GW1-2022-09604_Well Construction - GW1_20221021

RVA 3
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. ;FR
TO DESCRIPTION
Well Contractor Name ft' 18 fL non-potable water
4532-B fL
NC Well Contractor Certification Number
TO DIAMETER THICKNESS MATERIAL
Excel Civil & Environmental Associates, PLLC ft. in.
Company Name
WI#0300474 SIP#70003023 TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 tt. 9 fL 2 1° 0.154" Sch 40 PVC
List all applicable well permits(i.e.County,State, Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use):
Water Supply Well: FROM TO DIAMETER-: SLOT SIZE THICKNESS MATERIAL.
❑Agricultural ❑Municipal/Public 9 fL 18 fL 2 in, 0.10 1 0.154" Sch 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 4 ft- Cement Tremie pipe flow w/vibration
Non-Water Supply Well: Uw
e 4 4 ft. 6 rt. Sand/Cement Consolidation/Hydration
❑Monitoring ❑RSCo ery
Injection Well: T 1 6 ft- 18 fL #2 Sand ConsolidationNibration
❑Aquifer Recharge QC 1 1❑Groundwemediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery j►f ity arrier
❑Aquifer Test 1�1tDr"�f1 � ormwater Drainage 6 ft• 18 ft• #2 Silica Sand ConsolidationNibration
ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/mck type,gnin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks 0 ft. 1 ft. Concrete/Gravel
4.Date Well(s)Completed: Well ID#
9-29-22 IW-5 1 ft. 4 rr. Dk.,Red Brn Elastic Silt(Semi-Moist)
4 ft. 8 rt. Red Brn. Elastic Silt(Semi-Moist)
5a.Well Location:
Sam's Mart No. 25 00-0-0000013875 8 rt. 12 ft• Red Brn. Elastic Silt(Moist)
12 ft• 16 ft• Red Brn. Elastic Silt(Very Moist)
Facility/Owner Name Facility ID#(if applicable)
6201 N. Tryon Street, Charlotte, 28212 16 ft• 18 fL Dk. Red Brn Elastic Silt(Wet)
rY 18 ft• 18 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: 22.Cc cation:
(if well field,one lat/long is sufficient)
35.271363 N -80. 767989 9/30/2022
SibiMure of Certifii l Contra or 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 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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: 18 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00� construction to the following:
10.Static water level below top of casing: 12 (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: 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 24aabove, 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(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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