GW1-2022-10839_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.'WATERZ6NE8 .7,,'r
D.T. CHALMERS, JR. FROM TO DESCRIPTION
Well Well Contractor Name fL ft.
4146A It. it I
NC Well ContractorCertification Number
. FROM
GA To DIAMETER
IAETER nal,dose"d-loo
TI-ICIQJESS MATERIAL_
CATLIN Engineers and Scientists 0.4 fL 15 rL 2 in. Sch.40 PVC
Company Name Y
ea'6.OUTER'CASING'°fo�•mul'ti=cased,wdls ORZLINERsifa lica'tile'.,
:FROM TO I DIAMETER I TFRCKNESS MATERIAL
2.Well Construction Permit#: N/A ft. fL in
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
fL ft in.
3.Well Use(check well use): 1i.SCaEeN:t
Water Supply Well: FROM I TO DIAMETER SLOTSUE. THICKNESS MATERIAL
DAgricultural ❑Municipal/Public 15 tL 30 ft. 2 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT h• ;' _ se "
FROM TO _ MATERIAL EMPLACEMENT METHOD&AMOUNT.
❑Irrigation 0.4 ft. 0.5 it. Concrete Surface Pour
Non-Water Supply Well:
0:5 ft. 13 rL Bent.Pellets. Surface Pour
®Monitoring ❑Recovery
Injection Well: rL rL
❑Aquifer Recharge ❑Groundwater Remediation J9YISAND7GRAVELiPACKrifa"licalite
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL - EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage 13 tr. 30 it.I Torpedo Sand Surface Pour
❑Experimental Technology ❑Subsidence Control tt• fL
'20.DRII;liING:hOG'atfaeh�a8ditional3hee'ts'.ifnecessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO I DESCRIPTION color hardness soillrock type.wain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL k
4.Date Well(s)Completed: 11/15/22 Well ID#: MW-01 re
R ft s �O
5a.Well Location:
011600 fL ft.
NCDEQ-Former Texaco Food Mart No.2 0- l��'•^ �Xa �� V
fL
Facility/Owner Name Facility ID#(if applicable)
fL
1700 COTTON GROVE RD.,LEXINGTON,27292
Physical Address,City,and Zip ft. fL
DAVIDSON N/A-
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
35.777953 N -80.259585 W 11/23/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): 00 Permanent or O Temporary By signing thisfonn,I hereby certify that the well(s)was(were)constructed in accordance with
ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Consfntetion Standards and that a copy of
7.Is this a repair to an existing well: OYes or ®No this record Has been provided to the well oxmer.
1f 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 same construction,you
can submit one form. SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30.0 (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@100) construction to the following:
10.Static water level below top of casing: 25.35 (ft.) Division of Water;Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
1
11.Borehole diameter: 8•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 days of
12.Well construction method: HSA completion of well construction to the following:
(i.e.auger,rotary,cable,direcipush,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: 24c.For Water Svpaly&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.
f
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL CAGEOTETLIN
ENVIRO
Wines m,Raleigh,Was"on.
Ch"ston Engineers and Scientists
WELL LOG 221185 SHEET 1 OF 1
PROJECT NO.: 221185 STATE: NC I COUNTY: DAVIDSON LOCATION: LEXINGTON
PROJECT: FORMER TEXACO FOODMART N0.2 LOGGED BY: 'C. BLACK WELL ID:
DRILLER: D.T. CHALMERS JR. -01
NORTHING: 7404421 EASTING: 1626400 CREW: C. STRATTON
.SYSTEM: NCSP NAD 83 USft BORING LOCATION: LEFT TURN EXIT T.O.C.ELEV.: 98.84
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 25.4 TOTAL DEPTH: 30.0
START DATE: 11/15/22 END DATE: 11/15/22 124 HOUR DTW: NM WELL DEPTH: 30.0
BLOW COUNT OVA 0 L SOIL AND ROCK WELL
DEPTH LAB. I 0
0.5ft 0.5ft 0.5ft 0.5ft (PPm) s DEPTH DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE, 99.2 0.0
0.0 21 ASPHALT -0.4 0.6
15 6 0.1 D
4 (SW)-Brown,F.SAND with f.to med.gravel .
:
2.5 . 96.7
(CL)-Brown,CLAY with silt with HCO
5.0
2
4 5 e 1270 D
U
a
0
t
U
<V
10.0 10.0 89.2
2 4 (ML)-Brown,Clayey SILT with HCO
4 616.3 D
7
13.0
15.0 15.0
2
2 3 543.9 M
5
ff
f
20.0 imi 20.0 79.2
2 (CL)-Brown,Silty CLAY with HCO
2
3 1611 M - - - -
5 - - - oU
.. on>.
Uc
25.0
1730 Sat.
-
2
28.0 - €
2 2
4 647 VV
30,0 5 30.0 ! 69.2 30.0 30.0
BORING TERMINATED AT ELEVATION 69.2 ft in Silty
CLAY
Portland Cement Bentonite Pellets ' E]#2 Medium Sand