GW1--07493_Well Construction - GW1_20231120

-WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
T. Jason VVhite FROM TO DESCRIPTION
Well Contractor Name I. It.
3323A ft. ft.
NC Well Contractor Certification Number 15.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL.
CATLIN Engineers and Scientists 0 ft. 15 ft. 2 in. Sch.40 PVC
Company Name 16.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO DIAMETER _ THICKNESS \i\IPRI:\I.
2.Well Construction Permit#: N/A
ft. ft. 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 15 rt. 29.5 rt. 2 in. Slot.010 Sch.40 PVC
0 Geothermal(Heating/Cooling Supply) 0 Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial 0 Residential Water Supply(shared) 18.GROUT
FROM TO \I.\IE.RIAL I'\IPL\CE\IF,\T METHOD&:\\1()l\7
❑Irrigation 0.5 It 10 f. Portland Cement Surface Pour
Non-Water Supply Well: - -
®Monitoring ❑Recovery 10 e. 13 ft. Bent. Pellets Surface Pour
Injection Well ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
13 ft. 30 e. #2 Medium Sand Surface Pour
❑Aquifer Test 0 Stormwater Drainage -
❑Experimental Technology 0 Subsidence Control ft. ft.
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) 0 Tracer FROM I'() DESCRIPTION(color,hardness,soil/rock type,seam size,etc.)
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) ft. ft.
4.Date Well(s)Completed: 09/27/23 Well ID#: MW-06 it. ft. C tee
��ft. It. O)
5a.Well Location: - NIt pig;
NCDEQ P.:
n.
Facility/Owner Name Facility ID#(if applicable)
It.
1700 Cotton Grove Road,Lexington,NC 27292
Physical Address,City,and Zip It. u. -
21.REMARKS _
DAVIDSON _ _
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)
35.77808 N -80.25938 w / r+ r 11/16/2023
Signature of Certified Well Co or Date
6.Is(are)the well(s): MI Permanent or OTemporary By signing this form,I hereby certify Ihut the well(s)was(were)COIFS(flIC ted tit accordance with
15A NC AC 02('.0100 or 1.5A N(A('02('.0200 Well Construction Standards and that a copy of
7.Is this a repair to an existing well: D Yes or 18 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 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the hack 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 SUBMITTAL INSTRUCTIONS
can submit one form.
9.Total well depth below land surface: 30.0 (g,) 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@I002 construction to the following:
10.Static water level below top of casing: 20.4 ({t.) 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: 7.25 (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: 3.25" 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 Svpply&Injection Wells:
Also submit one copy of this form within 30 days of completion of well
construction to the county health department of the county where constructed.
13b.Disinfection type: Amount:
Adapted from Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised 2-22-2016

ENVIRONMENTAL.CIVIL
WELL LOG GEOTECHNICAL CATLIN
VOIns2211gton,Raleigh,Washington,
Charleston Engineers and Scientists
W2iimigttoon.NC SHEET 1 OF 1
PROJECT NO.: 221185 STATE: NC COUNTY: DAVIDSON LOCATION: Lexington
PROJECT: Former Texaco Food Mart #2 ID 22332 LOGGED BY: T. Park WELL ID:
DRILLER: T. Jason White MW-06
NORTHING: EASTING: CREW: CATLIN
SYSTEM: DRILL MACHINE: CAT2002 MOBILE B-57 92.3% 12/23/22 T.O.C.ELEV.:
VERT.DATUM: METHOD: 3.25" HSA 0 HOUR DTW: Dry TOTAL DEPTH: 30.0
START DATE: 09/27/23 END DATE: 09/27/23 24 HOUR DTW: 20.4 WELL DEPTH: 30.0
DEPTH BLOW COUNT OVA LAB o SOIL AND ROCK WELL
0.5ft 0.5ft 0.5ft 0.5ft (PPm) S G DEPTH DESCRIPTION DETAIL
0.0 Land Surface o.o
0.7 0.7 \ASPHALT 0.0
P _
s D (ML)-BROWN SILT WITH TRACE SAND. NO HCO
H —
U
> —
a
0
—
U —
(n
N _
10.0 p
- 10.0
s D A
H t♦
12.5
(ML)-REDDISH BROWN SILT. NO HCO ? 13.0
15.0
•
20.0 P
Mo>
H o
o v
•
rn L
Nj
28.0•
P
• M 29.5
S H 30.0 30.0 30.0
30.0
BORING TERMINATED AT DEPTH 30.0 ft
SA
SA
•
•
Portland Cement ;;� Bentonite Pellets #2 Medium Sand