GW1-2022-09413_Well Construction - GW1_20221007

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy J. Payne Jr. FROM TO DESCRIPTION
Well Contractor Name 12 ft• 19 fL non-potable water
4532-B
NC Well Contractor Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Excel Civil & Environmental Associates, PLLC n. ft. in.
Company Name
W I#0300474 S I P#70003023 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 fL 2 i° 0.154" Sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9 ft. 19 ft' 2 1n. 0.10 1 0.154" JSch40PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑IndustriaUCommercial rQResidenfial Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation , " ;^_' _: if I..z 0
Non-Water S40pi3kW,6w: " ` rt' 4 ff Cement Tremie pipe flow w/vibration
❑oMonitoring all ❑Recovery 4 rt. 6 rt. Sand/Cement Consolidation/Hydration
Injection Well: It 1 � 6 n. 19 ft• #2 Sand ConsolidationNibration
❑Aquifer Recharge 1'_TC"rroundwater Remediation
'6poI { �^' FROM TO MATERIAL EMPLACEMENT METHOD
e❑Aquifer Stotpge�nd I�esoafj�;%��• ❑Salinity Barrier ft. fL
6 19 #2 Silica Sand Cons olidationNibration
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillreck type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. Concrete/Gravel
4.Date Well(s)Completed: 9-15-22 Well ID# 1W-1 1 e. 4 «• Dk. Brn. Red Elastic Silt(Moist)
4 ft. 8 ft. Brn. Red Elastic Silt(Moist)
5a.Well Location: 8 ft• 12 ft• Org.Brn. Red Elastic Silt w/Clay(V Moist)
Sam's Mart No. 25 00-0-0000013875 12 ft• 16 ft• Org. Brn. Red Elastic Silt w/Clay(V Moist)
Facility/Owner Name Facility ID#(if applicable)
16 ft• 19 ft• Brn. Red Elastic Silt w/Clay(Wet)
6201 N. Tryon Street, Charlotte, 28212 19 ft• 19 ft• Termination
Physical Address,City,and Zip
Mecklenburg County 08923217 Injection well for GW remediation utilizing Klozur(See detail notes)
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: •Cer'[cation:
(if well field,one[at/long is sufficient)
35.271363 N -80. 767989 W 22 Aff 9/30/2022
grtature o Ce ell Co ctor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Z1No copy of 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 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 INSTUCTIONS
9.Total well depth below land surface: 19 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 12 (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 0/2"1 (in) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
4.25" auger-method 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 m Method of test: 24c.For Water Supply&Injection Wells:
(gp ) Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013

i
PROJECT: SM25
6201 N TRYON ST.,
MODIFIED 8"-0 X 12"-D STEEL WELL ID. NO. CHARLOTTE, N.C.
MANHOLE W/ MIN 18" X 18" WELL SIP # 70003023
CONCRETE PAD INJECTION WELL WELL CONST. # W10300474
(PAD WILL BE SLOPED TO MATCH NCWC # 4532-B
EXISTING GRADE SLOPE)
GRADE - 0'
VA LAYER #1-6" CONCRETE
° ♦ ♦' °
0.5 a. r.
LAYER #2-6" CONCRETE
° W 2" PVC CASING
0.5 -i: — — o'= 9'BGL
y7�
,4c WELL SEAL
NEAT CEMENT ;Y?� „` 4'-6' BGL
/ CONCRETE — — — — — — — —
SAND PACK
6' - 19' BGL
%" BENTONITE
HOLE PLUG 2" PVC SCREEN
9' — 19' BGL
UNDISTURBED EARTH
TOXIC SAFETY INFORMATION
Product Name: Klosur®SP
Product CAS-No: 7775-27-1
Synonyms:
#2 SILICA SAND
20-28 SLOT Sodium Persulfate;
Sodium Peroxydisulfate;
Disodium Peroxydisulfate;
Peroxydisulfuric acid,
GRAVEL PACK disodlium salt;
(IF APPLICABLE) Peroxydisulfuric acid,
SOIL LITHOLOGY SOdIUm Salt.
Alternate Commercial
I TOTAL DEPTH Name:Klosur®Persulfate
0.5' CONCRETE 'S — — 19' BGL Manufacturer/Supplier:
LAYER #i - PeroxyChem LLC
0.5' CONCRETE 2005 Market St Suite 3200
LAYER #2 Philaelphia, PA 19103
TYPE II PERMANENT +1 (267)-422-2400
0.5' GRAVEL sdsinfo®peroxychem.com
-F INJECTION WELL Emergency No. for leak
18' CONSTRUCTION or fire, spill or accident call:
SILTY CLAY BRN. (TAN) 1 (800)-424-9300
SIL DETAIL
Medical: 1 (303) 389-1409
BRN . (TYPICAL - N.T.S.)
33' SILTY CLAY
WEATHERED ROCK IT MAY BE NECESSARY TO MODIFY SOME/ALL OF THE MANHOLES BY TRIMMING THE METAL
ENVLOSURE. WE PROPOSE TO ALTER THE EMCO WHEATON A0721 MONITOR WELL MANHOLE BY
CUTTING THE HEIGHT OF THE MANHOLE DOWN TO APPROXIMATELY 6-INCHES TO CONFORM TO
THE EXISTING LAYER OF CONCRETE BECAUSE THERE IS 2=LAYERS OF 6-INCH THICK CONCRETE
35' LT. BRN ONSITE WHERE THE PROPOSED INJECTION WELLS ARE TO BE INSTALLED. IT WILL BE VERY
WEATHERED ROCK DIFFICULT FOR US TO CUT INTO THE SECOND LAYER OF CONCRETE SO WE PROPOSE TO ALTER
THE MANHOLE HEIGHT TO ACCOMMODATE THE THICKNESS OF THE EXISTING CONCRETE THICKNESS.
F:NC/PROJECTS/WELL INSTALL/SM25-CONSTDTL-9/6/22