GW1-2022-10835_Well Construction - GW1_20221209

WELL-CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ,
D.T.'CHALMERS, JR. FROM TER ZOOS DESCRIPTION _
Well Contractor Name fL ft.
4146A fL fL
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothermal closed-loop)
FROM I TO I DIAMETER. .THICKNESS I MATERIAL
CATLIN Engineers and Scientists 0 rL OIL OILI 1 Sch.40 PVC
Company Name 16.OUTER CASING(for multi-casedwells OR LINER if applicable
FROM TO DIAMETER THICKNESS MATERIAL ...
2.Well Construction Permit#: N/A
f4 fL in.
List all applicable well permits(i.e.Count)4 State, Variance,Injection,etc.J
fL .ft. in. '
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
[I Agricultural ❑Municipal/Public 0 fL 15 fL 1 in. Slot.010 Sch.40 PVC
❑Geothermal'(Heating/Cooling Supply) ❑Residential Water Supply(single) fL R in.
❑Industrial/Commercial ❑Residential Water Supply(shared) Is.GROUT
. FROM TO MATERIAL EhIPLACEMENTMETHOD&AMOUNT
❑Irrigation _ ...
Non-Water Supply Well: rt. fL
®Monitoring ❑Recovery fL fL
Injection Well: fL fL :.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifet Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft.❑Aquifer Test ❑Stomuwater Drainage
❑Experimental Technology ❑Subsidence Control 0 fL 15 ft. i; Natural Baekfill
20.DRILLING LOG attach additional sheets if necessary ,
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soilhock type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL fL
4.Date Well(s):Completed: 11/22/22 Well ID#: TMW-04 fL ft.
ft. fL S �O
5a.Well Location:
ft. ft.
NCDEQ-FORMER LIL COUNTRY STORE
Facility/Owner Name Facility ID#(if applicable)
ft
.6606 LEESVILLE RD.,DURHAM,27703 r
2077
Physical Address,City,and Zip rL ft D r 9
' 21.REMARKS
DURHAM N/A r
lrnLc- a�� Pr;�c. -m g Un.;t.
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)
35.9340209 N -78.7745463 W L 12/1/2022
Signature of Certified Well Contractor Date
6.IS(are)the well(s): ❑Permanent or ®Temporary By signing thisform,l herebv certifi.,that the wells)was(trere)construtcied in accordance with
15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constriction Standards and that a copy of
7.Is this a repair to an existing well: ❑Yes or ONO 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 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 saute construction,you can submit one form. SUBMITTAL INSTRUCTIONS
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 a200'and 2@100J construction to the following:
10.Static water level below top of casing: (ft.) Division of WaterAesources,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 Iniection Wells ONLY: In addition to sending the form to the
address in 24a above,also submit a copy of this form within 30 day_s 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 Supply&ilniection Wells:
Also submit one copy of this form within 30 days of completion of well
136.Disinfection type: Amount: construction to the county ieallth
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,CI
VIL
L
GEOTECHNICAL CATLIN
.. Wlmmgt°n,Raleigh,Washiigt°n,
y leStOn Engineers and Scientists
G ' 221140 SHEET 1 OF 1
PROJECT NO.: 221140 STATE: NO. COUNTY: DURHAM LOCATION: DURHAM
PROJECT: FO RMER LIL LOGGED BY: f C. BLACK WELL ID:
COUNTRY STORE:
DRILLER: D.T. CHALMERS JR.
NORTHING: 7049571 EASTING: 2066744 CREW: '. El DONTON TMW-04
SYSTEM: NCSP NAD 83 USff .. BORING LOCATION:.North.side of Leesville Rd.—20'from tel hone pole T.O.C.ELEV.: -NM. .
DRILL MACHINE, Diedrich D-25 METHOD: HSA ,. o HOUR DTW: NM. .TOTAL DEPTH: 15.0.
START DATE: 11/22/22 END DATE:11/22/22 24 HOUR DTW: N M WELL DEPTH: ' 15.0
BLOW COUNT 'OVA o ' SOIL AND ROCK WELL
DEPTH LAB.B' s c
0.5ft 0.5ft 0:5ft O.Sft (ppm) DESCRIPTION DETAIL
DEPTH `
f
0.0 LAND SURFACE 0.0
0.0 ;t (SVV)-.Dark brown,Gravelly SAND.with organics 0.0
3 5 -
6 3 0.2 D ASPHALT
2.0 >
a
(CL)-Gray and brown,Silty CLAY - p -
I,
5.0 { 5.0 _
2 4 0.3 M
5
8.0
(SM)-Brown,Silty F.SAND
e I
oa
10.0 =
4
5 0.1 M
6 7
i 12.5
13.0 - (ML)-Dark brown,Clayey SILT with sand
aL'U. 3 .. .. .. .. .. .. .. .. -_
. 3. 5 0.0 .M .. -
7
5'.0- :15.0 15.0 _ 1&0.
BORING TERMINATED AT DEPTH 15.0 ft in Clayey
SILT with sand
p
- - .. c
Native . .
Backfill