GW1-2022-10840_Well Construction - GW1_20221209

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
is
1.Well Contractor Information:
'14.'WATER ZONEs
D.T. CHALMERS, JR. FROM TO I DESCRIPTION
Well Contractor Name R. R
I
4146A fL
NC Well Contractor Certification Number 15ANNEWCASING'OMTUBING,reothernial'ld'ose&loo tea"
FROM I TO, I DIAMETER.. TMCRNESS MATERIAL.
CATLIN Engineers and Scientists 0.5 fL 15 ft � 2 Sch.40 1 PVC
Company Name r6^OUTER'GASING'(or;multi=casetl well`s'OR1I:INER'i4&` Lcable
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: N/A rL IL in.
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): i�;s`c1iEEiv` "A Water Supply Well: FROM TO I DIAMETERI SLOTS12E I THICKNESS I MATERIAL
❑Agricultural OMunicipal/Public 15 fL 30 ft. 2 in. Slot.010 I Sch.40 1 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft-1 in.
❑industrial/Commercial ❑Residential Water Supply(shared) T8.'GROUT l F.ra' �
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0.5 rt. 1 rL Concrete Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 1 rt. 13 rL Bent. Surface Pour
Injection Well: fL rL
•Aquifer Recharge ❑Groundwater Remediation 09�SANWGRAVEIAPA'CKt ira'Ilcable"
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StomtwaterDrainage 13 fL 32 rt Torpedo Sand Surface Pour
❑Experimental Technology ❑Subsidence Control It. rL
-26.DRILLINGtiOG'a"tiach,additionalsti is -
❑Geothermal(Closed Loop) ❑Tracer FROM TO I DESCRm'TION color hardness soittrockwoe.saitin size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (L (L j
4.Date Well(s)Completed: 11/15/22 Well IDk: MW-02 fL a ��
Sa.Well Location:
fL fL
0-011600
NCDEO Former Texaco Food Mart No.2 n V O—
n.
Facility/Owner Name Facility lD#(ifapplicable)
ft.
1700 COTTON GROVE RD.,LEXINGTON,27292
rL 'IT I
Physical Address,City,and Zip zI:RE NARKS1 Ci3fc+.
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 lat/long is sufficient)
35.777831 N -80.259529 W 11/23/2022
Signature of Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent Or OTemporary 4v signing thisfortn,lherebvicertifv that the well(s)was(were)constructed in accordance with
15A NCAC 02C.0100 or 15A MAC 01C'.0200 Well Construction.Standards and that a copy 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 known well construction information and explain the nature of
the repair under#21.remorks 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 I
can submit one form. SUBMITTAL INSTRUCTIONS
I
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@200'and 2@100) construction to the followi ig:
10.Static water level below top of casing: 21.63 (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: 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,direct push etc.) Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Se`ice Center,Raleigh;NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water SvaDIv&Iniection Wells:
Also submit one copy of this'form within 30 days of completion of well
13b.Disinfection type: Amount: construction to the county I 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 CATLIN
GEOTECHNICAL
Wlmhgt..Raleigh.WaslWOW,
Ct adestw Englneers and Selenttsts
WELL LOG z' SHEET 1 OF 1
PROJECT NO.: 221185 STATE: NC COUNTY: DAVIDSON LOCATION: LEXINGTON
PROJECT: FORMER TEXACO FOODMART NO.2 LOGGED BY: Fc. BLACK WELL ID:
DRILLER: D.T. CHALMERS JR. IVIVN-02
NORTHING: 7403971 EASTING: 1626416 CREW: C. STRATTON
.SYSTEM: NCSP NAD 83 USft BORING LOCATION: -7 FT IN FRONT OF RIGHT SIDE DOOR T.O.C.ELEV.: 97.68
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 21.6 TOTAL DEPTH: 32.0
START DATE: 11/15/22 END DATE: 11/15/22 124 HOUR DTW: N M WELL DEPTH: 30.0
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (ppm) s G DEPTH. DESCRIPTION ELEVATION DETAIL
0.0 LAND SURFACE 98.2 0.0
0.0 5 3 ASPHALT 0'S - 1.0
2 1.2 W
2 (GWS)-Gray CSE.SAND and GRAVEL.Slight HCO
(CL)-Reddish brown,Silty CLAY with tr.med.cse.
gravel. Slight HCO
No gravel or HCO from 5-10'BLS .
5.0
3
4 5 0.4 W
7
a
v
c
u
to
lV
10.0 10.0 88.2
2 4 (CL)-Brown to red and black,Silty CLAY. Slight HCO
q 0. W
7
13.0
15.0 15.0 83.z 16.0
3 5 NO RECOVERY
6 NM W
8 17.0 1 81.2
(CL)-Brown to red and black,Silty CLAY. Slight HCO.
i
20.0
3
4 5 1.0 W
6. �>
oa
NN
25.0
2 , 0.8 Sat.
2
30.0 30.0 68.2 30.0
2 (CH)-Brown to red and black,Silty highly plastic CLAY.
3 2 0.0 Sat. Slight HCO.
32.0 j 66.2 32.0
32.0 BORING TERMINATED AT ELEVATION 66.2 ft in Silty
CLAY
f -
E]#2 Medium Sand Portland Cement Bentonite Pellets