GW1-2022-02958_Well Construction - GW1_20220301

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WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
914CWATER'ZONENES
D.T. CHALMERS,JR. FROM t
DESCRIPTION
Well Contractor Name it4146A ft
LrK
NC Well Contractor Certification Number L.'15�`i1NNERrGASING'ORS7IJBING eo hermaUclr`osed-Iron
FROM TO I DIAMETER 7HICKNESS MATERIAL
CATLIN Engineers and Scientists 0 fL 2 It 2 is Sch.40 PVC
>ri&1(0UT910GASiNG forr.ul"ti-c4-WdWells ORTIJWER!i7,a liL.lk
Company Name FROM I TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: N/A A. IL Jn _List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
3.Well Use(check well use): 91I.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOTSUE I THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 2 ft. 12 e. 2 in. Slot.010 I Sch.40 1 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) sfgTGROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 n. 0.8 rL Concrete Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.8 ft. 1.8 rL Bent.Pellets Surface Pour
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 419:rSAND1GRAVEL®PACKYiLa- WYNIMMUMMr
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 1.8 fL 12# Medium Sand Torpedo Sa d
❑Experimental Technology ❑Subsidence Control n• tt
.20 DRIUL1NG06GratfachYaddir.WdIrsheeINfnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soillrock type,wain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rL fL
4.Date Well(s)Completed: 11/05/21 Well ID#: MW-04 rL rL
fL fL S� O
00
5a.Well Location: N
NCDEQ-Quick Stop Mart N/A
Facility/Owner Name Facility ID#(if applicable) ft.
Rp
ft
300 East Herring Ave.,Wilson,NC 27893
n. rL
Physical Address,City,and ZipMAR *A4
i:REkMGt S - E ,
WILSON N/A
vr� ti,
County Parcel Identification No.(PIN) *;n • -v re
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ` '
22.Certification:
(if well field,one lat/long is sufficient)
35.727617 N -77.90422 W 2/21/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): M Permanent or O Temporary By signing this form,I hereby certify that the wel(s)was(were)constructed in accordance with
ISA NCIC 02C.0100 or ISA NUC 02C.0200 Well Construction Standards and that a 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 and explain the nature of
the repair under 421 remarks section or on the back oflhis 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 mayjalso attach additional pages if necessary.
or multiple injection or non-water supply wells ONLY with the same construcdon,you SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 12.0 (R,) 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@100) construction to the following:
10.Static water level below top of casing: (B,) Division of Water`Resources,Information Processing Unit,
If water 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: 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 Svanly&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.
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Adapted from Fomr GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources .Revised 2-22-2016

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CATLIN
WELL LOG Engineers and Scientists
zz,°ns SHEET 1 OF 1
PROJECT NO.: 221049 STATE: NC COUNTY: WILSON LOCATION: Wilson
PROJECT: Quick Stop Mart LOGGED BY: 0. Da nes WELL ID:
DRILLER: D.T. CHALMERS JR. MW-04
NORTHING: 2325219 1 EASTING: 721545 CREW: ! E. Swain
SYSTEM: NCSP NAD 83 USft BORING LOCATION: In grass Island south of MW-3 T.O.C.ELEV.: 99.37
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTw: DrY TOTAL DEPTH: 12.0
START DATE: 11/5/21 END DATE: 11/5/21 124 HOURDTW: NM WELL DEPTH: 12.0
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5ft (PPM) LAB. s G DEPTH DESCRIPTION ELEVATION DETAIL
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0.0 LAND SURFACE 99.4 _ o.o
0.0 '—'.. 0.5 (ML)-Dark brown SILT with organics 98.9 0 Oa
a 8 MW-04 (SM/ML)-Brown SILT to Silty F.SAND v — 0'8
3 3 0.0 (0.5-2.5') D t
2.0 97.4 2.0
(ML)-Brown,SILT
5.0
5.5 93.9
3 (CL)-Red CLAY with sand. Moderatley plastic.
3 172.3 VV 3 Moderate HCO o
oa
oQ
�t
fV�
10.0 10.0 89.4
(CH)-Gray with orange mottling,Highly plastic CLAY
3 4 with sand.
s 8 1902 VV Strong HCO
12.0 12.0 87.4 12.0 12.0
BORING TERMINATED AT ELEVATION 87.4 ft in
Highly Plastic CLAY with sand.
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Portland Cement Bentonite Pellets I sEj#2 Medium Sand
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�d fn.'fir•"r�� Y3:�,-
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Y
550 GAL,
_' ,•• . =?G`A$OLINE U.S�TMSS' ......
e
'�•. ��NG PEE ` �'��' ' � `,�,,
a: FORMER
a
DISPENSERS r
t } �€ 'k tip. ISLANDS: 47� MW=1_R
� l°
`10;000-GAL.
.ie
LEGEND
® Active Monitoring
Well (Type II)
vi';c F
Approximate Location of FqS
Telephone Conduit Vault TGO
i Approximate Location
of Former UST System .• .
Parcel Boundary Sour s ax® GeoE-ye,Ea st r G ogr p ics,C•NES/Airbus
USDA,USG=,Ae R D, GN,a the GI= U Community.',
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 20 10 0 20 40
Feet
PROJECT TITLE FIGURE
QUICK STOP MART
CATLIN 300 E HERRING AVE SITE MAP
WILSON, INC
Engineers and Scientists
INCIDENT NO. I JOB NO. DATE SCALE i DRAWN BYICHECKED BY
3658 221049 FEB 2022 AS SHO`WN KMC/SJO
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