GW1-2022-10402_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.WATER ZONES
D.T. CHALMERS, JR. FROM TO DESCRHIUON
Well Contractor Name ft. ft
4146A
NC Well Contractor Certification Number 1S.INNER CASING OR TUBING eothermal closed-moo h
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft.1 5 rL 1 in.1 Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A it. 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 THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 ft. 1 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) If. ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL Eh IPLACEMENT METHOD&AMOUNT
❑Irrigation
rt. ft.
Non-Water Supply Well:
N Monitoring ❑Recovery ft ft
Injection Well: «. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.ElAquifer Test ❑Stomnvater Drainage
❑Experimental Technology ❑Subsidence Control 0 ft. 20 ft.1 Natural Baokfill
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION color,hardness soil rock ry e main size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) «. ft
4.Date Well(s)Completed: 11/03/22 Well ID#: TMW-05 rt.rt. ft.IL =
�O
Sa.Well Location: H
N/A fL FL �r
NCDEQ-Annie Bowlinq Property rt
. ;�*G
Facility/Owner Name Facility ID#(if applicable)
rt. s
13109 N.ROXBORO ST.,ROUGEMONT,NC 27572 rt. rL a V L_t�
Physical Address,City,and Zip
21.REMARKS
WAKE N/A L t.
County Parcel Identification No.(PIN) Dfl
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 1ih+� ti ✓ et(�I,�G
(if well field,one lat/long is sufficient) 22.Certification:
36.22048115 N -78.92738111 W _ 11/8/2022
Signanue of Certified Well Contractor Date
6.Is(are)the well(s): O Permanent or E Temporary Bysigning thisform,I hereby certify that the well(s)was(were)cons0-acted in accordance with
I5A N(AC 02C.0100 or 15A NCAC 02C.0200 Well Consiniction 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 421 remarks section or on the back ofthis forin. 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-wcaer supply wells ONLY with the sane construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20.0 (g,) 24a.For All Wells: Submit this form within 30 days of completion of well
For mahiple wells list all depths in dijJerent(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of casing: 18.18 (ft,) 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: 4.25 (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: 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 SvPyly&Iniection Wells:
Also submit one copy of this form within 30 days of completion of well
136.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
GEOTECHNICAL CATLIN
Vlfilrtingtan,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LOG 221053 SHEET 1 OF 1
PROJECT NO.: 221053 1 STATE: NC COUNTY: WAKE LOCATION: ROUGEMONT
PROJECT: ANNIE BOWLING PROPERTY LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS, JR. TMW-05
NORTHING: 899170 1 EASTING: 2021422 CREW: C. BLACK
SYSTEM: NCSP NAD 83 USft BORING LOCATION: -45 feet North of TMW-04 T.O.C.ELEV.: NM
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: DIFY TOTAL DEPTH: 20.0
START DATE: 11/1/22 END DATE: 11/3/22 24 HOUR DTW: 18.2 WELL DEPTH: 20.0
BLOW COUNT OVA o o SOIL AND ROCK WELL
DEPTH 0.5ft O.Sft 0.5ft 0.5ft (PPM) LAB. s c DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 (CL)-Tna grading to orange with black streaks,CLAY 0.0 _
3
3 3 0.0 M -_
6
U
a
I v
s _
to
5.0 s.a
s
' 0.0 M
10 15 -
10.0
2
3 3 0.0 M
5
o
oa
--o
o�
to t
13.0 e
LL 3
3 5 0.0 M
7 _
15.0
-
20.0 80RING TERMINATED AT DEPTH 2O.0 ft in CLAY 20.0 20.0
Native Backfill