RA-630_3880_P_UIC_20230906

2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598

September 6, 2022

Mr. Michael Hall
Raleigh Regional Office
North Carolina Department of Environmental Quality
Water Quality Regional Operations Section
1628 Mail Service Center
Raleigh, North Carolina 27699-1628

Reference: Injection Event Record – Permit # WI0600236
Former K&L Grocery
2281 Beaverdam Road
Enfield, Halifax County, North Carolina
NCDEQ Incident No. 3880

Dear Mr. Hall:

ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Former K&L Grocery site on behalf of the North Carolina Department of Environmental Quality
State Lead Program. The record documents an air sparge event on well AS-1 associated with
the above referenced site.

If you have questions or require additional information, please contact our office at [phone].

Sincerely,
ATC Associates of North Carolina, P.C.

Nicholas Kramer Gabriel Araos, P.E.
Project Scientist Program Manager
Direct Line: 919-573-1198 Direct Line: 919-573-1205
Email: [e-mail] Email: [e-mail]

cc: Linda Blalock

Attachments

Injection Event Record
Former K&L Grocery, Enfield, North Carolina

INJECTION EVENT RECORD

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
North Carolina Department of Environmental Quality – Division of Water Resources
INJECTION EVENT RECORD (IER)

Permit Number WI0501118

1. Permit Information

NCDEQ
Permittee

Former K&L Grocery
Facility Name

2281 Beaverdam Road, Enfield, Halifax County, NC
Facility Address (include County)

2. Injection Contractor Information

ATC Associates of NC, P.C.
Injection Contractor / Company Name

Street Address 2725 E. Millbrook Road, Ste 121

Raleigh NC 27604
City State Zip Code

[phone]
Area code – Phone number

3. Well Information

Number of wells used for injection 1

Well IDs AS-1

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__________________

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.

Concentration Not Applicable

If the injectant is diluted please indicate the source
dilution fluid. Not Applicable

Total Volume Injected (gal) Not Applicable

Volume Injected per well (gal) Not Applicable

5. Injection History

Injection date(s)__August 29, 2023

Injection number (e.g. 3 of 5)__1 of 1____________

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.

__________________________09/06/2023_____
SIGNATURE OF INJECTION CONTRACTOR DATE
ATC Associates of North Carolina, P.C.
PRINT NAME OF PERSON PERFORMING THE INJECTION
if necessary
Injectant(s) Type (can use separate additional sheets
Continuous Air
4. Injectant Information
abandoned.
Please include a copy of the GW-30 for each well
Number of Injection Wells__________________
Number of Monitoring Wells _______________
If yes, please provide the following information:
Yes No
event?
Were any wells abandoned during this injection
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018
1.Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
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 □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single) □Industrial/Commercial □Residential Water Supply (shared) □Irrigation □Wells > 100,000 GPD
Non-Water Supply Well: □Monitoring □Recovery
Injection Well: □Aquifer Recharge □Groundwater Remediation □Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage □Experimental Technology □Subsidence Control □Geothermal (Closed Loop)□Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: Well ID#
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Physical Address, City, and Zip
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 W
6.Is(are) the well(s): □Permanent or □Temporary
7.Is this a repair to an existing well: □Yes or □No
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:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10.Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
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:
14. WATER ZONES
FROM TO DESCRIPTION
ft. ft.
ft. ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
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
ft. ft. in.
ft. ft. in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft. ft.
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, soil/rock type, grain size, etc.)
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21. REMARKS
22.Certification:
Signature of Certified Well Contractor 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 wellconstructioninfo(add'SeeOver'inRemarksBox).Youmayalsoattachadditionalpagesifnecessary.
24.SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD:Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
DAVID HALL
A - 4459
GEOLOGIC EXPLORATION
WI0501118
0.0 15.0 SCH 40
15.0 20.0 .010
0.0 PORTLAND BENTONITE
13.0 20-40
0.0 SANDY CLAY 08/22/23 AS-1
K&L GROCERY
2281 BEAVERDAM ROAD ENFIELD 27823
HALIFAX BENTONITE SEAL ~ 10.0 - 13.0 FEET
36° 14' 04.88" 77° 41' 59.46"08/24/23
20.0
8.0
8.0
AUGER
PVC
SCH 40 PVC
2.0

2.0
10.0
20.0
20.0
FINE SILICA SAND
SLURRY