GW1-2022-10398_Well Construction - GW1_20221116

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
D.T. CHALMERS, JR. FROM I To DESCRIPTION
Well Contractor Name it I it
4146A ft. ft
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft 5 IJ 1 i..J Sch.40 PVC
Company Name 16.OUTER CASING for multi-cased a ells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A rt. ft. in.
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 THICI+'N'ESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft 20 R. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT MIETHOD&AMOUNT
❑Irri ation
rt. ft
Non-Water Supply Well:
®Monitoring ❑Recovery ft. ft
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIALEhfPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
n, ft.
❑Aquifer Test ❑Stommwater Drainage
❑Experimental Technology ❑Subsidence Control 0 ft. 20 ft Natural BaCkflll
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION color,hardness.soil/rock tvite.tvain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) �'{�". ."4 3
LiJ
4.Date Well(s)Completed: 11/03/22 Well ID#: TMW-04 �O
NOV hi n ? ft.
Sa.Well Location:
rt ft,
NCDEQ-Annie Bowling Property N/A tn4,01 f�"`
Facility/Owner Name Facility lD#(if applicable) r 4ttiT '
ft.
13109 N.ROXBORO ST.,ROUGEMONT,NC 27572
rt, rt.
Physical Address,City,and Zip
21.REMARKS
WAKE N/A
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)
36.22037936 N -78.92734223 W 11/8/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or M Temporary Br signing this form,I hereby certify that the well(s)u•as(were)constructed in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constntction Standardv 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.
Ifthis is a repair,fill ant known well consIrliction information and explain the nature of
the repair under 421 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 non-water supply wells ONLY with 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 mtthiple wells list all depths in different(example-3 a200'and 2@1009 construction to the following:
10.Static water level below top of casing: 17.41 (ft,) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
24b.For Infection Wells ONLY: In addition to sending the form to the
11.Borehole diameter: 4.25 (in,)
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,rolmy,cable,direci 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 Svpnly&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-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
VNlmington,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LOG 221053 SHEET 1 OF 1
PROJECT NO.: 221053 1 STATE: NC I COUNTY: WAKE LOCATION: ROUGEMONT
PROJECT: ANNIE BOWLING PROPERTY LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. TMW-04
NORTHING: 899133 1 EASTING: 2021433 CREW: C. BLACK
SYSTEM: NCSP NAD 83 USft BORING LOCATION: —50 feet North of MW-01 T.O.C.ELEV.: NM
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: DrY TOTAL DEPTH: 20.0
START DATE: 11/1/22 END DATE: 11/3/22 24 HOUR DTW: 17.4 WELL DEPTH: 20.0
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH O.Sft O.Sft 0.5ft O.Sft (Ppm) LAB. s � DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (CL)-Brown to orange grading,CLAY 0.0 _
1
2 3 - 19.3 M
5
U
a
0
v _
t _
rn
5.0 s.o
2 -
5 , 54.3 M
11
10.0
Zc
2 3 47.9 M
5 -
oL
oa
o� -
c
�t _
13.0
LL ly
2 3 0.0 D
5
18.0
0.0 M
20.0 20.0 zo.o _" zo.o
BORING TERMINATED AT DEPTH 2O.0 ft in CLAY
Native Backfill