WI0501086_Injection Event Record_20220119

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501086
1. Permit Information
_James A Buffaloe
Permittee
—McCullers Community Store
Facility Name
—7930 Fayetteville Rd, Raleigh, Wake Co., NC
Facility Address (include County)
2. Injection Contractor Information
_Terraquest Environmental Consultants, P.C.
Injection Contractor / Company Name
Street Address100 E Ruffin St
Mebane NC 27302
City State Zip Code
(919 ) 563-9091
Area code — Phone number
3. Well Information
Number of wells used for injection 5
Well IDS STEAM1-5
Were any new wells installed during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 5
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 5
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
_superheated water and steam
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 100%
If the injectant is diluted please indicate the source
dilution fluid. municipal water
Total Volume Injected (gal) 6732
Volume Injected per well (gal) 1346
5. Injection History
Injection date(s) 11/1-4-21
Injection number (e.g. 3 of 5) 1 of 5
Is 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 KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
12/4/21
SIGNATURE OF INJECTION CONTRACTOR DATE
Chris Palmer
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

Print Form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Jonathan R. Grubbs
Well Contractor Name
3001
NC Well Contractor Certification Number
Terraquest Environmental Consultants, P.C.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural
�IGeothermal (Heating/Cooling Supply)
�I Industrial/Commercial
Irrigation
Non -Water Supply Well:
Monitoring Ell Recovery
Ell Municipal/Public
DResidential Water Supply (single)
(Residential Water Supply (shared)
Injection Well:
�IAquifer Recharge
Aquifer Storage and Recovery
�IAquifer Test
�IExperimental Technology
�IGeothermal (Closed Loop)
Geothermal(Heating/Cooling Return)
EllGroundwaterRemediation
01 Salinity Barrier
01 Stormwater Drainage
DlSubsidence Control
01 Tracer
❑I Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1 1/1-4/21 Well ID#STEAM 1-5
5a. Well Location:
McCullers Community Store
0-006035
Facility/Owner Name Facility ID# (if applicable)
7930 FAYETTEVILLE ROAD, RALEIGH, NC 27603
Physical Address, City, and Zip
WAKE 0689973600
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
35.6654 N-78.6995
6. Is(are) the well(s)DPermanent or EITemporary
7. Is this a repair to an existing well: ElYes or XQINo
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.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 5
9. Total well depth below land surface: 29 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 28.5 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 2.25 (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:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop) •
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0 ft.
ft.
in.
ft.
ft.
in.
18. GROUT 1
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
29 ft.
bentonite
pour
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soillrock type, grain size, etc.)
0 ft'
29 ft•
sandy clay/clayey sand
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
W •
Signature of Certified Well Contractor
11/5/21
Date
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
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 Injection 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 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 construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information:
Jonathan Grubbs
Well Contractor Name (or well owner personally abandoning well on his/her property)
3001
NC Well Contractor Certification Number
Terraquest Environmental Consultants, P.c.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
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
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Retum)
MI Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 11/4/21
5a. Well location:
McCullers Community Store
0-006035
Facility/Owner Name Facility ID# (if applicable)
7930 Fayetteville Rd, Raleigh, NC 27603
Physical Address, City, and Zip
Wake
County
0689973600
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
35.6654
N-78.6995
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: STEAM 1-5
6b. Total well depth: 29 (ft.)
6c. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: 28.5
(ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): 25-29 (ft.)
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: 5
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 s Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
bentonite
7g. Provide a brief description of the abandonment procedure:
poured bentonite down hole
8. Certification:
Airetti'l
11/5/21
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 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 Iniection Wells: In addition to sending the form to the address in l0a
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
10c. 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.
Form GW-30
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016