WI0400543_Compliance_20200422

Vle►"North Carolina Department of Environmental Quality — Division of Water Resources
�QFt 1,�p20 INJECTION EVENT RECORD (IER)
Permit Number WI 0400543
1. Permit Information
AECOM
Permittee
Akzo Nobel Coatings, Inc.
Facility Name
3950 NEW WALKERTOWN RD Winston-Salem, NC 27105
Facility Address (include County)
2. Injection Contractor Information
Redox Tech, LLC
Injection Contractor / Company Name
Street Address 200 Quade Dr
Cary NC 27513
City State Zip Code
919 678-0140
Area code — Phone number
3. Well Information
Number of wells used for injection 22
Well IDs N/A (Temporary)
Were any new wells installed during this injection
event?
❑ Yes Al 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.
Were any wells abandoned during this injection
event?
Q Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 22 Temporary
Please include a copy of the GW-30 for each well
abandoned
4. Injectant Information
Calcium Peroxide
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 20-300 lbs per injection well
If the injectant is diluted please indicate the source
dilution fluid. Water (Hydrant)
Total Volume Injected (gal) 6,000
Volume Injected per well (gal) Varies
5. Injection History
Injection date(s) 3/11 /2020 - 4/10/2020
Injection number (e.g. 3 of 5) 1
Is this the last injection at this site?
❑ Yes 0 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
ST ARDS LAID OUT IN THE PERMIT.
u��sl���
SIGNATURE OF INJECTION CONTRACTOR DATE
Blair Mitchell
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. Well Contractor Information:
Blair Mitchell
Well Contractor Name
NCWC 4419-C
NC Well Contractor Certification Number
Redox Tech, LLC
RECEIVED
APR 17 2020
DVVR
CenttralQIoffice
Company Name
2. Well Construction Permit #: W 10400543
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
[]Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
El Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
El Geothermal (Heating/Cooling
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100,000 GPD
In Groundwater Remediation
❑ Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 F
4. Date Well(s) Completed: 4/8/20 Well ID# 1 -22
5a. Well Location:
Akzo Nobel Coatings
Facility/Owner Name Facility ID# (if applicable)
3950 New Walkertown Rd Winston-Salem, NC 27105
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one ]at/long is sufficient)
36.145345 N-80.188451
6. Is(are) the well(s): ❑Permanent or [']Temporary
14. WATER ZONES
FROM TO
DESCRIPTION
6 ft. 16 ft.
ft. ft.
15. OUTER CASING for ased wells) OR LINER ifs licable
FROM TO
TWO
DIAMETER
fnICKNE55
MA"i'F:RIAI_
ft. ft.
I in.
16. INNER CASING OR TUBING eother al closed-loo
FROM
TO
DIAMETER
THICKNESS
I MATERIAL
ft.
in.
in.
±fl
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
rt.
ft.
ft.
I ft.
20. DRILLING LOG attach additional sheets if necessary
FROST
TO
D F SC R I P11014 1 color, hardness, sail/rock [v e, grain size, etc.l
ft.
ft.
ft.
ft.
rt.
rt.
ft.
ft.
ft.
ft.
fL
ft.
ft.
rt.
21. REMARKS
22. Certi cati
W
Signal e ofCertrfied Well eontractor
7. Is this a repair to an existing well: ❑Yes or InNo
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 farm.
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: zz
9. Total well depth below land surface: 16
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 6
Ifwater level is above casing, use "+"
II. Borehole diameter: 1.5 (in.)
12. Well construction method: DPT
(i.e. auger, rotary, cable, direct push, etc.)
4/15/2020
"HU:
13v signing this form, I hereby certify that the wells) 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 construction info
(add 'See Over' in Remarks Box). You may also attach additional pages if necessary.
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),
(ft.) 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 Supp iv and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100.000 GPD: Copy to DWR, CCPCUA
13a. Yield (gpm) Method of test: Permit Program, 1611 MSC, Raleigh, NC 27699-1611
13b. Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL ABANDONMENT RECORD
1. Well Contractor Information:
Blair Mitchell
Well Contractor Name (or well owner personally abandoning well on his/her property)
NCWC 4419-C
NC Well Contractor Certification Number
Redox Tech, LLC
Company Name
2. Well Construction Permit #: W l 0400543
List all applicable well construction permits (i.e. UIC, County. State, Variance, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ❑Recovery
❑Aquifer Recharge
[]Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
[]Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
RGroundwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
[]Tracer
❑Other (explain under 7
4. Date well(s) abandoned: 4/1 0/2020
5a. Well location:
Akzo Nobel Coatings
Facility/Owner Name Facility ID# (if applicable)
3950 New Walkertown Rd Winston-Salem, NC 27105
Physical Address, City, and Zip
Forsyth
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f 11 f Id
For Internal Use ONLY:
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: 12
7b. Approximate volume of water remaining in well(s): 0 (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
0 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:
Soiduim bentonite no. 16
7g. Provide a brief description of the abandonment procedure:
Removed dpt rod and filled with sodium bentonite,
packed 5' bgs, and refilled with sodium bentonite
8. Ce ' t on:
,0, qjl�1202o
Sig ure Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 1 SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
(t we re , one laVwng is su—ment) 9. Site diagram or additional well details:
36.145345 N-80.188451 W 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.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or 1�� wells
ONLY with the same construction/abandonment, you can submit one fors
6a. Well ID#: 1 - 22
APR 17 2020
6b. Total well depth: 16 (ft.) NC DEQ/DWR
C®rural Office
bc. Borehole diameter: 1.5 (in.)
6d. Water level below ground surface: 6 (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known):
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 Infection 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 Supph• & 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.
6g. Screen length (if known):
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016