GW1-2022-09605_Well Construction - GW1_20221021

A%-V%UQ.
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' 18 ft.
non-potable water
4532-B ft. ft.
NC Well Contractor Certification Number
FROM TO DIAMETER - THICKNESS MATERIAL.
Excel Civil & Environmental Associates, PLLC ft. ft. in.
Company Name
W 1#0300474 SIP#70003023 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 ft- 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 ❑MunicipaVPublic 9 ft 18 ft 2 1D' 0.10 0.154" Sch 40 PVC
❑Geothermal(Heating/Coohng SuppA��r [�Fee4 1 ater Supply(single) ft' ft to
❑lndustrial/Commercial — A CdNi enttal Water Supply(shared)
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 4 fL Cement Tremie pipe flow w/vibration
Non-Water Supply Well: O
4 rt. g fL Sand/Cement Consolidation/Hydration
OMonitoring
Injection Well: tC� 6 ft' 18 fL #2 Sand ConsolidationNibration
❑Aquifer Recharge \n 1v! Groun emediation
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 6 ft. 18 fa #2 Silica Sand ConsolidationNibration
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock type,grain size,etc
❑Geothermal(Heating/Cooling Return) El Other(explain under#21 Remarks) 0 ft. 1 ft. Concrete/Gravel
4.Date Well(s)Completed: Well ID#
9-28-22 IW-4 1 ft. 4 ft. bk. Red Brn Silty Clay(Moist)
4 ft. 8 ft. Red Brn.Silty Clay(Moist)
5a.Well Location: 8 ft- 12 ft. Org. Red Brn.Silty Clay(Moist)
Sam's Mart No. 25 00-0-0000013875
12 ft- 16 ft. Org. Red Brn.Silty Clay(Very Moist)
Facility/Owner Name Facility ID#(if applicable)
6201 N. Tryon Street, Charlotte, 28212 16 f[; 18 f` Dk. Red Brn Silty Clay(Wet)
18 18 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•Certif Hon
(if well field,one lat/long is sufficient)
r
35.271363 N -80. 767989 W 9/30/2022
SVfiaturc of Certi ed Well tractor 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 ElNo 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
S.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 difterent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 12 (g,) 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 Infection Wells ONLY: hi 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-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013