GW1-2022-10836_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:
14.WATERZONES
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Contractor Name N fr. ?
i
4146A ft fl.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING eothennal closed-too
FROM : TO DIAMETER THIC[INESS MATERIAL..
CATLIN Engineers and Scientists 0 rt. 0 IJ 1 ild SCh."40 I PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER(ifapplicabie
.FROM TO DIAMETER THICKNESS.' .MATERIAL
2.Well Construction Permit#: N/A R. ft in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. i in.
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 0 ft 15 ft. 1. in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft.
❑IndustriaUCommeicial ❑Residential Water Supply(shared) 18.GROUT
FROM TO NATERIAL EMPLACEMENr14IETHOD&AMOUNT
❑Irrigation
rt. ft
Non-WaterSupply Well:
®Monitoring ❑Recovery ft. ft.
Injection Well: ft tc ;
❑Aquifer Recharge O Groundwater Remediation 19.SAND/GRAVE[:PACK if applicable)
'
❑_Aquifer Storage and Recovey ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control 0 ft 15 ft j, Natural Backfill
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soit/rock tvpe,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) rc rc
4.Date Well(s)Completed: 11/22/22 Well ID#: TMW-01 ft. rc
ft rt. �O
Sa.Well Location: �H
ft. fc
NCDEQ-FORMER LIL COUNTRY STORE 0-033130 �� p►
ft.
Facility/Owner Name Facility ID#(if applicable)
fc ter• ', a R� "' ,� .
.6606 LEESVILLE RD.,DURHAM,27703 rt. rc _ t
Physical Address,City,and Zip -
21.REMARKS 1 ..�.
DURHAM N/A'
County Parcel Identification No.(PIN) I r' "'si OB };rC=��.rr,;r� Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well field,one lat/long is sufficient)
35.9340539 N -78.774758 W 12/1/2022:
Signature of Certified Well Contractor Date
6.IS(are)the weil(S): ❑Permanent or ®Temporary By signing thisform,I hereby certify that the wells)was(were)constricted in accordance wiih
- " . ]SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Constnretion Standards_bird that a co&of
7.Is this a repair to an existing well:. O Yes or ®No this record has been provided to the well owner.
If this is a repair,fill out!mown well construction information and explain the nature of
the repair under#21 remark's 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 ollwells 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 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@1009 construction to the-following:
10.Static water level below top of casing: (ft.) 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
II
13a.Yield(gpm) Method of test: 24c.For Water.Svauly&Infection Wells:_
Also submit one copy of thislform within 30 days of completion of well
13b.Disinfection type: Amount: construction to the county he 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

i
ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN.
Raleigh,wasNngtan,
G'ad�fon Engineers and 5clentists
' LOG�
EOTE 221'a° SHEET.1 OF. 1
PROJECT NO.: 221140 -STATE: NC, .1 COUNTY: DURHAM _.. LOCATION! DURHAM
PROJECT: LOGGED BY: c.I BLACK WELL ID:
FORMER LIL COUNTRY STORE.
DRILLER: D.T. CHALMERS JR. TMVN-01
NORTHING: 704968 1 FASTING: 2068681 CREW: E. 00NT.ON
SYSTEM: NCSP NAD 83 USft BORING LOCATION: South side of Leesville Rd:—25'North of bride T.O.C.ELEV.:" NM
DRILL MACHINE: Diedrich D-25 METHOD: HSA 0 HOUR DTW: NM TOTAL DEPTH: 15.01 :.
START DATE: 11/22/22 -. END DATE: 11/22/22 24 HOUR DTW; NM I WELL DEPTH: 15.0
BLOW COUNTj . OVA o o SOIL AND.ROCK' WELL
DEPTH 0.5ft 9,5ft 0.5ft o.5ft (PPM) LAB. s G DEPTH DESCRIPTION. . DETAIL
0.0 LAND SURFACE.,. 0.0
0.0 (SP)-Brown F.to Med.SAND 0.0 _
16 ;
70 0.0 . ' D SPHALT
(CL)-White and brown,Silty slightly plastic CLAY.
a
c
N
5.0 5.0 _
.2
s.. 0.7 D r -
� e
8.0
(SM)-Brown and black Silty F.SAND with clay
... .. .. , .. o a
10.0
• �t
3 1.6 M
6 7 -
_
g.
Qu
1'3.0
.20, 38 0.7 D
83 -
15.0 a 15.0 15.0 15:0 . .
BORING TERMINATED AT DEPTH 15.0 ft in Silty
SAND with clay .
j
I
j
Native Backli I