GW1-2022-10317_Well Construction - GW1_20221114

WELL CONSTRUCTION RECORD For Internal Use ONLY
This forrn 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 RECF rt• rt.
4146A
NC Well Contractor Certification Number N�\I 1 4 2,0�� 15.INNER CASING OR TUBING eothermal closebloo
V FROM TO DIANVIhE- THICKNESS MATERIAL
CATLIN Engineers and Scientists its, Uo 0 n. 6 ft.1 2 Sch.40 PVC
Company Name IV40ov, _,��/rjO'J 16.FROM ER CASING for i-cased OR LINER ifa icable
�JY7�°� FROM TO Dl.•L\IE:TER TMCKNESS MATERIAL
2.Well Construction Permit#: N/A
List all applicable well permits(i.e.County,State, Variance,bliection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SI7.F HIK KNESS MATERIAL
❑Agricultural ❑Municipal/Public 6 rt. 16 ft. 2 in. Slot.010 Sch. 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commerwal ❑Residential Water Supply(shared) Is.GROUT
FROM TO NOIFRML 1\wLACEMENTMETHOD&ANIOUNr
0 Irritzation 0 rt. 1 ft. Portland Cement Surface Pour
Non-Water Supply Well:
ZMonitoring ❑Recovery 1 ft. 4 rt. Bent.Pellets Surface Pour
Injection Well: a. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK 6ta icable
FROM TO MATERIAL I ENIPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage 4 ft. 17 fr #2 Medium Sand Surface Pour
❑Experimental Technology ❑Subsidence Control ft. rt
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO Nf (RIPTION color i,.,rdn-soa ror�n w-in size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. n.
4.Date Well(s)Completed: 11/02/22 Well ID#: MW-03 tt n. � -w ..0O
ft. ft. G�
5a.Well Location: -
PNCDEQ-Foodmart#8
I t.
Facility/Owner Name Facility ID#(ifapplicable) 1
r�.
12924 N.ROXBORO ST.,NC,ROUGEMONT,NC 27572
Physical Address,Cite,and Zip -
21.REMARKS _
DURHAM _
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/Iong is sufficient)
36.21792391 N -78.92587565 W `' 11/9/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or O 1 emporary By signing this form,l hereby certifi,that the wdl(s)was(were)constructed in accordance with
15A MAC 02C.0100 or 1 SA NC.4('02C.0200 Well Consiniction Smndards and that a copy of
7.Is this a repair to an existing well: OYes or ®No this record has been provided to the well owner.
If this is a repair,f ll out known well construction information and explain the nature of
the repair under x21 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: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or ram-water supply wells ONLY with the style consbucdon,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 16.0 ({t.) 24a.For All Wells: Subunit this form within 30 days of completion of well
For multiple wells list all depths in dii#erent(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 Infection 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 Svnaly&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-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL CATLIN
GEOTECHNICAL
WELL LOGVdInwo n,Raleigh.Waslr w.
ch.i.ston Engineers and Scientists
22tast SHEET 1 OF 1
PROJECT NO.: 221051 STATE: NC I CouNTY: DURHAM LOCATION: ROUGEMONT
PROJECT: LOGGED BY: T. PARK WELL ID:
FOODMART #8 DRILLER: D.T. CHALMERS JR.
NORTHING: 898239 EASTING: 2021867 CREW: C. BLACK MV11-03
SYSTEM: NCSP NAD 83 USft BORING LOCATION: SOUTHWEST OF BUILDING NEAR US Hwy 501 T.O.C.ELEV.: 99.19
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: DrY TOTAL DEPTH: 17.0
START DATE: 11/2/22 END DATE: 11/2/22 124 HOUR DTW: Dry WELL DEPTH: 16.0
BLOW COUNT OVA o L SOIL AND ROCK WELL
DEPTH 0.5ft 0.5rt o.5n 0.5rt (PPM) LAB. Is DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 99.2 0.0
0.5 0.5 (GW)-ASPHALT and GRAVEL mix 98•7 0.0
1.0 98.2 — 1.0
4 s CLG)-Gr to tan,Gravel CLAY
31 52 0.0 D U
(ML)-Green to tan,SILT(SAPROLITE)
Tan to green at 5.0'BLS o
Tan with tr.sand at 10.'BLS t
4.0
<V
5.0 ze
47 ssi 1870 "w-03 D 6.0
2 (5)10.0 of
87 o a
sz 3910 D �,Q
L
(V�
14.0 85.2
(ML)-Tan to green and white,Sandy SILT
15.0
17 16.0
82z 3612 D
17.0 17.0 s2.2 .. �7.0
BORING TERMINATED AT ELEVATION 82.2 ft in
Sandy SILT(SAPROLITE)
ElPortland Cement Bentonite Pellets El#2 Medium Sand

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MW-01
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LEGEND
® Monitoring Well
(Type II)
Unknown Utility Lines \ ��
i
Parcel Boundary
MW-03
Souroi Esri.Maxar. Earthstar Geographics and the GIS User Community
NOTE: Utility locations were obtained from ESP Associates,
Inc., and are approximate. 20 10 0 20 40
Feet
=40JECT TITLE
FIGURE
FOODMART#8
ATLIN 12924 US HWY 501 SITE MAP
CROUGEMONT, NC 1
Engineers and Scientists
INCIDENT NO I JOB NO DATE SCALE DRAWN BVICHECKED BY
6280 221051 NOV 2022 AS SHOWN KMC/SJO