WI0300317_DEEMED FILES_20160523

Permit r-,umber
Program Category
Deemed Ground Water
Permit Type
WI0300317
Injection Deemed Air Well
Primary Reviewer
shristi. shrestha
Coastal SWRule
Permitted Flow
Facility
Fac"ility Name
Catawba ABC Store Incident #36483, Rob & Don's incident #27640
Location Address
5640 NC Hwy 150
Maiden NC
Owner
Owner Name
NC Deq State Lead Program
Dates/Events
Orig Issue
5/23/2016
App Received
5/18/2016
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28650
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
5/23/2016
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Scott Ryals
1646 Mail Service Ctr
Raleigh
Region
Mooresville
County
Catawba
NC
Issue
5/23/2016
Effective
5/23/2016
27699164
Expiration
Requested /Received Fvent s
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Monday, May 23, 2016 1:20 PM
To: 'Jason Whittle'
Cc: Basinger, Corey; Pitner, Andrew; Watson, Edward M; Rogers, Michael
Subject: WI0300317 NOI NCDEQ State Lead Program RE: Air Sparge/Air Injection NOI -
Catawba ABC- Si_ # 36483
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOI) for the above referenced
site.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when competed. Please provide copies of
the GW-1s and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-
30). If well construction/abandonment information is the same for the wells, only one farm needs to be
completed- just indicate total number of injection points in the Comments/Remarks section of form. These forms
can be found on our website at
http:// dec.nc.g.oviabout/divisions/water-resourceslwater-resources-permits/wastewater-branch ground-water-
protection/ground-water-reporting-forms
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at Shristi,shrestha ncdenrsov or via regular mail to address
below. When submitting the above forms, you will need to enter the nine -digit alpha -numeric number on the form
(i.e., WIOXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number WI0300317. This number is also referenced in the subject line of this email_ You may if you
wish, scan and send back as attachments in reply to this email, as it will already have the assigned deemed permit
number in the subject line.
Thank you for your cooperation.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi. shresthaslncdenr.eov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
. T Nco(hing Compares -,
Cm.,:! ....�...n..nn.:..n.+r. In .l fees... fi,nrl.lrnnn :n n..h:r1n4- Fri in el.

North Carolina Public Records Law and may be disclosed to third parties.
From: Jason Whittle [mailto:[e-mail]]
Sent: Tuesday, May 17, 2016 1:12 PM
To: Shrestha, Shristi R <[e-mail]>
Subject: Air Sparge/Air Injection NOi -Catawba ABC-SL# 36483
Hi Shristi,
ATC is providing this Notice of Intent to perform an 8-hour ambient air sparge event at the Catawba ABC site located
at 5640 Highway 150 East in Denver, NC.
The attached NOi form includes site information, ownership details, monitoring well construction details/locations for
use as air sparge wells, and an access agreement with the property owner.
We currently have the field work scheduled for May 26, 2016.
If you need additional information or have questions please let me know. Thanks in advance for your help.
-Jake
Jason (Jake) Whittle, CHMM I PROJECT MANAGER I ATC Group Services LLC
[phone] I [phone] mobile
7606 Whitehall Exec. Center Dr., Suite 800 I Charlotte, NC 28273
[phone] fax I j ason.whittle @atcassociates.com I www.atcg rou pservices.com
This email and its attachments may contain confidential and/or privileged information for the sole use of the intended recipient(s). If you
are not the intended recip ient, any use, distribution or copying of the information contained in this email and its attachments is strictly
prohibited. If you have ,eceived this email in error, please notify the sender by replying to this message and immediately delete and
destroy any copies of this email and any attachments, The views or opinions expressed are the author's own and may not i·eflect the
views or opinions of ATC.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Monday, May 23, 2016 1:18 PM
To: Basinger, Corey; Pitner, Andrew; Watson, Edward M
Cc: Rogers, Michael
Subject: WI0300317 NOI NCDEQ State Lead Program
Attachments: WI0300317 NOI - Catawba ABC- SL 36483 (00000002).pdf
Please find the attached NOI.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shresthav7 ncdenr.00v
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
"'N�stttig Compares --
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

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 15A NCAC 02C .0200. This form shall be submitted at least 2 weeks prior to injection.
AQUIFER TEST WELLS (15A NCAC 02C .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
I) Passive Injection s , stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale Injection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the 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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: _____ _, 20 PERMITNO. V\f.103 603/7 (to be filled in b~WR)
c~£.ii
~D/,t.i
WELL TYPE TO BE CONSTRUCTED OR OPERA TED h t:-o~Q A.
B.
C.
'Y/4 r , vo11,J?
YES Air Injection Well ...................................... Complete sections B-F, K,M . ~ I 8 <P, (1)
(2)
(3)
'"'0101}. '9/e V/6
___ .Aquifer Test Well ....................................... Complete sections B-F, K, N ~10,o. :r-%·eili
P . I .. S C I . BF HN ~uo,,. ~ ___ ass1ve nJectton ystem................... ..... . .. .... omp ete sections - , -.s-~
&ct;ol) ..
(4) ___ Small-Scale Injection Operation ...................... Complete sections B-N
(5) ___ Pilot Test. ................................................ Complete sections B-N
(6) ___ Tracer Injection Well ................................... Complete sections B-N
STATUS OF WELL OWNER: Business/Organization RECEIVED/NCDEQ/OWR
WELL OWNER -State name of entity and name of person delegated authority to sMA'(nJJ:BMll1 6f the
business or agency:
Name: NC DEQ State Lead Pro!!ram-Attn: Scott R \'als
Mailing Address: 1646 Mail Service Center
Water Quality
Regional Operations Section
City: Ralei uh State: NC Zip Code: ___ 2_7_6_9_9-_1_64_6 __ County: Wake
Day Tele No.: 919-707-8168 Cell No.: __________ _
EMAIL Address: ___ s~c~o~tt~.r_, a~l~s ·_a_n_c~d~enr_. !l~o~v_ Fax No.: ___________ _
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page I
D. PROPERTY OWNER (if different than well owner)
Name: Catawba Count\ Alcoholic Beveraue Control Board
Mailing Address: ____ ! 9_1_0~F~ai_r _1!.r~o_v~e_C~h_u~r~c_h_R~d~S~E ________________ _
City: Netwon State: ~N~C~_ Zip Code: __ ~2=8~65~8~-~8~53~l~_County: Catawba
Day Tele No.: _]28-464-7192~---Cell No.: --"""A~ttn: J~ay Abernath.,__ ___ _
EMAIL Address: ___ --'C~a=ta=w_b=a~C~O~A=B~C~•-"w,....g=•m=a=i=l.=c~01=n~_ Fax No.: ___________ _
E. PROJECT CONT ACT -Person who can answer technical questions about the proposed injection project.
Name: A TC Group Services/ A TC Associates-C/O Jake Whittle
Mailing Address: --~7~6~0~6_W~h=it=e=h=a=ll --'E=x=e~c~u=ti _ve~C~e=n=te=r--'D~r=i_ve-=---------------
City: Charlotte State: NC Zip Code: 28273 County: Mecklenburn.
Day Tele No.: 704-529-3200 Cell No.: ---------
EMAIL Address: Jason.whittle a>atcassociates.com Fax No.: 704-529-32 72 ---------
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 5640 NC Hi ghwa\ 150
County: Catawba
City: Maiden State: NC Zip Code: 28650
(2) Geographic Coordinates: Latitude**: 35° 55' 88.23" or 0
Longitude**: 81° 06' 37.25" or 0
Reference Datum: _________ Accuracy: ________ _
Method of Collection: Goo ule Ma ps Aerial
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ square feet
Land surface area of inj. well network: square feet(:::. 10 ,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: ( must be ::::_ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
UIC//n Situ Remed. Notification (Revised 3/2/2015) Page 2
I.
J.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and
duration of injection over time.
INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets ifnecessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online · at
http://portal.ncdenr.org/weblwq/aps/gwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
Injectant:
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
Injectant: ----------------------------------
Volume ofinjectant:. _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
lnjectant: ----------------------------------
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: _____ Proposed Three li nstall dates unknown l 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 with the same construction details. Well
construction details shall include the following: Air S pa rn e at monitoring wells MW-11 . 12 & 15R.
Well construction s pecifications are provided in the attached tables . and locations shown on the attached map.
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
( c) well contractor name and certification number
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activitic s.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchaeter 02L result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certifr, under penalty of law, that I am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately
responsible, for obtaining said information, I believe that the information is true, accurate and complete. I am
aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting
false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well
and all related appurte►ice yli ► . dance tivith the 15.4 NCAC 02C 0200 Rules."
Signature of Applicant
Jake Whittlesas ATC Associates/Consultant Auen j
Print or Type FuII Name
PROPERTY OWNER (if the proper\ is not owned in the.permit applicant):
"As owner of the property on which the injection well(s) ore to be constructed and operated, I hereby consent
to allow the applicant to construct each injection well as outlined in this application and agree that it shall be
the responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction
Standards (I5A NCAC 02C . 0200 r. "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A
well is real property and its construction on land shall be deemed to vest ownership in the land owner_ in
the absence of contrary agreement in writing.
See attached access agreement with owner and NC DE! ± UST Section
Signature* of Property Owner (if different from applicant) Print or Type Full Name
* An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Submit the completed notification package to:
DWR — U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
UICIIn Situ Remed. Notification (Revised 3/212015) Pagc4

6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the landowner. AEAda.sz 5Atke c
TIWe agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Signature
r
Type/Print Name of Owner or Agent
F?S- V4 v ' f /92
Phone Number
jglc ► t;r ( -
Add ss
City/State/Zip Code
Date

RTI-I 'CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WASTE MANAGEMENT
MICHAEL F. EASLEY, GOVERNOR
William G. Ross Jr., SECRETARY
Dexter R. Matthews, DIRECTOR
AVA
NCDENR
+ ouro. Duluamirffr oF
Fxv,ran.n.r• ur Awn Nmwwrro w^rn
UNDERGROUND STORAGE TANK ,SECTION
June 6, 2008
Mr. Scott C. Ryals, P.E.
Environmental Engineer
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: ABC Store
5640 NC HWY 150.
Denver, Catawba County, NC
Incident Number 36483
Dear Mr. Ryais:
MEW
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and hereby
permit the Department of Environment and Natural Resources (Department) or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwater under the authority of G.& 143-
215.3(a)2.
1 am/We are granting permission. with the understanding that:
I. The investigation shall be conducted by the UST Section of the Department's Divisiou of Waste
Management or its contractor.
2_ The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor: The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or.. its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any clainns which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143, of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and es otherwise provided by law.
5_ The information derived from the investigation. hall be made available to the owner upon request and is
a public record, in accordance with G.S. 132-1.
DIVISION OF WASTE MANAGEMENT/UST SECTION
1637 MAIL SERVICE CENTER; RALEIGH. NORTH CAROLINA 27699-1637
PH0NE: 919-733-8486 1FAx: [phone]
I NTERN ET: lattp://weew.evastenotenr.state.nc.us
Ara EQUAL OPPOPTUMTYIAFFIRMATIVEACTION EMPLOYER - 50% RECYCLED/iO% POST -CONSUMER PAPER

Source: Google
Earth Pro 2013

Well ID
MW-1
MW-2
MW-3
MW-4
MW-5
MW-6
MW-7
MW-8
MW-9
MW-10
MWall
MW-12
MW-13
MW-14
MW-15
MW-15R
VMW-1
TABLE2
MONITORING WELL CONSTRUCTION DETAILS
CATAWBA ABC STORE and ROB AND DON'S SPORTSMAN
5640 and 5622 East Highway 150
Denver, North Carolina 28650
NCDEQ Incident #36483 and #27640
Date Installed Screen Interval (feet) Well Diameter Total Depth (feet) (inches)
Unknown 10-30 2 30
Unknown 10-30 2 30
Unknown 10-30 2 30
Unknown 10-30 2 30
Unknown 11-31 2 31
Unknown 15-35 2 35
Unknown 15-35 2 35
Unknown 15-35 2 35
Unknown 15-35 2 35
Unknown 15-35 2 35
Unknown 15-]5 .,.._ 2 -35 I I
Unknown "!" 15-35 ~ ---~= 35 --
Unknown 15-35 2 35
Unknown 15-35 2 35
Unknown 15-35 2 35
2/18/2016 10-30 2 30
Unknown 92-102 2 102
Top of Casing elevations relative to an arbitrary benchmark elevation equal to 100.00 feet above sea level.
Top of Casing
Elevation
100
102.87
99.89
99.53
100.54
102.23
103.68
101.8
100.45
99.44
97.86
97.80
97.38
97.03
96.94
.96.46
99.75
lb. Static water level below top orcasiug:
1, wirier lurel ix irhrrtte coxing,, cox "
11. Borehole diameter: 2 (in.)
12. Weil construction method: Auger
(Et. auger. rotary. cable. direct puab. etc.)
WELL CONSTRUCTION RECORD
This farm ran be herd for single et multiple wells
1. Well Contractor Information:
Daniel Summers
Well Contractor Name
2579-A
NC Well C o lacer L'avtihc iiinn Number
Carolina Soil Investigations, LLC
Company Name
2. Well Construction Permit #:
l.r.er al rypplk-ohle u•r/1pc•rnurr (I,r, r'eorig, hllurltrrro, vied
3. Well Use (check well use):
Water Supply WeII:
J Agricultural
❑Geothermal (Henting/Cooling Supply)
❑ Industrial/Commercial
❑ Irri _'ation
LlMunlei pal/Public
LJResidential Water Supply (single)
©Residential Water Supply (shared)
Non -Water Supply Well:
Z Mon Minna
❑ Recovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
7Aq uifer Test
:.1 Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothernal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
L7Subsidence Control
CiTraccr
❑Other (explain under #21 Remarks)
4. Dale Well Completed: 02-18-16 Weil MN
S. Well Location:
Catawba County ABC Store
Facility/Owner Name
MW-15R
Fouiliry it» (if applicable)
5640 Hwy 150 East Deriver, NC
Physical Address, City,. and Zip
Lincoln
County Parcel Identihcation No. WIN)
Sh. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
?if well Field. cinc !oolong is sufficient}
35.55885-81-06374
6- Is (arc) the wcll(s): tZZPerntanent or 17Tcmporary
7- la this a repair to an existing well: f1Yea or 17114o
1!'rlrrm re et retina., till r,ur knout' a rll rvrrarrrucri ,n rulerrrrrurlrr:r ow( explain Ole reurrrn rrf shy
reran. order 21 ran nrkx NNrrlurr rot tin the ALIA rlf ilri.r fort''
8. Number of wells Constructed:
Fr,r nohiplc• -rrr„ r- sitar Argg'h 'rdll, L'!,/'l. l' tool' On same curtrrrocii nr. ,ron con
Nohow •alL. /urea.
9. Total well depth below land surface: 30 (ft.)
Fr,r rrrrr/Nple well:, last oil rkprlrr e1i/jc•rrrrl fisnotplr- it 2i/1' anti 2r5.If11Y1
0
(ft.)
FOR WATER SUPPLY WELLS ONLY:
i 3a, Yield (gpm) _ Method of test.
13b. Disinfection type: Amount:
Far Internal Case °NI.Y
tJ, W ATFR ZONES
FROM
TO
hESCR'FT1ON
ft.
R,
ft.
fl.
15. OUTER CASING tfor multikased wells! OR LINER if licabiel
r•'RO►l
TO
DIAMETER
sch 40
■pp
7HICIC'ti FS$ MATERIAL.
0h'
10 R.
2 in-
16. 1NN15R CASING OR 'FUSING (geothermal closed -loon'
pvc
FROM TO DIAMF.I ER kab MATF,RIAI
ft
ft.
in,
IL
ft.
in.
17. SCREEN
FROM
rt.
TO
ft.
DIAMETER SLOT 1Zr THICKNESS
2 in' 010 sch 40
in.
MATERIAL
pvc
F 1& GROUT
FROM
TO
MATERIAL
EM PLACEMENT METHOD & AMOUNT
0
It.
06 ft,
06 n'
88 It.
portland
bentonite
mix & pour
tremie
R.
fL
19. SAND/GRAVEL PACK iifApril icahlet
FROM
TO
51ATERLAL
EMPLACEMENT METHOD
8 Fr.
30 Fr.
10/30 silica sand
prepack
It,
ft.
20. DRII. LING LOG Ipkirsch additional sheets If uterusrt
FROM
0 t7.
TO
30 rt.
DESCRIPTION 'color, hardneaa. soil/rock rJk. •i,tia .ter. ere.)
brown silt loam and brown silty clay
fL
Fr.
R-
rL
fr.
ri.
rt.
ft_
13.
fL
ft
rL
xi. REnl•4RI*,
22. Certification:
Daniel Summers a9'44
5
97'dq °artial
Summers
02-18-16
SignatureofCertified Well Conrrst:ter pare
Ny .ri nl, rlrrs . f rrm, 1 berth'• cerl(jt' drat the towntxl was /wen.) mrorimrerl rn at -caramel..
15.,1 ,4'{': f{' rl'[ ' .1110NJ or / S,l ,41 .1(' ON' .0201 WY'rll f'onxlrrwlmn Sciontordx and Oro/ rr
con• ry'rlur record haw lu;rrr provided rrr Ore nvll 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 INSTL'CTIONS
2.4a. For All Wells: Submit this form within 30 days of completion of wel!
construction to the following:
Division of Water Resources. Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY; bl addition to sending the torn to the address in
24a above, also submit a copy of this Forst within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program..
1436 Mail Service Center, Raleigh, NC 27699-1636
24e. For WaterSuppl) & Injection Wells:
Also submit one copy of this form within 30 days afcompletion of
well construction to the county health department or the county whore
constructed.
i'onnUW-1
North Carolina Depeutmem of Environment and Natural Resources — Division of Winer Resources Revised Auguas 7413