50 METHOD: HSA 10 HOUR DTW. 29.1 1 TOTAL DEPTH: 32.0
START DATE: 12/15/21 END DATE: 12/15/21 124 HOUR DTW: NM I WELL DEPTH: 30.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (PPM) s c DEPTH DESCRIPTION ELEVATION DETAIL
(ML)-Red SILT w/Trace SAND and Med.Plasticity �>
oa
(continued) o g
fA'e
fV�
2 5.0 25.0 69.7
'soil was dry,spoon was wet
21 29 pulled up augers to see potential recharge
20 129.3 D
27
30.0
30.0 64.7 30.0
Brown and Gray-Green SILT
14 20 'spoon was dry,pulled up augers to see potential
36 6.4 D recharge
64 water level meter detected water when retested
32.0 BORING TERMINATED AT ELEVATION 62.7 ft in SILT 32.0
ElPortland Cement Bentonite Pellets El#2 Medium Sand

/ VF
PUMP FORMER
ISL-AND 3-3,000 GAL.
GASOLINE USTS
FORME R •► OPERATIONAL
2,000 GAL. MW-4 3-8,000 GAL.
DIESEL UST ,GASOLINE USTS
MW-3
POSSIBLE FORMER
UST 10,000 GAL.
j Y ;., MWi7 GASOLINE UST
MW-4
LEGEND
r r4/,
�MW-5
® Active Monitoring
Well (Type II) ~�
® Destroyed Monitoring
Well (Type II) MW-6
❑ Approximate Location +
of Former LISTS
❑ Parcel Boundary ce: Es i, Maxar.�GeoEye, Earthstar Geograp I• ,GIN us DS,
D AeroGRID; IGN,and the GIS user Community
NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 50 25 0 50 100
Feet
PROJECT TITLE FIGURE
FAST WAY FOOD MART
ATLIN 217 WEST BROAD AVE SITE MAP
CROCKINGHAM, NC 1
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BVICHECKED BV
4092 220283 FEB 2022 AS SHOWN KMCBJA