MO-6739_27493_CA_WR_20240408

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____WI0300460_________________
1. Permit Information __R.J. SHELL & SON, INC._________________ Permittee
____A-1 Superette____________ Facility Name _1110 S. Center St, Hickory, NC Catawba, 28602____ Facility Address (include County) 2. Injection Contractor Information ___Terraquest Environmental Consultants, P.C.____ Injection Contractor / Company Name
Street Address___100 E Ruffin St_________ __Mebane_________NC___________27302____
City State Zip Code (919_____) __906-0960_______________
Area code – Phone number 3. Well Information Number of wells used for injection _____32______ Well IDs__BORE1-32__________________ 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______32____________

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_______32___________ Please include a copy of the GW-30 for each well
abandoned. 4. Injectant Information
_Oxygen Biochem__________________________ Injectant(s) Type (can use separate additional sheets
if necessary Concentration ____1,900#/960gal_______________ If the injectant is diluted please indicate the source dilution fluid.______municipal water___________ Total Volume Injected (gal)____960______ Volume Injected per well (gal)_____30_________
5. Injection History Injection date(s)_________4/1-5/2024______
Injection number (e.g. 3 of 5)_______2 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.
____________________________________________4/8/2024_
SIGNATURE OF INJECTION CONTRACTOR DATE __Wes Sorrells________________________________________________ PRINT NAME OF PERSON PERFORMING THE INJECTION
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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:

Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
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
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 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.
Wesley Sorrells
3577
Terraquest Environmental Consultants, P.C.
WI0300460
32
4/1-5/2024 BORE1-32
-1 Superette 00-0-0000004363
1110 S Center St NW, Hickory, NC
Catawba 370215549376
35.717851 -81.338325
50
39
8.25
auger
4/8/2024
0
37 39 bentonite pour
0
43
43
50
silt to saprolitic silt
saprolite
32 8.25" boreholes drilled and 30 gallons of Oxygen Biochem
slurry poured in. 50# bag of bentonite added on top.
Print Form
WELL ABANDONMENT RECORD
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
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 □Municipal/Public
□Geothermal (Heating/Cooling Supply)□Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
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 7g)
4. Date well(s) abandoned:
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
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#:
6b. Total well depth: (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (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:
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 □Bentonite Chips or Pellets
□Sand Cement Grout □Dry Clay
□Concrete Grout □Drill Cuttings
□Specialty Grout □Gravel
□Bentonite Slurry □Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
8. Certification:
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 Injection Wells: In addition to sending the form to the address in 10a
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.
Wes Sorrells
3577 32
Terraquest Environmental Consultants, P.C.
WI0300460
50# bag per hole bentonite hole plug
4/1-5/2024
32 8.25" boreholes drilled and 30 gallons of Oxygen Biochem
slurry poured in. 50# bag of bentonite added on top.
A-1 Superette 00-0-0000004363
1110 S Center St NW, Hickory, NC 4/8/2024
Catawba 370215549376
35.717851 35.717851 -81.338325
BORE1-32
50
8.25
39
none
none
none