WI0400600_Injection Event Record_20240306

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number: WI0400600
Were any wells abandoned during this injection
1. Permit Information event?
❑ Yes ® No
NCDEQ,DWM,UST Section, State-Lead Program
Permittee If yes,please provide the following information:
TF#20709—Allison Tree Number of Monitoring Wells NA
Facility Name
Number of Injection Wells NA
4020 Old NC Hwy 601,Dobson, Surry Co,NC 20709
Facility Address(include County) Please include a copy of the GW-30 for each well
2. Injection Contractor Information abandoned.
ATC Associates of NC,PC 4. Injectant Information
Injection Contractor/Company Name Compressed Air
Injectant(s)Type(can use separate additional sheets
Street Address 7606 Whitehall Executive Center if necessary
Drive, Suite 800
Charlotte, NC 28273 Concentration 100%
City State Zip Code
If the injectant is diluted please indicate the source
(704)-529-3200 dilution fluid. NA
Area code—Phone number
Total Volume injected(cubic feet) 66,096
3. Well Information
Volume Injected per well(cubic feet)32,400/33,696
Number of wells used for injection 2
5. Injection History
Well IDs DMW-1 and DMW-2
Injection date(s) 1/29/2024-2/2/2024
Were any new wells installed during this injection Injection number(e.g.3 of 5)2 of unknown
event?
❑ Yes ® No Is this the last injection at this site?
If yes,please provide the following information: ❑ Yes ® No
I DO HEREBY CERTIFY THAT ALL THE
Number of Monitoring Wells INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Number of Injection Wells INJECTION WAS PERFORMED WITHIN THE
Type of Well Installed(Check applicable type): STANDARDS LAID OUTN THE PERMIT.
❑ Bored ❑ Drilled ❑ Direct-Push
❑ Hand-Augured ❑ Other(specify) SIGNAT^E OF INJECTION CONTRACTOR DATE
/�'/ "41 it /e 3-
Please include a copy of the GW-1 fora:for each PRINT N OF PERSON PERFORMING THE INJECTION
well installed
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) For Internal Use Only:
1.Wea Contractor Iaformatioa:
(Owl" gol Qe-a 14.WATER ZONES
Well Contractor Name FROM TO DESCRIE'RON
ft. It.
3 3o-1 ft. R
NC Well Contractor Certification(Number M 0117'F.R TM tir �,
ommariponedim
EY1�I11fiMYHCoi11�1 P21��1Kt) {`�f0�ixq Sefy1'ceSlTitC FROM To 211MArITa THICHPrLSs MATERIAL
- r— — -- -- 55ft. I O it (0 is, kh.t-4o PVC
Company Nano 16.INNSR CASIM OR T apse 0111101
2.Wig CoashimAwtermit#: FROM TO DIAMETER 'Iffi(3LNM MATERIAL
List all gWh4ab/s'wall,6eir6bucrion permits 0 e [",Cr County,State,parlance,etc) in.
3.Well Use(check well use): fL ft hL
Water supply"Wells 17.SCREW
FROM TO D1AMETKR SLO TO T SM TCZUQM MATERAAI.
Agncuhural DMunicipal/Public r7 ft (!0 tt 'ZUL0.01 SC11.t+0 �1G
Geothermal(Heatmp/Cooltng Supply) [)Residential Water Supply(single) F• ft is
Industrial/Commercial Residential Water Supply(shared)
1ti t;ROiTi'
hTigahon FROM TO MATERIAL EMI LACIMENr METHOD 6 AMOUNT
ater Supply well: "' !E r�(R. Cie 1► Mi Fp Tfft. go powix
Monitoring Recovery �(A ILl- �.�> }
tojeetioo Wen: '.
EGwAfwmal
echarge a v �fwater Remediation
i' SAl't,ID1fWA'VEL 1 AdX
torage and Recovery �. " Barrier FROM To MATERIAL EMPLACFJaINT METHOD
est ter Dr-dinage �OS rt S� fl 'Z men yaks
e=
ntal Technology Subsidence Control ft fL
al(Closed Loop) Tracer 2L DdxIlJZ4G LOG addYiaual ii
(HeatittglC noting Retu m) Other(explain under#21 Remarks) FROM To DFSCRwnoN —.kr•iv..ltn.ct ct<
iZ ft
4.Date Well(s)Completed: (o l `(a S wen mg 1 11 1-I�z ft ft.
Sa.weer Location: ZO Z-3 fL a.
I�-l1�bvin. Tree �er►i ce - _ --ft
Facility/Owner Name Facility IDk(t`. k,ahste) ft R
LL0 L O d ld- i-t,gnwav� (0 o) No 50A f`
Physical Address.City,and Zip rt fL
2L UTIAL48M
County Parcel Identification No.(PIN)
Sb.t Broil letegiw&to degrees/mizates/seeonds or decimal degrees:
(ifw'tKs�;,3 lat/loag is sufficient) 22.Certification:
N W
6.ls(are)the well(s) Permanent or OTemporary S ertrfied ll am
By Sig g this rm, 1 here rhfil thbt re (s)was(were roa#ruded in accordance
7.Is this a repair to an existing well: Dyes or DNo with 5A AC 02C.010jn15A MCA C.0200 Well Construction S7an&uds•and that a
If this is a repair.fill our known well conaruction information ad aplain the nature of due copy a this record'has bevi o the well owns.
repair under a21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
consrnxxion,only Lf�W-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I WO SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (L) 24s. For All Wens: Submit this form within 30 days of completion of well
For multiple wells list all depths if diluent(®ample-3@200 and 2@1003 constnidtion to the following:
19.Static water level below fop of casing: (fL) Division of Water Resources,Information Processing Unit,
if wider level is above casing,use t 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: �� UQ (in) 241L For lajeetioa Welts: in addition to sending the form to the address in 24a
t nn
17-Wee construction method: above,also submit one copy of this form within 30 days of completion of well
Itr t�t9 hOutl
(i-e.auger,rotary,able,direct push,etc) oonstrtidion to the following:
Division of Water Resources,Undergrod Injection Coubvi program,
FOR WATER SUPPLY WELLS ONLY: ®
1636 Mad Service Center,Raleigh,NC 270,fA-16M
13a.Yield(gpm) Method of test 24e.For Water Su & 4kc-Cme Wells: in addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the cotmty health department of the cotmty
Where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Rtvised 2-22-2016

• DEEP MONITORING WELL: DMW-1
ArA%
k C (Page 1 of 1)
Allison Tree Service Date(s)Drilled 06/07-08/2023 Boring Diameter :HA=3.25"
4020 Old NC Highway 601 Drilling Conractor :EDPS :AR=10.00"
Dobson, North Carolina
ATC Project No.SLC2070903 Drilling Method :Hand Auger(HA)
Client: NCDEQ State Lead Program Air Rotary(AR) Logged By :Kyle Harris
a) Well: DMW-1
LL U_
.S 2
U) a DESCRIPTION
O Cover
0
Asphalt Outer
Red silty clay,low plasticity Casing
5 CL
10
ML Red silt mixed with light red/white silt, no plasticity
Red silt, low plasticity, poorly sorted with<1 cm long crystalline rock
15
a
20
0
N
J
ML
25
8 Grout
m
0
Inner Casing
30
U
C
35
N Light brown silt,low plasticity,mixed moist silt,wet at 40'bgs
N
t.
O
40
0
0
N
45 MIL
0 50
N
g
0 55
F Grayish brown sandy silt, no plasticity, poorly sorted with<1 cm long crystalline Sand
rock Bentonite
a
60 MIL
0
U
m
65 End of Boring Screen
in
z
w 70
0
U
z ft bgs=ft below ground surface
vi
M
N
O
N
N
O

ArA• DEEP MONITORING WELL: DMW-2
jr %T
k C (Page 1 of 1)
Allison Tree Service Date(s)Drilled 06/07-08/2023 Boring Diameter :HA=3.25"
4020 Old NC Highway 601 Drilling Conractor :EDPS :AR=10.00"
Dobson, North Carolina
ATC Project No.SLC2070903 Drilling Method :Hand Auger(HA)
Client: NCDEQ State Lead Program Air Rotary(AR) Logged By :Kyle Harris
a) Well: DMW-2
LL U_
.S 2
Cn a DESCRIPTION
Cover
0
rAhsa, Outer
CLAY, low plasticity Casing
5
10 CL
15
a
20 Medium brown SILT, poorly mixed with<1 cm long rock fragments, moist at 35'
m
bgs
0
25
8 Grout
m
M
o Inner Casing
30 ML
U
C
O
N
35
O
N
N
t.
O
40
Silty CLAY, low plasticity, poorly sorted with rock fragments, mud from boring at
50'bgs
N
45 CL
° 50 Brown sandy SILT,wet,grayish brown at 55'bgs with 1/2 cm long slate
N
g fragments intermixed
N
f6
0 55
r Sand
MIL Bentonite
a
60
0
0
U
m
65 End of Boring Screen
in
Z 70
0
U
z ft bgs=ft below ground surface
�i
M
N
O
N
N
O