WI0700503_Injection Event Record_20200612

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10700503
1. Permit Information
NCDEQ DWM UST SECTION Trust Fund
Branch; Scott Rvals
Permittee
Former Phillips Store
Facility Name
414 Snug Harbor Road, Bethel, Perquimans
County, NC 27944
Facility Address (include County)
2. Injection Contractor Information
ECS Southeast LLP
Inj ection Contractor / Company Name
Street Address 9001 Glenwood Avenue
Raleigh NC 27617
City State Zip Code
(_919_) 861-9910
Area code — Phone number
3. Well Information
Number of wells used for injection
Well IDs MW-1, MW-2, MW-11, and MW-12
Were any new wells installed during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 1
Number of Injection Wells ,4
Type of Well Installed (Check applicable type):
❑ Bored ® Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells,
Please include a copy of the GW-30 for each well
abandoned!
4. Injectant Information
EnviroBac
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration _3 Kilos EnviroBac blended in 5
Gallons of water: to 30 eallons of water
If the injectant is diluted please indicate the source
dilution fluid. Local Municipal Water
Total Volume Injected (gal) 240
Volume Injected per well (gal) 60
5. Injection History
Injection date(s) 5/20/2020
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
❑ Yes ❑ No ® Possibly
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
6/1 2oz0
SIGNATURE OF IN ION CONTRACTOR DATE
t\f-
Submit the original of this form to the Division of Water Resources within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
James D. Barker
Well Contractor Name
3106A
NC Well Contractor Certification Number
Quantex, Inc.
Company Name
2. Well Construction Permit #: NA
List all applicable hell construction permits (i.e. County. State, Variance, etc.)
3. Well Use (check well use):
Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑ Municipal/ Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
O Monitoring ❑ Recovery
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (HeatingiCoolinQ
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 1
4. Date Well(S) Completed: 5/14/20 Well ID# MW-12
5a. Well Location:
Former Phillips Store NA
Facility'Owner Name Facility ID# (if applicable)
414 Snug Harbor Road, Hertford, NC 27944
Physical Address, City, and Zip
Perquimans
County
0
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lavlong is sufficient)
36.113469 N 76.481874 W
6. Is (are) the well(s): 2Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out knovin %ell construction information and explain the nature of the
repair under 021 reunarks .section or oil the brick o/ this form.
8. Number of wells constructed: 1
For multiple it jectimt or not-water.supply wells ONLY with the same construction. Your can
subunit one form.
t
9. Total well depth below land surface: 15
(ft.)
For multiple ire//s list all clepths ifdifferent (ercrnrple- 3(11200' and 2w 100')
10. Static water level below top of casing: „31
If water level is above casing, rise " r "
11. Borehole diameter: -71
1
(in.)
12. Well construction method: _
(i.e. auger, rotary, cable, direct push, etc.)
Auger
(ft.)
14. WATER ZONES
FROM
TO
DESCRIPTION
3 ft•
3.5 ft•
Grey Fine SAND
ft.
ft.
15. OUTER CASING for multi -cased wells) OR LINER if a livable
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 rt.
2 ft.
2 in'
Sch 40
PVC
16. INNER CASING OR TUBING eothermal closed400
FROM
TO
I DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2 ft,
15 ft-
2 in.
0.010
Sch 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
1 ft.
neat cement
Pour 20 lbs. neat cement
1 ft.
1.5 ft-
bentonite
Pour 10 Ibs 1/4" Bent. Pellets
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
MPLACEMENT METHOD
1.5 ft•
15 ft-
#2 sand
Pour
ft.
ft.
20. DRILLING
LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, sotVrock type, grain size, etc.)
0 ft.
1 ft.
Sandy Top Soil
1 ft.
6 ft.
Grey Fine SAND
6 ft-
15 ft'
Grey Medium Clayey SAND
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certific 'on:
5/16/20
Signature of enified Well Contractor Date
BY signing this farm, I hereby certify that the uell(s) it -cis (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provider/ to the n'el! owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: 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
construction to the following:
Division of Water Quality, 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 & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of 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 Quality Revised Jan. 2013