WI0800503_DEEMED FILES_20180223

Permit Number
Program Category
Deemed Ground Water
Permit Type
Wl0800503
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Pender Gas & Oil
Location Address
14540 US Hwy 421
Wilmington
Owner
Owner Name
Springer-Eubank Company
Dates/Events
NC
Orig Issue
2/23/2018
App Received
2/14/2018
Re gulated Activities
Groundwater remediation
Outfall
Waterbody Name
28409
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
2/23/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
MajorlMinor
Minor
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Greta Stanley
123 Shipyard Blvd
Wilmington
Region
Wilmington
County
Pender
NC
Issue
2/23/2018
Effective
2/23/2018
28412
Expiration
Re q uested /Received Events
Streamlndex Number Current Class Subbasin
ATC
ENVIRONMENTAL • GEOTECHNICAL
$LIIUIING SCIENCES IF SUM
February I, 2018
509A Pinar Road
Suite 115
Wilmington, North Carotina 28409
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineerin License No. C-1598
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate injection Wells
Former Pender Gas and Oil
14540 U.S. Highway 421
Wards Corner, Pender County. North Carolina
Risk Classification: High
Dear Ms, Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of Springer Eubank Co., Inc. The permit
application covers the performance of passive remediation in one monitoring well associated
with the above referenced site
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
_ 1
Maureen A. Jackson, PG.
Senior Project Manager
cc Ms. Greta Stanley, Springer Eubank Co., Inc.
Attachments

NOTICE OF INTENT FORM
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION O:F 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 fo rm shall be submitted at least 2 weeks prior to in iection.
AQUIFER TEST WELLS (ISA NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (ISA NCAC 02C .0225) or TRACER WELLS (ISA NCAC 02C .0229):
1) Passive In· ection 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 In jection 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 ·ection 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.
DA TE: February I , 201L PERMIT NO. W J1) 8 0 0 5"V 3 (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
___ Air Injection Well. ..................................... Complete sections B-F, K , N
___ Aquifer Test Well ....................................... Complete sections B-F, K , N
X Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
(I)
(2)
(3)
(4)
(5)
(6)
___ Pilot Test.. ............................................... Complete sections B-N
___ Tracer Injection Well ................................... Complete sections B-N \VEDINCOEQJDWR
ST A TUS OF WELL OWNER: Business/Organization
rEB 12 2018
ua\\ , Raoional "v.J' ter ti on
WELL OWNER -State name of entity and name of person delegated authority to sign on beiQ}f o :li e business
or agency:
Name: Greta Stanley. S pringer Eubank Co., Inc.
Mailing Address: 123 Shi pyard Boulevard
City: Wilmin gton State: NC Zip Code: 28412 County: New Hanover
Day T ele No.: ~9 "--'10'--=-34~3'--~19'-'9'""'1"--------Cell No .: Not Available
EMAIL Address: ___ .._.e.s~t=an=l~e.,__v@ ... a--=,s=pr=i=n g_,_e=r~o=il =.c~o=m~ __ Fax No.: Not Available
UIC !ln S itu Remed. Notification (Revised 3/2/2015) Page I
D. PROPERTY OWNER (if different than well owner)
Name: ___ _,_M=ah,.,_,m'-'--'--"'o~ud~DC-'..__._A~jl!:'.e.:::!en~ _____________________ _
Mailing Address: 126 South gate Road
City: Wilmin gton State: _NC_ Zip Code:_~2~8~4~12~ ___ County:....,_N~e~w'-'-----'-H-'-=a~n""o--'-v.:::!er'-------
Day Tele No.: 910-604-2221 Cell No.: 910-604-2221
EMA IL Address: Not Available Fax No .: __ ........:a:UC!-'n,._,kn=ow=n _____ _
E. PROJECT CONT ACT -Person who can answer technical questions about the proposed injection project.
Name: ___ _.!M=a~ur~e~e~n..!!.J~ac~k~s~o:!_!n...:::....;A~T~C'....!A..!;s~s~o~c,!..!c'· a~tee.::!s~o~f__._N~o,!!rt~h~C=ar,_.,,o~li~n~a"--'1 P'---'.,..,,C::.:.·------------
Mailing Address: __ ___,!:6!.!,0~9.!_A'---'P'---'1!..!.;·n~e!_r ~R~o~ad~•...!:S~u:!..!.it~e:....,l'--'1'-='5'--------------------
City: Wilmin gton
Day Tele No.: 919-561-3893
State: _NC_Zip Code: . .=2=8-'-40=9'--___ County: New Hanover
Cell No.: 919-561-3893
EMAIL Address: ___ =m=a=u=re=e=n~. j=ac=k=s~o=n@.._c.=a=tc=a=s=so~c'-'-'ia=t=es=.c=o=m=-----Fax No.: ___ 7'-"3'--'7-'-2,:,.;0"--7'--=8=26-"--'-I ___ _
F. PHYSICAL LOCATION OF WELL SITE
(I) Physical Address: 14540 U.S. Hw y 421 County: Pender
City: Wards Corner State: NC Zip Code: ---=2=8_,_42=5'-----------
(2) Geographic Coordinates: Latitude**: 34° __]J' ___JU_" or 0
Longitude**: 78° ____ Q_f __ 1_9" or 0
Reference Datum: ___ N_/~A _____ Accuracy:. __ --=---1 O~-=m~e'""'te=r __ _
Method of Collection :.-'G"'--"-oo"'.Jg:,.!l""'e'""'E""a"--rt"'h'--'P--'-r-"'o ___________ _
**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 (.:S I 0,000 ft2 for smal I-scale injections)
Percent of contaminant plume area to be treated: (must be_:::: 5% of plu~e for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(I) 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.
See Figures 1 through 4 for site location and injection zone maps.
UIC//n 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.
ATC will install Adventus O-SOXs in monitoring well AEW-8 in order to aide in natural attenuation and reduce
com pounds concentrations to below the North Carolina Groundwater Quality Standards (2L Standards). Based
on the most recent sam lin g, event performed in Au gust 2017 . the followin g com pounds exceeding the a p licable
2L Standards: benzene at 110 micro •rams/liter · !benzene at 760
u g/L. n-Buty lbenzene at 260 ug/L. sec-Butylbenzene at 94 ug/L. na phthalene at 290 µg/L. C5-Cs Ali phatics at
7.000 ug/L. C9-C1s Ali phatics at 172 .000 btg/L. C19-CJ6 at 1 LOOO 11g/L, and C2-C 22 Aromatics at 28 ,2 00 ug/L.
The socks come in 3-foot sections. A TC will install two 3-foot sections at the base of the wel l, across the well
screen. The socks will release oxidizing solids into the groundwater for a pp roximatel v 6 months . at which point
the chemicals in the socks will have de feted.
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 :l!portal.n cdenr .orgl weblwqlapslgwpro. All other substances must be reviewed by the Divis ion of Public
Health, Department of Health and Human Services. Contact the VIC Program for more info (919-807-6496).
lnjectant: Adventus O-SOX
Volume of injectant: -~9~0~5~in~3_--'-v=o~lu=m=e~o~f =so~c=k=s __________________ _
Concentration at point of injection: --~9~0~o/c~o ___________________ _
Percent if in a mixture with other injectants: __ ....,N..,_o=t:...:A--=-,e.p.,_pl:..:.ic=a=b'-'-le=----------------
See Appendix A for MSDS.
K. WELL CONSTRUCTION DATA
Number of injection wells : --~O ___ Proposed ___ ~ __ .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:
(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
See Appendix B for well construction details and the well construction record.
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Two weeks after submitting this NO i. ATC will install the Adventus O-SOXs in monitorin g wells AEW-8A.
UIC//n Situ Remed. Notification (Revised 3/2/2015) Page 3
I. attachment 1 , ' ·, _ plan to be ns~d · dt:·termin ..
• t I '! the inje~·t;n,1 activity.
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··Ow11cr'· mi..:,m~ :nn p..:r-,un \,h,1 lwkb i:L· fee or uthi::r PfC1PL'rl) ric'.hb , , tlw \\,:I] bl:ing con,;,truett.:J. ,\ well
i~ r<c'ttl pr,,p1..rty ;rnd it b,1d :;hall lw ,ki:mcd tn ve~t O\\m·r:;hip in the iand O\,ner. in 111L'
l'f:C:,. ,\f,:.n, ,•·,c, "-r"1_ tin \\Ti<t_lc'. .
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•' nt: rnp~r .;, Ow1i.·r n; thfi-.. ren• fr· :n :,pphc:rnt1 l'riui nr T:·pc Fu,! ,\iame
{ 1J1i.:nr · .:, !'....' 1, ,. .1: • .' , :,,,.! r.,~, :,'.>•;rty t•}U, 1 n,~ry f;c sufin, !it u: /i ... :u 1_.~(a _,i'<ntJt1.u·L uJ1 this),.Jr1n.
uWR "I l( l'n Jran:
1t,3n \!ail ::>..:rvii.c C\:rllcr
R"i...·igh. l\:C 27699-1636
Tdcrht)nc: J<)) S'P--6-lid
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.
Annual sam .ling events of select monitorinst wells -is performed in AuQust. ATC's next samkplinm event will
occur August.2018. During the next samplinii event ATC will collect a sample from monitoring well A EW-8A
for analysis of volatile arg is compounds by EPA Method 6200E and MADEP Methods for VPH and EPH.
The samples will be _shipped to Con -Test Laborator in East Longmeadow. Massachusetts. ATC will also
measure dissolved oxygen, —conductivity, temperature. nH and oxygen reduction potentialjn select wells during
the Auiust 2018 sam linu event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT; "'hereby certify, under penally oflaw, 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
far.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
rill related appurtenances' in accordance with the I SA NCAC 02C 0200 Rules.'
.
Signature of Applicant print ar Type Full Name
PROPERTY OWNER cif the propert%. is not owned by the permit applicant);
"4s owner of the properly 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 wets) conform to the Well Construction Standards
NCAC 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's 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]
Welk Situ Reined. Notification (Revised 312/2015) Page 4

FIGURES
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A S'AR C I
2725 E. Millbrook Road, Ste 121
Raleigh, NC 27604
' [phone]
PROJECT NO: SPRING006
SCALE: SEE ABOVE DATE: 03/2015 REVIEWED BY' EAA
FIGURE it SITE TOPOGRAPHIC MAP
PENDER GAS AND OIL COMPANY
14540 US HIGHWAY 421
WARDS CORNER, FENDER COUNTY,
NORTH CAROLINA

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APPENDIX A
MSDS FORM
ADVENTUS
�l1 rERIAl. `WAIF! 7'S' DA1:1 Sl1EL'f:
! )-SOX'1"'t Page: 1 ,it 3
1. 1)1tODUC 1 11)E\ 1 ia• IC'ATION: f l-SON I %1
1'Rt lDU C I USL:
and wawr treatment.
MA' 1TF.1(" I L'HI'.R: I:.IIERGI?iC'f PHONE:
I-R.1' SPOR1 ITTON O! 1JANGFItOI 5 GOOD CLASSIi'1C': 1TION:
h 1. ('I.i.• I'(i L N
�i111]Iti Ui.. S%il'i(':1 Ll() \:
COM1f OSI TIOr fu' Fok\i.vl ION ON INGRELTF11S
fu;rrdient. fet•rmula CAS No 1'creentag
- Y li'r
•' .I +1 �}
;. P1-1 SI(U 1):l A
4. RA 7. A R11S MEN 111 ICA I•(C O N
1:mergenr► ter ier►
1`utr„ tint Iii;ilth F:1Tert:
r
:, •.4 n 0 woke
Solid
“ring fron,
}' ncrn-re+parable ‘_t-n.;allinr
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fig tilt'. a tang dhc•Nc• f
iu+

DVENTI
M_1TERIAI. 5.11.1•:T}• 11 VIA SHEET:
O_SO; r'1 Page: ,,t•
c +.11:+.
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+ns.
[. rli7 (. I cle►: ieli
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t•m' .1 MID 'L11 ASCRLS
rev. • In: h S.•.k In:NIL:.1 :mention
• c! Mac: lerth
•
• In
l:. FIRi'. E'fi;1I1'IN(; \U LSI RE
I. Iutil1 Point
• • Ili
1 I inn°i i iiit►
Il;uiliaa I•rinpei.iturc
I],ing,:r 11r Explii,inn
Extinguishing Nta.'di:l
• Ve tt ...
• ,eith ' ,:I1 ;ink '• •- 'ui anti largo •
l•if11i i.' 1n.h::,1 l•
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1111I1 lll:aei
Fire ilIarurdc.
• i.h:t,hze•r. iiLmil
tia] h.eti,•

ADVENTUS
Niel' TRIAL SAFETY Y DATA SHE.FIC:
U-SoXTl t'age:3 ;
•,\I i_Cri oil hea:
i'rc� it ntine.i he tetl or
Fire Fighting Measures
•
• id do. on
•
AC( !DENIAL R1:i FAST NIF.tti[.'Rl•:4
Spill glean -up Pt -met -Ian.
• Dl i:Iii.er Eliminate :II ;r•1.rL•c o i itiT.'.i,il. }_y-Li:t t't' tnlprotL.-ted }!_r n:ic-i from equipment
• Shon•l or .Weep irtotrrr.! or %cmr.i containers for dtsc •ta. ho not r Luirl .1lillc•il
ori.:,ni7lrt:inatell IL,1Leri...1 I A1Old ]rliLk!I1 (Rol.
•
• p.lil ttn.aerial. Kip :PA.') trim: cowl,,...-t.i,lets ,,,.,i+,l. paper.
ntat let or or
HANDLING AND STORAGE.
Strrranti
• t.tRi�l:
It
Ai
• !. Do not .tinv tll
• 1 livk.p ..ont.rrit'r.
hn,ure pii- lire
• tilt•re . , an ithin Inateri.t . Avoid that may lead
Iia:ldlink
Or •111L71a V,Orn
• el cell ;hem tigi T1) ch
• 'li

ADVENTUS
MATERIAL .A1TT\ 1l l IA SI17.FT: O-SOXT`1
page: a ri I' ;
'. l_41'(l l RI. t'[l'•i ROI S/I'I.RS) .IL PRO CEA.•I'1€'
I'Jigintt'.'•Ing ('i iitrtn4
•
c 4liau.. I' •• .tech'.uri or 1 •thee
iw.*J1d :U tlidititiiin airhucric• levels helovv rr.-I niiiic:nded exposure limns.
/1ainLin i.tslcsiu Do
'i U.tc•ri mnni•nrur. ,Iii ,i'.ci
Respirator Protection
• } [': II. It -. tr. :iiistcii: hot.,t er, i i [iutit}' orunknown
t . •.l�:rti .ce:r e NiOSi I alrpro eJ r: Whir. unr.
I•:}el3 ace Protection
Skin Pi mectiuti
•
Other I'roteri %e i;tluipmcnt
• I:re-►►a'li 41aa„n
•
t sent r.e1 f 1ti Oen( ('uri•ideratiotit
■ 4r•:1
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itl. 4r.�Bh1 1TV .AND RL•.A(.T'I\ I TN
Stability
• St_ti•1.
Condition to .!► &
•
•
SUM
• Salt- of
• 1Zed:ieitis_ agents
•
1{.tr,tt•db.uw il[tumpuriti in VrivIttet.
■ IJ%;►
w..i�
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it
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t•Ins and . t the 1 e . wri.k i),I1. Goes
+t ..•7►' 171 Ierwwc►i : x.in souls

ADVENTUS
ARTERIAL SFET1 DATA SHEL1:
Q-SOXTM Page: 5 =.11 5
11. It XLC[]l-OClCAI 1NPOR,11.1 I'LO\
• LI15ta ' • \iii1.2t .1 1r}w;l,_. r '
• Min. �t,i1r11n�11._'
• -
i-:c rl.of,1c_u I\l'OI 1.tTIO'.
r_ecital9rulurviV l Informal kin
•
Chemical Fate Irtt'urnultion
•
13. DISI'l1•SAL CONSIDER 1 F1ONi
1 tr' prnliu. t
arltra,;r 4rt� iit
r11 1rr• .•n'
NVastt' 'real meat
• an atah rived ,1ltractnr in ,'Inr.pli:n1i.e u:th
Parl.at1e• 1 reatrnttit
• 1 lic i nl1'iti :.nj :.n
14. 'I RANSPou r 1'FOR t1 E'ER Y\
•
• i'ackina:l'tri'!:p:It
In. RI:i:11 LA'1[7RY INFORMATION
•
I it_ PRI.P.-11t vrio . 1"►iNOR\T.Vi l4)"•
l' lnt.tr1
i W
M.:d.�f 1�1c:tl
9/1
i'I:'r 11f1S_'73-z; T_

APPENDIX B
MONITORING WELL CONSTRUCTION DETAILS
Physical Address, City. and Zip
WELL CONSTRUCTION RECORD
This form cnn ba used far Tink nr rnuttiple wvEL
I. WO Contractor information:
-avt,k. t .>•
Wcl1 Contnakx Name
A-
NC- Well Con:meter CertipsaHnrn7ifsltiber
f 5t9Ea 4 e s
Company Nam¢
2. Wditonndr'uctton Permit #:
Liei all applicably $Tell aerator (r.e, (artnps Mn,SYarioree. InJa fk n: etc)
3. WdI Eke (chock well use):
Water Supply Well':
❑ Agricultural
°Geothermal (Heating/Cooling Supply)
t tlndsistrial/Commercial
°Irrigation
❑Municipal/F'ublic
©Residential Water Supply (single)
❑Residential Water Supply (shored)
Non -Watts Supply Well:
)ilonitoring
Injection 'Web:
❑ Agolfer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
OGeuthennai (Ciused Loop)
❑Graothermai (Nepting/Cooting Return)
7Recoveryr
QGroundwater Rcmediation
❑Salinity Barrier
E Sto rmwa ter Drainage
°Subsidence Control
❑Tracer
❑Other(explain under 0i2i Remarks)
4.11ate Well(s) Completed: j b Well MO Ps 11--- I
Sa. Well Location:
Pr RAW/0 O • A3-E61�
AI
facilindOw nu Name Faciliey(DP (if applicable)
g15,3 (,1 bli.rf 5-5 u3,. Sb.r oc.
PAC C )r
County Parcel Idcmilicetian No. (PIN)
5b. Latitude and. Longitude in degrees/minutes/seconds or decimal degrees:
(ifwall Rnld, one ta11larig is wRieiantl
33 r.S3 9o52- sY "��}O?o5Li- 7 w1741,
6. Is (are) the well(s): Kermnnent or ❑Tempnraiy
7. lti this a repair to anexistingwell: ❑Yes or
Vail is a repotr.JM' fait brown well CIMItfrtlrrntl lrrfirrnlartaa a explain the n wr nfihe
repair oettler k71 r'ectoris sever:n or on the hark of $his form.
S. Number of wells constructed:
;tor miultipfs iiiiaert n or area-water.rrrppfy ,cored ONLY with Thu some outsinirttion, yin, eon
submit ar;a farm. ��7]
9. Total well depth below hind wince: +r.,! - (11)
Par unWripie woos /no all depthx i(dO&,vni (example- .42Ir1' and 2 IIOU'}
19, Static water level below top of easing:
iilatr'r lard tr above ming, ins ",
11. Borehole diameter: 3r err (in.)
12. Well construction method: H f 1.0 ❑ i# ere.
(is. eager, rdwry, cable, direst push, etc,)
1.l
(R-)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (pm) Method of test: -
13b. Disinfection type: Amount; _
Per Use 0NLV'
^i,rrernel
- -
PROM
,�
DESCRITTSON
NWT filiti tIR
'TO • .. rirMI
a i k7i1fsirrig1, i '' '..
FROM • TO
DIAMETER •
THICKNESS
MATCR1AI.
n. j Fitit. 0.
in.
PROM
TO
DIAMETER
TRICK -NM
MATERIAL
1t.
ft.
in.
[t
ft. in
• : ttiilt9tTl'ri ` ' a,r1.. � .47-, .N;." 'i4 : + ' ; 4..: `3F='.:. ;ts ;; , ' r'r
FROM
TO
? DIAMITER
'SLOT SIZE ' THICKNESS •
MATERIAL
a. i
La rt.
in
, Oat) IC
J r'1 go
P VC-
rt. R
Irk
��
lilliMR::1111 �._'"7i • kr_5fi= •,,'yE
�
'3.E w'RO,,F �..'...gi.:'i• -:'
FROM TO
MATERIAL
EMPLAGSMENr METHOD & AMOUNT
4 tin.
6.0 n
sdr.�rxtte.
13,i d
it
rt,
ft.
it.
I9: SARiG11.01.f.:YACH'f
IAal i ) - — • _ iA''1../'.51; .+s ?,..
roost
TO
MATERIAL
- E.v.PLACr.Mr.n T METHOD
1,2.r ft,
1 rt
1 ptDrr4Utt5
5 N.t'
1t
it.
:tea. OW I.LINd-L'fG
ii4ie711nddttianershiiitilrtapieiseirvIt--i
.
FROM
TO
orSCRIYriON (color, bandana,.erYi.dr type jl n$SW, MC.l
ft
ir.
flp r, it .4 r& $
PtH n:
ks f'
roDJA Sancti 6i-L
..a.L! fr.
I' fr.
Orci U . a I,
grtrl
r1)"
elm i I isr~ tr SilA
i Oft.
U•orL'
di Oft.. .
C c4
22.. Certification:
Sigiature of Certified Well Cenh'actor
Date
ay sig#ng ti cfi rat, i hereby kertyy that the welfrc) wax (mere) ronxtrurted to avunrduice
with ISA N('AfO2C .AlArl nr ISA NC:.4C' 112t:.O2ri0 Weft C:onsrrotetlnn Sra,datxt, and Mar o
copy (phis Forgrkibar been provided to tin ivell erner.
23. Site diagram or Rttditiooal well details:
You may use 'ha back of this page to provide additional well site details or well
construction details- You may also alto& additional pages if necessary.
SHBMWfAL INSTUC[1ONS
24a. For All Wells: Submit thin term within 30 days of completion of welt
construction to the following'
Division of Water Resources, information Processing Unit,
1617 Mail Service Center. Raleigh, NT; 27699.1617
24h. For tilled -ion Welch ONLY: In addition to sending to foreto die address ;n
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program.
1636 Malt Service Center. Raleigh, NC 27699-106
24c. For Water Supyly & infec'tion Wells:
Also submit one copy of this Corm within 30 days of completion of
HsII construction to the county health department of the county where
constructed.
•,_-.� • .--,.-- ^•.�+-...,, ,.rP....i.,,ernr•.n: cot 1'fatnrrl Rpsmlrons—Division of Water RcrourC[a Revised August 2l]t7