GW1-2022-10403_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 DESCRIPTION
Well Contractor Name ft. It
4146A ft. fL
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermaI closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft 5 f,.l 1 Sch.40 1 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER(ifapplicable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A ft. 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. 15 ft. 1 in. SIDt.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEhIENr1,ETHOD&AMOUNT
❑Irrigation
fL rt.
Non-Water Supply Well: -
MMonitoring ❑Recovery rL rL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ira licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To I MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control 0 ft. 15 ft. Natural Backflll
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness,soillrock type,Brain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 921 Remarks) fL fL
4.Date Well(s)Completed: 11/01/22 Well ID#: TMW-04 rL rt. M
ft. n. ,D �O
5a.Well Location: �N
. �♦
NCDEQ-Tackett Residence N/A ft. ft. `
Facility/Owner Name Facility ID#(if applicable) fL ► °�' "-r
13117 N.ROXBORO ST,ROUGEMONT,27572
Physical Address,City,and Zip n. n.
21.REMARKS
WAKE N/A
County Parcel Identification No.(PIN) Dl4/R 3
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
36.22135487 N -78.92777856 W 11/8/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ❑Permanent or M Temporary Br signing this form,1 hereby certify that the well(r)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slandardr and that a cony 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 consiniction information and explain the nature of
the repair tinder#21 remarks section a•on the back ofthis 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 sauce construction,you SUBMITTAL INSTRUCTIONS
can submit one form.
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@100) construction to the following:
10.Static water level below top of casing: 8.65 (g,) Division of Water Resources,Information Processing Unit,
Ifwater 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 Svpplv&Infection 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
GEOTECHNICAL CATLIN
NAlirongton,Raleigh,Washington,
Charleston Engineers and Scientists
WELL LOG 221052 SHEET 1 OF 1
PROJECT NO.: 221052 1 STATE: NC I COUNTY: WAKE LOCATION: ROUGEMONT
PROJECT: TACKETT RESIDENCE LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. TMW-04
NORTHING: 899488 1 EASTING: 2021304 CREW: C. BLACK
SYSTEM: NCSP NAD 83 USft BORING LOCATION: -45 feet North of MW-01 T.O.C.ELEV.: NM
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: N/A TOTAL DEPTH: 15.0
START DATE: 11/1/22 END DATE: 11/1/22 124 HOUR DTW$.7 Dry WELL DEPTH: 15.0
BLOW COUNT OVA o L SOIL AND ROCK WELL
DEPTH 0.5ft 0.5ft 0.5ft 0.5a (PPM) B. s G DEPTH DESCRIPTION DETAIL
0.0 LAND SURFACE 0.0
0.0 '—,":_ 0.5 (CL)-Brown to orange,Clayey TOPSOIL 0.0
2 2 (CL)-Brown to orange grading to green,CLAY _
3 0.0 M _
3
a
0
t
U -
5.0 5.0
2 -
3 3 0.0 M
5
o L)
oa
10.0
3 !�
6 11 10.8 D
16
12.0
(ML)-Tan to green,SILT(SAPROLITE)
13.0 -
19 16 12.1 D -_
31
'LfL15.0 15.0 15.0 _ 15.0
BORING TERMINATED AT DEPTH 15.0 ft In SILT
SAPROLITE
LL
Native Backfill