WI0800441_DEEMED FILES_20160610

' Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael:
vvJo 8 otJ4'-tt I
David Pyne <[e-mail]>
Friday, June 10, 2016 5:26 PM
Rogers, Michael
Jay Holley [e-mail])
WI0800441 Shallotte Township District Park Aquifer Test Wells -Injection Event Report (IER)
Injection Event Record -Brunswick County ASR _ 8 June 2016.docx; Brunswick County -well
completion records.pdf
Pursuant to the referenced "deemed" permit number dated 20 November 2015, we are pleased to submit the attached
Injection Event Report (IER) for injection at two monitor wells, Lower Peedee Aquifer Monitor Well and Black Creek
Aquifer Monitor Well at Shallotte District Park, Brunswick County. Injection of treated drinking water occurred during
March -April 2016 and after a one week storage period, stored water was recovered, ending on 3 May 2016. The Well
Construction Records (G-1 Forms) were prepared by the well drilling contractor for this project, A.C. Schultes of North
Carolina, and are also attached. A Well Completion Report, incorporating all data and results from monitor well
construction, testing and monitoring at this site, is being prepared and will be provided to you shortly.
Please advise if you have any questions or need further information at this time.
Best regards,
David Pyne
R. David G. Pyne, P.E.
President
ASR Systems LLC
540 NE 5th Ave
Gainesville FL 32601
352.336.3820
352.373.2381 Fax
352.215-0319 Cell
d [e-mail]
www.asrsy stems.ws
1
North Carolina Department of Environmental Quality -Division of Water Resources
INJECTION EVENT RECORD {I ER)
Permit Number WI0800441
I . Permit Information
Brunswick County
Permittee
ASR Monitor Wells at Shallotte District Park
Facility Name
Shallotte District Park, Brunswick County
Facility Address (include County)
2. Injection Contractor Information
ASR Systems LLC
Injection Contractor I Company Name
Street Address 540 NE 5 A venue
Gainesville, Florida 32601
[phone]
Area code -Phone number
3. Well Information
Zip Code
Number of wells used for injection 2
Lower Peedee Aquifer MW
Well IDs_ Black Creek Aquifer MW
Were any new wells installed during this injection
event?
D Yes X D No
If yes, please provide the following information:
Number of Monitoring Wells 2
Number oflnjection Wells 0
Type of Well Installed (Check applicable type):
D Bored D Drilled X D Direct-Push
D Hand-Augured D Other (specify) ___ _
Please include a copy oftlte GW.,J [o rmfor each
well installed.
Were any wells abandoned during this injection
event?
0Yes ONoX
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number of Injection Wells --------
Please include a copy of the GW-30 for each well
abandoned.
4 . Injectant Information
Treated Drinking Water
Jnjectant(s) Type (can use separate additional sheets
if necessary
Concentration
If the injectant is diluted please indicate the source
dilution fluid. ------------LP DA 4,067,473 gals
Total Volume Injected (gal) BCA 1,639,214 gals
Total 5,706,687 gals
Volume Injected per well (gal) _______ _
5. Injection History
Injection date(s) 17 March to 15 April 2016
Injection number ( e.g. 3 of 5) Continuous
ls this the last injection at this site?
OYesX 0No
DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
ST AND ARDS LAID OUT IN THE PERMIT.
~-----;;
{<~?f,f-'.✓, /
8 June 2016
SIGNATURE OF IN.IECTlON CONTRACTOR
BOBBY ALRED/ A.C SCHULTES (WELL DRILLER)
DATE
PRINT NAME OF PERSON PERFORMING THE lN.IECTlON
Submit the original of this fonn to the Division of Water Resources within 30 days of injection. Form UIC-IER
Attn: LJIC Program, 1636 Mail Service Center. Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016
WELL CONSTRUCTION RECORD rcW-II
Print Form
For internal Use Only:
1. Weil Contractor information:
Bobby Allred
Well Contraoor Norm
2610-A
NC Well Coatracor Cxrificatioa Number
A C Schultes of Carolina, Inc.
Company NWrme
2. Well Construction Permit
l.rxe all aryrlrcrrhlr uY11 eansiturllp1r perlrrns (r.e, (1IC'. ramuy. Sage.. Variance, err.)
3. Well Use (rheas well use):
Water Supply Well:
DAgricuitvral DMunicipal/Public
DGeothermal (Heating/Coo/ins Supply) DResidentiai Water Supply (single)
lndustrial/Cornmmercial jResiidential Water Supply (shared)
Ire ation _
Non -Water Supply Well:
Monitoring °Recovery
injection Well:
Aquifer Recharge.
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heat
11. WATER ZONES
FROM T TO I DESCRIPTION
285 " 360 " j dray sand
ft-i5-OUTER
CASING Oar mulct erred *Alt i OR LINER ofop Erablai
FROM TO DIAMETER 1 roiciotrss j MATERIAL
0 rt. '50 rL r 18 in- 1.375 steel
Ku INNER CASING OR TUBING (eoothrneai doledaeeni
FROM TO DIAER j TBIClaYEM Ss T ATERIAL
+3.2 t>s 285 '� 1MET6-1/4 sdr 17 _pvc
L 355 k• 1360t 4 in. l scg 10 304 ss
17. SCREEN
FROM
285 tc
[Groundwater Remediatian
DSaiinity Barrier
JSiormwater Drainage
DSubsidcnce Control
OTracer
inglCoolmg Return) Daher (explain under 1121 Remarks)
4. Date Welt(s) Completed:
Sa. Well Location:
Lion:
Brunswick County
April 2016 Well lD# LIMA( PI t
As1
Faciiiio -Owner N:.no Feeiliry 1t)q (ifepplicablc)
5550 Main Street, Shallotte, NC 28470
Physical Address. City, and 2io
Brunswick
Coolly Parool identirrearitx No.1P1N)
Sh. Latitude and longitude in degrees/minutes/seconds ordecimal degrees:
Orwell field. oneta.rtang it sufficient)
331" 571 53.25
7e 24 31.57
W
6. ls(Rre) the yells) )Permanent or f Temporar3'
7. Is this a repair to an existing well: QYes or ONO
//dm is rI repair. . frrrl.rof bunco 4.0 tNrrerurucrr rrrf(Ir/r.areaa and ctpraln the !moan.. o1 Ern
repair.nnlrr ,2I lxeiork, awcrrtsn Fr on MAd bad' al elk farn.
S. For GeoprobelfPT or Closed -Loop Geothermal Wetls having the same
construction, onfy I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: j_
9.Total well depth below find surface: 360 (it-)
Far awhile n&/A rirrall &peps Ifdrffererar (axon p1r. 3@200' and 2g10t1
10. Stu vie wet ter level below top of casing: 12.17
tftokr 1.•vvl I-,' ahem t1I. #,•,Irk
11- borehole diameter: 14-112 (its.)
12. Well construction method: Rotary
(T:r RIJEor, rola!). cable- direct putt, etc.
(ft1
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) 250 Method of test: Pumping
1311 Disinfrc[wrr type: Bleach Amount: 2 gallons
Forst OW- I
TO
355 n-
! DIAMETER ! SLOTSI=E
4 I .030
THICIC1fESS
MATERIAL 1
304 ss
ft.
ft.
lu.
15. GROUT
FROM r To MATERIAL T F.MPL*CEMENTMETRROD& AMOt1NT
0 IG ; 50 cement tremmie
10 FL ; 258 It cement tremmie
1258 lt. 1268 " cement tremmie
r 19. SAND/GRAVEL PACT{ firapplkeatdel
PROM TO MATERIAL • EMPLACEMENT METHOD
268 its 360 rLj ##2 gravel 'tremmie
[141, DRILLING LOG !Attach additional sheets it • e s r 1
FROM -T 0L r 1teTIOPe (cekr, t.rud emu, eaRkate •.1+ yraie si......
rt. I f4
0 ad 14 re sand
14 rt• 1 30 fL + silt sand
30 ft. 65 r'• silty cla _
65 . 80 rL i sand, shells and silt
80 fL _ 104 re. sand
104 "LT 120 rt'sand & clay
120'� 1 130 n , gray sand & silt
11. REMA.RTiS
ZZ. Corti Era Don:
Stgm:we er g . d Wetl Contraernr
6/8/2016
Dare
1{v Xigrawg this farce, 1 hereby cerlf(y fhnl Om nrrl(s) »ur (twee.) c9rwrreared in arrurdnnca
.••lrh 154 NC ar• 42C' .0100 ar 15,4 NC'AC 02(' OTUA I04111 C aaVrile a'an Senakriyir 00.1 rhae e
copy of Mil recarclharbeen proWed ra eha men owner.
23. Site diagram or additional well details:
You may use the back of Ibis page to provide additional well vie details or well
construction details_ Yos may also attach additional pages it -necessary
SUBMI'LTA.L INSTRUCTIONS
24a_ for MI Wells: Submit this form within 30 days of completion of well
construction to the following'
Division or Water Resources, Information Procestsing Unft,
1617 NIxi1 Servitt Cen ter, Raleigh, !VC Z7699-1617
24b. Far lnierlioo Welts: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Lin derground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c For Water Suc'tlh' & Iniettion Wells: In addition Io sending the farm to
she address(es) above. also submit one copy of chit faun within 30 days of
completion of well construction to the county health department of the county
where constructed.
None Caroline Deparrn e.0 Of En%v.nmrmnin! Quality - Division or Wetcr Rcwurce: Revised 2-22.2016

WELL CONSTRUCTION RECORD (GW-1
For Internal Use Only:
pn
Print Fofrn J
1. Well Contractor Information:
Bobby Allred
Well Contractor Name
2610-A
NC WO Couleactor Certification Number
A C Schultes of Carolina, inc.
Canvas"), Mime
2. wet! Construction Permit 0:
! tyt oil appifenFit well um:go-avianpermrtr 0.e. UK'. County SSW!. Yarean & err)
3. WeIl Usc (cheek well use)_
6 Water Supply We11:
}L--y3 Agricultural'Municipal/Public
Geothermal (Heaung)CoolirrgSupply) jResidemial Wate: Supply (single)
Industrial/Commercial DResiclential Water Supply (shared)
lrri •arson
Non -Water Supply Well_
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Tess
Experimental Technology
Geothermal (Closed Loop)
jRecovery
DGroundwater Reined iation
0/Salinity Barrier
QSLorrnwater Drainage
DStthsid ace Control
DTracer
Geothermal (I teatintCooting Return) rf,Other (explain under 421 Remarks)
4. Date Well(s) Completed: April 2016 We11 il;lti i,.oted-PetDe{
sn. wen Location: 4S/2_Tts- WLI1
Brunswick County
Facilit. 'D ace Name ?milky Ds tit -applicable)
5550 Main Street, Shallotte, NC 28470
Physical Address, City, and Lip
Brunswick
Cotenty Parcel Identification Na- {PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell !i&d, our Iat,dng is safneieril)
33°57f 53.25 h 78241 31.57
6. ls(arej the wei!(1)0Permanent or EJTemporary
7. is this a repair roan existing well: DYes or 0ND
�jthir er a n7x.lr f ll eras kunw-er w rl! in r]rneLi le PA + eritweleon pad espial)] Ike Rowan glebe
repine aereir,- 21 reeeufrks rereinn Or DIP the hack gfIhtc farnn•
8. For GeoprobtfDPT or Closed -Loop Geothermal 'Wells having the same
construction, only I OW-1 is needed. TndicascTOTAL NUMBER of wells
drilled. 1
9-Tout well depth below land surface: 360
t nr multiple n1.11., Ad all dep1I OA:gerwer feseorple- 30100' ew,S2@10DY)
19. Stalk water level below lop of -egging: 12.1 7
I 'rater le• :! . etarecournp, use
1 l Borehole diameter: 14-1/2 (in.)
12. W'eIl eons/rut-hnn method' Rotary
(i.e. auger. rpier±r. ruble- direct P. at.)
(ft)
(ft.)
FOR WATER SUPPLY WELLS ONLY
13a. Yield (gpm) 250 Method of trot: Pumping
13b Disinfection type: Bleach A„,„„„, 2allOns
form CP -1
14. WATER ZONES _
PROM TO DESCRIPTION
285 fL
360 arav sand
fL fL
I
IS. OUTER CASING (for mold• -acted wens OR LINER Ora lieab ei
FROM i TU
I1Lr+at6TER
THICKNESS MATERIAL
0 Ft' 50 R'
18 'n-
.375 (steel
16 INNER CASING OR T URlNG feenthetnigl dosed -loop i
FROM
Tt1 DIAMETER •ralcKNFss MATERIAL
4-3.2 ft
285 fL
6-1/4 i°'
sdr 17_J ❑vc
355 fL
360 '`
f _ 4 IA. t
scq 10 ' 304 ss
17_SCREEN
PROM
TO
DJAMlTSR SLAT SILE Ti11CIOgiSS t MATERIAL
.1
285 rt-
355 n-
_i
4 in.
.030 '304 ss
fr.
fL
in.
j
1& GROUT
FROM
TO
MATERIAL EMPLACEMENT MMIOD & AMOUNT
0 It
50 f-
cement_} tremmie
0 4-
258 "1'
1 cement ! tremmie
258 k
268 ' 1
cement f tremmie
19. SAND/GRAVEL PACK
Of minable
FROM TO
MATERIAL ( £MPIACFMENTMICITIOD
268 ft.
360 fL
#2 gravel tremmie
it. it
0. DRILLING LOG iaoncb tldditlorn& sheen. if netessrn +
FROM 1 TO
4
` inscniPTlON ,rotor, hardness, soilhart.:• ne. prrie :mine d
13fJ� 190 IL
silty sand
190 it 225 f`• ? side white clay & sandstone
225 iL 260 ft-1 silty clay
260 k ! 360 fr. quartz, mineral sand & white silt
21. REMARKS
6/8/2016
Sipu.riac ofC turf Cenfrgidor f Date
iJy ,reptrte,R rh:i .=rm.) hvrehr, crer0, that the w ent's) was (iar,•ry rnnsrrerrvrd +ei ncmrrina..V.
wireh ISA MAC l7Nt • 0/00 or /14 ?J[ ale' ❑2C .0200 Well Canrtrvchnn Srandarrh and drat o
rapt• nfdtia record has hero prm'rded ra the h dr 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 paves if necessary.
Sj)BMif &LIPISTRUS RUCTIONS
24a. For All We113: Submit this form within 30 days of completion of well
construction so the fbalowing:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lniettien Heells: In addition to sending the fore: to the address in 74a
above, also submit one copy of this form within 30 days of completion of well
conslruction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Msi1 Service Center, Raleigh, NC 27699-1636
24c. For Water Santr& InlecIi jn WSj1a: In addition to sending the form In
the address(cs) above, a!so submit one copy of this form within 30 days of
completion of well consruction to the county health department of the county
where constructed.
[worth Carolina Department ofEnr,mnmenie! ❑uatiry - Dl.•intvn of Water Resources Revineu 2-222.2016

•
WELL CONSTRUCTION RECORD r G W-1
For Internal Use Only:
Po f
Print Form
1. Well Contractor Information:
Bobby Allred
Weil Cortlsector Name
2610-A
MC Wall Cantrawx Csrthicatinn Nwribrr
A C Schultes of Carolina, Inc.
Company Name
2. Well Construction Permit f#:
WI all upphcchle Hrl! canlerocllan perFatta• (tr. Ulf', Conti Siare. Variance, etc)
3. Welt Use (check well use):
Wafer Supply Well:
Agricultural
Geothermal (HeatingiCooling Suppy)
Q Indust ri alVCommercial
rlrricarian
Non -Witter Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquil'CrTesl
Experimental Technology
Geothermal (Closed Loop)
Geothermal( Hearin: oolin- Reulrn}
fMumcipal/Public
JResidentiai Water Supply (single)
f Residential Water Supply (Sham)
DRec°very
DGrvundwater Rcmediation
El/Sidinity Sarver
DStormwater Drainage
[Subsidence Control
Tracer
Oth i (explain under i12I Remarks)
4_ Date Well(s) Completed: May 2016 well I[xiBlack Creek
AS T LU�.i I
Sa. Well Location:
Brunswick County
Facilil] -O vie: Name Facility IDC [if applicable)
5550 Main Street, Shallotte, NC 28470
Physi. a1 Addmem City. and Zip
Brunswick
County Puree Ideeuilraion No. (PIN)
Sb. Latitude and longitude, in degrees/Minutes/seconds or decimal degrees:
It€wail field. one latflong u au F(cimii r
33° 571 52.92 N 7Ef 24 31.63
W
6. is(Arc) thll(s)f Permancnt or JTemporar2'
7. Is this a repair to an existing well: Q vex or �]x No
;lard, fd a repair, fill r+ue 0,10101 *ell re>rwnecnon ;nrumorner rr aenl esplrnn +hr noiurr of Mr
rrparr anrier remnr*a J-rx•Non err (NI the bock •frhin form.
8. FnrCeoprob&DPT o► Closed -Loop Geothermal Wells having the same
CanyTnmC1 mn-poly I OW-1 is netted. lndlea le TOTAL NUMBER of %veils
drilled: 1
9_ Total well depth below land surface: 56Q
l'rrr +nulapir %Ott I.sr ell depths if d erewr (example- 36200' end 261fin')
10. Static water level below top of casing: +7.17
if worm tarnsx'that' mming •se -. .
I I_ Borehole diameter: 11-1 /2 (1n_)
12. Well construction method_ Rotary
(a)
i,e. auger. wary_ cable. direct pus!!, etc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gym) 200
Method of lest: Pumping
13h. Disinfection type: Bleach Amonnt:2
gallons
Point ( -1
14. WATER ZONES
FROM 1 TP ! DESCRIPTION
440 tl- 1490 aL f silty sand
525 fL 560 Et Greenish/arav sand
IS. OUTER -CASING Ym multi-csaed wens) OR -LINER py1-rcablel
1 FROM TO T DIAMETER , THICI(TIF3S
MATERIAL
0 ft. j 50 "- 14 m. .375
stee#
I6s INNERCASWG OR TOEING ireotbermfi elmed-loop'
FROM TO
DIAMETER
THICKNESS MATERIAL
fR 445 "-
1
6.5 in-
�sd r 17 pvc
490 ft. 525 ft"
4 i.'
sob 10 304 ss
17, SCRESN
FROM , TO DIAMETER sumsIZE 1 macrons
MATERIAL
I.
1445 it. , 490 n' 4 i�.1.050
304 ss
1304
525ft.: 555 14 I .030 1
ss
1s. GROUT -
FROM T TO
MATERIAL SR[PfAcsboz T ammo dr_ AmouriT
10 it 50 ft.
cement tremmie
0 ft- 425 "-
cement tremmie
425 rt. 435 ft
cement tremmie
} i 9. SAND/GRAFEL PACK Illuniiticabtei
FROM TO MATERIAL
EMPLACEMSNr M1THDD
435 ft' 505 n. #3 gravel
tremmie
515 (t- 570 n- #2 gravel tremmie
20. DRILLING LOG int tacit additional sheets if wry]
PROM TO
0ESCR11710% , whir. 6ardnersLm3Drack
sand
It lw anew'km. etsl
0 ft. 14 "'
14 tL 30 "-
silt sand
30 f` 1 65 tt.
silty clay
65 " ' 80 ft.
sand, shells, silt
80 re• 104 fi. sand
104 fL 120 iL
sand & clay
120 ff_ 130 11
gray clay & silt
21_ REMAAKS
22- Cep -titivation:
6/8/2016
Signature ofce Wel; Contracwr -1 C]otc
By rip:kg this farm. 1 Ir'reby cerlifp that rhz wktl(af wax (Warne ewurrured in accordance
with ISA HEA(' 02r_61W or 15.4 .Ak::i('!17(' _o'm10 Wet! C'arrsrrae1iurr Standards and the! ❑
exlenv bfthIs racers) box herrr prrfl•md to sure u li owner.
Site diagram or additional well details:
You may use the hack of this page to provide additional well site details or well
construction details_ You may also attach additional pages ifnecessary.
bt • Bta'iITTAL iNSl R_ZICTICiNS
24a. For plij Wells: Su'nnaii this form within 30 days of completion of well
construction to the following.
Division of Water Resources, iuformation Processing Unit,
I617 Mail Service Center, Raleigh, NC27699-1617
24h. For leitction Weft: In addition to sending the form to the address in 74a
above, also submit one copy of this form within 30 days of completion of wet!
construction to time following:
Division of Water Resources, Underground !ejection Control Program,
1636 Mail Scrvlce Center, Raleigh, NC 27695,-1636
24c. For Water Supjdv & infection Welts: In addition to sending the forth to
the addr 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_
Noah Caroline Depanmenl of Enrirwmmcmal Qualify- Diritian ofWatcr Resocvccs Rrvisod 7.-22-2016

WELL CONSTRUCTION RECORD i GW-11
For Internal Use Only:
Pact
IPont- Forr.1
t. Well Contractor information:
Bobby Allred
We! Contactor Name
2610-A
NC welt caneraci or Certification N rancor
A C Schultes of Carolina, Inc.
Company Name
2. Well Construction Perrrut #:
t,isr an oppdre'ahle well CprrsrrmrroNI pOrMit {i.r. IilC', (•Quart Yrare. Variant& eir)
3. well We (check well ate):
Water Supply Well:
Agnctiitural !Municipal?Public
IJGeothcrmal (Heating/Cooling Supply) DResidenual Water Supply (single)
Industrial/Commercial DResidentiel Water Supply (shared)
Imitation
Non..WaterSupply ►Fall:
Monitoring 1 Recovery
injection Well:
Aquifer Recharge °Groundwater Remediation
Aquifer Storage and Recovery DSahnity Barrier
Aquifer Test DStormualer thdinage
Experimnenlal Technology DSubeidencc Contrnt
RGeothermal (Closed Loop) DTrdcer
Geothermal (llRatinglCooliag Return) DOttier(explain under 42] Remarks)
4_ Date Well(s) Completed: May 2016
5a. Well Location:
Brunswick County
Well DoBlack Creek -
M5Q I es4-Lui- I1
Facilit'Owner Name Facility ID (if applicable.;
5550 Main Street, Shallotte, NC 28470
Physical Address, City, and by
Brunswick
County Parse! 1demifieasion No, (PIN)
Sb. Latitude and longitude in degreesiminutes/serunds or decimal degrees:
(ifRead. one larllong is sufRcienty O r
33° 57'52.92 78 24 31.63
w
6. !siert) the well(s)0Peretanear or j'remporary
7. is this a repair to an existing well: ElYes or Ox No
(/rhu 61 a rclorr.,rll ran 4rr11.11 x111 carrrrrucrian rn(rrrmavnrr and Kspla n the nature r jrhe
wptur wider •?1 remark, ACCrrmrr ❑r use Hie hack of rhrr figm,
S. For Groproh&JDPTor Closed -Loop Geothermal Wells halting the same
construction, only i GW- I is needed Indicate TOTAL NUMBER of wells
driIlce• 1
9. Total well depth below Land surface: 560
irmlrrnlc caelf., liar uH dkplli! +f ililfrrrru {cramplr- 3 r[ IpR' rend i:ri}Itrp•)
ill- Static a.•ater level below trip of easier. +7.17
!f tram- tail i-, pMrsr oaw,g. rose - .'
1 1. Borehole diameter: 1 1-1 /2 (in.)
12. Vre1l construction method: Rotary
0„ auoei. rotary. calk. duce/ push. etc.
{fL)
FORWATER SUPPLY WELLS ONLY:
13a. Yield Moro) 200 method of teal: Pumping
13b. Disinfection type: Bleach Amount: gallons
t . wATER ZONES
FRO/6!
TD
DESCRIPTION
440 R 490 r<
525 t31. 560
silty sand
areenishlurav sand
1S. OVTER CAS[NGSor rwulk-eased wells] OR LINER (if ep rn irablr)
FROM 1 TO DIAMETER ] TUICRP4ESS ' MATERIAL
0 150 t- 14 In. 1.375 steel
16. INNER CASING OR TEItsJNG to thermal etnaad-loop]
FROM 1 To DIAMETER 1 THICKN S
+3 ftj 445 rt•
490 El, 525 fl.
17. SCREEN
MATERIAL
6.5 Isdr17 pvc
4 `a lscg10
304 ss
FROM TO DIAMFTF.R 1 sr-arSt.E 1 Tim 'Ts
445 fL 490 ". 4 'rr. i .050 1
525fi. j 555 fL 14 I" , _030 1 1304 ss
la. GROUT _
RRUM 1 To I MATERIAL EMPtACEMF,NT METHOD & AMOUNT
505 1L 515 t-' bentonite tremmie
fr. R
EL R
19. SANDIG'f[AY£L PACK
far tirable
MATERIAL
304 ss
FROM 1 TO MATERIAL EMPLACEMENT Mr!'noD
435 505 fL I #3 gravel tremmie
515 ft ' 570 f`- ! #2 gravel tremmie
20- DRILLING LOG_Aitich additional sheets if r cif Ir.)
FRUM 1 TO DESCRIPTION [color, lundonmsolite kryt,e,trwin drgrlc.,
130 n- 190 it- silty sand_
190 fr. 225 ft
5FL 260 "1
260 rr
360 fr. 3
387 fL 443 fr. I
443 r H 580 Fr. 1
REMARKS
REMARKS
silty white clan & sandstone
silty clay
360 f' quartz,mineral sand, white silt
87 IL clay & gray shells
_gray sand & clay
silt gray/green sand
22. Certificjtian:
Signature efC• 3% d We71 C'ontraeIDr
6/8/2016
Date
1SN sknirrg Acts farm. 1 harry' rerrrji that die we/7(s) war (wire, comb -acted le;ace-a:Thar.
x,th ISA Nr A{-1rlr. fW Ile 134 NeAr112(-.117640 wet (n ,rnceorr Standrre4 and Aar a
ropy of oh s rrcara, hnrhorn p oWdrd RP rhr (rower.
23_ Site diagram Or additional welt details:
You may use the back of this page to provide additional well site details or well
constriction details. You may also anach additional pages if necessary
UaMITTAL (INSTRUCTIONS
24a. For Alt Wells: Submit this form within 30 days of completion of well
construction to the following.
Division of Water Resources, information Promoting Unit,
]617 Moil Srrvire Center, Raleigh, NC27699-16l7
24b. For Injection Walls: In addition to sending the form to the addres in 24a
above, also submit one copy of this form within 30 days of completion of welt
construction to lite following'
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC27699-1636
24e. For Water Sorrily & ]niection Wells: Ir addition to scndins the forma to
the address[ss] above, also submit one copy of tIiiform within. 30 days of
completion of well construction to the county health defiarmrnt of the county
where constructed.
Fatal Ow. i North Carolina Deparrmeni orEnvironmcnnt [hmlity - Division of Mum: Rcsom-
Rr+ised 2-Z2 261(

Permit Number WI0800441
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Aquifer Test Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Shallote Township District Park
Location Address
5550 Main St
Next To Water Tower
Shallotte
Owner
Owner Name
NC
Brunswick County Public Utilities
Dates!Events
Orig Issue
1/15/2016
App Received
11/16/2015
Regulated Activities
Well Construction
Outfall
Waterbody Name
28459
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
2/18/2016
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 -County
Owner Affiliation
Jerry W. Pierce
PO Box249
Bolivia
Region
Wilmington
County
Brunswick
NC
Issue
1/15/2016
Effective
1/15/2016
28422024
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
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 iniection.
AQUIFER TEST WELLS (1 5A 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):
1) Passive Injection S y 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 In jection 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: November 9, 2015 PERMIT NO. L.J~ 0800'-jl.J\ \ (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
___ .Air Injection Well ......... :-............................ Complete sections B-F, K, N
XXXX Aquifer Test Well ............ ,.1~!~!..1,~ .?.~.1.~ ........ Complete sections B-F, K, N
___ .Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
___ Pilot Test. ................................................ Complete sections B-N
___ Tracer Injection Well ................................... Complete sections B-N
B. STATUS OF WELL OWNER: County Government
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: Mr. Jerry Pierce. Director of Public Utilities. Brunswick County. NC
Mailing Address: P.O. Box 249
City: Bolivia State: NC Zip Code: 28422 County:. ___ =B"'-'ru=n=s-'-'w-=ic=k
Day Tele No.: [phone] Cell No.: __________ _
EMAIL Address: [e-mail] Fax No.: [phone]
VIC/In Situ Remed. Notification (Revised 3/2/2015) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: Brunswick Countv (Same )
Mailing Address:---------------------------------
City: _____________ State: __ Zip Code:. _______ County: _____ _
DayTeleNo.: ____________ _ Cell No.: __________ _
EMAIL Address: _____________ _ FaxNo.: ___________ _
E. PROJECT CONT ACT -Person who can answer technical questions about the proposed injection project.
Name: R. David G. Pyne, P.E.. ASR Svstems . LLC
Mailing Address: 540 NE 5th Ave
City: Gainesville State: FL Zip Code: 32601 County: Alachua
Day Tele No.: (352 ) 336-3820 Cell No.: [phone]
EMAIL Address: dp ne /a asrs vstems.ws Fax No.: [phone]
F. PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Physical Address: ------'S=h=a=ll=o=tt=e_,,T--=o"""'w=n=sh=i""p"""'D::.ei=st=ri=ct"""P:..:ar=k,,_,5 ... 5=5=0-"-M=ai=n"-"S""'tr""'e=et.c.__ __
________________________ County: Brunswick
City: Shallotte State: NC Zip Code: 28459
Geographic Coordinates: Latitude**: TI._0 57' 53.08" or ___ 0 _______ _
Longitude**: 78° 24' 31.37" or ___ 0 _______ _
Reference Datum : ________ Accuracy: _______ _
Method of Collection: GIS A pp roximation (See Fi gure 1)
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COO RD INA TES.
G. TREATMENT AREA
Land surface area of contaminant plume: ______ ~square feet
Land surface area of inj. well network: square feet (:s 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.
UICI In Situ Remed. Notification (Revised 3/2/2015) Page 2
I. 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.
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/web/wq/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 of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
Injectant: ----------------------------------
Volume of injectant:
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:
K. WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: --~2~-~Proposed ______ Existing
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:
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(Permanent. To be converted to monitorin!! wells )
(b) depth below land surface of grout, screen, and casing intervals See Attached Figure 2
(c) well contractor name and certification number (N ot determined. Pro ject being bid out).
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 3
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 Subchapter 02L result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certif v, 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 passibility of fines and imprisonment, for submitting
false information. I agree to construct. operate, maintain, repair, and if applicable, abandon the injection well
and all rel • ed appurtenances in accordance with the I 5.4 NC4C 02C 0200 Rules."
oat
3-ew iti?itieste-
pPrint or Type Full Name
Signature of
PROPERTY OWNER. Oldie propert' is not owned b\ the permit applicant):
"As owner of the property on which the injection well(s) are 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 (];A itiCAC 02C .0200r. "
"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 Property Owner (if different from applicant) Print or Type Full Name
* An access agreement between the applicant and property owner may he submitted in lieu of a signature on this form.
Submit the completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
UICIIn Situ Remed. Notification (Revised 312/2015) Page 4

RACK CREGC ACIRFER
TEST YELL
Ire PIT CASING
COADTT CRG'JT
20•4 BCREIOLE •
6"9 SOR 17 -
PVC CASTNC
13..5"O BCREHIX-E
iF-MENT CROUT
RENTON:1F SEAL
6. X 4• REDUCER
UNWORN 5ANO PAC%
4•* 30—SLOT SS SCREENS
4.9 ss HLAMC cA9NGs
GROUT PDCT HOLE DELDW
SPEOF1E'0 HELL DEPTH
LEGEND
SAND
CLAY
PEEDEE ACTJIFER
IEST VEIL
LAND SURFACE
14•e PIT CASTNC ------ ,.j
CEMENT CROUT
20•0 BCREHCLE ---
6.9 SOR 17
PVC CASING
13.3'0 BCRE}IC E
CEMENT CROMT
eENTOONE SEAL
s' x 4" REDUCER —
UNIFORM SANG PACK-
4.0 70—SLOT SS WREN
ON1 SS 6LANN
WOOD C.L= CCHFINING LMER
mot
t11 SI-LLL — SILT
PROJECTED LITHOLOGY FROM
F7, REGIONAL CORRELATION
5LS
TOO—
_
250
350-
450
500 —
GOO-
550—.= —
700
GMA
D
6ERicAL
5•,.ALE 1N ,EET
'File: DRA1 S/70207
F1G 2 PROP NELL
;Project No. 70207
PROPOSED WELL CONSTRUCTION OETAILS FOR TWO TEST WELLS
AT THE SHALLOTTE TOWNSHIP DISTRICT PARK
BRUNSY CK COUNTY, SHALLOTTE, NORTH CAROL.INA
Dote 10/12/15
Figure' 2

PRI
(
BRUNSWICK COUNTY PUBLIC UTILITIES
OPERATIONS CENTER
MAfuNG ADDRESS
PosT OFFICE Box 249
BOUVIA, NORTH CAROLINA, 28422
November 12, 2015
Mr. Michael Rogers
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
250 GREY WATER ROAD NE
SUPPLY, NORTH CAROLINA 28462
Re: Notification of Intent to Construct or Operate Injection Wells
Dear Mr. Rogers:
TELEPHONE
[phone]
FAX
[phone]
Enclosed please find our Notification of Intent to Construct or Operate Injection Wells Form. Brunswick
County through its contract with ASR Systems, Inc. plans to construct two Aquifer Test Wells as a part of
its Aquifer Storage and Recovery Feasibility Study.
Please let us know if you have any questions or need additional information.
Sincerely,
Ct .. w(v~
J@ . Pierce, P.E
Director of Public Utilities
cc: David Pyne, ASR System
Morella Sanchez King, NC DEQ WRO
Jay Holly, GMA
J