WI0400514_MISCELLANEOUS_20190509

44‘ SOANNED
Central Files: APS _ SWP
5/9/2019
Permit Number WI0400514 Permit Tracking Slip
Program Category Project Type
Deemed Ground Water Active New Project
Permit Type
Injection Deemed In -situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Permitted Flow
Facility
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Facility Name
Sam's Mart # 97(Former Crown NC-015)
Location Address
1102 Summit Ave
Greensboro
Owner
NC 27405
Major/Minor Region
Minor Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Name Owner Type
Sam's Mart LLC Non -Government
Owner Affiliation
Adnan Jazairi
President Vice
7935 Council PI
Dates/Events Matthews
NC 28105500
Scheduled
App Received Draft Initiated Issuance Public Notice Effective Expiration
2/1/2019 1/17/2019 2/1/2019 2/1/2019
Regulated Activities Requested /Received Events _
Groundwater remediation
Outfall
Waterbody Name Streamlndex Number Current Class Subbasin

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400514
1. Permit Information
Excel Civil and Environmental Associates
Permittee
(Former) Sam's Mart 97.
Facility Name
1102 Summit Avenue, Greensboro, Guilford County
Facility Address (include County)
2. Injection Contractor Information
Excel Civil and Environmental Associates
Injection Contractor / Company Name
Street Address 625 Huntsman Court
Gastonia
City
NC
State
28054
Zip Code
(704) _853-0800
Area code — Phone number
3. Well Information
Number of wells used for injection 4
Well IDs I-1 thru I-4
Were any new wells installed during this injection
event?
X Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 4
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled X 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?
X Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 4
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Klozur SP and Sodium Hydroxide
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 25%
If the injectant is diluted please indicate the source
dilution fluid. municipal water_
Total Volume Injected (gal) 665
Volume Injected per well (gal)__ 166
5. Injection History
Injection date(sL_3/19/19 and 3/20/19
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
X Yes ❑ No
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.
4/41
SIGNATURE I JECTION CONTRACTOR DATE
If 57/ /:
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Michael T. Stanforth, P.E.
Well Contractor Name
2525
NC Well Contractor Certification Number
Excel Civil & Environmental Associates, PLLC
Company Name
2. Well Construction Permit #: WI0400514 (injection)
List all applicable well permits O. e. County, State. Variance, Injection etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (I lealing/Cooling Supply)
❑ lndustrial/Commercial
❑ lift cation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
MGeothermal(Closed Loop)
❑Geothermal (ileatina Cooling Return)
4. Date Well(s) Completed: 3/19-20/1
5a. Well Location:
Sam's Mart No. 97
OGroundwater Retnediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
9Well ION 1-1 thru 1-4
Facility Owner Name Facility IL) (ifapplieablel
1102 Summit Ave, Greensboro, 27405
Physical Address, City, and Zip
Guilford
County
Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field one latlong is sufficient)
36.089384 N 79.773471
6. Is (are) the well(s): ❑Permanent or l Temporary
11'
7. Is this a repair to an existing well: ❑Yes or ONo
OAP; is a repair, Jihl.aut known well construction in/imitation and explain the nature oldie
repair under -2! remarks section or on the back </ibis /brit.
8. Number of wells constructed: 4
For multiple injection or non -water supply wells (LVI.F with the sate construction. you Can
submit otrc• form.
9. Total well depth below land surface: 20
For multiple wells list all depths nfd arrit (example- Save 20(1' and 2 n100)
(ft.)
10. Static water level below top of casing: 6 (ft.)
1J water lereI it above casing. rise "-
I I. Borehole diameter: 1.5 (in.)
12. Well construction method: direct push
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
I3b. Disinfection type: _ Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
6 ft,
20 n.
ft.
ff.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap limbic)
FROM
TO
DIAMETER
TIIICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed400p)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
n.
in.
ft.
II.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft,
R.
in.
18. GROUT
FROM
1 TO
MATERIAL.
EMPK ►CEMENT METHOD & AMOUNT
ft.
ft,
ft.
ft.
ft.
D.
19. SAND/GRAVEL PACK inapplicable)
FROM
10
MATERIAL
EMPLACEMENTMET1IOD
ft.
R.
ft.
ft.
I0. DRILLING
LOG (atn
h additional sheep If necessary)
FROM
TO
DESCRIPTION ( rolnr, hardness. soil/rack type, groin six. ter -I
0 n•
1 ft.
asphalt/concrete
ft.
n.
unknown (direct push/pull)
ft.
ft.
ft.
n.
a.
n.
fr.
tt.
f1.
n.
21. REMARKS
22. Certification:
iignature ofC'rrtil
Contractor
By signing tins Jorm, ! hereby serge that the well(v) was (Were) cotsrrricted in accordance
With 15.4 .V( 'AC 02(• .01(ffl sr /5:1 /t'(4(• 02(• .020H1 awl own -maim standards end that a
cop) of (his retard has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
constnlction details. You may also attach additional pages if necessary
SUBMITTAL 1NSTUCTIONS
24a. For All Wells: Submit this font within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center. Raleigh, NC 27699-1617
24h. For Inieelion 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
construction to the following.
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this font within 30 days of completion of
well construction to the county health department of the county where
constructed.
Forst CM -I North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Mike Stanforth
Well Contractor Name (or well owner personally abandoning nell on his/her property)
2525
NC Well Contractor Certification Number
Excel Environmental Associates
Company Name
2. Well Construction Permit ft: W10400514 (injection)
Lice all a/ pbeahle o t ll ronsrraciton permits lie. UI('. ( bung•, Mate, r irriance, etc./ ifknmrn
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
•Monitoring
❑Recovery°
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑ Geotlietntal (Closed Loop)
❑Geothermal (Heatine;Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 3/20/19
Sa. Well location:
Sam's Mart No, 97
Facility Owner Name
Facility ID= fifappIicablet
1102 Summit Ave, Greensboro, 27405
Physical Address. City, and hip
Guilford
County
Parcel Identification \o. (PIN )
5b. 1.atitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laalong is sufficient)
36.089384
79.773471
N
CONSTRUCTION DETAILS OF WELIASt BEING ABANDONED
.drlachwell construction record/sJifaeaihthle.For mntlipk•abjectionarnon-5aterstrpph ne!/s
ONLY with the .same cortstrncaan abandonment. pm can submit one lam
6a. Well IDO: 1-1 thru 1-4
6b. Total well depth: 20
6c. Borehole diameter: 2
(ft.)
6d. 1Vater level below ground surface: 6
6e. Outer casing length (1f known):
6E Inner casing/tubing length (if known):
6g. Screen length (if known):
Form GW-30
_(ft.)
(ft.)
(ft.)
(ft.)
North Carolina Department of rrw ironmental Quality - Division of Water Resources Res iced 2-22-2016
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only. 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining in well(s): < 1
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
❑ Neat Cement Grout
❑ Sand Cement Grout
IN Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7e. Sealing materials used (check all that apply):
• Bentonite Chips or Pellets
Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain tinder 7g)
7E For each material selected above, provide amount of materials used:
Concrete 5 Ib (+/-)
Bentonite Pellets 5 Ib (+/-)
7g. Provide a brief description of the abandonment procedure:
Bentonite pellets were poured into the wells to near ground level.
Concrete Grout was poured to replace the existing surface.
3. Certification:
Signature ofCern 'ell Contractor or Well Owner
Dale
By slgaiug this form. I hereby cerrh• that the wars) was (were) abandoned br
accordance with I S.1 A'I.AC 02C .0M O or 2C .0200 Well Construction Standards
and that a copy of this record has been prorided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMIITTAI. INSTRUCTION]
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above. also submit one copy of this fonn within 30 days of completion of well
abandonment to the following:
Division of Water Rtsources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh. NC 27699-1636
10c. For Water Sunnh' & Injection Wells: In addition to sending the fonn to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.