WI0700471_DEEMED FILES_20180803

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North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0700471 --;:::=:::::::::::::::::::::=======-----------------,
1. Permit Information
The Town of Bath
Permittee
Wastewater Infiltration Basin!freatment Facility
Facility Name
111 Jackson Swamp Rd., Bath, NC (Beaufort Co.)
Facility Address (include County)
2. Injection Contractor Information
James Holley. P.G.
Groundwater Mana gement Assoc .,I nc .
Injection Contractor / Company Name
Street Address 4300 Sapp hire Ct.
Greenville NC
City State
[phone]
Area code -Phone number
3. Well Information
AUG i · 2018
. '. Water Quaffty
Number of wells used for injectior eotonal (\Perations s
Well IDs __ ;a..aA,..,.Oc..:TB==-3 _______ _
Were any new wells installed during this injection
event?
[gl Yes D No
If yes, please provide the following information:
Number of Monitoring Wells ---~--0
Number oflnjection Wells. ___ _,l=------
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured [gl Other (specify) rotazy
Please include a copy of the GW-1 fonn for each
well installed.
Were any wells abandoned during this injection
event?
[gl Yes O No
If yes, please provide the following information:
Number of Monitoring Wells ___ O.___ __ _
Number of Injection Wells ____ l ___ _
Please include a copy of the GW-30for each well
abandoned.
4. Injectant Information
Potable Water from Hydrant-Beaufort Co. Water De pt.
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration ------------
If the injectant is diluted please indicate the source
dilution fluid. ------------
Total Volume Injected (gal) 148.5 gal
Volume Injected per well (gal) 148.5 gal.
5. Injection History
Injection date(s) 6/21/18-6/22/18
Injection number ( e.g. 3 of 5)_--=l _,o=f --=1 ___ _
Is this the last injection at this site?
[gl Yes D No
I DO HEREBY CERTIFY THAT ALL TIIE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
~/2 I
DATE
James K. Holley. PG
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
GMA
Groundwater Management Associates, inc.
4300 Sapphire Court, Suite 100
Greenville, North Carolina 27834
Telephone: (252] 758-3310
www._,ma-nc.com
The Groundwater Experts Apex and Greenville, NC
August 3, 2018
Ms. Shristi R. Shrestha
Hydrogeologist
North Carolina Department of Environmental Quality
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699 1636
Re: Injection Event Record, Permit # WI0700471, Town of Bath Wastewater Facility, Bath, Beaufort
County, NC
Dear Ms. Shrestha,
Attached is the Injection Event Record (UIC-IER) for the injection testing that we performed at the Town
of Bath Wastewater Injection Basin/Treatment Facility, Bath, Beaufort County, NC. Injection testing at
test well AQTB3 was performed at the facility on June 21s' and 22 d, 2018 to evaluate potential
improvements of the Town's High Rate Infiltration Basin that may lead to a workable long-term solution
to the Town's wastewater effluent disposal needs. A total of 148.5 gallons of potable water supplied by
the Beaufort County Water Department was injected during the two-day event. The test well was
installed on June 21i, 2018 and abandoned on June 28th, 2018. A GW-1 (Well Construction Record) and
a GW-30 (Well Abandonment Record) for test well AQTB3 is included with the attached Injection Event
Record.
Let me know if you have any questions or need additional information,
Best regards,
Groundwater Management Associates, Inc,
Q.
Kelley A, Smith, P.G.
Project Hydrogeologist
Enclosures: Injection Event Record and Well Construction Records
CC: Mr. Greg Churchill, P,E. — Rivers & Associates
Bubs Carson — Town of Bath

Central Files: APS T SWP
4/27/2018
Permit Number Wf0700471 Permit Tracking Slip
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Aquifer Test Weil
Primary Reviewer
shristi.shrestha
Coastal SWRrile
Permitted Row
Facility
Status Project Type
Active New Project
Version Permit Classification
1,00 Individual
Permit Contact Affiliation
Facility Name
Town of Bath Waster water Treatment Facility
Location Address
111 Jackson Swamp Rd
Bath
Owner
NC 27808
Major/Minor Region
Minor Washington
County
Beaufort
Facility Contact Affiliation
Owner Name
Town of Bath
Dates/Events
Owner Type
Government - Municipal
owner Affiliation
Bubs Carson
103 S King Si
Bath
NC 27806
Orig Issue
4/27/2018
App Received
4/16/2018
Draft Initiated
Scheduled
Issuance Public Notice Issue Effective
4/27/2018 4/27/2018
Regulated Activities Requested /Received Events
Groundwater remediatlon
Outfall
Expiration
Waterbody Name Streamindex Number
C+�• •ibbasin
'frtxtv;
1

GMA
March 23, 2018
Ms. Shristi Shrestha
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Groundwater Management Associates, inc.
4300 Sapphire Court, Suite 100
Greenville, North Carolina 27834
Telephone [phone]
Re: Notice of Intent to Construct an Aquifer Test Well for Injection Evaluation, Town of Bath
Wastewater Treatment Facility, Beaufort County, NC
Dear Ms. Shrestha,
Attached please find a Notice of Intent (N0I) to Construct or Operate Injection Wells form for a
proposed aquifer test injection well to be constructed at the Town of Bath Wastewater
Treatment Facility on Jackson Swamp Road in Beaufort County. Per the instructions on the
form, we have completed sections B through F and K and N.
Supporting documentation for item K and other requirements of the form includes:
• A site map showing the proposed location of the aquifer test well
• A diagram snowing the proposed construction details of the aquifer test well
• The proposed well will be abandoned following completion of the testing
• The well contractor will be Stuart Spruill (Certification #2193) of RES/SGI, Inc.
Let us know if you have any questions. We anticipate drilling and aquifer testing in early to
mid -April, depending upon drilling contractor availability and other coordination issues.
Best regards,
Groundwater Management Associates, Inc.
fm-A-44, t4-1),(6_
x
James K. Holley, P.G.
Senior Hydrogeologist
CC: Greg Churchill, R.E. — Rivers and Associates
Bubs Carson —Town of Bath

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT (NOT) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `iermitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15,i NC -IC 02C.0200. This form shall be submitted at least 2 WEEKS prior to injection.
AQUIFER TEST WELLS (t,. Nf:A('0!t..uznL)
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):
t) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion rnethods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — 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 contarnioation. 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: March 23. 2018 PERMIT NO. {r1% -C' 4-0 0 Y ! (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(3) Air Injection Well .Complete sections B through F, K, N
(2) X. Aquifer.Test Well .Complete sections B through F, K, N
(3) Passive Injection System .Complete sections B through F, H-N
(4) Smalt-Scale injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through Nri.DINCtE41O\f
(6) Tracer •injection Well Complete sections B through N
ANi Ifi21)/3
N&ter tattaAlty er l
WELL OWNER(S) - State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
STATUS OF WELL OWNER: Municipal Government
Name(s): The Town of Bath - Mr. Bubs Carson - Town Administrator
Mailing Address: 103 S King Street
City: Bath State: NC Zip Code: 27808 County: Beaufort
Day Tele No.: 252-923-0212 Cell No.:
EMAIL Address: TownotbathfiDembaramail.com Fax No.: 252-923-0313

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: ______________________________ _
Company Name-------------------------------
Mailing Address: ______________________________ _
City: ____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address: ____________ _ FaxNo.: __________ _
E. PROJECT CONTACT (fypically Environmental Engineering Firm)
Name and Title: ___ J_am_es_H_o_l_le_v~, _P--G-' ._-_S_e_ru_·o_r_H~y_d_ro-g~e_ol_o=gis~t __ _
Company Name Groundwater Management Associates. Inc.
Mailing Address: 4300 Sapphire Court, Suite 100
City: Greenville State: NC Zip Code: 27834 County: Pitt
DayTeleNo.: 252-758-3310 CellNo.: 252-814-6361
EMAIL Address: [e-mail] Fax No.: __________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ____ T.:...:..own:..:.=.::co.:..;f B=ath=--:Wc.:...a:::s:.:cte::..:w.:.::a:.:.te:.:r-=T:.::raaaea==tm=e==nt=-=F:...:a:.:c:..:.ili:.:.tyL....... ______ _
111 Jackson Swamp Road
City: Bath County __ : -----"B""'e=a=ufi=o=rt'--__ Zip Code: --=2-'--78""0'""'8'--
(2) Geographic Coordinates: Latitude"'*: --__ " or 35 °.4 -'-8"-6'-'6-"'8 ___ 1 __ _
Longitude**: _________ ,, or -76 •. 805597
Reference Datum: ________ Accuracy: _______ _
Method of Collection: Estimated from Google Earth
**FOR.AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITrED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of confaminant plume: ______ square feet
tand surface area ofinj. well network: square feet~ 10,000 ft? 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 plwne 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 exisnitg and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -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.
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.l!.ov/about/divisi ons/water-
res ou rces/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-inj ectants.
ALI other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info
(919-807-6496).
Injectant: --------------------------------
Volume of injectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
lnjectant: --------------------------------
Volume ofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent ifin a mixture with other injectants: ___________________ _
Injectant: ______________________________ _
Volumeofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: __ -l_Proposed'--___ _,Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-1 s, provide well construction details for each
injection well in a diagram or table fonnat. 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 (indicate if construction is proposed or as-built):
(a) Well type as permanent. Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout typ~ and depth, screen, and sand pack
(c) Well contractor name and certification number
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
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 ' • icr 02T. result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "f hereby certify. 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 info • lion. I .: • r. construct, operate, maintain, repair, and if applicable, abandon the injection well
and all r antes in accordance with the 15A NCAC 02C 0200 Rules."
I�i • . C a Es c , + i Zytimirs'TPi ►VZ--
Print or Type Full Name and Tide
PROPERTY OWNER (if the property is not owned by thepermit a plicant):
"As owner of the property on which the injection wells) are to be constructed and operated, 1 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 NC.AC 02C .0200,). "
"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.
Signature* of Properly Owner (if different from applicant) Print or Type Full Name and Tole
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send this NOI electronically to Shristi.Shresthaflncdenr.vov AND one hard copy to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]

_ , t.
lap Showing Proposed Aquifer Test Well
tth VVestewater Treatment Facility
OWD5 - 6 ft
ivAm4- 5 ft
4PW2 6 it
Legend
Existing Monitoring Well
a Proposed Aquifer Test Weil

a" 46 PVC CASING
13ENTONI tE ;ROUT
k=.
12'0 BOREHOLE —n
•
3 GRAVEL PACK
•
6'
LAND SURFACE
30'
LEGEND
SCALE IN FEEL
HORIZONTAL SCALE
0
E 11
VERTICAL SCALE
GMA
cavuHow,« MAIOALTAINTwssovuls,ix<.
FIIe:DWGS/21345/FIG 2
PROPOSED INFILTRATION AQUIFER TEST BORING
Dote: 3/16/18
Project No. 2134-5
Town of Bath Wastewater Treatment Facility. Bath. Beaufort Cty, NC
Figure 2