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Home My WebLink AboutGW1-2022-05687_Well Construction - GW1_20220426 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 I TO DESCRIPTION Well Contractor Name ft. ft 4146A ft. rr NC Well Contractor Certification Number IS.INNER CASING OR TUBING(geothermal closed-loo FROM TO DIAMETER T1llCKNESS MATERIAL CATLIN Engineers and Scientists 0 ft. 5 ft. 2 in.I Sch.40 1 PVC Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable FROM TO DIAMETER TIUCRNESS MATERIAL 2.Well Construction Permit#: NSA ft. �. ;n. List all applicable well permits 6.e.County,State, Variance,Injection,etc) ft. ft. in. 3.Well Use(check well use): 17.SCREEN Water Supply Well: FROM TO DIAMETER SLOT SIZE TIRCKNESS MATERIAL ❑Agricultural ❑Municipal/Public 5fr. 15ft. 2 in. SIOt.olo Sch.40 PVC ❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ff fr. in. ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM TO MATERIAL EMPLACEMENT MET1IOD&AMOUNT ❑Irrigation 0 ft. 0.5 It. Portland Cement Surface Pour Non-Water Supply Well: ®Monitoring ❑Recovery 0.5 ft. 3 It. Bent.Pellets Surface Pour Injection Well: rt. rt. ❑Aquifer Recharge ❑Groundwater Rcmcdiation 19.SAND/GRAVEL PACK if a licable ❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENTMETHOD ❑Aquifer Test ❑Stonnwater Drainage 3 f. 15#t Medium Sand Torpedo Said ❑Experimental Technology ❑Subsidence Control ft ft. 20.DRILLING LOG attach additional sheets if necessar ❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION"color,hardness soil/rock rype,grainsizc,etc. ❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft. 4.Date Well(s)Completed: 04/14/22 Well ID#: MW-03 fr. fr. - ft. ft. 5a.Well Location: ft. ft. Khaled Elmawy M&M GRILL ft Facility/Owner Name Facility ID#(if applicable) ft. 217 E.South Main Street,LITTLETON,NC 27850 ft. IT Physical Address,City,and Zip 21.REMARKS HALIFAX County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: (ifwell field,one lat/longis sufficient) 36.435972 N -77.909093 w C -� 4126/2022 Signature of Certified Well Contractor Date 6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the welf(s)was(were)constructed in accordance with 15ANCAC 02C.0100 or 15ANCAC 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 of this form. 23.Site diagram or additional well details: You may use the back of this page to pro-ride additional well site details or well 8.Number of wells constructed: construction details. You may also attach additional pages ifnccessary. For multiple injection or non-wader supply we11s ONLYwith the same construction,you can submit one form. SUBMITTAL INSTRUCTIONS 9.Total well depth below land surface: 15.0 (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@1009 construction to the following: 10.Static water level below top of casing: 7.79 (ft,) Division of Water Resources,Information Processing Unit, Ifwate-level is above 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 ofwell 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 Svuuly&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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016 WELL LOG CATLIN Engineers and Scientists 221233 SHEET 1 OF 1 PROJECT NO.: 221233 STATE: NC COUNTY: HALI FAX LOCATION: LITTLETON PROJECT: M&M GRILL LOGGED BY: T. Park WELL ID: DRILLER: D.T. CHALMERS, JR. MW-03 NORTHING: 2320939 EASTING: 979381 CREW: E. SWAI SYSTEM: NCSP NAD 83 USft BORING LOCATION: —10'north of Former UST Basin T.O.C.ELEV.: 101.17 DRILL MACHINE: CME 45B TRACK METHOD: HSA 0 HOUR DTW: 8.7 TOTAL DEPTH: 15.0 START DATE: 4/14/22 END DATE: 4/14/22 24 HOUR DTW: 7.8 WELL DEPTH: 15.0 DEPTH BLOW COUNT OVA LAB o a SOIL AND ROCK WELL 0.5ft 0.5ft 0.5ft 0.5ft (ppm) s G DEPTH DESCRIPTION ELEVATION DETAIL 0.0 LAND SURFACE 101.2 0.0 0.0 ;• 0.5 (GW)-Gray,Sandy GRAVEL 100.7 0.0 0.5 a 4 (SC)-Brown,Clayey F.SAND 2 29.7 M 6 a 0 v 3.0 98.2 3.0 (ML)-Orange to yellow,SILT with tr.weathered quartz N 5.0 5.0 2 3 4 247.7 M 5 of oa 10.0 N L (V U 1 N 1 1 1,650 W 1 15.0 15.0 86.2 15.0 15.0 BORING TERMINATED AT ELEVATION 86.2 ft in SILT EjPortland Cement Bentonite Pellets El#2 Medium Sand 5� N ■ MW-01 f _ � ®MW-02 5 MW-1 D � v�NMP`N ( MW-04 LEGEND ® Monitoring Well (Type II) OMonitoring Well (Type III) Approximate Location of Former UST Basins Parcel Boundary Source: E rs axa, GeoEye, Ear, ar Geog�riap cs, CNES/Airbus IDS,USDA, USGS1wAoGRID, IIG�N and the GIS User Community NOTES: 1. UST locations were obtained from previous reports prepared by other consultants and are approximate. 20 10 0 20 40 2.Well locations were obtained during field activities Feet conducted on August 19,2021. PROJECT TITLE M & M GRILL FIGURE ATLIN 217 E SOUTH MAIN ST SITE MAP CLITTLETON, NC Engineers and Scientists INCIDENT N I JOB NO. DATE SCALE DRAWN BY/CHECKED BY 38688 221233 APR 2022 AS SHOWN KMC/BJA 5� N ■ MW-01 f _ � ®MW-02 5 MW-1 D � v�NMP`N ( MW-04 LEGEND ® Monitoring Well (Type II) OMonitoring Well (Type III) Approximate Location of Former UST Basins Parcel Boundary Source: E rs axa, GeoEye, Ear, ar Geog�riap cs, CNES/Airbus IDS,USDA, USGS1wAoGRID, IIG�N and the GIS User Community NOTES: 1. UST locations were obtained from previous reports prepared by other consultants and are approximate. 20 10 0 20 40 2.Well locations were obtained during field activities Feet conducted on August 19,2021. PROJECT TITLE M & M GRILL FIGURE ATLIN 217 E SOUTH MAIN ST SITE MAP CLITTLETON, NC Engineers and Scientists INCIDENT N I JOB NO. DATE SCALE DRAWN BY/CHECKED BY 38688 221233 APR 2022 AS SHOWN KMC/BJA