WI0501096_Notification of Intent (NOI) – GW Remediation_20220928

ckeGe,\jeO
DeCIL% fiC Dtoo\epartment of Environmental Quality — Division of Water Resou ep (M17922
RECEIVED
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INT;ELLS
Central Office
The following are "permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells is located within an area that does not exceed five percent of the land surface
above the known extent of groundwater contamination. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.
4) Air Infection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
5) In -Situ Thermal Wells (IST) — Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: September 15 , 2022
PERMIT NO.
to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
A.
Permit No. WI
Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well
(2) Aquifer Test Well
Complete sections B through F, J, M
Complete sections B through F, J, M
Complete sections B through F, H-M
. Complete sections B through M
Complete sections B through M
Complete sections B through M
Complete sections B through M
(3) Passive Injection System
(4) X Small -Scale Injection Operation
(5) Pilot Test
(6) Tracer Injection Well
(7) In -Situ Thermal (IST) Well
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 1

B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): Eaton Corporation: Jeffrey P. Allen _
Mailing Address: Mail Code 4S. 1000 Eaton Blvd
City: Cleveland State: OH Zip Code: 44122 County: Cuyahoga
Day Tele No.: 440-523-4777 Cell No.:
EMAIL Address: JeffPAllen ' Eaton.com Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Bill Sharek, President and CEO
Company Name: Johnston County Industries, Inc.
Mailing Address: 1100 East Preston Street
City: Selma
State: NC Zip Code: 27567 County: Johnston
Day Tele No.: 919-743-8702 Cell No.:
EMAIL Address: bill.sharek(cr�jcindustries.com
Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Bilgen Yuncu. Project Manager
Company Name Draper Aden Associates/TRC (DAA) _
Mailing Address: 114 Edinburgh South Drive Suite 200 _
City: Care State: NC Zip Code: 27513 County: Wake
Day Tele No.: 919-582-7267 Cell No.:
EMAIL Address: [e-mail] Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Johnston Count Industries. Inc. (Former Eaton Corporation facility)
1100 East Preston Street
City: Selmo County: Johnston Zip Code: 27567
(2) Geographic Coordinates: Latitude**: 35 ° 31 ' 33 " or
Longitude**: 78 ° 17 ' 02 " or
0
°
Reference Datum: WGS84 Accuracy: +/- 1 meter
Method of Collection: Goon=1e Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: 650,000 square feet
Land surface area of inj. well network: 890 square feet ( 10,000 f 2 for small-scale injections)
Percent of contaminant plume area to be treated: <5% (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 2

H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
DAA will inject PLUS (nutrient mixture) supplied by EOS Remediation, LLC through the ten existing injections
wells in the area near MW-18 to support and enhance the Growth of the microbial population Qrowth and
reductive dechlorination. Each injection well will receive about 500 pounds (lbs) of nutrient mixture (gravity
injection) and 200 gal of water to distribute the reagents thro uhout the treatment zone.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 10 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): — 12 to 30 ft
(3) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemioloy section of the NC Division of Public Health. Department
of Health and Human Services can be injected. Approved injectants can be found online at
http://deq. nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ eround-water-
protection/ground-water-app roved-inj ectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program Jbr more info if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no injectants are to be used use N/A.
Injectant: PLUS Total Amt. to be injected (gal)/event: 550
Injectant: Water Total Amt. to be injected (gal)/event: 2,000
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Total Amt. to be injected (gal/event): 2,550
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

No. of separate injection events: 1 Total Amt. to be injected (gal): 2,550
Source of Water (if applicable): Hydrant on site
L. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
Approximately six months following the injection event. monitoring well MW-18 will be sampled for VOCs.
TOC. sulfate. nitrate. ferrous and ferric iron. magnesium. alkalinity. sulfide. MEE, VFAs and MBTs. Prior to
sampling, water level will be gauged in MW-18. The well will then be purged with a peristaltic pump and one-
time -use new tubing using low -flow purging and sample collection procedures. During well purging, the water
quality indicator parameters pH, temperature, dissolved oxygen (DO). oxidation-reduction potential (ORP),
conductivity, and turbidity will be measured at three to five-minute intervals until these parameters stabilize
within specific ranges. Following purging, groundwater samples will be collected and submitted to a North
Carolina certified laboratory for VOCs by EPA8260D, TOC by SM 5310B, alkalinity by EPA310.2. nitrate and
sulfate by IC300, ferrous iron by SM3500), ferric iron and magnesium by EPA 6010D, sulfide SM4500, and
MEE by RSK 175. Samples will also be analyzed for MBTs by CENSUS analyses performed by Microbial
Insights. Inc. in Knoxville. TN. and for VFAs by method AM23G performed by Pace Analytical LLC in
Pittsburgh, PA.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
ODA_
6'4.1flei
Signlglure of Applicant
Karen E. Souza AESI. Agent for Eaton Corporation
Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
elWie ! Bill Sharek. President. and CEO
Signature* of Property Ow (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 4

Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at Least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 5

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114 Edinburgh South Drive, Suite 200
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Phone: [phone]
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LEGEND
REFERENCE:
USGS 7.5 MINUTE TOPOGRAPHIC MAP
SELMA, NC. 2013
0
2000
4000
PROJECT:
FORMER EATON FACILITY
1100 EAST PRESTON STREET
SELMA, JOHNSTON COUNTY, NC
TITLE:
SITE LOCATION MAP
SCALE IN FEET
DRAWN BY:
KStark
CHECKED BY:
BYuncu
APPROVED BY:
BYuncu
DATE:
9/1/2022
PROJ. NO.:
017025
FILE: 2023 Annual Progress Report.dwg
1

f.1
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4
LEGEND
SHALLOW MONITORING
WELL
DEEP MONITORING WELL
MW-1 AREA INJECTION WELL
PHASE 1 INJECTION
WELL
PHASE 2 INJECTION
WELL
MW-18 AREA
INJECTION WELL
PROPERTY BOUNDARY
CULVERT
DRAINAGE FEATURE
— v — WATER LINE
— E — ELECTRICAL LINE
-- ss — SEWER LINE
— sv — STORMWATER LINE
— — TELEPHONE LINE
1W-88
IW-90
I W-91
. IW-74
0
60
120
IW-79
IW-92
SCALE IN FEET
IW-68
CARDBOARD AND PARTS
STORAGE AREA
MW-1
IW-73
IW-70
IW-72
IW-75
1W-78 IW-83
I W-82 I W-80
1W-85
IW-93
MW-25 1
�T}•
IW-76
1 W-81
IW-84
IW-86
4.'1W-2 IW-3 IW-4
i3M*16
IW-5
IW IW- IW-8 41W-9
+IW--10
IW-12AL_ IW-
IW-C s"1-1—Vv,Ys,. ---
' WOOD
STORAGE
BUILDING
OIL S
4IW-26 4
IW-41 V 42
sW
N
0
1W-87
1W-95
GTRC
114 Edinburgh South Drive, Suile 200
Cary, NC 27587
Phone: [phone]
www.tresolutions.com
` " IW-14 IW-15
��
+IW-16IW-17
-Sir
m ss sv ss —sw.�s v
*IW-25ORMERiol l +IW
IW-30�IW-314-IW-32+I
IW 4a
IW-4 w —� 4
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MW 1t
PROJECT:
FORMER
EATON
FACILITY
— E
MW-7
IW-18 4.IW--19 IW-20 +I W-21
1
y 4,�.i► 35 ; Ivy_ i8
t3Z. tw_3a W0
MVY--222
168
4•1W-6
IW-22 +IW-23 IUN_ MW
ss sW
MW-4
A.
Ir i Y IW-39
Y
W-20 c
0,
FORMER EATON FACILITY
100 EAST PRESTON STREET
SELMA, JOHNSTON COUNTY, NC
vIV
I.2
c
N
ti
W v
W
c
4I W-45 I W-46
IW-4B
W W
—W W E E1
+IkV 49 4IW-5
M- 23
+IW-51
+IW-52
+IW-53
ss — ss ss -- ss
+IW-54
-63
4MW-9
TITLE:
INJECTION WELL LAYOUT
I W-554 0-56
IW-57
ss W ss- IV58s
MW-3
IW-599
IW + IW-6!
DRAWN BY:
CHECKED BY:
APPROVED BY:
DATE:
PROJ. NO.:
FILE:
MW-T9
- -
KStark
BYuncu
BYuncu
9/1/2022
017025
2023 Annual Progress ReporLdwg
6
Version: 2017-10-21

163.25
W-24
163.23
163.0
�M W-21
162.84
1
172�
163,75
'172'
172
164,2
164,0 16
.43 MW-1
163.56
164.5
17
163.5964;5
MW-2
RDBOARD AND PARTS
STORA EA
NOTES:
1) BASEMAP OBTAINED FROM JIMMY BARBOUR SURVEYING, PA, APRIL 2008.
2) WELL LOCATIONS ARE BASED ON SURVEY DATA PROVIDED BY KCI
ASSOCIATES OF N.C. JUNE 2008, JULY 2010, & OCTOBER 2013 AND BY DRAPER
ADEN ASSOCIATES AUGUST 2018, JULY 2019 AND JULY 2021.
164.75
i
WOOD
TORAGE
ILDING
1 W-13
164.87
MW-6
NG
164.90
MW-16
164.97
MW-2
FORMER
OIL STORAGE REA
,MW-17
164.83
FORMER
EATON
FACILITY
164.90
MW-7
164.93
17 MW-20
164.45 -
MW-5
164.40
17
-9
164.
1
1
164.67
M W- 1'
+MW
164.62
W-11
164.93
8
MW-4
164.96
MW-23 0�0
164.92 N
co
1—
w
w
tY
z
O
1—
w
0
1—
rA
w
9
JOHNSTON
COUNTY
SHRINER'S
CLUB
169.10
NG
0
SHALLOW MONITORING WELL
MW-18 AREA INJECTION WELL
GROUNDWATER FLOW
DIRECTION
GROUNDWATER ELEVATION
(FT AMSL)
CULVERT
DRAINAGE FEATURE
GROUND SURFACE CONTOUR
NOT GAUGED
100
200
SCALE IN FEET
GTRC
114 Edinburgh South Drive, Suite 200
Cary, NC 27587
Phone: [phone]
www.tresolutions.com
PROJECT:
FORMER EATON FACILITY
100 EAST PRESTON STREET
SELMA, JOHNSTON COUNTY, NC
TITLE:
GROUNDWATER ELEVATION MAP
JULY 2022
DRAWN BY:
CHECKED BY:
APPROVED BY:
DATE:
PROJ. NO.:
FILE:
KStark
BYuncu
BYuncu
9/1/2022
017025
2023 Annual Progress Reportdwg
3
Venal' 2017-10.21

<0.220
MW-24
MW-21
QT� 0.560
A
M 1
0.
MW-25
0.362 J
CARDBOARD AND PARTS
STORAGE AREA
123 •
MW-
WOOD
ST
ILOING
MW-13
-- 97.9
.MW-6
MW-16
<0.220
0.266 J
FORME!,
OIL STORAGE ..REA
M W-17
34.5
FORMER
EATON
FACILITY
MW-20
56.0
8.4 rL
M W-5
6.62
MW-8
MW 9
728
6.09
M W-
8
23 co
N
1-
W
NW
LL
co
z
0
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ct
�
MW-19
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MW-11
7 790
A''
\\Q...„,..,,
JOHNSTON
COUNTY
SHRINER'S
CLUB
i
4
100
\
LEGEND
SHALLOW MONITORING WELL
MW-18 AREA INJECTION WELL
PCE CONCENTRATION ( g/L)
CULVERT
DRAINAGE FEATURE
PROPERTY BOUNDARY
f t
CROSS SECTION LOCATION
0
PCE (ug/L)
C,'Cv0
100 200
SCALE IN FEET
Trail
114 Edinburgh South Drive, Suite 200
Cary, NC 27587
Phone: 919.827,0864
www.tresolutions.com
PROJECT:
FORMER EATON FACILITY
100 EAST PRESTON STREET
SELMA, JOHNSTON COUNTY, NC
TITLE:
SHALLOW PCE PLUME MAP
JULY 2022
DRAWN BY: KStark
CHECKED BY: BYuncu
APPROVED BY: BYuncu
DATE: 9/1/2022
PROJ.NO.: 017025
FILE: 2023 Annual Progress Report.dwg
4
Verson:2017-1021

aten self.; Pvxerine elignmenl;
ELEV
(ft msl)
175
170
165
160
155
150
145
140
135
130
125
120
115
110
105
100
A
MW-
WOOD
STORAGE
MW-15
CARDBOARD AND
PARTS STORAGE
AREA
0.
0.373
MW-2
•
ML
0.0-0. „
0 - c! I' O
-cPO.O 1p
ND GRAVEL
1'O'O'O.
O O O d
b'O
266
AO-
• 1,2704
MW-7 M W-8
MW-4
Aent
DITCH —\
421111110r,/,
s✓
wip
OP O 0 0 0 O
0 ' 0 SCC I _ �` 0
294
' 0' 0 w 0-0
.- . O . O k• r 0 .0 . 0
I r— D O O 0960.0.
—T6.62p '0'0'0-0'0
A
RESIDUUM (CLAYEY SILT)
gri WEATHERED BEDROCK
COMPETENT BEDROCK
ab-
ML
EAST PRESTON
STREET
DRIVE POINT
PIEZOMETER
—BAWDY SWAMP
CREEK
.09
rl1
0
CL
SC
SP
ML
RCP
163.62
18,200)
LEGEND
TOPSOIL, SILT
SILTY CLAY WITH SAND STRINGERS
SAND, VARIES BETWEEN CLAYEY AND SILTY,
SOME LARGE GRAVEL LENSES
RESIDUUM, CLAYEY SILT, BECOMES HARDER WITH DEPTH
WEATHERED BEDROCK
COMPETENT BEDROCK - HARD, SLIGHTLY WEATHERED TO
WEATHERED GRAY -GREEN METAVOLCANIC ROCK
CLAY
CLAYEY SAND
GRAVELLY SAND
SILT
REINFORCED CONCRETE PIPE
STATIC WATER LEVEL
JANUARY 18, 2022
MONITOR WELL SCREENED INTERVAL
PCE CONCENTRATION (IJg/L) JULY 2022
HORIZONTAL SCALE
100
200
0
SCALE IN FEET
VERTICAL SCALE
10
20
SCALE IN FEET
PCE (ug/L)
>_10,000
>1,000
>_ 100
>_ 0.7
Ix
Tr c
114 Edinburgh South Drive, Suite 200
Cary, NC 27587
Phone: [phone]
www.tresolutions.com
PROJECT:
FORMER EATON FACILITY
100 EAST PRESTON STREET
SELMA, JOHNSTON COUNTY, NC
DRAWN BY:
CHECKED BY:
APPROVED BY:
KStark
BYuncu
BYuncu
TITLE:
GEOLOGIC CROSS
SECTION A -A'
DATE: 9/1/2022
PROJ. NO.: 017025
FILE: 2023 Annual Progress Report.dwg
5
Vasim:2017.70.21

I?OS
EOS Remedblion, LLC
PLUS
SAFETY DATA SHEET
Section 1: Identification
Product Name:
PLUS
Chemical Description:
Mixture, semi -transparent liquid
Manufacturer:
EOS Remediation
PO Box 14266
Research Triangle Park, NC 27709
(P): 919-873-2204
www.eosremediation.com
Recommended Use:
Groundwater bioremediation (environmental applications)
Restricted Use:
Not for human consumption.
24-Hour Emergency Contact:
ChemTel: United States
(P): 800-255-3924
ChemTel: International
(P): 813-248-0585
Section 2: Hazard(s) Identification
Hazard Classification:
Irritant (skin and eye)
Signal Word:
Warning
Hazard Statement(s):
Potential eye and skin irritant
Pictograms:
Precautionary Statement(s):
Not for human consumption. Avoid contact with eyes and skin. Wear
protective gloves and eye protection.
Section 3: Composition/Information on Ingredients
Common Name(s) CAS NO.
% by Weight
Quick Release Soluble Substrate
Trade Secrete
Proprietary
30-50
Nitrogen -releasing substrate
Trade Secreti
Proprietary
10-15
Phosphate -based blend
Trade Secret
Proprietary
2-5
Cyanocobalamin
68-19-9
< 0.1
Food additives
Trade Secret
Proprietary
<5
Water
7732-18-5
<50
1—The soluble substrates and emulsifiers are generally recognized as safe for food contact.

SAFETY DATA SHEET
Section 4: First -Aid Measures
Routes of Exposure
Emergency First -Aid Procedures
inhalation
Remove to fresh air.
Eye Contact
Flush with water for 15 minutes; if irritation persists see a physician.
Skin Contact
Wash with mild soap and water.
Ingestion
Do not induce vomiting. Seek advice of a physician immediately
Section 5: Fire -Fighting Measures
Extinguishing Media:
CO2, foam, dry chemical.
Special Fire Fighting Procedures:
Fire Hazard(s):
Wear self-contained breathing apparatus and chemical resistant clothing.
Use water spray to cool fire exposed containers.
Burning will cause oxides of carbon.
Section 6: Accidental Release Measures
Personal Precautions:
Avoid contact with eyes and skin. Do not consume.
Emergency Procedures:
N/A
Methods & Materials used for
Containment:
Compatible granular absorbent.
Cleanup Procedures:
Spread compatible granular absorbent over spill area and sweep using
broom and pan; dispose in appropriate receptacle. Clean area with water.
Section 7: Handling and Storage
Safe Handling & Storage:
Store in cool, dry, well -ventilated area away from all sources of heat and
ignition. Keep out of direct sunlight and protect from moisture and
incompatible materials. Do not store near excessive heat or oxidizers.
Other Precautions:
Consumption of food and beverages should be prevented in work area
where product is being used. After handling product, always wash hands
and face thoroughly with soap and water before eating, drinking, or
smoking.
Section 8: Exposure Controls/Personal
Protection 11' -
- ■--
Exposure Limits
OSHA PEL:
NE
ACGIH TLV:
NE
NIOSH REL:
NE
Personal Protective Measures
Respiratory Protection:
Not normally required. N95 respirator if aerosols might be generated.
Hand Protection:
Protective gloves are recommended.
Eye Protection:
Recommended.
Engineering Measures:
Local exhaust ventilation if aerosols are generated.
2

SAFETY DATA SHEET
Section 9: Physical and Chemical
Appearance:
Properties
Yellow, semi-
transparent liquid
Explosive Limits:
NE
Odor:
Mild, ammonia -like
Vapor Pressure:
NE
Odor Threshold:
NE
Vapor Density:
Heavier than air.
pH:
7.0 - 8.0 (SU)
Relative Density:
1.2
Melting Point/Freezing Point:
Liquid at room
temperature
Solubility:
Miscible in water.
Boiling Point:
212°F (100°C)
Partition coefficient:
NE
Flash Point:
>300°F (149°C)
Auto -ignition Temperature:
NE
Evaporation Rate:
NE
Decomposition Temperature:
NE
Flammability (solid, gas):
NE
Viscosity:
< 50 cP
Hygiene Measures: Wash promptly with soap & water if skin becomes irritated from contact.
Other Protection: Wear appropriate clothing to prevent excessive skin contact.
Section 10: Stability and Reactivity
Stability:
Stable
Incompatibility:
Strong oxidizers.
Hazardous Decomposition
Products:
Hazardous
Reactions/Polymerization:
Thermal decomposition may produce oxides of carbon and nitrogen.
Will not occur.
Conditions to Avoid:
None known.
Section 11: Toxicological Information
Likely Routes of Exposure:
Ingestion, dermal and eye contact.
Signs and Symptoms of Exposure:
None known.
Health Hazards
Acute:
Potential eye and skin irritant.
Chronic:
None known.
Carcinogenicity
NTP:
No
IARC:
No
OSHA:
No
Section 12: Ecological Information (non -mandatory)
There is no data on the ecotoxicity of this product.
3

SAFETY DATA SHEET
Section 13: Disposal Considerations (non -mandatory)
Waste Disposal Methods:
Dispose of according to Federal and local regulations for non -hazardous
waste. Recycle, if practical.
Section 14: Transport Information (non -mandatory)
The product is not covered by international regulation on the transport of dangerous goods.
No transport warning required.
Section 15: Regulatory Information (non -mandatory)
L N/A
Section 16: Other Information
Date of Preparation:
20 April 2022
Last Modified Date:
11 May 2022
The information contained herein is based on available data and is believed to be correct. However, EOS
Remediation, LLC makes no warranty, expressed or implied, regarding the accuracy of this data or the results
to be obtained thereof. This information and product are furnished on the condition that the person
receiving them shall make his/her own determination as to the suitability of the product for his/her particular
purpose.
4

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable welt construction permits (i.e. County•, State. Variance, etc.)
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:
OMonitoring
❑ Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heatin Cooling Return
4. Date Well(s) Completed: 05/18/1
5a. Well Location:
EATON FACILITY
❑ Groundwater Rernediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 421 Remarks)
8 Well 100 I W-61-A, B
Facility/Owner Name Facility 1D# (if applicable)
1100 EAST PRESTON STREET SELMA 27576
Physical Address, City, and Zip
JOHNSTON
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35° 31' 35.43" N 78° 16' 57.82"
W
6. Is (are) the well(s): OPermaaent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ENo
If this is a repair, fill out known well construction information and explain the nature al -the
repair under ii21 remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection ar non -water supply wells ONLY with the satne construction, you can
.submit one form.
9. Total well depth below land surface: 30.0/20.0 (ft.)
Par multiple wells list all depths if different (example- 3 ct200' and 2@100')
10. Static water level below top of casing: 12-0 (ft.)
If water lerel is above casing, use
11. Borehole diameter: 10.0 (in.)
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method of test:
13b. Disinfection type: Amount:
Form G W- I
For Internal Use ONLY:
t4. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft,
ft.
ft.
15. OUTER CASING (for multi -eased. wells) OR LINER (if applicable)
FROM
TO
DIAMETER t TnICKNESS 1
MATERIAL
ft.
ft.
inle
16. INNER CASING OR TUBING ineothermal closed -loop)
FROM
TO
DIAMETER 1 THICKNESS
MATERIAL
0.0 ft'
23.0 ft•
2.0 'a•
SCH 40
PVC
0.0 ft-
12.0 ft-
2.0 'n'
SCH 40
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
23.0 ft-
30.0 ft-
2.0 in'
.010
SCH 40
PVC
12.0 ft-
20.0 ft-
2.0 in
.010
SCH 40
PVC
l8. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
7.0 ft,
r°annwssurowe
SLURRY
ft.
ft.
ft.
ft
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
F:atrt_VC1:\LENT METHOD
22.0 ft-
30.0 ft•
20-40
FINE SILICA SAND
10.0 ft-
22.0 ft•
20-40
FINE SILICA SAND
20. DRILLING LOG (attach additional sheets if nreeisorvl
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 ft•
13.0 ft
TAN CLAY
13.0 ft-
30.0 ft-
TAN SILTY SAND
ft.
ft.
ft.
ft-
rt.
ft.
ft.
fL
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 20.0 TO 22.0 FT & 7.0 TO 10.0 FT
***NESTED WELLS***
22. Certifrcatio
Signature o 'ertified Well Contractor
06/25/18
Date
By signing this form. 1 hereby certify that the well(s) was (were/ constructed in accordance
with 15A NCAC 07C..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 INS"TUCTIONS
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 Infection Welk: 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,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sup pl. & 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.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit#:
List al/ applicable well construction permits (i.e. Counry. Stale, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑lrrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
1Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
Tracer
❑Other (eNillain under #21 Remarks)
05/18/18 IW-62-A,B
4. Date Well(s) Completed: Well ID#
5a. Well Location:
EATON FACILITY
Facility/Owner Name Facility ID# (if applicable)
1100 EAST PRESTON STREET SELMA 27576
Physical Address, City, and Zip
JOHNSTON
Counry Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
35° 31' 35.43" N 78° 16' 57.82"
6. Is (are) the well(s): l7Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the hack of this form.
8. Number of wells constructed: 1
Far multiple infection or non -water supply 1,ells ONLY with the Brune construction, you can
submit one form.
9. Total well depth below land surface: 30.0/20.0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@!00)
10. Static water level below top of casing: 12'0 (ft.)
!Prater level is above casing, use "+"
11. Borehole diameter: 1 0.0 (in.)
AUGER
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-t
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
rt. ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if aplh
icablel
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal dosed-hhopl
FROM
TO
DIAMETER
THICIJYI:SS
MATERIAL
0.0 ft'
23.0 It•
2.0 'n•
SCH 40
PVC
0.0 It
12.0 ft•
2.0 'n'
SCH 40
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
Tt11CK ILSS
MATERIAL
23.0 It
30.0 ft
2.0 in'
.010
SCH 40
PVC
12.0 it
20.0 D•
2.0 '°'
.010
SCH 40
PVC
IS- GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
7.0 ft.
paraunoeennourrE
SLURRY
ft.
fL
ft.
ft.
19. SAND/GRAVEL PAChtif applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
22.0 ft.
30.0 it
20-40
FINE SILICA SAND
10.0 ft.
22.0 ft
20-40
FINE SILICA SAND
20. DRILLING LOG latlach additional sheets if necessary]
FROM
TO
DESCRIPTION (color. hardness, soiVmrk type. rain sine. etr.I
0.0 ft.
13.0 ft.
TAN CLAY
13.0 It•
30.0 It•
_ TAN SILTY SAND
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 20.0 TO 22.0 FT & 7.0 TO 10.0 FT
***NESTED WELLS***
22. Certification •
arnaitsiti
06/25/18
Signature ofirertified Well Contractor Date
By .signing this .form, I hereby cerni* that the well(s) was (were) constructed in accordance
with l5A NCAC 02C .0I00 or /3A 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 LNSTUCTIONS
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 Injection 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,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Welts: 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.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. Cormry, Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
0 Industrial/Commercial
❑Irritation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
0 Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Storinwater Drainage
❑Subsidence Control
❑Tracer
❑Other ; explain under #21 Remarks)
4. Date Well(s) Completed: 05/18/18 Well ID# IW 63-A,B
5a. Well Location:
EATON FACILITY
Facility/Owner Name Facility ID / (if applicable)
1100 EAST PRESTON STREET SELMA 27576
Physical Address, City, and Zip
JOHNSTON
Comity Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one tat/long is sufficient)
35° 31' 35.43" N 78° 16' 57.82"
6. Is (are) the well(s): OPermanent or ❑Temporary
W
7. Is this a repair to an existing well: Dyes or E1No
!phis is a repair, fill out known well construction information and explain the nature of the
repair under 021 remarks section or on the back of this farm.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the some construction, you can
submit otre form.
9. Total well depth below land surface: 30.0/20.0 (ft,)
For multiple wells list a0 depths if dperent (example- 3@t,200' and 2 r3100')
10. Static water level below top of casing: 12.0 (ft.)
If water level is above casing, ase "-
11. Borehole diameter: 10-0 (in.)
AUGER
12. Well construction method:
(Le. auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-1
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRH'TION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licaHe)
FROM
TO
DIAMETER I THICKNESS' MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING ;geothermal dosed -loop)
FROM
TO
DIAMETER j THICKNESS
MATERIAL
0.0 ft•
23.0 fL
2.0 'n' 1 SCH 40
PVC
0.0 ft•
12.0
•
n• 2.0 '1 SCH 40
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
23.0 ft-
30.0 ft
2.0 'n"
.010
SCH 40
PVC
12.0 ft•
20.0 f •
2.0 '
.010
SCH 40
PVC
IS. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUN
0.0 ft'
7.0 it
PORRANDBENTOeaTE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK lirapplicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
22.0 ft•
30.0 ft
20-40
FINE SILICA SAND
10.0 ft-
22.0 ft-
20-40
FINE SILICA SAND
20. DRILLING
LOG (attach additional sheets if necesaar) )
FROM
TO
DESCRIPTION icalor, hardness, soirtoek type,;rain size, eIe1
0.0 ft
13.0 it.
TAN CLAY
13.0 ft•
30.0 ft-
TAN SILTY SAND
ft.
fe.
ft.
ft.
re.
re.
ft.
ft.
ft.
fe.
21. REMARKS
BENTONITE SEAL FROM 20.0 TO 22.0 FT & 7.0 TO 10.0 FT
***NESTED WELLS***
22. Certifica
f
06/25/18
Signature of Certified Well Contractor Date
By signing this firm, I hereby certify drat the well(s) was (Were) canstnrcted in accordance
with I5A A'CAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
copy ()Phis 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 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 Injection 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,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sulrltlt & 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.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Ian. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State. Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑1rri,2ation
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
DMonitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating Coolin Return!
❑Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
4. DateWell(s) Completed: 05/18/18 Well ID# IW-64-A,B
5a. Well Location:
EATON FACILITY
FacililylOwner Name Facility ID# (if applicable)
1100 EAST PRESTON STREET SELMA 27576
Physical Address, City, and Zip
JOHNSTON
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35° 31' 35.43" N 78° 16' 57.82"
6. Is (are) the well(s): ©Permanent or ❑Temporary
W
7. Is this a repair to an existing well: ❑Yes or IJJNo
If this is a repair, Jill oat known well construction information and explain the nature of the
repair under /21 remarAs section or on the back of thistarn_
8. Number of wells constructed: 1
For multiple infection or non -water supply wells ONLY with the same construction, you can
submit one farm.
9. Total well depth below land surface: 30.0/20.0 (ft.)
For multiple wells list all depths ifdii jerem (example- 3@200' and 2Q100)
10. Static water level below top of casing: 12.0 (ft.)
I f water level is above caring use "t "
II. I. Borehole di10.0 (in.)
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test
13b. Disinfection type: Amount:
Form GW-I
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
rt
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap, Geablet
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING leeothernral closed-Isup}
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
23.0 ft.
2.0 r"'
SCH 40
PVC
0.0 ft.
12.0 ft-
2.0 r"'
SCH 40
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
23.0 ft.
30.0 ft
2.0 t"'
.010
SCH 40
PVC
12.0 ft,
20.0 ft•
2.0 in-
.010
SCH 40
PVC
I8. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft,
7.0 ft.
poKrupmErroNtrE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
22.0 ft
30.0 ft
20-40
FINE SILICA SAND
10.0 ft.
22.0 ft. 20-40
FINE SILICA SAND
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION Leder, hardness, sod rock rrpe,:rain size, etch
0.0 ft.
13.0 ft.
TAN CLAY
13.0 ft
30.0 ft.
TAN SILTY SAND
ft.
ft.
ft.
ft.
ft.
ft.
ft.
f.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 20.0 TO 22.0 FT & 7.0 TO 10.0 FT
***NESTED WELLS***
22. Certification:
i+t . L 4P0n:v /
Signatures ertified Well Contractor
06/25/18
Date
Ri signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with /5A NC.4C 02C .0100 or !SA NCAC 02C .0200 Well Construction Standards and that a
copy alibis 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 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 injection 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,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supplv & 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.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (Le_ County, State, Variance, etc.)
3. Well Use (check well use):
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
f.
15 OUTER CASING (for multi -cased wells) ORLLNER(ifap llcabtet
Tttlf'1C,ES'S MATERIAL
FROM
ft
TO
ft.
DIAMETER
in.
16.1NNER.CASING OR TUBING (teothermal dined-fonp)
FROM
TO
DIAMETER
THICI:NrwS
MATERIAL
0.0 ft.
23.0 ft
2.0
in.
SCH 40
PVC
0.0 ft.
12.0 ft.
2.0
in.
SCH 40
PVC
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Obligation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
giMonitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
Aquifer Storage and Recovery
CAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return
4. Date Well(s) Completed: 05/1$/1
5a. Well Location:
EATON FACILITY
❑Groundwater Remediation
❑Salinity Barrier
0Stormwater Drainage
❑Subsidence Control
0Tracer
❑Other (explain under #2 Remarks)
8 WenlD# IW-65-A,B
Facility/Owner Name Facility ID* (if applicable)
1100 EAST PRESTON STREET SELMA 27576
Physical Address, City, and Zip
JOHNSTON
County Panel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
35° 31' 35.43" N 78° 16' 57.82"
6. Is (are) the well(s): 2IPermanent or DTemporary
7. Is this a repair to an existing wen: ❑Yes or ONo
Ij this is a repair, fill our known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction. you can
submit one form.
9. Total well depth below land surface: 30.0/20.0 (ft.)
For multiple wells list all depths ifdifferent (example- 3Q200' and 2Q100')
10. Static water level below top of casing: _ 12.0 (ft.)
If water level is above coxing. use
11. Borehole diameter: _ 10.0 (in.)
12. Well construction method: AUGER
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
Form GW-1
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
23.0 ft
30.0
2.0 in.
.010
SCH 40
PVC
12.0 fL
20.0 ft.
2.0 In.
.010
SCH 40
PVC
IS. GROUT
FROM
TO
MATERIAL
EM PLACI. M ENT METHOD & AMOUNT
0.0 ft.
7.0 ft.
ronn.rwoaurronae
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO
MATERIAL
EMPESCEMMENTMETROD
22.0 ft 130.0 ft.
10.0 ft. 22.0 ft.
20-40
20-40
FINE SILICA SAND
FINE SILICA SAND
20. DRILLING LOG (attachadditionalsheets if necessary)
FROM
0.0 ft.
TO DESCRIPTION i colorhardness, soil/rock t. pr. .rain sire, etc.!
13.0 ft. TAN CLAY
13.0 ft•
30.0 ft TAN SILTY SAND
ft.
ft.
ft.
tt
ft.
ft.
ft.
ft
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 20.0 TO 22.0 FT & 7.0 TO 10.0 FT
***NESTED WELLS***
22. CerlTeat" iin:
Signature of Certified wen Contractor
06/25/18
Date
By signing this form. I hereby certify that the well(s) was (were) constructed in accordance
with I5A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided 10 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 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 Injection 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,
1636 Mail Service Center, Raleigh, NC 27699-1636
Z4c. For Water Suvkly & Iniection 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.
North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan. 2013

N
1111 Superior Ave
Cleveland. Ohio 44114
Tel: [phone]
Powering Business Worldwide Fax: [phone]
February 10, 2012
Ms. Karen Souza, P.G.
Allegheny Environmental Services, Inc.
28 Oak Knoll Drive
Pittsburgh, PA 15238
RE: Agreement to Sign North Carolina REC Certification Pages on Behalf of Eaton
Corporation
Dear Ms. Souza:
Eaton Corporation is mindful of the rules goveming signature of certification pages within
the North Carolina Registered Environmental Consultant (REC) Program under 15A
NCAC 13C .0306. As such, Eaton Corporation grants you the permission to sign North
Carolina REC Certification pages on our behalf.
Yours Truly,
Jeffrey Allen, PG, CHMM
Manager, Growth, Acquisitions and Remediation
Environment, Health, Safety and Security
CAMy Documents-r_00199761Project RemediationsWorth America\Sanford\permission for Karen to certify docs.docx