WI0400602_IER 7-11-2023_20230711

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number vv1U4UU0Uz
1. Permit Information
NCDEO DWM, UST Section, State Lead
Permittee
TF#22633 Fork Exxon
Facility Name
3341 US Hwy 64 E, Advance, NC 27006 (Davie)
Facility Address (include County)
2. Injection Contractor Information
ATC Associates of North Carolina, P.C.
Injection Contractor / Company Name
Street Address 7606 Whitehall Exec Ctr Dr, Ste 800
Charlotte North Carolina 28273
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 1 g'zq
Well IDs DMW-2
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 DMW-2
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
Air (-2.9-4.3 cfm for —50% of the 96 hrs)
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 100% air
If the injectant is diluted please indicate the source
dilution fluid. NA
Total Volume Injected (gal)—20,700 CF
Volume Injected per well (gal)—20,700 CF
5. Injection History
Injection date(s) Ma 1-5 2023
Injection number (e.g. 3 of 5) 1 of unknown
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
SILANDARDS,LAID OUT IN THE PERMIT.
V�
S TURE INJECTION CONTRACTOR DATE
Ashleigh Thrash, ATC Associates of NC, P.C.
PRINT NAME OF PERSON PERFORMING THE INJECTION
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 (GW-1)
1. Well Contractor Information:
4 ©ft!n M SO LAa"
Well Contractor Name
330 ?
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (i.e. UDC, Coun(, State. Variance, etc.)
3. Well Use (check well use):
Water Supply
(Heating/Cooling Supply)
igation
-Water Supply Well:
Recharge
Storage and Recovery
Test
rental Technology
mal (Closed Loop)
bMunicipal/Public
Residential Water Supply (single)
bResidential Water Supply (shared)
Groundwater Remediation
Salinity Barrier
bStormwater Drainage
Subsidence Control
Tracer
bother (explain tinder #21 f
4. Date wen(s) completed: y)Zy-4} -n
Sa_ Well Location: ZO23
_Fo' k Exxo In
Facility/Owtxr Name
Well ID# oMW "?.
Facility ID# (if applicable)
33 41 VS 4wH U9 East ftAyance) tic,
Physical Address, City, and Zipot
'- 0"11 e
County
Parcel Identification No (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
_ N
6. Ir4are) the wells) Permanent
or bTemporary
W
7. Is this a repair to an existing well: byes or �No
Lf 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 NUN(IBER of wells
drilled: 19IN E -
9. Total well depth below land surface: } 0 00
For multiple wells list all depths if different (example- 3@200' and 2@100�
1(L Static water level below top of casing:
If water level is above casing, use
11. Borehole diameter' (Q (in.)
12. Well construction method: Ali' 464"
0 e. auger, rotary, cable, direct push, etc.)
It WATER ZONES
FROM
TO
DESCRIPTION '
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ft
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I& (Rim COGN�DAmRad w
FROM
HiIACKNESS
MATERIAL
15 ft
O ft
!Q m Scin.yo
Put,
16. Il�INEit CASxNG t)R "i'BSi4iiG
FROM
TO
D14ACE R
THICE9M%
MATERIAL
4AS It
ft
Z is
� gyp
(c�G
ft
ft
in.
17. SCREEN
FROM
TO
DIAME1TiR
SLOT SrLE
THIC4iNiS.S
MATEBUfI.
Taft
!a5 ft
Z..
tL
fL
is
IL GROUT
FROM
TO
MATERIAL
EMPI ACKMENTML+THOD & AMOUNT
ft
ft
19. SAND/GRAVEL PACK (if appReaW
FROM
TO
MATERIAL.
I1NPI.tiC%MEN'I' METHOD
?oft
(a 3 ft
At Z ,tiea.t+ri
ft
ft
2L DR1i l ING LOG at uetai Lail
FROM
TO
DFSCR.II'TION Wem; harimm" m Ynek . as ere.
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ft
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ft.
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,
ft
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21. REMARKS77777
22. Certification:
5 Z1z3
Si ofC find o . Date
signi Is form, hereby certify the welts) was (were) constructed in accordance
A, NG 4C 02C .. NCAC 02C .0200 Well Construction Standards and that a
copv 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:
{fL) Division of Water Resources, Information Processing Unit,
t 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 one copy of this form within 30 days of completion of well
construction to the following:
FOR WATER SUPPLY WELIS ONLY: Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 2769946M
13a. Yield (gpin) Method of test: 24c. For Water Supply & Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
131L Disinfection type: Amount: 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