WI0501034_DEEMED FILES_20191025

Dee w. 039,
North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501.034
. Permit Information
Wake County Public School System
Permittee
Willow Springs Elementary School
Facility Name
6800 Dwight Rowland Rd. Wake Count%
Facility Address (include County)
Injection Contractor Information
Mid -Atlantic Associates
Injection Contractor / Company Name
Street Address 409 Rogers View Ct
Raleigh
City
NC
State
[phone]
Area code — Phone number
. Well Information
27610
Zip Code
61
t aUa�;,rl S e011
Number of wells used for injection date eegkoay
Well IDs MW-1..MW-3. RW-1.001 2: borings
B 1 through B-23 (direct push, no well constructed)
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 - 2 wells, 23 borings
Type of Well Installed (Check applicable type):
0 Bored ►1 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 23 (borings only)_
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Gravity injection of approximately 500 gallons of 4% solution
of EnviroClean surfactant into existing monitoring wells MW-
1. MW-3. RW-A. RW-B. and borings B-1 through B-23 on 9/27
and 9/28/19.
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 4%
If the injectant is diluted please indicate the source
dilution fluid. Willow Springs municipal water
supply
Total Volume Injected (gal) 500
Volume Injected per well (gal) 5 to 48
5. Injection History
Injection date(s) September 27-28, 2019
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
❑ Yes ® No — TBD will evaluate results.
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 t. ID 0 T THE PERMIT.
10I I�
SIG ' TURE OF INJECTION CONTRACTOR ATE
V./OP/DO S. MPMh4 ANT, -
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection. Form ULC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016

WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells
1. Well Contractor Information:
James D. Barker
Well Contractor Name
3106A
NC Well Contractor Certification Numher
Quantex, Inc.
Company Name
2. Well Construction Permit N: NR
List all applicable well construction permits (i.e. County, State. 1 irriance, etc.)
3. Well Use (check well use):
For Internal Ilse ONLY:
14. WATER ZONES
FROM r TO
DESCRIPTION
10 ft.
11
ft.
Light Brown Clayey Sand
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER Of heahle)
THICKNESS MATERIAL
FROM
fL
TO
IL
DIAMETER
in.
16. INNER CASING OR TUBING lteotber_mil dined-Imp)
FROM TO DIAMETER
THICKNESS
MATERIAL
0
fL
5
fL
4
in.
Sch 40
PVC
ft.
ft.
in.
17. SCREEN
Water Supply Well:
❑Agricultural
❑Geothermal (Dealing/Cooling Supply)
❑ industrial/Commercial
❑ 1ITic.A lion
❑Municipal/Public
:Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring BlRecovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (i{eatingiCooling Retum)
4. Date Well(s) Completed: 9/27/19
❑Groundwater Remed lation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #121 Remarks)
Well IDf! RW-1 + RW-2
5a. Well Location:
Willow Spring Elmntry NA
Facility/Owner Name
Facility IDtl(if applicable)
6800 Dwight Rowland Rd., Willow Spring 27592
Physical Address. City. and Zip
Wake NA
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iat1ong is sufficient)
35,593559 N 78'728093
6. Is (are) the well(s): ®Permanent or ❑Temporary
►►•
7. Is this a repair to an existing well: OYes or IBNo
Obis. this is a repair, fill sin known well rmrerrarrinn infi,rmarinn and explain the nature of the
repair under 021 remarks section or on the hack of this form.
If. Number of wells constructed: tWO
For multiple injection or non -water supply wells ONLY with the same construction. 1•nu can
submit one jinm.
r
9. Total well depth below land surface: 15
For multiple wells list all depths if di/)/'rent (example. .kit 200' and 246,001
10. Static water level below top of casing: 11.51
If water ter cl is above casing, use ••+ "
11. Borehole diameter: gn (in.)
12. Well construction method: Auger
(ft.)
(ft-)
ti.e. auger, rotary, table, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 fly
15 fL
4
in.
0.020
Sch 40
PVC
f.
fL
In.
1S. GROUT
FROM
To
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
0 ft.
3 fL
neat cement
145 lbs. - pour
3 ft.
4.5 ft.
bentonite
30 lbs. - pour
19. SAND/GRAVEL PACK lif aptrticabler
FROM
4.5 ft.
TO
15 ft.
MATERIAL
#3 sand
EMPLACEMENT METHOD
Pour
f1.
fL
20_ DR➢LLISG LOG (attach*dditional sheets ifaecessaey)
FROM
TO
DES rRIPTIO.®i (cebr. hardness, seilrsck type. grain sin. etc.r
0 ft.
0.5 a
0.5 fL
7 fL
ground cover - Reddish Tan SILT
Reddish Brown Clayey SILT
7 ft.
15 it.
Light Brown Clayey Sand
ft.
fi.
ft.
fL
fL
fL
u.
fL
21. REMARKS
22. Certiifrestt'on:
1
Signalnre of j'citified Well Contractor
9/30/19
Date
By signing dris,farm, 1 herchr urliIi' that the well's) was (were) coru9ueted in accordance
with 15A NCAC 02C.0100 or 1SA A'C4C 02C 0200 Hell Construction Standards and that a
cope of this record has been provide,/ 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 INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h. For Iniection Wells: In addition to sending the foul to the address in 24a
above. also submit a copy of this form within 30 days of completion of well
constniclion to the following
Division of Water Quality, Underground injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sutmly & Infection 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
Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan, 2013

WELL C0NSJ'JUJg:JON RECORD
Th• ,,..,, ,.., ... u>td for llllflt"' l'llh•rlr .. •!ts
I. Wrll Co11t111nor hllormalkm:
JAMES 0. BARKER
3106A
OVANTEX, lNC.
\\<ll(t1ttlllut11u,,1uml1&._ NA 1r/_7~e>.;o I 03l.f-
J. Wtll fo~ (d1ttl. 1Adl lllt'):
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4, lbtc \\ I'll(~) ('ompl~td: 09/26/19 \\ •II IIJI< 8· 1 thrU 8-7
!la. "rll l.otadon;
Willow Spring Elmntry NA ------
I ►
6800 Dwight Rowland Rd., Willow Spring 27592
WAKE NA
I , I
!lh. l.•tiludt llnd Lu11;lludt in dri;r1•t-s.•min11lo lt1:<!1Hh <lr dr<inuol dti?,.•t•:
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:--78.728093 -----------35.593559 _______ \\
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10 .... ,,. •'II .
0
~6,0
fl, FINE SANDY CLAY
8.0 15.0 fl. CLAYEY ANE SAND , .. ,,.
fl. fl.
n. n.
I ft. 1 ti ..
~ il-1__ ---i.n. I f.'\fA.IU.:.',
NO WELLS INSTALLED • HOLE PERMANENTLY ABANDONED I
A~E.R INJECTION OF SURFACTANT INTO BORING J
?;•1rirn1o:J. A j
1 t4?J ~--
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10110/19
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11. Korrl,ol-t, dia111t1n: 2,0 !in.)
11. Well COIUlfUdioa lllr1hod: Direct Push (Boreholes ONLY)
(' e liU;'C:f . mbl) ,.-bk. l'.!.ncl r·.nl:. th, t
IJa. \'jfl<I 11:prn).
.\mount:
llhiilo11 or \\altf QualllJ, luhtrm.lluu Pr..c:Hiht£ l nil.
1617 Mall Stnln-C.-ntn, l«lf~k. Nt 2W99-1611
14b, foe lplrs:Jlon \\di~: ln 11dd,1111111,, loe:'ICftnl! tbc forrn 10 1h11 r.ldrn•s in ~~i
ah,w,. al.., 1ubmi1 • .-or)· ,,r lhl, fonn ,.;lhin 30 day, 1>( eompltti,11: <>f ,.tJI
,on11ra~tion to 1he followini-
(lhhit•o ol Waltr (.!ut11il), l'lldo-fJ!rCllltHI l ■jl!'l:lk,n ('on1rol f'rQf:t11nt,
Iii;\!, ~h,il S.-t'"\itt (·.,,.ft!", ft.It-Ii~-1\(" 271>9'l•llo.'b
l◄t·. J,'pr "11rc ~MPPb & 1·utrsU99 \\ rlJti In atUnion '" .. M"h1,h"l~ 1hr (1,1rm h.l
11,~ ...-liff~•jl<'O abo•"C. ,1.0 sut-inu onr <"eorr of th,~ l..m• .,,,h•n )(1 d1}1 o,;I
f ••• ~. ~ I rousIru1.~11nn lu die cuun1} l~nlth 1.h. ~ !'Ir _ of the ,ou.n1y ,,,
, I>
OC1 2 5 '2.0\9
WELL. CONSTK(:C•7'ION RIXO (11
TEA I.r:..fnlw...ed{;,rrvT lrrll-t'l..tl.
i 7►lit (6la4WRL%Or Informarwi:
JAMES b. BARKER
3108A
OUANTEX, INC.
2 1►(111 un►Iro/ul•n !'(linen *., hrR
1. Heil I'u [ehrel'ir11 uml
Rare Nuppl)
Now 'VI ►I Niel ,upph ►■rn•
injection
1 ;k•••ir- parh.••r
1 _w ? I1}•-.uuu : 24110-, kc:u,,:.
! Ilau '. IIi .i [ op,pIiItd �'�Srj
t o 14 f111.k.iiun
►tiro ID:B•8 thfu B•10
Willow Spring Elrnnlry NA
6800 Dwight Rowland Rd., Willow Spring 27592
WAKE NA
S L, l ■oludr and I ungisudr 14 dt}real fui114Ie] ►ei on.h ue d.r. I elms' rs.
1 1• u1,'
35.593559 78.728093
1.12 faro 11h1 w411,11 L Ikrnl.nlne a4 fd7 rmpwran
▪ h sin . Rpm. u• ill i 4N11,11 *or :,r No
e - . •i 1•. F- •• 1. 1 • ••
%r.i11INi of 3.3113 111111N urltd: 3 bOrehole5
• . r OS, 1 , .n I. here , .w•rr.. ,.
M I out well depth I,tlau land twins r: 1 4
10. 3•1111e M11rr 1• icd brier,ua1, rrl .mini: 9'5
lE 11111rhuh dianw err; �0 lin.l
t L9;1I'. f h're+l
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n
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II. fa I.
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1444717"1--Ili _ul+, filF11 _ u.y...,rro, salmi r•, inl.w. .9.4.
I/ 0 0 „• 8 0 " I FINE SANDY CLAY
$ 0 11- 14 0 11• CLAYEY FINE SAND
! fr f,
if. 11 --
It ' h T
li. ri.
14 f1.
ND WELL S INSTALLED - HOLE PERMANENTLY ABANOONED 1
AFTER INJECTION OF 'SURFACTANT INTO BORING
1.:T n sir siLalf:
i
/i, 11ri
21. \sir diagram of ■ddifionlll Bell drl.ils'
'4'• i lr } tlM T ,r I.•ri nl Ihli pagl i-, I+Iv.1dl
[+M1t;4L,.1- 5r•1-flln1 s'• an.. F.
1W10.i19
hl 117•1I1 1 NI I1..4 t-e 111111
ill s 2111 L1* 11.f 154111 Snla„i' ,.• !•• 1 n..n. i. c } n' ..,-rrlr um
eRY
l:. ► 1I tunisrurliein mrehred Direct Push (Boreholes ONLY)
111k 4t.•2 I iktl I'i•I 1 HF 21 %11'1 1:
i 4 i l 0.1d twin; %It! hod 1.1 14.1.
13h. llisinirsliu * fipr: .Inrulim.
• r•
11i4131r,:1 n115 a131 Quail!). Ip16I1II11llrn reVrrul.0 1 .,1.
1017 ►tall tirr.kc 1 rain.. Wirier, 4t 2769?-161:
at, t we EniHiian Hrik• er..JJrt,.n I •:nd r.r 1 hve, ra Inc ndJ•4- 1!1 2=
al• .r, al., su`ra r cop) rl 22. lrn'l lll:hln =., due• ;! c.••1lpksr+.1 r, 4:11
liitiiiVfl of ►►awl Q1Iiit Lndergrtlurd Injection Conte u1 Piot'law
I±•7[: Nail Str.]rr [ snit*. Rskigli, \C 2769Y 1631,
Zee j ui,►►JFIir�YQ>?JLI� Irmertletj_►►$I1): 1 . .Jd;r, a1 s .a. lr1,e 1.1_
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1•, • rdli

WELL CONE1 T1ON 1 ECOHO
The km can br I k4 to Io& n fsdliFk INAS
1. 1Ye11(;anlnctor Infbrmelion:
JAMES C. BARKER
3106A
rll' Waitianaranlle Crrl.Lcienwl N jiil ,
QUANTEX. INC.
Company liamr
2 %%et C tiasir lrtiow Peradl R:
#n+ nR yyJ. •11A I.rrt.lra&Lac ewa #wnwrr. Re
3. ►►r11 Vse (cleric seen usrl:
NR
H'aref Supply With
•
'r.m-Watrr!uppli P'rll:
(njrnian •+ • is
71%Io 11c roat•puh!�s
. •.r 1 i!.
' ■y: n - . `., uII •r
1 •+..I.1w_r.1 IHI . L . ..F••err„ ....n
=1,.,sAiS1..''.i ►a.r
_,.:......-...lid R•,."•
4.liot! %%ow nipltied: 09t26119
►►rrl ID" B-11 thru B•17
3a. Well l,otoilon:
Willow Spring EIrnnlry NA
6800 Dwight Rowland Rd., Willow Spring 27592
WAKE NA -
3b.l.alitudr mad 1.unit war in drgrels•rs14nuIeciucond+or delimit drum:
t11 writ flrtd opt tat long 11 W#iAKti 1
35.593559 78.728093
6. Is tarn lhr msllist: Z.'Perrnrlrrnl or UTemp,lrar}
I.IF,. or.u..•$.tlion,.,..Ill 1.. ti_
11. +amber uf+rdls roniiruttrd % borBI oleS
#,r .11..44r l' merrh,rr er i•o• k+ sir+I• ••riff OW r Old I rsaner rrarrrailUr
.).••n17 oar la.n
9. Totrl Hell depth boom load vetoer: 12 Lit.]
rsmbp),Ir.rauTrig didgy}+Md. 'A n,erNminer ad UV,
10. hulk now It%el beta% Ioi1 of ailing: 8nowin.l
11. 1larrhukr domhler: 2 0 _ in.1
iJ. I1r11 canllrlKlioa mrlhad Direct Push (Boroholes ONLY)
FOR ►1 ATER SUI'1'i.] wE.1.1.5 ONLY:
I3a.1'arld (gm _ w
1311, ilhinfrc+iir 1)pr:
ilrlbud W,eat:
fl-+i�•f�C:l
i �l�rr.r r. rr srlartkoN
fl, n_
(1. re.
IL ll• t 1 Is c:4.s city ..rwe, %pm R IAW11Lg _..._-.
..s1ai -- } RI' ola+lcrsil TArreNEW r MillTa1Ar.
Ili R. to.
111 t' ITI s'AfiiyC 4* TLlI rrlalsarerA sii.ed 1y
,lorry _I �¢ _ - 1 Din•I_MR f 114110.:wW MAtiotr4._
WA n. 1N/A II' ' IL
TI. n.. ht" 1
MOM 7CI
N41 n• NIA
re.
t • emvi
1 -hM Tr3 _ . RAC Mrk! Mt rn.,y a A•tioi
N+A (1. NIA ft.
fr. ft.
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la.
rl,
to. to.
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NA It. NIA It _
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7.0 n. 12.0 rl.
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h. III.
1,
n. ,
1t.RF.MAPG.S -
NO WELLS INSTALLED - HOLE PERMANENTLY ABANDONED
AFTER INJLCTION OF SURFACTANT INTO BORING
22.1 rrtiilfP lion: 1
j
FINE SANDY CLAY
CLAYEY FINE SAND
ti,
1D110,19
13. She diagram or addititipll Hell dtsaill:
'olio may use LW boa, of tills pair w pn..vidr wkii.onal Kel] flit Urud6
4041ftrVriliil1 death I'M in1) "Inv Fli#CIh,4dlli:efOl p.gra . . . . •
SUP5IIT1 AL 1N'StiAl i t1'.S
210. For ,all ►+d11: Submit [hit room xithpl 36 4ti1 ul Ly11,111etwa of
r,.naln,cs+an #D lhr fo11n%ittg
IHA%len of H air( Qgili1 .Infosnralivn Proensiss:lili.
1617 irldl Ser+let Center. Raleigh. St' 27694-1617
21h• for ililertion Writ: In addition trndir% the font) iu Ihr addlrar m 24n
ubuve, s13n aL1l.mil r ropy of 1114 form *thin 39 divi of comp/L-11on of +ir11
mirk inuction 1* iha (S.11nwsnr:
Ui.l+io. of 1► attr ()!ueft; , 1lndrrg►onod injection Control Program.
1636 IIL*U stroke Crater. Raleigh, rsC• 29a19.16.'{6
[e. 11.r H rfrrSitgyj,}Alilr5tloo %{Weill_ J[e Iiddlt.ji ru arlldutf the liam t.•
shr addrr.,irl.l .k"w alto fubmil one sop) or fht turn, alshln 3u days „!
curryiktiun of IAe11 consoruNtion In LKe count!.
Mier( .1m.vo mots

►►'1F I,I. (X »STRUCI ION KLi'O111)
1t.. tort cii br r•' k' almk [• ma:: •h rtir•
i• ►►etl t *Re r Ii.lolmltiest:
JAMES D. BARKER
3106A
❑UANT Ex
2 1►ell( dn[truello. Permit •. NR
3. 13dl t i4 I.hrc► +.elf s.rI
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i Sdndt�Z..•'c
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F■ 'Arll I 'sallow
Willow' Spring Elmntrp
. wr-tirnc
NA
6800 Dwight Rowland Rd., Willow Spring 27592
WAKE NA
Sl+• 1.3il trot sad 1 oug li .dr it. 4t tr ea . ni inisir. ►rt ee.l • .. di i i m al d r} 1 rr+•
,r.r: rtri..rr�
35.593559 * 78,728093
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lk tI1h . riper or. an tsit hog %ell - 1 n t•r Y. �.•
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00 re. 70 II. FINE SANDY CLAY
7 D ' Ir 10 0 11 CLAYEY FINE SAND
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11.
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NO WELLS INSTALLED HOLE PERMANENTLY ABANDONED
1 ER INJECT 10 • (F SURFACTANT INTO BORING
.: { Cr11 �1r1itap:
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r._
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• + , l enU..rrla • t. • si>r f.d I •
tit SLAM. ..alrr fr4r. 1.elan tnr nl rufinr;. _7.
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11.1T• ►lell `rr+ie. ! rater, Raleigh. tit 2T419.16:(s
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�•. 1 k r. -w'

WELL ABANDONMENT RECORD
This farm can be used for single or multiple wells
1. 11'eti Contractor Information:
GARY FISCHER
Weil Contractor Name (or well owner personally ehandoning well on hiseher tlrupoty)
3339
NC W e Ii Ca nsraq or Cc n i licati on Number
MID -ATLANTIC ASSOCIATES, INC
Company Name
2. Well Coariructiort Permit f: NA
list nil oppelrob/ w H con51,7.c11o, perrnirs O.e. Ceanty, Sallee, lbreaacr, eta.) if k corm
3. Well use (check well use):
►Voter Supply Wrell:
❑Agrieulturai
❑Geothermal (]-icaong/Cooliag Supply)
O lndusm a i'Comm crc ia1
❑ irri •. anon
Non -Water Supply Well:
OMonitoring ❑Recovery
❑ Municipa VPublio
Q Residential Water Supply (single)
° Resi dent i al Water Supply ( shared)
Injection Well:
❑ Aquifer Recharge
°Aquifer Stonigc and Recover.
❑ Aq uifin
❑Experimeatai Technology
❑Geothennal (Closed Lop)
o eothermal (Heating/'Caoling Return)
61 Groundwater Remcdiatiar
❑ Salinity Earner
❑Sssmnx oler i)tginage
❑ Subsidence Control
❑Tracer
❑ Other (explain wicks 7
4. Date htell(s) abandoned:J28/201 g
52. Well location:
WILLOW SPRINGS ELEM.
Facllil)tCtwnerHams iaciiiry iDn (if applicable)
6800 DWIGHT ROWLAND RD., WILLOW SPRING
Physical Addtcss, City. and Zip
WAKE
County iarcel Idenlificatlrn N9- (YIN)
Six Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(iFwell field, arc Irllnng is sufficient)
35° 25' 36.67" •78° 43' 41.11 °
►;,
CO.NSICKCTION DETAILS OF V f.4,tSi RF.Ihg ABANDQJSR13
Auar]l !lm eonsernri o «eord(s) ,fInvtilahlr,. For arulnplc u,fredon or non.xnrrr supply
weirs OIa1• mat thr some conrtrtrrr[anllGnnddnmeu, you con ,rubnal one form.
6a. Well I D#:
B-1 THRU B-7
Ob. total well depth:15
'
M.)
6e. Borehole diameter: 2.0 Om}
6d. Water level bcinx ground surface: 12 Oh)
6e. Outer rasing length (if known]: N/A (it.)
6f, Inner casing/tubing length Of known): N/A fft.)
6g- Screen length (if known): N1A _ (ft.)
Farm CiW-10
For MUTT/Ili/se ONLY:
WELL ABANDONMENT BETA.15
7a, Number of wells being abandoned: 7
For muhrpfe lojeceion Of Ron -„ ate,' supply'
cons+rucdonlobandonnrerr, you Con sxbrnlr one form.
urns ONLY with the sum
7h. Approximate volume of water remaining in well(s): 0'25
FOR WATER SUPPLY WELLS ONLY:
lc. Type of disinfectant used:
7d. Amount of disinfectant used:
7r. Sealing materials used (check an that apply):
0 Neal Cement (maul Bentonite Chips or Pellets
❑ Sand Cement Grout 0 Dry Clay
Cl Concrcie Grout 0 Drill Cuttings
❑ Specialty Grout 0 Gravel
❑ Bentonite Slurry 0 Other (explain under 7g)
7C For each material selected above, provide amount of materials used:
1.25 CUBIC FEET
7g. Provide a brief description of the abandonment procedures
BORING ABANDONED BY FILLING HOLE WITH
BENTONITE CHIPS (HOLEPLUG)
8. Crap
Si :.,r e, of Celli ft s Contracto or Well Dwne
10/10/19
Date
By signing rhls form, I hrrrby ccrfify that she warts.) WAS (xerel abandoned m
accordance x°irlr I SA NCAC 02C ,0100 or 2C .0200 Well Cansrruclion Slandards
Gad Thal a cap • of this morel has bren provided Jo the well owmrr.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment derails. You may also anach additional pages if necessary,
St.'BMITTA INSTRUCTJQhS
NNa. For Al Wells: Submit this fora within 30 days of completion of well
abandonment to the following:
Division of ►Voter Quality, Information Processing Unit,
1617 Mall Service Center, Raleigh. NC 27699-1617
10b. For Ip14Stion ►►ci}s; Iu addition to sending the form to the address in lOa
Above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10e. For Water Sunnis & Injection Wells: In addition to sending the form to
the addresses) 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].
North Carolina ❑epaMIX ni of r-:m•irttnrnenr and Kassa -al neroruces - Division of Winer Qua liq Revised March 2013

WELL ABANDONMENT RECORD
This farm son be used for single or multiple wells
1. Well Contractor information:
GARY FISCHER
Weil CmumctorNome Or well owner personally abandoning welt on holier property'
3339
NC Well Contractor Certification Number
MiD-ATLANTIC ASSOCIATES, INC.
Company Naas
2. Weil Construction Permit #: NA
2(11 all ap,oheable well eunrtnrcriaa permits (r.e. f oam% Slate, Variance, err i. if boors
3. Weil use (check well use):
Water Supply Well:
El Agricultural
°Geothe mal (Heating/Cooling Supply)
❑ Industrial/Commercinl
❑irrigation
ion -Wiser Supply Well:
DMonitoring
1MunieipMIPuhlic
O Residential Water Supply (single)
o Residential Water Supply (shared)
°Recove y
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
0 Aquifer Test
❑ I•xperimentai Technology
❑Crcothertnal (Closed ).stop)
❑Geothermal (I.leatinle,Cooting Return)
Groundwater Rcmediation
°Salinity Barrier
❑ Slonowater Drainage
❑Suhsidrnec Control
OTr cer
00ther (explain under 7E
4, Date well(%) abandoned: 09I2$I20 f 9
Sa. Well location:
WILLOW SPRINGS ELEM.
Facitityt47wner Name Facility II)M ri(eppiieable)
6800 DWIGHT ROWLAND RO., WILLOW SPRING
Physic's! Address, City, and Yip
WAKE
County Farrel ldcnsification No, (PIN)
ib. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
f if well field, one sal+long is sufficient)
35' 25' 36.67" h -78° 43'41.11"
t 11NST RUC 1'l0N DETAILS O tF WELLSSI B>E I Nt: Ale 1'gPffriy0
Asmrh well canrtraaion reeord(i r/arwitub(r. For muhrplr infection or non -roar sryrpb
netts ONLY with the same corirtrucoonintrandanrtum, you con.sabmrr ruse Th ie.
6a. Well WC
B-8 THRU B-10
6b. Total well depth: 14.0
fie. Borehole diameter: ' tin.)
6d. Water level below ground surface: 10.5 lit,i
6e. Outer easing length (if known): (ft.)
M. Inner casiogltubing length (if known):
NiA
NIA (ft.)
6g. Semen length (if knuw n): NIR ill.)
Farm(iW.lo
ear )edema) use ONLY:
WELL ABANDONMENT MENT DETAILS
7a. Number of wells being abandoned: 3
Far muhrplr infection or non -inter sseyiplj wells °Par with the same
rnnoruerinnlahendonmem, you ran submit one form.
7h. Approximate volume of water remaining in well(%):
0.25
(gal,)
FOR WATER SUPPLY WELLS ONLY:
7c. T ypc of disinfectant used:
7d. Amount of disinfectant used:
7e. Seating materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Groat
❑ Concrete Grow
❑ Specialty Cirnul
O Bentonite Slimy
Bentonite Chips or Pellets
0 Ury Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f, Fur each material selected above, provide amount of materials used:
1.1 CUBIC FEET
7g. Provide a brief description of the abandonment procedure:
BORING ABANDONED BY FILLING HOLE WITH
BENTONITE CHIPS (HOLEFLUG)
0. Certi
1 0/1 0/1 9
Ssgrle ,1 ofCer?ific St e0 Cormanl•r or Well Owner ' lame
1
By signing this form, .1 ht'reht errs • that tie ma(s) was (were) abandoned its
accordance with 1 SA NCAC Q2C .0100 or IC' .02019 Wei C'ons(rurrion Standards
and than a tops• of this rceard has been provided ro the well owner,
9. Site diagram or additional welt details:
You may use ttty back of this page to provide additional wt:11 site details or well
abandonment details. You may also erode additional pages if necessary.
St'BMI7lAL LNSTR(JCIW.
10s. For All Wells: Submit this fnna within 30 days of completion of well
abandonment to the following.
Division of Water QualiI3, Information Processing Unit.
1617 Mall Service tinter. Raleigh, 7iC 27699-1617
10h. For inleetinn Wefts; in addition to sending the form to the address in 103
above, also submit one ropy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center. Raleigh, Pi 27699-I636
Ilie. For Niter Supply & ipiection Wells;: In addition to sending the form too
the address(ev1 abo w, 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
Na-1ICarotins t)epertnwni nl Cnvimnnrrn and Neural Resnuracs— ❑ivislonof WatcrQua?rt; Revised Mare h?el

WELL ABANDONMENT RECORD
This from can be used far single or multiple wells
I. Well Contractor Information:
GARY F ISCH ER
Well CoiUracrarNemo {Orwell Owner personalty abandoning well on Itisiber property)
3339
NC Well Conuoctor Certification Number
MID -ATLANTIC ASSOCIATES, INC.
Company Name
2. Well Construction Permit dt NA
List all applicable well contraction permfis ( . Clingy, Stare, Parionce. etc;) fkuotrtr
3. Well nee (check well use):
Water Supply Wen:
QAgricultural
❑Geothermal (Reating/Cooiing Supply)
0 Industrial/Commercial
rOirrigation
Non -Water Supply Well:
❑ Monitoriiig
DMunicipallPublic
❑Reaide ntia1 Water Supply (single)
❑ Residential Water Supply isharcd)
❑ Recovery
Injection Well;
DAquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
o Geothermal (Heating Cooling Reuam)
li7Gri undwater Itemediation
°Salinity Harrier
OSio nwcier Drainage
❑Subsidonce Control
❑Tracer
DOdrer (explain under 7p)
4, Date well() abandoned: 09/2/2018
Sa. Well location:
WILLOW SPRINGS ELEM.
Facility/Owner Name facili% ICU (if applicable)
6800 DWIGHT ROWLAND RD., WILLOW SPRING
Physical Address, City, and Zip
WAKE
County
For Irucrnal the ONLY:
WELL ABANDONMENT DE_TAIL.5
7a. Number of wells being abandoned:
Fur multiple injection ar non -Knorr supply xeNs O.VLI' %irh rAr tame
ransararrle mMbaardoamrnt. you can submit oarrform.
7b. Approximale volume of water remaining in we11(s): 0.25 (gal.i
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used:
7d. Amount of disinfectant used:
7e.Sealing maleriale used (cheek till that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
0 Concrete Grout
0 Specialty Grout
0 9entonite Slimy
I Heaatonitc Chip or Pellets
G] Dry Clay
LI Drill Cuttings
❑ Gravel
❑ Other(explain under 7g)
7f. For each material selected otiose, provide amount of materials used:
1.0 CUBIC FEET
7g. Provide a brief description of the abandonment procedure:
BORING ABANDONED BY FILLING HOLE WITH
BENTONITE CHIPS (HOLEPLUG)
� t•.�
.r
Silkuny 'eatred r Antroctor br Well Owner
10/10/19
Dote
By signing this form. 1 hereby cord. that she wrfl(s) was (were) abandoned Or
Parcel !dagger/Ow No. (PIN) accordance with ISA NCAC 02C.0100 or 2C .0200 Well Construction Standards
and altar a copy of this record has been prorided to the well owner.
Sea. Latitude and longitude in degrcesiminrrea/secands or decimal degrees;
Orwell field, one laugong is sufficient]. p
355' 25' 36.6T' • -78° 43' 41.11" ►�'
CONSTRUCTION DETAILS i' wgl.f,lsl n) ING ABANDONED
Attach a ell connructle r swung!) if aewilablr. For multiple ►ryertio. ar timer.sorer supply
sells ONLI' with the some rwarrruru0a/obandonment. you Can su. weir am farm,
B-11 THRU B-17
6a, Well MC
6b. Total NNell depth: 12.0 (ft.)
6c. Borehole diameter:2.0 (in.)
6d. Wafer level helms ground surface: (ft.)
6e. Outer easing length (If known): NIA (ft-)
bf: Inner easing/tubing length (if imown): NIA (ft.)
6g. Screen length (Ifknow'n): N/A (ft.)
Fc.rm W •30
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 1F STRUCT1ONS
iOa. for All Willi: Submit this loon within 30 days of completion of well
abandonment to the following;
Division of Water Quality, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-I617
lab, For Injection Wells; in addition to sending the form to the address in 10o
above, also submit one copy of this form within 30 days of c[unpletion of well
abandonment to the following:
Division of Water Quality,1Jndergraand Injection Control Frugram,
1636 ?Mil Sen•ice Center, Raleigh, NC 27699-1636
10c. far Water Supply & infection Weill; 1n addition to sending the form to
the address(ea) above, also submit one copy of this Corm within 30 days of
Vtmpietion of well abandonment to the county health department of the county
where abandoned.
North Clef aline Department arEnvt rim mretit and Natural Resources— Division of Water Quality Revised March 2013

WELL ABANDONMENT RECORD
This form can he used for singk or multiple wells
I. Well Contractor Information:
GARY FISCHER
Well Contraciot Name tar KYII owner personally abandoning well on his:her property!
3339
Mf Well Contractor CertMeat ion Number
MID -ATLANTIC ASSOCIATES, INC.
Company Name
2_ well Construction Permit 6: NA
t.isi art opplirahIr sire' roasrrxrrior permits air r'ounn•, Slur, Variance, err.) lfboatra
3. Well use (check wvA use):
Water Supply Well:
O Agricultural
❑ Geotltcftnal (Heating'Cooling Supply'
O Industrial/C'cnnmercia I
Oirrigalion
!' o n-Water Supply Well:
❑Monitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer lest
°Experimental Technology
❑Geothermal if'Imed tuop)
❑Geothermal (Hcanng'(ooling Return)
❑ MtmicipaVPubiic
❑Residential Watts Supply (single'
❑ Residential Water Supply Isharcdy
❑Recovery
fdGmundweter Relncdlatilon
❑Salinity harrier
❑Stormwatcr Drainage
❑Subsidence Control
Dialect
❑Other(explain under lg1
4. Bate weB(sj abandoned: 09/28/2019
Set. Well location:
WILLOW SPRINGS ELEM.
Faciliry!Own r lame facility lti I of applicable)
6800 DWIGHT ROWLAND RD., WILLOW SPRING
Physical Address, Coy, and Zip
WAKE
County
For Internal Use ONLY:
WELL ABANRO.tiM N_TDETA1LS
7a. Number of wells being abandoned: 6
For mufniplc fryer -don or non-w0rer supply urns ONLY tinN, oho some
roasourrianlahagdnnmen i, pore rein .ruhmer oar jrxnr.
7b. Approximate volume of water remaining in well(s): D'25
[gal.j
FOR HATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing maierials used (check all than apply':
❑ Neal Ccmenl Grout ti7 Bcntonite Chips c Pellets
❑ Sand Cement Grout ❑ Dry Clay
O C'nncrele Grout ❑ brill Cuttings
❑ SpecialtyOrotil ❑ Gravel
0 13entonitr Slurry ❑ Other (explain under 7g)
71. For each material selected above, provide amain of materials ased:
0.75 CUBIC FEET
7g. Provide a brief description of the abandonment procedure:
BORING ABANDONED BY FILLING HOLE WITH
BENTONITE CHIPS (HOLEPLUG)
1
R. Certirtrilion:
10/10/19
kpnari,re of read: H'rR Cemrartor i s Wcll Owner pane
By signing rlirs form, 1 hentt' eeri I that the wellfsl was herrrl abandoned in
Forte! ldrnLi ficarinn do [PIN I accordance with 15A A'CAC NC .0100 or 2C WOO Well C'unsrrurriwl Standards
and lhal a ropy qf this record hoc heen provided ra rhr xd! owner.
Sb. Latitude and longitude is degrees lminutesdsecoeds or decimal degrees:
Orwell field, one lat.9org is sunicienr)
35' 25' 36.67" -78° 43' 41,11"
►►'
CONS1'RUCI'ION DETAILS OF WELLIS) BEING ABANDONED
Auarh %di rnnsusreuon nerorrr(5J if available% Far nadrlprr it jrtuon or min-unlrr supply
mei& ONLY aril rhrsanw rnnsrr ucreunlabaudwr"rnr, ai coo salmi(' oar forty.
6a. well trio: B-18 THRU B-23
6h. Poise sell depth: 1 0.0
6c, Borehole diameter: 2'0 (in,)
6d, Water level belowground surface: 7 in.)
6c.Outer union length (if &noun): N/A (R.)
61. Inner easing/tubing length iif known}: N/A ift•1
6g, Screen length (if known): NIA (n-1
Fs,rm tiW-Ill
9. Site diagram or additional Hell dctallat
You may use the back of this page io provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SVSJHITTAL INSTRUCTIONS
I0a. Far All Wells: Submit this form within 30 days o1' completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
)617 Mail Service Center, Raleigh, NC 27699-1617
iOb. Foy lnisgtion WO: in addition to sending the firm to the adder,~ in I[ta
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality. underground Injection Control Program,
1636 3.1ail Service Center. Raleigh, NC 27699-1636
10e. for Water Simiily $, lniectIon 1j'clis: In addition to sending the form to
the addresses) shove, 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.
Nrnh t'atnlina Department al Enyimnneno and Nalual Reantlreer — division of Water Quality Revised March 2013