WI0700510_Injection Event Record_20210722

North Carolina Department of Environmental Quality — Division of Water Reso#8
INJECTION EVENT RECORDJEER) t°0
20?�
nlr$lR
-wee
Permit Number Onit0 JiD
Per
E
Permi
S
Facili
it Information
tfiA5lovro NC,
Facility Address (include County) 2,4'6
9w,
(AA)
. Injec t'on Contractor Information
R ,; bx LLG
Inject
Street
n Contractor / Company Name
200 QL•t a ,c. Os
ddress
NC
Area
Well
State
68-01�+0
rode — Phone number
formation
Numb r of wells used for injection
Well I
Were
eve
Y
If yes, please provide the following information:
Numb } of Monitoring Wells
Numbr of Injection Wells_ 1
Zip Code
s Oy"en I I ~ 1& -b 26,
1y new wells installed during this injection
Type
❑ B
❑ H
❑ No
Well Installed (Check applica e type):
red ❑ Drilled Direct -Push
nd-Augured ❑ Other (specify) _ _
Plea include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
eve
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
I I
?Covet4- —OX - CISCO re -ay it0
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
b 1 w2 cok,-6
If the injectant is diluted please indicate the source
dilution fluid. V\y drw` y �ak-cks4-
Total Volume Injected (gal) 2, L S
Volume Injected per well (gal) 19
5. Injection History
Injection date(s)
3-)2Z1Z1
Injection number (e.g. 3 of 5)
[s this the last injection at this site?
❑ Yes ❑ No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDG ND THAT THE
INJECTION WAS PERF 'IPD WITH THE
STANDA
sWzi
SIGNA / INJECTION CONTRACTOR DATE
PRINT N NIE`C PERSON PFRFG MlNG THF. 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
ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Cont-actor Information:
Kyle Baseley
Well Contracto
4410-B
Name (or well owner personally abandoning well on his/her property)
NC Well Conn-
Redox T
ctor Certification Number
ech LLC
Company Name
2. Well Cons
List all applicaa
� ruction Permit #: 0 ) 5
to well construction permits (i.e U1C. County, State, Variance, etc.) if known
3. Well use (c[teck well use):
Water Suppl t Well:
❑Agricultural
❑Geothermal (1{eating/Cooling Supply)
❑industrial/Cajnmercial
❑Irrigation
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
ORecovery
Injection We®i
❑Aquifer Rec-arge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experiments 1 Technology
❑Geothermal Closed Loop)
I❑Geothermal fleating/Cooling Return)
4. Date well(s bbandoned: 7/22/21
5a. Well Meat on:
SJAFB
®Groundwater Remediation
OSalinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
Facility/Owner Njrtte Facility tOt (if applicable)
1055 Wr'oht Bros Ave. Goldsboro, NC 27534
Physical Address.
Wayne
City, and Zip
County
OT029
Parcel Identification No. (PIN)
5b. Latitude aud longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.346593882394444 N-77.95926721145747
CONSTRUCT ION DETAILS OF WELLS) BEING ABANDONED
Attach well cons!'/tction records) ijavailable. For multiple injection or non -water supply wells
ONLY with the some construction abandonment, you can submit one form.
I P-16 to 26
6a. Well tD#:
6b. Total well depth: 18
(ft.)
6c. Borehole d imeter: 1 .5 (in.)
6d. Water levrl
below ground surface:
6e. Outer cash!), length (if known):
6f. Inner casing/tubing length (if known):
6g. Screen tenth (if known):
(ft.)
(ft.)
(ft.)
(ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 OW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: t'
7b. Approximate volume of water remaining in well(s): _(gal•)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout B Bentonite Chips or Pellets
❑ Sand Cement Grout 0 Dry Clay
❑ Concrete Grout 0 Drill Cuttings
0 Specialty Grout 0 Gravel
❑ Bentonite Slurry 0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Granular Bentonite 185 lbs
7g. Provide a brief description of the abandonment procedure:
Gravity fed open boreholes with granular bentonite from 15' bgs to surface.
Packed top 5' and refilled with granular bentonite.
8. Certification:
Signature o`f ' ed Well Contractor or Well Owner
02.1
Date
Bying this form, 1 hereby certi), that the well(s) was (were) abandoned in
ordance with 15A NC/IC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided 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.
SUBMITTAL INSTRUCTIONS
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 form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10e. For Water Supply & Injection Wells: In addition to sending the form 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.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contactor Information:
Kyle Baseley
Well Contracto
4410-
Name
NC Well Cotttrictor Certification Number
RedoxTech LLC
Company Naml /i� /�
2. Well Consruction Permit #: ��) fr) 00510
List all applic'+le well construction permits (i.e. U/C. County, State. Variance. etc.)
3. Well Use ( eck well use):
•
r
•
Water Suppl
Agricultura
Geothermal
Industrial/
lrri _ ation
Well:
DMunicipal/Public
iiHeating/Cooling Supply) DResidential Water Supply (single)
mmercial DResidential Water Supply (shared)
Non -Water. tpply Well:
•
Monitoring
Injection Welt:
Aquifer Recharge
Aquifer Stohage and Recovery
Aquifer T
Experiment.I Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
} Completed: 7/22/21
5a. Well Loc• It ion:
SJAFB
Facility/Owner
1055
I: Recovery
4. Date Well(
12. Well cons
(i.e. auger, rotar
10. Static wa
If water level iv
0Groundwater Remediation
Salinity Barrier
DStormwater Drainage
Subsidence Control
Tracer
Other (explain under #21 Remarks)
Well ID# I P-16 to 26
ame Facility IDS (if applicable)
right Bros Ave. Goldsboro, INC 27534
Physical Address
Wayne
City, and Zip
County
OT029
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, onL I lat/long is sufficient)
35.3465882394444 -77.95926721145747 W
6. Is(are) the
ell(s)OIPermanent or DTemporary
7. is this a re •hir to an existing well: ®Yes or DNo
If this is a repot . fill our known well construction information and explain the nature of the
repair under =2 remarks section or on the hack of this form.
8. For Geopr be/DPT or Closed -Loop Geothermal Wells having the same
construction, lily I OW -I is needed. Indicate TOTAL NUMBER of wells
drilled: 11
9. Total well epth below land surface: 18
For multiple we .}' list all depths if different (example- 3@a.200' and 2@100')
r level below top of easing:
'hove casing. use "-
I1. Borehole .Pameter: 1.5 (in.)
fluction method: Direct Push
cable, direct push, etc.)
FOR WATE
SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfectfion type:
(ft.)
(ft.)
Method of test:
Amount:
FROM
For Internal Use Only:
14. WATER ZONES -
FROM
ft.
TO
ft.
DESCRIPTION
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licableL�
THICKNESS ( MATERLML
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM TO DIAMETER THICKNESS
in.
FROM
TO
ft. ft.
ft.
DIAMETER
ftin.
MATERIAL
17. SCREEN
MATERIAL
18 ft.
ft.
18. GROUT
FROM
ft.
TO
8
TO
ft.
J
ft.
ft.
DIAMETER I SLOT SIZE
1.5 in' expendable up
in.
THICKNESS
MATERIAL T EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO
MATERIAL
EMPLACEMENT METHOD
ft. ft.
ft.
ft. h
20- DRILLING LOG (attach additional sheets if necessary)
DESCRIPTION (color, hardness, sod/rock type, grain size. etc.)
FROM TO
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certificatio
Signal �• ertified Well Contractor vase
8 going this form. I hereby certify that the well(s) was (were) constructed in accordance
i/h 15A NCAC 02C -0100 or 15A NC.4C 02C .0200 Well Construction Standards and that a
copy of this record 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
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form 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
24b. For infection Wells: In addition to sending the form to the address in 24a
above, also submit one 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 Suorly & l jection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.