GW1-2023-02865_Well Construction - GW1_20230418

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. FRO��TERZO os DESCRIPTION
Well Contractor Name ft. ft.
ft. fL
NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-too
FROM TO DIAMETER THICKNESS MATERIAL
CATLIN Engineers and Scientists 0 ft. 1.4 ft, 2 i..J Sch.40 PVC
Company Name 16.OUTER CASING for multi-cased wells OR LINER if a licable
FROM I TO I DIAMETER TmcKNEss MATERIAL
2.Well Construction Permit#: N/A rt, rL 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 I SLOTSIZE THICKNESS I MATERIAL
❑Agricultural ❑Municipal/Public 1.4 0: 21.4 rt. 2 in. Slot.010 Sch.40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT pHITHOD&AMOUNT
❑Irrigation 0 ft. 0.7 ft. Concrete. Surface Pour
Non-Water Supply Well:
®Monitoring ❑Recovery 0.7 ft. 1 ft. Bent.Pellets Surface Pour
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
El Aquifer Storage and Recovery ❑Salinity Barrier
13 Aquifer Test ❑StomlwaterDrainage 1 rL 21.4a Torpedo Sand Surface Pour
❑Experimental Technology ❑Subsidence Control ft. fL
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock tv e.Brain si a etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) B. A.
4.Date Well(s)Completed: 04/06/23 Well ID#: MW-15 ft. ft. ��-
ft. ft. S �O
5a.Well Location:
ft. rL
NCDEQ-Hawkins Ave. Grocery and Grill N/A o -
;
Facility/Owner Name Facility ID#(if ap
plicable) r
ft.
809 HAWKINS AVENUE,SANFORD,27330 nn
ft. ft.
Physical"Address,City,and Zip 6 LI S 2l1��
21.REMARKS
LEE 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)
t
35.491945 N -79.18066 W 4/11/2023.
Signature of Certified Nell Contractor Date
6.Is(are)the well(s): M Permanent or ❑Temporary By signing thisform,I hereby certi&that the a ell(s)war(were)constructed in accordance with
iSA NCt C 01C.0100 or 15A NC1C 01C.0200 Well Construction Standards and that a copy 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 construction information and explain the nature of
the repair under#21 remarks-section or on the back ofihis 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 constructioti details. You may also attach additional pages if necessary.
For multiple injection or non-water-smpply wells ONLY with the scone construction,you SUBMITTAL INSTRUCTIONS
can subinit one form.
9.Total well depth below land surface: 21.4 (ft.) 24a.For All Wells: Submit this form within 30 days of completion of well -
For mtthiple wells list all depths in different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 12.49. (ft.) Division of Water Resources,Information Processing Unit,
ifsvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8•25 (in,) .24b.For Injection 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,rolaty,cable,clirecipush,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 Svaaly&Injection Wells:
Also submit one cop)'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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL,CIVIL
GEOTECHNICAL CATLIN
Wlmmgton,Raleigh,Washington,
cnarleston Engineers and Scientists
WELL LOG 220243 SHEET 1 OF 1
PROJECT NO.: 220243 STATE: NC I COUNTY: LEE LOCATION: SANFORD
PROJECT: HAWKINS AVE GROCERY AND GRILL LOGGED BY: T. PARK WELL ID:
DRILLER: D.T. CHALMERS JR. MW_15
NORTHING: 634020 1 EASTING: 1946224 CREW: T.MIZELLE
SYSTEM: NCSP NAD 83 USft BORING LOCATION: Middle of Former UST Basin T.O.C.ELEV.: 100.26
DRILL MACHINE: Diedrich D-50 METHOD: HSA 0 HOUR DTW: 12.5 TOTAL DEPTH: 21.4
START DATE: 4/6/23 END DATE: 4/6/23 124 HOUR DTW: NM WELL DEPTH: 21.4
DEPTH BLOW COUNT OVA LAB o o SOIL AND ROCK WELL
0.5ft :0:5ft 0.5ft 0.5ft (PPM) S DEPTH DESCRIPTION. ELEVATION DETAIL
0.0 LAND SURFACE 100.3 0.0
0.0 ''—': (SP)-Brown,F.SAND 0.0> -
a —
0.7
2 1.0
2 NM D :•
2. 1.4 N
(ML)-Brown to red,Sandy SILT. Strong HCO
5.0
WOH WOH WOH 2 1101 M
9.0------------------------ 91.3
(ML)-Brown to red SILT.
Slight HCO from 10-21.4'BLS
10.0
10 -
15 qo j
25 49.1 W sEL
34
y t
N�
15.0
LL
10 .21
19 111.0 M
21
20.0
5
78 22i 271.4 Sat.:
111111 21.4. 78.9 21.4 21.4
21.4
Ej Port5W&qe1 �t tAT 4 eWsE
R TI :..; U/I9dium Sand.: .

Q N
Q
MW-14
�MVV-•3
®MW-7
Former Dispenser
MW;�6 MW ' Island-11 MW-4 c(f) T3
® MW-1
MW-13. MW-15 T2 ,.
\Former Product
Limit . Former T1 ® Lines
U,ST Basin. Age
. MW-9
BMW-8 MW-8R
(CNL)® el{ I� -
MW-10
MW-11,Z
(CNL0m ® MW-5
LEGEND ®(CNL)
® Monitoring Well -'--
(Type II)
Destroyed Monitoring ►,
® Well (Type II)
OMonitoring Well
(Type III)
0 Parcel Boundary ' s
Approximate Location
of Former UST System
o cep Esri,Maxar, Earthstar Geoaraohics,an• the 'FS User Communi,
NOTES:
1.Well and tank locations were obtained from previous reports 60 30 0 60 120
prepared by other consultants and are approximate.
2. CNL=Could Not Locate Feet
PROJECT TITLE
HAWKINS AVENUE FIGURE
ATLIN GROCERY AND GRILL SITE MAP
809 HAWKINS AVENUE
CSANFORD, NC 1
Engineers and Scientists
INCIDENT N0. I JOB N0. DATE SCALE DRAWN BVICHECKED BY
12114 220243 APRIL 2023 AS SHOWN KMC/SJO