GW1-2022-09415_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 rr• 19 rL non-potable water
4532-B rt. ft.
NC Well Contractor Certification Number
FROM TO DIAMETER THICKNESS MATERIAL.
Excel Civil & Environmental Associates, PLLC
Company Name
WI#0300474 SIP#70003023 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 ft. 9 fL 2 in. 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 I TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 9 ft 119 fL 2 in. 0.10 0.154" Soh 40 PV
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 4 ft. Cement Tremie pipe flow w/vibration
Non-Water Supply Well:
�'I,--s 4 ft. 6 IL Sand/Cement Consolidation/Hydration
OMonitoring - ' 3. i,n a, e:Covery
Injection Well: ` '' � "' 6 rr' 19 rL #2 Sand Consolidation/Vibration
❑Aquifer Recharge O CI O 7 2022❑Groundwater Remediation
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
., .. 6 rr• 19 f° #2 Silica Sand Consolidation/Vibration
❑Aquifer Test lrr��: s `�'''^''''"`" ormwaterDrainage rt ft.
❑Experimental Technologp,.r 3t✓ ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock typa,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 1 ft. Concrete/Gravel
9-26-22 IW-3 1 ft. 4 rt. Dk. Brn. Red Elastic Silt(Moist)
4.Date Well(s)Completed: Well ID#
4 rL 8 ft. Brn. Red Elastic Silt(Pockets of Clay)(Moist)
5a.Well Location: 8 tt• 12 n• Org. Brn. Red Brn. Silty Clay(Moist)
Sam's Mart No. 25 00-0-0000013875
12 n• 16 rc• Org. Brn. Red Brn.Silty Clay(Very Moist)
Facility/Owner Name Facility ID#(if applicable)
Tryon Street, Charlotte, 28212 16 rt• 19 rt• Red Brn Silty Clay(Wet)
6201 N. T
rY 19 rc• 19 rt• 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•Ce cation:
(if well field,one lat/long is sufficient)
35.271363 N -80. 767989 W 9/30/2022
ignature of i err' Well Conn or Date
6.Is(are)the well(s): ©Permanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or I5A 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: 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@100� 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 Infection 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 completion of well
12.Well construction method: 4.25„ auger-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

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
NCWC 4532—B
(PAD WILL BE SLOPED TO MATCH I #
EXISTING GRADE SLOPE)
GRADE - 0'
's •. .q — — —
` '• LAYER #1-6" CONCRETE
.• 4 • • 1� • •. •.•
•� ' r ° LAYER #2-6" CONCRETE
° -2" PVC CASING
0.5 0' - 9' BGL
:t= WELL SEAL
NEAT CEMENT 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
#2 SILICA SAND ' Synonyms:
Sodium Persulfate;
20-28 SLOT 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 — — 19' BGL Manufacturer/Supplier:
LAYER #1 - PeroxyChem LLC
CONCRETE 2005 Market St Suite 3200
0.5' LAYER #2 Philaelphia, PA 19103
+ TYPE II PERMANENT +1 (267)-422-2400
0.5' GRAVEL [e-mail]
T INJECTION WELL Emergency No. for leak
CONSTRUCTION or fire, spill or accident call:
SILTY IS' BRN. (TAN) 1 (800)-424-9300
SILTY CLAY 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 27- 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 IOF THE EXISTING CONCRETE THICKNESS.
F:NC/PROJECTS/WELL INSTALL/SM25-CONSTDTL_9/6/22