GW1-2022-05685_Well Construction - GW1_20220426

WELL CONSTRUCTION RECORD For InternalU, 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 ft
NC Well Contractor Certification Number 1S.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERLll.
CATLIN Engineers and Scientists 0 ft. 5 ft. 2 irt.I Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if applicable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: NSA ft. ft. ;n.
List all applicable well permits(i.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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5fr. 20ft. 2 in. SIOt.olo Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 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 ❑StonnwaterDrainage 3 ft. 20;0 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 rmc,grain size,etc.
❑Geothermnal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 04/12/22 Well ID#: MW-03 ft. ft. -
ft. ft.
5a.Well Location:
ft ft
NCDEQ-Tackett Residence NA
ft.
Facility/Owner Name Facility ID#(if applicable)
ft.
13117 N. ROXBORO ST,ROUGEMONT,NC 27572
ft. IT
Physical Address,City,and Zip
21.REMARKS
WAKE NA
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/longis sufficient)
36.221162 N -78.927856 w C 4125/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(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: 1 construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLYwith the same construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (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: NM (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2 7 699-1 61 7
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,rotanv,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 Svuuly&Injection Wells:
Also submit one copy of this form within 30 days of completion of well
13b.Disinfection type: Amount: construction to the comity 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

CATLIN
WELL LOG Engineers and Scientists
zzlosz SHEET 1 OF 1
PROJECT NO.: 221052 STATE: NC COUNTY: WAKE LOCATION: ROUGEMONT
PROJECT: TACKETT RESIDENCE LOGGED BY: OLIVIA DAYNES WELL ID:
DRILLER: D.T. CHALMERS, JR. MW-03
NORTHING: 2021282 EASTING: 899472 CREW: TREVOR MIZELLE
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Behind store in grassy area T.O.C.ELEV.: 98.51
DRILL MACHINE: CME 45B TRACK METHOD: HSA 0 HOUR DTW: NM TOTAL DEPTH: 20.0
START DATE: 4/12/22 END DATE: 4/12/22 24 HOUR DTW: NM WELL DEPTH: 20.0
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 98.5 0.0
0.0 (ML)-Orange slight to mod.elastic SILT 0.0 — 0.5
WOH Brown with rock fragments from 15-20'BLS
3 4 0.7 M
6
U
a
3.0
N
5.0 5.0
z 5 MW-03
6 $ 0.8 �s_8) M
10.0
2
4 5 1.0 M
8
o�
LL
LL
oa
o�
�L
V N
15.0
12
LL 24 38 1.0 D
38
LL
20.0 20.0 78.5 20.0 20.0
BORING TERMINATED AT ELEVATION 78.5 ft in SILT
with rock fragments
EjPortland Cement 0Bentonite Pellets El#2 Medium Sand

G
s N
V'
f r �O
O
'PO
- - - MW-01
y
MW-02
MW-03
WSW-6
P
LEGEND
® Monitoring Well
(Type II) `
y s
O Active Potable it
Water Supply Well
Approximate Location
of Former UST Basin P
U Parcel Boundary
Source: Esri,Maxar, GeoEye, Earthstar Geographies, ONES/AirbL4 DS,
USDA, USGS,AeroGRID, IGN,and the GiS User Community
NOTE:Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 30 15 0 30 60
Feet
PROJECT TITLE
FIGURE
TACKETT RESIDENCE
ATLIN 13117 US HWY 501 SITE MAP
CROUGEMONT, NC
Engineers and Scientists
INCIDENT NO. JOB N0. DATE SCALE DRAWN BY/CHECKED BY
13145 221052 MAY 2022 AS SHOWN KMC/SJO