WI0100272_EFile_20201105

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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule"and do not require an individual permit when constructed in accordance
with the rules of l 5A NCAC 02C.0200. This form shard be submitted at least 2 weeks prior to injection.
AQUIFER TEST WELLS (15A NCAC 02C.0220)
These we]Is arc used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC..92C.0225) or TRACER'WELLS (15A NCAC III C-0229):
1) Passive Injection Systems - In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socics, i OC systems, and other gas infusion methods.
2) Sma.11-Scale I6ection Operations — Injection wells located within a land surface:area not to exceed 10,000
square meet for the purpose of soil or.-rourldwater rernediation or tracer tests. An individual permit shall be regitired
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - PreliMirlary studies conducted for the purpose of evaluating the: technical feasibility of a
rci-nedintion strategy in order to develop a full scale remediation plan for future implemo-atation, and Where the
surface area of Lhc injection zone wells are located within an area that does not exceed five percezit of the land
suri'aGC aboue die known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
11rint Clearly or Type Information. Illegible Submittals 'Will Be Returned As.Incomplete.
DATE; December 30 , 2013 PERMIT NO. (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) X A.iT Injection Well......................................Complete sections B-F, K,N
(2) Aqui1`e:r Test Well....--.-- ............... .........Complete sections B-F, K,N
(3) Passive I11jeCLi0n Sys=.............. ..............�COMPlete sections B-F,H-N
(4) _Studl1-Scale Injection Operation......................Complete sections B-N
(5) _pilot Test....................................................Complete 5 --O sections n
(6) Tracer Injection Well.............
......................Completesectlons -,
B. STATUS OF WELL OWNER. Business/organization
C. WELL OWNER — State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: Sunoco Inc R&M- Devon Watts
Mailing Addni ss: 203 South Falkeriburg Drive
City: Tampa _ State: _'L^Zip Code: 33619 _ _County:FIillsborough —
Day Tcle No.: S:t3-634-7789 Cell No-:
ENVUL Address: [e-mail] Fax No-:
UIC11n Situ Rcmcd. Notification(Revised 111191201.3) Page 1

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D. PROPERTY OWNER(iF different than well owner)
Name::
Mailing Address:
State: .Lip Code: County:
City:
Day Tele No.: Cell No.:
EMAL L Address; Fax No.:
1:. PROJECT CONTACT Person who can answer technical questions about the proposed injection project.
Navne; John Coyne
Mailing Address: 13109 0ver100k Pass
City: Roswell State: GA_Zip Code:: 30075_ __County: Fulton
Day'lc1.e No.: 770-777-1 Ll Cell No,:
EMAU-Address: nx Fax No.:
P. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: ?53 Cedar Malley Road _County:Caldwell
Cary: Hudson State:NC Zip Code: 2W8
(?) Geographic Coordinates: Latitude": — —
Or
Lougi tulle**: _ or
keferencc Datum: Accuracy:
Method of Collection:
**POP,AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITT MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN L1EU OF GEOGRAPHIC COORDINATES.
G. TREATMENT"AREA
Land surface area of contaminant plume: square feet
Land surface area of ini. well network: square feet L< 10,000 ft�for small-scale injections)
percent of contaminant plume area to be treate:d:_(inust be<5%of plume foz pilot test injections)
H. INJECTION LONE MAPS—Attach the foilowill; to the n.otificatiou.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
oontaminanc plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-sections) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, cha119es in lithology, existing and
proposed monitoring wells, and existing and proposed injection wells.
l iuina Situ Remed, NoZicaliOa(Revised't 1119f20I3) Page 2

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Y. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — provide a brief narrative >-egarding the
purpose, scope, and goals of the proposed injection activity.
J, )INJECTANTS --provide a MSDS and the following for each injectant. Attach additional sheets if necessaty-
NOTE; Approved injectants (tracers and remediation additives) can. be found online at
All alher substances must be reviewed by the Division Of Public
Health, Department of Health and Human Services. lettuce the UIC Program for more i�afo (919-807-6496)-
injectant:
Volume of injcctant:
Concentration at point of injection_
percent if in a mixture with other injectants:
Injectant:
Vc11t1me of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectan t_
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: S proposed 0 Existing
(2) Provide well construction details for each injection well in a diagram or table format. A.single
diagram or line in a table can be used for multiple wells witl-i the sa3-ne construction details. Well
construction details shall include the following:
(a) well type as permariont,direct-push,or subsurface distribution system(infiltration gallery)
(b) depth below land surface of grout, screen, and casing ii)tErvals
(c) well contractor name and certification number
UlC/lri Si ai Rcrried,NolificaLiocf(Revised 11/19/2613) Page

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L. SCHEDULES—Briefly describe the schedule for well.construction and in_jcctioD activities.
MONITORING PLAN—Describe below or in separatc attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subcha ter 02L restllt from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT. "I hereby certify, ulldgr penalty of law, that I am familiar with the inforrnation submitted In
r1lis docurn?.eni and all attachrllents thereto and that, based on my inquiry of those individuals immediately
responsible for obtaining said inforna,ation, i believe that the irlpr7nation is trice, accurato and complete. I arm
aware that there are significant penalties, including the possibility of fines and imprisonment,for submitting
false information. I agree to Construct, operate, rnairrtain, repair, and if applicable, abandon the injection well
and all 1' lated appacrreli.anoes in accordance with the.7 5A NCAC 02C 0200 Rules.„
Devon Watts
Print or Type Full Name
Signature of Applicant
PROPERTY OWNLl2 if the PLOWrty is not owned by the erirut a licant :
"As owner of th,c:property on. which the injection weU(s) are to be constructed and operated, I hereby consent
to allow The applicant to construct each in ec�tion.well as outlined in this application and agree that ii shall be
the responsibility of the applicant to ensure that the injection o,ell(s) conform to the Well Construction
Standards(15A NCAC 02C,0200).„
"Owner" means any person who holds the fee ox other property rights in the well being constructed. A
w 1.1 is teak property and its construction on land shall be deemed to vest ownership in the land. owner, in
the absence of contrary agreement in writing.
Signature*of Property owner(if different From applicant) Print or Type Full Narne
* An access aoreerrcent between the applicant and property owner may be submitted in lieu of a signature on this form_
SubtWt one copy of the completed notification packazte to:
DWR—UIC Program
1636 Mail Service Canter
Raleigh,NC 27699-1636
Telephone: [phone]
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13109 OVERLOOK PASS, ROSWELL, GEORGIA 30075 REVISION DATE: 1/27/14 REVISED BY: B.S. HUDSON, NORTH CAROLINA
PHONE: [phone]

aSTATC4
�Vp NoNRESIDENTIAL WELL CONSTRUCTION RECORD
pp North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 2580
ao- r�
1.WELL CONTRACTOR: :d. TOP OF CASING IS 0.0 FT.Above Land Surface'
JASON MANTAK 'Top of casing terminated aVor below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118,
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name e. YIELD(gpm): N/A METHOD OF TEST N/A
176 COMMERCE BLVD I. DISINFECTION:Type N/A Amount N/A
Sheet Address ;g. WATER ZONES(depth):
STATESVILLE NC 28625 :Top Bottom Top Bottom
City or Town State Zip Code ;Top Bottom Top Bottom
70( 4 ) 872-7686 :Top Bottom Top Bottom
Area code Phone number
Thickness/
2.WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# N/A :Top 0.0 Bottom 30.0 Ft. 2 INCH SCH 40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) : Top Bottom Ft.
SITE WELL ID#(ifapplicabie) AS-1 :Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring W Municipal/Public❑ : 8. GROUT: Depth Material Method
Industrial/Commercial❑ Agricultural❑ Recovery ) To 0.0 Bottom 24.0 Ft. PORTL NDBEWONITE SLURRY
❑ Injection❑ Top
-0.0
Other[] (list use) :Top Bottom Ft.
DATE DRILLED 08/31/11 :Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
255 CEDAR VALLEY ROAD 28638 :Top 30.0 Bottom 35.0 Ft. 2.0 in. .010 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) ;Top Bottom Ft. in. in.
CITY: HUDSON COUNTY CALDWELL :Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope []Valley ❑Flat ❑Ridge ❑Other 10.SAND/GRAVEL PACK:
Depth Size Material
LATITUDE _°_' "DMS OR DD :Top 28.0 Bottom 35,0 Ft. 20-40 FINE SILICA SAND
LONGITUDE _ "DIMS OR DD ;Top Bottom Ft.
Latitude/longitude source: ❑GPS ❑topographic map :Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) 11. DRILLING LOG
5.FACILITY(Name of the business where the well Is located.) Top Bottom Formation Description
HUDSON SITE-GAS STATION N/A 0.0 / 2.0 ORANGE CLAY
Facility Name Facility ID#(if applicable) 2.0 / 24.0 ORANGE SILTY CLAY
255 CEDAR VALLEY ROAD 24.0 / 30.0 RED SILTY CLAY
Street Address 30.0 / 35.0 TAN SILTY CLAY
HUDSON NC 28638 /
City or Town State Zip Code /
SUNOCO INC /
Contact Name /
203 SOUTH FALKENBURG ROAD /
Mailing Address J
TAMPA FL 33619
City or Town State Zip Code 12.REMARKS:
(� BENTONITE SEAL FROM 24 0 TO 28,0 FEET
Area code Phone number
6.WELL DETAILS: IRRD
EBY CE TIFY THAT THIS W L W ftUCTEO IN ACCORDANCE C2C, LCONSTRa. TOTAL DEPTH: 35,0 FEET HAseRo�vlDe wNER.
1� 09/07/11
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO qI :SIGNATUR F CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 25.0 FT. JASON ANTAK
(Use"+^if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Submit wltHin 30 days of Completion to []vision of Mtei Quality lnformatlon Processing, Rev.2/09
i 1 77 Mail Service Genter Raletgh"N c 27699 761 9)Phone !(91 a07 6 00

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
MARK GEMS 14,WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft fL
A - 2345 fL ft.
NC Well Contractor Cenification Number 15,OUTER CASING ffor muiti�ased wd is t?R LIliIER if a licible
FROM TO u[AMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC I'L ft in.
CompaM Name 16.INNER CASING OR TUBING iEeathersual dosedaoo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 0 ft- 35 0 fL 2,0 SCH 40 PVC
Lest all applicable well construction permits 0.e.County,Slate,variance,etc.)
fL ft- in.
3.Wdl Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 ft. 37.0 ft. 2.0 i" 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft,
❑IndustnaUCommercial )Residential Water Supply(shared) I&GROUT.
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 2,0 fL 30.0 fL wa ,hoar.aM,r SLURRY
Nun-Water Supply Well:
ft
❑monitoring ❑Recovery fL
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANI)IGRAVEL PACIC(if a ricable
FROM TO MATERIAL EM PLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 33.0 ft 37.0 ft 20-4❑ FINE SILICA SAND
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology []Subsidence Control 0.0 fL 2.0 rL 20-4C FINE SILICA SAND
❑Geothermal Closed Loop) .20.DRILLING LOG attach additional sheets if
( p) ❑Tm FROM TO U�SCRIPTION{color, aaiUreck rain arc,etc
❑Geothermal (Heating/Cooling Return) E30ther(explain under 421 Remarks) 0.0 It- 20.0 f' DARK RED SILT
4.Date Wdl(s)Completed: Well IDLE
10/21/13 AS-2 20.0 fL 37.0 fL BROWN SILT
fL fL
5a-Well Location: fL &
SUNOCO SERVICE STATION
fL fL
Facility/Owner Name Facility mN(if applicable)
IL fL
255 CEDAR VALLEY ROAD HUDSON 28638
IL ft
Physical Address,City.and Zip 21.REMARKS
CALDWELL BENTONITE SEAL FROM 30.0 TO 33.0 FEET
Cousuy Parcel Identification No.(PIN) "'AIR SPARGE..>
5b.Latitude and Longitude in degrees/minotes/seconds or decimal degrees: 2 Certification•
(if well 5eld,one lat/long is sufficient)
35° 50' 44.97" n 810 28' 4$.90" W .. `1 10/24/13
Signature of Certified Well Contractor Date
6.is(are)the well(s): ( Permanent or ❑Temporary By signing this form,1 hereby cert6fy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stardards and that a
7.Is this a repair to as existing well: ❑Yes or PJNo copy of ibis record has been provided 10 the well owner.
1f this is a repair,fell out known welt construction information and explain the nature of the
repair under 911 remarks section or on the back of Ars form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONL F with the attire catrstractson,you can
submit one form. SUBMITTAL.INSTUCTIONS
9.Total well depth below land surface: 37.0 (ft-) 24a. For Alt Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdrfferent(example.3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 20.0 (ft_) Division of Water Quality,Information Processing Unit,
!f wooer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Wrier Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 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
13b.Disinfection type• Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Depatunent of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

WELL CONSTRUCTION RECORD For Iniernal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
MARK GETTYS 14.WATERZONES
FROM TO OFSCRIPTION
Well Contractor Nano it. ft.
A - 2345 ft. FL
NC Well Contractor Certification Niunher 15.OUTER CASING(for multi-cased wells OR LAYER if a licable
FROM 1 TO I DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC ft, ft. in,
Company Name 16,INNER CASING OR TUBING(geothermal closed-loo
FROM TO DLAMETER THICKNESS MATERLAL
2.Well Construction Permitil: 0 0 fL 35.0 ft- 2.0 in' SCH 40 PVC
List all applicable well construction permits(ix,County,State,Variance.ete.J
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 rL 37.0 rt• 2.0 rn 010 SCH 40 PVC
❑Geothermal(Heating./Cool i ng Supply) ❑Residential Water Supply(single) rL fL in.
❑IndustriallCommercial ❑Residential Water Supply(shared) IN.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
DIrrigation 2.0 rL 30.0 Ft' SLURRY
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: & ft.
❑Aquifer Recharge ❑Groundwater Remediation '19.SANDIGRAVEL PACK if a licable
DAquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage 33.0 fL 37.0 rt 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 0,0 It- 2.0 tt. 20-40 FINE SILICA SAND
20.➢RC.LING LOG attach additional sheets if riccesstt _ _
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(ml-,hardness,soith ock type,cr,iin sin,etc.)
❑Geothermal(Heating/Cooling Return) ❑Otter(ex lain Under021 Remarks) 0.0 f'- 20.0 fL DARK RED SILT
10/21/13 AS-3 200 rt 37.0 fL BROWN SILT
4.Dale Well(s)Completed: Well ID#
ft. ft
Sa.Well Location: ft. fL
SUNOCO SERVICE STATION
rt. rt.
Facility/Owner Nank Facility IDN(ifapplicable)
rt. rt.
255 CEDAR VALLEY ROAD HUDSON 28638
ft rt
Physical Address.Cm and Zip 21.REMARKS
CALDWELL BENTONITE SEAL FROM 30.0 TO 33.0 FEET
County parcel Identification No (PIN) ***AIR SPARGE***
Sb.Latitude and Longitude in degreesiminutes/seconds or decimal degrees: r'tcap
(if well field,one Iadlong is sufficient)
35° 50' 44.90r' N 810 28' 49.12" �, 10/24/13
Signature of Certified Well Contractor Date
6.Is(are)the welt(s): [OPermanent or ❑Temporary
By signing this form,!hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Con imcreon Standards and rhar a
7.Is this a repair to an existing well: ❑Yes or QNo copy afthis record has been provided to the well oxner.
f thrs is a repair.fill out known well construction information and explarn the nature of the
repair under 021 remarks semon or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional Awl site details or well
8.Number of wells constructed. construction details. You may also attach additional pages if necessary.
Far multiple injection or non-wafer supple•wefts ONLY>.alb the same construction,you can
submit one form_ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37.0 (ft) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rf different{example-3@200'and 2@100') constmclion to the following:
10.Static water level below top of casing: 20.0 (ft.) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Injection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this form within 30 days of completion of welt
12.Well construction method: construction to the following:
(i.e,auger,rotary,cable,direct push,etc.)
Division of Water Quakily,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 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
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Wata Quality Revised]an.2013

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
L Well Contractor Information:
MARK G E TTYS 14.WATER ZONES
FROM TO DESCRIPI70N
Well Contractor Name ft. ft.
A - 2345 R. ft-
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR L ER if a licable
FROM TO TH1C1(7VE55 MATERIAL
GEOLOGIC EXPLORATION, INC ft. '- D14M ETEAin.
Company Name 16...INNER CASING OR TUBING(geothermal ciosed400
FROM TU DIAMETER THICKNESS MATERIAL
2,Well Construelioe Permit#1: 0.0 f`- 35.0 ft. 2.0 '"� SCH 40 PVC
List all applicable well construction permits(i.e,County.Stale, Variance,eic.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water SopplyWell: FROM To DIAMETER SLAT SIZE MCkNESs MATERIAL
❑Agricultural ❑Municipal/Public 35.0 iL 37.0 rL 2.0 'o' .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Coolin Supply) OResidential Water Supply h• ft. in.
( !31 S pP Y) pP Y(single)
❑Industrial/Commercial OResidential Water Supply(shared) 19.GROLTf
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri uon
Non-Water Supply Well: 2.0 rL 30.0 rL uav�«aa'rr SLURRY
❑Monitoring ❑Recovery FL ft.
Injection Well: ft. 11.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SANDIGRAVELPACK(if applicable)
_
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERLAL EMPLACEMENT METHOD
❑Aquifer Test QStormwater Drainage 33.0 f` 37.0 rL 20A0 FINE SILICA SAND
>7Experimental Technology ❑Subsidence Control 0.0 !` 2.0 rL 20-40 FINE SILICA SAND
-20.DRILLING LOG lattach additional sheets if nec .r'.
❑Geothermal(Closed Loop) ❑Tracer FROM TO PESCRiPT1ON(roles.hardness,saitloack tyK Z-r-sin,eft-1
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0.0 fL 20.0 fL DARK RED SILT
4.Date Well(s)Completed:
10/22/13 Well Ip# AS-4 20.0 fL 37.0 fL BROWN SILT
5a.Well Location: rt. rL
SUNOCO SERVICE STATION
rL rL
Facility/Owner Name Facility IDA(ifapplicablc) fL fL
255 CEDAR VALLEY ROAD HUDSON 28638 rL e.
Physical Address,Ciry,and Zip 21.REMARKS st }
CALDWELL BENTONITE SEAL FROM 30.0 TO 33.0 FEET
County Parcel identification No.{PIN) ***AIR SPARGE***
5b.Latitude and Longitude in degreeslminuteslseconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
35" 50' 44.96" N 810 28' 49.60" W, 10/24/13
Signore ofCeruficd Weil Cort - or Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary
By xrgning this form. 1 hereby perm rhor the well(s)was(were/coresrracred in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consrruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ®No copy ofthis record has been provided to the well owner.
If this is a repair,fill our known well comiuction information and explain the nature of the
repair under 921 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number ofwells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same com'rrtrchan,you cal
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lost all depths ijd fJereni(example-3 aC200'and 2 a 100') construction to the following
10.Static water level below top of casing: 20.0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use•'+' 1617 Mail Service Center,Raleigh,NC 27699-1 6 1 7
11.Borehole diameter: 8.0 (in.) 14b. For iniection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER S17PPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 76 9 9-1 636
13a.Yield(gpm) Method of test: 24c.For Water Supuh•di Infection 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 county health department of the county
where constructed
Form GW-I North Carolina Department of Environment and Natu it Resources-Division of Water Quality Revised Jan.2013

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for single or multiple wells
1.Well Contractor Information:
MARK GETTYS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
A - 2345 ft. ft.
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER if a licahle
FROM To DIANIFTER THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC ft I ft. in.
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N. 0.0 IL 35A fL 2.0 '°' SCH 40 PVC
List all applicable well construction permits(i.e.County,Stale,Variance,ete.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL.
❑Agricultural DMunicipal/Public 35-0 rr. 37.0 1t. 2.0 in, .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. It,
❑Industrial/Commercial ❑Residential Water Supply(shared) gas.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT'
FlIrrigation 2.0 at- 30.0 rt roan,weararoarte SLURRY
Non-Water Supply Well:
ft.C3Monitoring ❑Recovery ft.
Injection Well: ft, Ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACK Ifs licuble
ROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Sal inity Barrier
F33.0 fl. 37.0 1'. 20-40 FiNE SILICA SAND
OAquifer Test ❑Stormvater Drainage
OExperimental Technology OSubsidence Control 00 fL 2.0 at- 20-40 FINE SILICA SAND
20.DRILLING LOG attach additional sheets ifnecessary
OGeothermal(Closed Loop) C]Tracer FROM TO DESCRIPTION(color.hardness,soiUnek type,grair size,etc.l
❑Geothermal(Heatin Coohn Return) ❑0ther(explain undcr1121 Remarks) 0.0 fL 20.0 fL DARK RED SILT
10/22/13 AS-5 20.0 fL 37.0 ` BROWN SILT
4-Date Well(s)Computed: Well MN ft. fL
5a.Weil Location: fL fL
SUNOCO SERVICE STATION
ft. fL
Facility/Owner Name Facility ED*(if applicalle)
ft, ft-
255 CEDAR VALLEY ROAD HUDSON 28638
ft. A.
Physical Address,Cn}' and lip
21-REMARKS
CALDWELL BENTONITE SEAL FROM 30.0 TO 33.0 FEET
County Parcel Identification No.(PIN) -AIR SPARGE-
5b.Latitude and Longitude in degrecs/minuteslsecoods or decimal degrees:
(ifwell field,one iatiiong is sufficient)
35° 50' 44.96" N 810 28' 49.72" W V-11" 10/24/13
Signature of Certified We11 Contractor Date
6.Is(are)the well(s): ❑Permanent or EiTemporary
13y signing this farm, I hereby ceriofv that the well(s)was(were)constructed in accordance
wtlh 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to as existing well: ❑Yes or E]No copy of this record has been provided ro the well owner.
If this is a repair,fill our known well consiniction information and explain the nature of the
repair under#21 remarks section or on the back ofihis form 23,Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY r irh the some consrruc&n,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37.0 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifterent(example-3(@ 00'and 20a 100') construction to the following',
10.Static water level below top of casing: 20.0 00 Division of Water Quality,Information Processing Unit,
If wafer level is above casing.use -," 1617 Mail Service Center.Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Iniection_Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push.etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13e.Yield(gpm) Method Of test: 24c.For Water u •1 &Injecton Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Faint GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
I.Well Contractor Information:
MARK GETTYS 14.IWATER ZONES
FROM To DESCRIPTION
Well Contractor Name !L fL
A - 2345 !L fL
NC Well Connbctor Cenificalion Number IS.OUTER CASING(far multi-eased wells)OR LINER(if a licable
FROM To DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft. in.
Company Name 16.INNER CASING OR TUBING igeotherutal closed-lop
2.Well Construction Permit
FROM TO DIAMETER THICKNESS MATERIAL
#t• 0.0 ft• 35.0 fL 2.0 '°� 5CW 40 PVC
List all applicable well construction permits(t,e.Counry,Stare,Variance,etc,)
ft. f[. in.
3.Well Use(chick well use): 17. CREEN
Waiter Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 17Municipal/Public 35.0 "' 37.0 ft. 2.0 "' 010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in.
❑Industrial/Comm ere Lal ❑Residential Water Supply(shared) 18.FROM ROUT TO MATERIAL EMPLACEMENT METHOD d AMOU
Qllin
o-Waate NT
er Supply Well: 2.0 fL 30.0 fL romvwamewroaae SLURRY
Non-
❑MDnittxing ❑Recovery rt. !L
Injection Welt: !L fl.
QAquifer Recharge OGroundwaler Remediation 19.SANDIGRAVEL PAC IC ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL J EMPLAC'EMEPrrMETtIOD
33.0 ft• 37.0 fc 20-40 FINE SILICA SAND
❑Aquifer Test ❑Storm water Drainage
❑Experimental Technology ❑Subsidence Control 0-0 ft, 2.0 fL 2040 FINE SILICA SAND
211.DRILLING LOG attach additional sheets if omessa
OGeothemtal(Closed Loop) ❑Tracer FROM To DESCRWTION(-]-,hii,d--.sah k rai.ai e,nc.
❑Geothermal(Heating/Cooling Return) QOther(explain under421 Remarks) 0.0 ft, 20.0 IL DARK RED SILT
4.Date Wdl(s)Completed: 10/22/13 Well(D#{ A5-6
20.0 fL 37.0 !L BROWN SILT
ft. fL
5a.Well Location: fL fL
SUNOCO SERVICE STATION
ft. fL
Facility/Owner Name Facility II)*(if applicable) f4 fL
255 CEDAR VALLEY ROAD HUDSON 28638 FI. IL
Physical Address,City.and Zip
CALDWELL II.REMARKS
BENTONITE SEAL FROM 30 0 TO 33.0 FEET
Counry Parcel Identification No.(PIN) "'AI R S PARGE"'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattiong is sufficient)
35e 50' 44.72" N 810
28' 49.52" W 10/24/13
Signature of Certified Well Contractor Date
6.Is(are)the well(s): UlPermanent or ❑Temporary
By signing This form.1 hereby certify that the well(s) was(were)cortsrrucied in accordance
with 15A NCAC 01C.0100 or 15A NCAC 07C.0200 Well Consrruciron Standards and that a
7.Is this a repair to sin existing well: ❑Yes or E)No copy ofthis retard has been provided to the well owner
lfthis is a repair,fill out known well construction information and explain the nature of the
repair under i�21 remarks section or on the hack of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells Constructed: construction details. You may also attach additional pages if necessary,
For multiple injection or non-wafer sappiy wells ONLY with the same construction,you can
submit one form- SUBMITTAL INSTUCPIONS
9.Total well depth below Is ad surface: 37.0 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list ali depths rfdi(ferent(example-3C 00'and 2@100') construction to the fol lowing-
I0.Static water level below top of casing: 20.0 (fL) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use",- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b. For Infection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i-e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY. 1636 Mail Service Center,Raleigh,NC 2 76 99-1 636
13a.Yield(gpm) Method of test; 24c.For Water Suppy,At Iniection Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed
Form GW-3 North Carolina Deportment of Environment and Natural Resources-Division of Water Quality Revised Ian.2013

WELL CONSTRUCTION RECORD
For Internal Use ONLY
This form can he used for single or multiple wells
1.Well Contractor Information:
MARK GETTYS 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name fL fr-
A - 2345 fr. fL
NC Well Conumoor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER if a litable
FROM TO DIAMETER THICKNESS MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft- I in.
Company Name 16.INNER CASING OR TUBING eotherrnal elosed-Ioo
FROM TO DIAMETER THICKNESS MATERIAL
2,Well Construction Permit#: 0.0 fl• 35.0 ft- 2.0 in' SCH 40 PVC
Lai all applicable well construction permits(te.CoarnV,State,Variance,etc.)
IL ft. in.
3.Well Use(check well use): 17.SCItEEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35,0 rL 37.0 IL 2.0 in, .010 SCH 40 PVC
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft, ft. in.
❑industrial/Commercial El Residential Water Suppiy(shared) :'I&GROUT =i'•
FROM TO MATERIAL £MPLACEMENTMETHOD&AMOUNT
LJ Imigation 2.0 fL 30.0 fL PonrugeEMTaRf SLURRY
Non-Water Supply Well: rL ft
❑Monitoring ORamery
Iajettion Well: ft fL
❑Aquifer Recharge ❑GroundwaterRemediation 19-SAND/GRAVEL PACK(if applicable). -
FROM TO MATERIAL EMPLACEM ENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier 33 0 rL 37 0 fr• 20�0 FINE SILICA SAND
❑Aquifer Test ❑Stonnwater Drainage
❑Experimental Technology ❑Subsidence Control 0.0 fL 2.0 rL 20-40 FINE $1LICA SAND
20.DRILLING LOG attach additional sheets if nmessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color.hardn-oitiraete r p gin vie,etc.)
❑Geothermal(Heatin Cooling Return) ❑Other(explain under i121 Remarks) 0.0 fL 20.0 IL DARK RED SILT
10/22/13 AS-7 20.0 fL 37.0 fL BROWN SILT
4.Date Well(s)Completed: Well ID# fL ft
Sa.Well Location: ft ft.
SUNOCO SERVICE STATION
fL ft
Facility/0%mcr Nanic Facility ID#{ifapplicable)
ft, rt
255 CEDAR VALLEY ROAD HUDSON 28638
ft- fL
Physical Address,Con,and Zip 21.REMARKS
CALDWELL BENTONITE SEAL FROM 30.0 TO 33.0 FEET
County Parcel Identification No-SPIN) ""AIR SPARGE-
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 ertifrcation:
(if well field,one latilong is suffieient) ,V��-R1�_
350 50' 44.41" N 81° 28' 49.52' 10/24/13
Signature of Certified Well Contractor Date
6.is(are)the well(s): MPermanent or ❑Temporary
By signing this form,!hereby certify that the well(s)was,(were)constructed in accordance
with 15A NC4 C 02C.0100 or 19A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E1No copy of this record has been provided to the well owner
1f this is a repair,fill out known well construction information and explain the nature of ibe
repair under#21 remarks section or on the back of this foror. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details- You may also attach additional pages if necessary
For multiple injection or non-water steeply w-elly ON1-Y with lire same construction.you can
submit one form. SUBMITTAL INSTUC'TIONS
9.Total well depth below land surface: 37-0 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100') construction to the following,
Ill.Static water level below top of casing: 20.0 (fL) Division of Water Quality,Information Processing Unit,
!f water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 8'0 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following.
(i.e.auger,rotary,cable,direct push,etc,)
Division of Water Quality,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2 76 99-1 636
132.Yield(gpm) Method of test: 24c.For Water Supn�&Infection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13h. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be used for single or multiple wells
1.Well Contractor Information:
MARK GETTYS 14.WATER ZONES
FROM '1'O DESCRIPTION
Well Connaclor Name It, fL
A - 2345 ft. ft.
NC Well Contractor Cenitication Number 15.OUTER CASING for multi-cased wetly OR LINER if a licablc)
FROM TO ➢lAM£rER THICIQV E.CS MATERLAL
GEOLOGIC EXPLORATION, INC fr. rt. in.
Company Name 16.INNER CASING OR TUBING eothermat dosed-loop)
FROM TO DLAMETER THICKNESS MATERIAL
2.Well Construction Permit#; 0.0 ft 35.0 ft 2.0 1° SCH 40 PVC
List all applicable well eanslmcriorr permits(t,e.County,State.Variance,etc.)
fL fL In.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 35.0 fL 37.0 1- 2.0 '° .010 SCH 40 PVC
[]Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. f.
I&GROUT
❑Industrial/Commercial QResidential Water Supply(shared) FROM TO MATERIAL EMPLACEMENT METHOD d AMOUNT
DIrrigation
Non-Water Supply WeII: 2.0 ft. 30 0 SLURRY
❑Monitoring ❑Recovery rc rl
Injection Well: ft fL
❑Aquifer Recharge ❑Groundaater Remediatlon 19.SAND1GkAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑SaliniryBarrier FROM TO MATERLAL EMPLACEMENT'METHOD
DAquiferTest ❑StormwaterDrainage 33,0 ft- 37.0 fi. 20-40 FINE SILICA SAND
❑Experimental Technology ❑Subsidence Control 0.0 ft. 2.0 ft. 20-40 FINE SILICA SAND
2%DRILLING LOG:Intnich additional sbeets if neresma
❑Geothermal(Cl)sed Loop) ❑Tracer Fk OM TO DESCRIPTION Icolor.hardness.snitlrork t a9a are,etc)
❑Geothermal(Heatin oolin Return) QOther(explain under P21 Remarks) 0.0 fL 20.0 fL DARK RED SILT
4.Date Well(s)Completed: Well ID#
10/23/13 AS-8 20.0 It- 37.0 " BROWN SILT
FL ft.
5m.Well Location: fL ft.
SUNOCO SERVICE STATION
fL fL
Facility/Owner Name Facility 10sr(ifappiicable)
lc, It.
255 CEDAR VALLEY ROAD HUDSON 28638
rL ft.
Physical Address,City.and Zip
11.11EMARIiS
CALDWELL BENTONITE SEAL FROM 30.0 TO 33.0 FEET
County Parccl Identification No.(PIN) wtitudeca "`AIRSPARGE"""
(if La and Longitude in degrees/minuteslseconds or decimal degrees: `!
(if well field,one lot/ions is sufficient)
350 50' 44.59" N 810 28' 49.44" H 10/24/13
Signature ofCcrtificd Well Contractor Date
6.Is(are)the pell(s): Permanent or ❑Temporary
8}'signing this form,1 hereby cenifi•that the well(s)was(were)constructed to accordance
walh l.iA NCAC 02C.0100 or IBA NCAC 02C.0200 Well Construction Standards and that a
7.Is this o repair to an existing well: ❑Yes or ONo copr�ofrhis record how heen provided to the well owner.
If this is a repair,fill out brown well construction information and explain the nature of the
repair under 021 remarir,rection or on the back of ibis form, 23.Site diagram or additional well details:
You may use the back of this page to provide additional welt site details or well
S.Number of wells constructed: 1 construction details, You may also attach additional pages if necessary_
For multiple roieclion or non-water supply wells ONLY with tire same construcdon,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 37.0 (ft) 242. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Iisl all depths if diierew(example-3 aC1l200'and 2C100') construction to the following,
10.Static water level below top of casing: 20.0 00 Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 241L For Injection Wells: In addition to sending the form to the address in 24a
AUGER above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Infection Control Program,
FOR WATER SLTPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) Method of test: 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
13b.Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed,
Form GW-I North Carolina Department of£nvirontnent arrd Natural Resources-Division of Water Quality Revised Jan.2013