WI0800206_Injection Event Record_20131010

MAT C
ATC ASSOCIATES OF NORTH CAROLINA, P.C.
Engineering Individual Solutions
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcassociates.com
N.C. Engineering License No. C-1598
October 7, 2013
Mr. Michael Rogers
NCDENR Division of Water Quality
Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
RE: Injection Event Record
Injection Permit WI0800206
Former Conoco Store #33051 (RM #6265)
2636 Castle Hayne Road
Wilmington, New Hanover County, North Carolina
ATC Project No. 45.75118.6265
RECEIVEDIDENRIDWQ
OCT I02013
Dear Mr. Rogers:
Aquifer Protection Section
ATC Associates of North Carolina, P.C. (ATC), on behalf of Phillips 66 Company, is submitting an
Injection Event Record per the requirements of Injection Well Permit WI0800206 issued on August 30,
2013. On April 4, 2013, ATC submitted a modification plan to the UIC-Program requesting approval to
over -drill the existing six injection wells to a depth of 25 feet below ground surface. On April 29, 2013,
the UIC-Program approved ATC's request to over -drill the existing wells. Injection wells IW-1 through
IW-6 were over -drilled between June 4, 2013 and July 15, 2013. On July 22, 2013, ATC submitted a
renewed application for Injection Permit WI0800206 that was subsequently approved on August 30,
2013. The injection event took place on September 16 through September 18, 2013. The event consisted
of injection of magnesium sulfate. Attachment 1 contains the Injection Event Record form and
Attachment 2 contains the injection well construction records. A separate report will be submitted at a
later date containing pre and post -injection groundwater monitoring data and additional details regarding
the injection activities.
If you have questions or require additional information, please do not hesitate to contact us at (919) 871-
0999.
Sincerely,
ATC Associates of North Carolina, P.C.
J
Ashley Winkelman, P.G. Gabriel Araos, P.E.
Project Geologist
cc:
Senior Project Manager
Ed Kuhn — Contract Program Manager for Phillips 66 Company
Deborah Mayo — NCDENR DWM-UST Section
Morella Sanchez -King — Wilmington Regional Office
Attachments:
Attachment 1 — Injection Event Record
Attachment 2 —Injection Well Construction Records

ATTACHMENT 1
INJECTION EVENT RECORD

RECEIVED!DENRIDWQ
OCT I 0 2.U13
INJECTION EVENT RECORD Aquifer Protection Section
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number WI 0800206
1. Permit Information
Mr. Steve Helin, Eastern Regional Manager (Phillips 66 Company)
Permittee
Former Conoco Store #33051
Facility Name
2636 Castle Hayne Road, Wilmington, New Hanover County, NC
Facility Address
2. Injection Contractor Information
ATC Associates of N.C., P.C.
Injection Contractor / Company Name
Street Address 2725 E. Millbrook Road, Suite 121
Raleigh
City
NC
State
( 919 ) 871-0999
Area code — Phone number
3. Well Information
Number of wells used for injection
Well names IW-1 through IW-6
27604
Zip Code
6
Were any new wells installed during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
6 well locations were
Number of Injection Wells over -drilled
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies of form GW-1 b for each
well installed.
Were any wells abandoned during this injection
event?
❑ Yes 0 No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
3,000 pounds of magnesium sulfate in 6,000 gallons of
water
Injectant Type
Concentration 0.5 pounds / gallon
If the injectant is diluted please indicate the source
dilution fluid. City of Wilmington
Total Volume Injected 6,000 gallons
well 1,000 gallons of magnesium
Volume Injected
per_sulfate and water mixture per
injection point
5. Injection History
Injection date(s) 9/16/13 - 9/18/13
Injection number (e.g. 3 of 5) 1 of 4
Is this the last injection at this site?
❑ Yes 0 No
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
STNDARDS LAID UT IN THE PERMIT.
SIGNATURE OF INJECTION CONTRACTOR DATE
Gabriel Araos, P.E.
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IER
Rev. 07/09

ATTACHMENT 2
INJECTION WELL CONSTRUCTION RECORDS

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK GETTYS
Well Contractor Name
A - 2345
NC Well Contractor Certification Nwnber
GEOLOGIC EXPLORATION, INC
For Internal Use ONLY:
WOW
PROM
�t�9�r6'ksS�:�a irsIt�a�Ftu'.'���•`:��`t�
TO
DESCRIPTION
f6
ft.
ft 1 rt.
'}YSAKITKIV YA'$Irtektai;•muth-calm Ili i�i2Y i1d�) Ri((f pftcatltp).'�`__ WarO ,
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
2. Well Construction Permit 11: _
List all applicable well construction pemrlts (i.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrilalion
Non -Water Supply Well:
flMonitoring
Injection Well:
❑Aquifer Recharge
:Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Municipal/Public
DResidential Water Supply (single)
:Residential Water Supply (shared)
❑Recovery
['Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
DTracer
❑Geothermal (Beating/Cooling Return) DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 06/04/ 13 Well ID#
5a. Well Location:
RMR - 6265
IW-1
Facility/Owner Name Facility (if applicable)
2636 CASTLE HAYNE ROAD WILMINGTON 28401
Physical Address. City, and Zip
NEW HANOVER
County Parcel identification No. (PIN)
01.611fN1 E VOINCr(1'tRIC iffiC.i gfhe_r`x"�, a'ITeSa"$, ". PAP -f -'•r" T. ,
MATERIAL
FROM TO DIAMETER
THICKNESS
0.0
ft.
5.0
ft.
4.0 in.
SCH 40
PVC
ft.
ft.
tpri315 kt`L17:r
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
.t
5.0 ft.
25.0 fi. I 4.0
tn.
ft.
R.
IIIitt_`, >Iz9L4Titigi' r
FROM TO
.020
SCH 40
PVC
in.
'N Tf1 1i):
MATERIAL EMPLACEMENT
METHOD & AMOUNT
0.0
f1.
3.0
it
roams OBENTO me
SLURRY
ft
ft.
ft.
ft.
yorafixqagejzgmf,ifffiahavcirzwaiwag
FROM TO MATERIAL EMPLACEMENT METHOD
4.0
R.
25.0
ft.
20-40
FINE SILICA SAND
ft.
ft.
g eliitltlt tN('ay3UCi'�i[ticla'a�iiitionTll s);r i w5rraaarx l ,rcY :.t
PROM TO DESCRIPTION Odor. hardness, soiliroektyp. grain ear. err.)
0.0 ft. 5.0 ft,
GRAY CLAY
5.0
ft
12.0
ft.
LIGHT GRAY CLAY
12.0 fL
20.0 ft'
TAN SANDY CLAY
20.0
fL
25.0
ft.
GOLD SAND
fL
rt.
rt.
ft.
ft.
ft.
721 tY1mMs.r-x3,F
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees tificati
(if well field, one let/long is sufficient)
340 17' 27.34" N 77° 55' 14.50"
6. Is (are) the well(s): OPermanent or ❑Temporary
7.-E this a repairer an extsttng v- T "Mires or ❑No
Ifthls is a repair, fill out known well construction information and explain the nature of the
repair under 112i remarks section or an the back of thisform.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one fonn.
9. Total well depth below land surface: 25.0 (ft.)
For multiple wells list all depths ((different (example- 3®200' and 2Q100)
10. Static water level below top of casing: 10.0 (ft)
"water level is above casing, use "+"
11. Borehole diameter: 10.0 (in.)
12. Well, construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-I
Signature of Certified Well Contractor
06/27/13
Date
By signing this form. I hereby cerufr that the wells) was (were) constructed in accordance
with ISA NCAC 02C .0100 or .15.4 NCAC 02C .0200 Well Construction Standards and that a
copy aphis record has been provided 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
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following
Division of Water Quality, Underground Injection Control Program,
1636-Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sunni' & Iniection Wells: hi 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.
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK IRELAND
Well Contractor Name
A - 4163
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (I.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
DResidential Water Supply (shared)
Non -Water Supply Well:
1+7Monitoring
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal tHeating/Coolins,. Return)
4. Date Well(s) Completed: 07/15/13
5a. Well Location:
RMR - 6265
❑Recovery
❑Groundwater Remed iation
❑ Salinity Barrier
❑Stortnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (expla', I under #21 Remarks)
WeII ID# I W 2
For Internal Use ONLY:
KMOVATOTZON
PROM l TO
DESCRIPTION
ft.
ft.
ft ft.
ictKOWAlikaRKROViituitkafeAwM19 t1f�TdIY_. 'R.{rf ppLjcab`]e).'ss:,-`r °h_ ti�;l
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
lEarIi!t iKIMSl! TG-beet j t iCs Mt(ieit7a "i11440)a •xYr
FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft' 5.0 ft• 4.0 SCH 40 PVC
ft. rt.
by BGll E1!Lti:'=3•:- ;rzl a1 rsx'," AlleT `r Y
FROM TO DIAMETER
5.0 'ft. 25.0 ft• 4.0 in.
SLOT SIZE 1 THICKNESS I MATERIAL
.020
SCH 40 1 PVC
ft.
rt.
In.
�s'1tgl)O[lla.�'£z."K.0.�MMO��..`WW.`��+L%.f1..:ISid
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0.0 tt.
3.0 ft
PORTLAND ENroNn.
SLURRY
ft.
ft
ft.
?kf4 .SelfhP
ft.
ki Xi itaill a lit
FROM 1 TO MATERIAL
EMPLACEMENT METHOD
4.0 fL 1 25.0 ft
20-40
FINE SILICA SAND
R
ft
-leitAtlEri IGii100ffttiehsddp-ionT7i Aiee ➢lfmWt f.:' '=-r- '-
FROM TO DRSCRICIRIN(.aer,hai°er,sWlrvek Isge, trdn siv ete.Z
0.0 rt 5.0 rt
SANDY CLAY
Facility/Owner Name Facility ID# (if applicable)
2636 CASTLE HAYNE ROAD WILMINGTON 28401
Physica] Address, City, and Zip
NEW HANOVER
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34° 17' 26.97" N 77° 55' 14.80"
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or IZ]No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 121 remarks section or on the back of this form.
9. Number of wells constructed:
For multiple injection or non -wafer supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: _ 25.0
For multiple wells list all depths If different (example- 3@200' and 2@100)
10. Static water level below top of casing: 15.0
If water level is above casing, use "+"
11. Borehole diameter: 10.0 (in.)
AUGER
12. Well construction method:
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: _ Amount:
Form GW-I
North Carolina Department of Environment ar
5.0
ft.
25.0
ft
SAND
ft
ft
fL
ft
tL
ft
ft. ft
ft ft.
-.?:.nfiS$it&;Y7rr:2angYld*MM'i YaafFt��<: ;='=r11kl.kw:rifg
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
ificatioy:
Zf
07/17/13
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certt,5, that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided 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 276994617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suanly & Iniection 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.
id Natural Resources -Division of Water Quality ' Revised tan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK GETTYS
Well Contractor Name
A 2345
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
For Internal Use ONLY:
11441WAI'S{!B'Lbrim`S15 e
FROM TO DESCRIPTION
ft.
ft.
Company Name
2. Well Construction Permit#:
List all applicable well construction permits (i.e. Counry. State, Variance, etc,)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural ❑Municipal/Public
❑ Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
❑lrri _ ation
Non -Water Supply Well:
I21Monitoring ❑Recovery
Injection Well: •
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
❑Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Coolin: Return) ❑Other(explain under#21 Remarks)
4. Date Well(s) Completed: 06/04/13
5a. Well Location:
RMR - 6265
Well ID# IW-3
Facility/Owner Name Facility ID# (if applicable)
2636 CASTLE HAYNE ROAD WILMINGTON 28401
Physical Address, City, and Zip
NEW HANOVER
Couoty Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds ordecimal. degrees:
(if one latAong well field, is sufficient)
ft.
ft
iitAVIDOMSII?I_Cw(f9% n sied +figlls Oltd l${ifiltin ab' j NZ -
THICKNESS MATERIAL
FROA TO DIAMETER
ft
VerkilitwOW
FROM
0.0
TO
ft
5.0
ft
ft. ft
POSGRV
FROM TO
5.0 rt
ft
l(r1'3
FROM TO MATERIAL
DIAMETER
In.
4.0
in.
0.0
ft.
3.0
THICKNISS
MATERIAL
SCH 40
SLOT SIZE THICKNESS
ft m pg/lDBEmONfE
.020 SCH 40
PVC
MATERIAL
PVC
EMPLACEMENT METHOD & AMOUNT
SLURRY
ft. ft.
ft.
FROM TO
4.0
ft.
25.0
ft.
ft
ft ft.
itZCORT1![TNGSDOVViiclehilin�'n`rl,aE�ct+,if:n'irei�il�r"�) .
FROM TO DESCRIPTION (calor, hardness, snNrnrk type, train du, etc.!
GRAY CLAY
t a: lcabl
MATERIAL
EMPLACEMENT METHOD
20-40 FINE SILICA SAND
0.0
5.0 rt
ft
5.0
11.0 ft
TAN CLAY
11.0
ft
20.0 ft
BLACK SAND
20.0
ft
25.0
ft.
GRAY SAND
it
ft
ft.
ft
ft.
ft.
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
22. Certification:
34° 17' 27.27" N 77° 55' 14.80" w
Signature of Certified Well Contractor
By signing this form. I hereby cerl fy that the wells) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I5A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided 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 nerecsary.
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
24b. For lniection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Snnphv & 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.
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or elNo
If this is a repair,•ffll out known well construction information and explain the nature of the
repair tinder #21 remarks section or on the back of this form. _
8. Number of•wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 25.0 (fk)
For multiple wets list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of easing: 10'Q (ft)
If water level is above casing, use "+"
11. Borehole diameter: 10.0 (in.)
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Form GW-1
06/27/13
Date
North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECO 1; i 1
This form can be used far single or multiple wells
1. Well Contractor Information:
MARK GETTYS
Well Contractor Name
A-2345
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
For Internal Use ONLY:
9:;•►I!AMMr.TEMftlii,04W65'.6f.1.501-.W1g0fa74-;..0trkrr
FROM TO DESCRIPTION
ft.
ft.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑Irrigation
Non -Water Supply Well:
l2lMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothennal(Closed Loop)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
°Subsidence Control
❑Tracer
°Other (explain under#21 Remarks)
❑Geothermal (Heating/Cooling Return)
4. Date Well(a) Completed: 06/04/13
5a. Well Location:
RMR - 6265
Well ID# I W-4
Facility/Owner Name Facility ID# (if applicable)
2636 CASTLE HAYNE ROAD WILMINGTON 28401
Physical Address, City, and Zip
NEW HANOVER
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwelt field, one lat/long is sufficient)
34° 17' 27.41" N 77° 55' 14.46"
6. Is (are) the well(s): ❑Permanent or ❑Temporary
W
ITiis a repair to an eiustiog well: ❑Yes or .. Lf3No
1f this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of thisform.
8. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: 25'0 (ft)
For multiple wells list all depths ifd fereni (example- 3(2O0' and 2 a@100)
10. Static water level below top of casing: 10' 0 (ft)
If water level is above casing, use "+"
11. Borehole diameter: 10'0 (in.)
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method of test:
13b. Disinfection type: Amount:
Form GW-I
ft.
ft.
O.R1sitr`aSINOICrut pl( cuse irelliVitt ti (fCapgl l j is %sue g..
FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
( tATMER1OXSIHGIOR 's1B1[C A ertnini Au 6".
FROM TO DIAMETER THICKNESS MATERIAL
0.0 ft.
5.0
ft.
4.0
In.
SCH 40
PVC
ft.
in.
10.1.80000
FROM
5.0 ft
TO
25.0 ft•
DIAMETER
4.0 in'
SLOT SIZE
.020
TUICKNESS
SCH 40
MATERIAL
PVC
ft.
ft
i tl', 0'()1`` y'�Kj
FROM
0.0 ft
ft
TO
3.0 rt.
ft
PoflnAea BENTONITE
in.
laglikligaitatieMEWLVMOIE
MATERIAL EMPLACEMENT METHOD & AMOUNT
SLURRY
ft. ft.
ALYNNHf1J, rR'iiXWL%kti rtil' riIWl2)y° litr gtiV.,,s
FROM TO MATERIAL EMPLACEMENT METHOD
4.0 ft 25.0 ft
20-40
FINE SILICA SAND
ft. - ft.
%20:41Rtf. G AG:'(ono'r.:aiditiilidwrlylsteG`sY 14.01I , • o:W._e' 4.� .•.
FROM I TO DPSCRIPfioN (eelvr, haziness, iniltrark type, grain ore, et r.J
0.0 ft
5.0
ft
5.0 ft
13.0
ft.
GRAY CLAY
LIGHT GRAY CLAY
13.0
ft
19.0
ft.
TAN SANDY CLAY
19.0 -
25.0 ft
ft
ft.
GOLD SAND
ft
ft
ft
ft
AfAink
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
22. Certification:
Signature of Certified Well Contractor
06/27/13
Date
By signing this form. 1 hereby certt& that the wall(s) was (were) constructed In accordance
with ISA NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided 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
constriction 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
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
' 1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water &uni,, & Injection 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.
North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan. 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK IRELAND
Well Contractor Name
A-4163
NC Well Contactor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit8:
Lis/ all applicable well construction permits (i.e. County, Siam, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Fleeting/Cooling Supply)
❑Industrial/Commercial
❑Irri: tion
Non -Water Supply Well:
2lMonitoring
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heatin Coolin: Return)
❑Manicipal/Public
DResidential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
['Tracer
❑Other (explain under821 Remarks)
4. Date Well(s) Completed: 07I1 SI13 Well ID#
5a. Well Location:
RMR - 6265
IW-5
Facility/C+wnerName Facility ID# (if applicable)
2636 CASTLE HAYNE ROAD WILMINGTON 28401
Physical Address, City, and Zip
NEW HANOVER
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one lat/long is sufficient)
34° 17' 26.86" N 77° 55' 15.06"
6. Is (are) the well(s): IZPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or IZJNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under ill/ remarks section or on the back of this form.
8. Number of wells constructed: 1
For multiple infection or non -water supply wells ONLY with the same construction. you can
submit one form.
9. Total well depth below land surface:
For multiple wells list all depths el -different (example- 3@200' and 2 r@e 100)
25.0
(ft.)
10. Static water level below top of casing: 15' 0 (ft.)
If water level Is above casing, use "+"
11. Borehole diameter: 10.0 (in.)
12. Well construction method: AUGER
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Form GW-I
Method of test:
Amount:
For Internal Use ONLY:
FROM
FL
TO
fe.
DESCRIPTION
f.
It.
.e7'S iDUTtR dASIPiO (for lintel asea-34 6l Q EINMIClifiOdable) .s_.Ai , t' i
FROM TO DIAMETER MATERIAL
THICKNESS
ft. ft. in.
lfNiY.tyR'G{'$IWiOTty7i1E113fNGckeuitie`rice:'1-.s1oSi:d4o9`d]'6i'F:'r :'.:>:liWszt�`.a.=..,`:ltl
DIAMETER THICKNESS
FROM "TO
MATERIAL
0,0
ft
5.0 ft.
fG
4.0
in.
in.
SCH 40
PVC
41. t l$N} .IFF I i` Pst r i7I3A-1.' . YMNIAUa .` f r hale / . V
DIAMETER
4.0 -
FROM
5.0 ft
TO
25.0 f°
SLOT SIZE
.020
THICKNESS
SCH 40
MATERIAL
PVC
ft
ft.
in,
ilaM.OUrt "1 ,ilcu aliital it. s.a..`r�;M; +< �'",�.,iu i ri
FROM TO MATERIAL
EMPLACEMENT M ErHOD & AMOUNT
0.0 rL 3.0 ft
PCSTANOOEMraanE
SLURRY
ft
ft
ft 1
ft
giWANDARXV.DIS '.I�.E'•. itjf
FROM TO MATERIAL EMPLACEMENT METHOD
4.0 ft 25.0 rt
re. ft.
tiai*DRIIOW
FROM
0.0 IL
20-40 FINE SILICA SAND
TO
5.0 ft-
Vat`�fie'rif�icCe�iaiy)
1JESCRLPT I ON (color, 6.rdarq sn:rtreok type. rrein rise, etc.)
SANDY CLAY
5.0 ft
25.0 ft
SAND
ft.
ft.
ft
ft
ft
ft
ft
ft
ft.
ft
K a;.H:l:�.. :�s�il:i�-h'r ..3:.�,s-,. 1'�� � •ti it'd;°=-.Yf •-
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
22. Certification: /C
07/17/13
Signature of Certified We7Contractor Date
By signing This farm, I hereby certt& that the well(s) was (were) constructed in accordance
with i JA NCAC 02C .0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
copy of this record has been provided 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 ifnerresary.
SUBMITTAL INSTUCT1ONS
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
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Contra/ Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Suonlv & 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.
North Carolina Department ofEnvironment and Natural Resources -Division of Water Quality Revised Jan. 2013

4. Date WeI1(s) Completed:
5a. Well Location:
RMR - 6265
WELL CONSTRUCTION RECORD
This form can he used for single or multiple wells
1. Well Contractor Information:
MARK GETTYS
Well Contractor Name
A - 2345
For Internal Use ONLY:
1'A 1Vii ]E 3NtSi
FROM 1 TO
+ .117 We ir$ $[ =120A1 `-
DESCRIPTION
NC Well Contactor Certification Number
GEOLOGIC EXPLORATION, INC
ft
ft
ft.
ft.
40#517:pER
FROM
SIIEKkfi vi"aiWOW-Ali (*jTWRiLitVla i rcaffel e=<a'"-?n
TO DUMErmR THICKNESS Af ATERIAL
ft
ft.
in.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (l.e. County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑lint:. tion
Non -Water Supply Well:
Monitoring
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other i explain under #21 Remarks
06/03/13 We11ID# IW-6
Facility/Owner Name Facility ID# (if applicable)
2636 CASTLE HAYNE ROAD WILMINGTON 28401
Physical Address, City. and Zip
NEW HANOVER
etaitR iMIXE1R1Y D{Yealh i!'m" l Tn9�goo
FROM TO DIAMETER THICKNESS MATERIAL
0.0
FROM
0.0
ft.
ft.
5.0 rt,
4.0
tn.
SCH 40
PVC
TO
25.0 ft
ft.
ft.
DIAMETER
4.0 in.
in.
SLOT SIZE THICKNESS MATERIAL
.020 SCH 40 PVC
TO MATERIAL EMPLACEMENT METHOD &AMOUNT
R roalw+oaENTOI1TE
SLURRY
iL�'�Y,E3'T�'�t1:.Cal{i{ifEsaplica'lile"' , - `5�y;'
FROM 1 TO
MATERIAL
EMPLACEMENT METHOD
4.0 ft
25.0 ft,
20-40
FINE SILICA SAND
ft. I ft I
AZI;t111Rllifdfi3' . .M g e 'Apiion'"`(e 5he"e` Sij yY LF
FROM TO DrSCR tPT1 Ot4 (color, hardmsc, twairaek type, vain me, ctr.]
0.0
5.0
It.
ft
5.0
11.0
ft
ft
GRAY CLAY
LIGHT GRAY CLAY
11.0 ft
20.0
ft.
TAN SANDY CLAY
20.0 n'125.0
ft.
LIGHT TAN SAND
ft I ft.
ft 1 ft
fL J ft.
BENTONITE SEAL FROM 3.0 TO 4.0 FEET
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
34° 17' 27.55" N 77° 55' 14.36"
6. Is (are) the well(s): 121Permanent or ❑Temporary
'"73i-this a repair to ii eziiting well: Dyes . or ONo
if this is a repair, fill out known well construction information and explain the nature of the
repair under 121 remarks section or on the back of this form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the sante construction, you con
submit one farm.
9. Total well depth below land surface: 25' 0 (ft.)
For multiple wells list all depths Ifdifferent (example- 38200' and 2@l00)
10. Static water level below top of casing: 10.0 (ft.)
If water level is above casing. use "+"
11. Borehole diameter: 10.0 (in.)
AUGER
12 Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount: _
Form GW-1
22 ,Cerjification:
Signature of Certified Well Contractor
06/27/13
Date
By signing this form, 1 hereby certt& that the well(s) was (were) constructed in accordance
with 1SA NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided 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 ifnececcary,
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
24b. for Infection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center,Raleigh, NC 27699-1636
24c. For Water Supply & Injection 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.
North Carolina Department of Environment and Natural Resources -Division of Water Quality Revised Jan. 2013

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number La ©g 6V c2 66
1.
Permit Information
phut/'ts (oc eo
Permittee
For( r- Coco 3 305
Facility Name
6436 eas-ff e /4c y r e
Facility Address
2. Injection Contractor Information
Sat x --T�r. 1-4 C.
Injection Contractor / Company
jName
Street Address au a 6/e. »r
CC44. ,'1 Aie caz 5 3
State Zip Code
OR-01q
Area code — Phone number
3. Well Information
Number of wells used for injection
Well namesW i.TI.JZ 31.J3 tL+.�) ' rW
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
6
Type of Well Installe (Check applicable type):
❑ Bored Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies ofform GW-Ib 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
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
' e1 '41 6 I' -�'°-( e
Injec1dnt Type
560 l 5 m, 5 ._-. /000 (5aIS
Concentration W -t er
If the injectant is diluted please indicate the source
dilution fluid. fit) a + e_r
Total Volume Injected 001
Volume Injected per well /C) 0 0 ct
Injection History �J
Injection date(s) l 7 13
Injection number (e.g. 3 of 5) '
Is this the last injection at this site?
❑ Yes. ❑ No
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 LAID OUT IN THE PERMIT.
9 -(3
SIGNA OF INI TION CONTRACTOR DATE
GQ r n P e (5
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IER
Rev. 07/09

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resource — Division of Water Quality
Permit Number 1.k ©g 00 =2 C C
1. Permit Information
Phi' bi 6 Co
Permittee
Former -
Co :Co 3 3 0 5-
Facility Name
643 Caff e 1� e Rod
Facility Address r
2. Injection Contractor Information
•e to . --- re ln. 2-4 C
Injection Contractor / Company Name
Street Address a©d Ceutd e- (-'
/V, c, 027 51,,E
State Zip Code
(911) (. fig-01 4
Area code — Phone number
3. Well Information
6.
Number of wells used for injection
Well names E(/ 1 Zt.J Z I1.J3 TLa.) rta S
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
Type of Well Installe (Check applicable type):
❑ Bored [Drilled ❑ Direct -Push
❑ Hand -Augured El Other (specify)
Please include two copies ofform GW-lbfor each
well installed.
Were any wells abandoned during this injection
.event?
] Yes eNo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
5Lim St,/-ca.( e
InjecTmt Type
500T-65 S , -- /000 gals
Concentration
If the injectant is diluted please indicate the source
dilution fluid. (A)0.. e. r
Total Volume Injected 00 Q
Volume Injected per well /0 0 0
5. Injection History 2
Injection date(s) / / 6 - , f 3
Injection number (e.g. 3 of 5) ' 2
Is this the last injection at this site?
❑ Yes. ❑ No
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 LAID OUT IN THE PERMIT.
q•1 j-13
ffT
SIGNATt OF IN TION CONTRACTOR DATE
Gary e Veis
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IER
Rev. 07/09

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number Luu L OgOt9aOG
1. Permit Information
Fhtl11`s 66, Co,
Permittee
For rl er- Co v Co
Facility Name
6436 £ f1.e /4 ri Rol
Facility Address
2. Injection Contractor Information
Feat k L. L C
Injection Contractor / Company Name
Street Address "2'e:4 I e. IS
CA-r y M C` a 7 50
City State Zip Code
(9[?) 72-0144
Area code — Phone number
3. Well Information
Number of wells used for injection
We11 names�W 1)11.) 2 �1.J3 IL } ZW S
/ 1 ja-4lro
Were any new wells installed during this injection
event?.
❑ Yes dNo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
6
Type of Well Install(Check applicable type):
❑ Bored ['Drilled ❑ Direct -Push
O Hand -Augured ❑ Other (specify)
Please include two copies ofform GW-1 b for each
well installed.
Were any wells abandoned during this injection
event?
>. Yes eNo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
n g 3 l u re) 5 t, -cad e
Injeccant Type
,doTbs € S, -- /eoo (uis
Concentration t-- �,:,r er
If the injectant is diluted please indicate the source
dilution fluid. Wait v'
Total Volume Injected 00 d M f •
/DOO
Volume Injected per well
5. Injection History p
Injection date(s) / " , �'� /3
Injection number (e.g. 3 of 5) :L) —
Is this the last injection at this site?
❑ Yes. ❑ No
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 LAID OUT IN THE PERMIT.
9-1J - i3
SIGNATU OF INJECTION CONTRACTOR DATE
Golf y 1 e ers
PRINT NAME OF PE ON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IER
Rev. 07/09

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resource — Division of Water Quality
Permit Number IV7 ©g CV Co
1. Permit Information
fht-///,:es 66 eo
Permittee
Former Cort,i,Co 3 3 6 I
Facility Name
6436 t -f-1 e 14_ r Rod
Facility Address
2. Injection Contractor Information
Esot y.—Tcin LLC
Injection Contractor / Company Name
Street Address(' PvaIe.
ry
N, Cr 027 51,,E
State Zip Code
Ott) 67R _0140
Area code — Phone number
. Well. Information
6
Number of wells used for injection
Well names7'G) l,I JLIGJ3, mil) ci) 114 S
zwro
Were any new wells installed during this injection
event?_
❑ Yes L No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installe (Check applicable type):
El Bored [Drilled ❑ Direct -Push
❑ Hand -Augured El Other (specify)
Please include two copies of form GW-1 b for each
well installed.
Were any wells abandoned during this injection
event?
p • Yes IZNo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
•('lacqynre.5iurn Sr, /fa-4 e
InjecTant Type
500b s , 5 , -- /oo o &a Is
Concentration k,),,ti Cr-.
If the injectant is diluted please indicate the source
dilution fluid. W.o 4 ew
Total Volume Injected l . 00 0 y i
Volume Injected per well t/4 0
5. Injection History ` J
Injection date(s) / / 7 i3
Injection number (e.g. 3 of 5) CL)
Is this the last injection at this site?
❑ Yes. ❑ No
i
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 LAID OUT IN THE PERMIT.
SIGNA'
9-I —(3
OF INi CTION CONTRACTOR DATE
Gar ki Pt)e er-
PRINT NAME OF PE ON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IER
Rev. 07/09

f.,.JEl VEDIDENRIDWQ
INJECTION EVENT RECORD SEP 2 0 2013
North Carolina Department of Environment and Natural Resources — Divis�ii i'oiTECII "CbOCI
Permit Number Id •r ©g 00-2°G
Permit Information
Phil/,5- 66 Co
Permittee
ForIII er $ v �Co
Facility Name
a43 h iosfl e ti c, Rod
Facility Address
3305'1
2. Injection Contractor Information
ESctex — r C A I -LC
Injection Contractor / Company Name
Street Address a'©o
ctw y N° c ` 027 55(3
City State Zip Code
L2,Lt 67R-0ILO
Area code — Phone number
. Well Information
Number of wells used for injection 6
We11 names7GJ 1 Tt,) IU3 S
Wereany new wells installed during this injection
event?
❑ Yes No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installe (Check applicable type):
Cl Bored [Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies of form GW-1 b for each
well installed.
Were any wells abandoned during this injection
event?
;❑ Yes 2rNo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
M�q net f 5 r, /44.-( e
Injec tnt Type
50o 6 s p , S , -- /00 o aQ 1s
Concentration er
If the injectant is diluted please indicate the source
dilution fluid. (A)04.4 e.
Total Volume Injected id OO d .1 •
Volume Injected per well /D 0 O
5. Injection History
Injection date(s) / /fo — l3
Injection number (e.g. 3 of 5.) U '51.
Is this the last injection at this site?
❑ Yes. ❑ No
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 LAID OUT IN THE PERMIT.
SIGNAT
9- [R — (3
OF IN ION CONTRACTOR DATE
GarPe Ce(3
PRINT NAMEOF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IER
Rev. 07/09

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resource — Division of Water Quality
Permit Number 6.1 g CV 2
1. Permit Information
Permittee
Former- Co h, Co 3 3 0 • /
Facility Name
0436 e, sf/e (ar e
Facility Address
2. Injection Contractor Information
geflax--7�ck L.L C
Injection Contractor / Company Name
Street Address 42'©6 �v a r`
.r
City
c, 27 5( 3
State Zip Code
at 67R-0Iq
Area code — Phone number
3. Well Information
6
Number of wells used for injection
Well names 3W SW Z 11,J3 Ti j r! rt•,1 S
1 1 1 }ZA16
Were any new wells installed during this injection
event?
❑ Yes EINo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installe (Check applicable type):
❑ Bored [Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies ofform GW-1 b 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
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
f �`l n Q t f u rn 511-Cc1-4 e
Iujecnt Type
66 OOTIS M, S , -- /000 euIs
Concentration (,) Sri Cr
If the injectant is diluted please indicate the source
dilution fluid. W o f &
Total Volume Injected (0 00 d f •
Volume Injected per well , 0 0 0 0�
5. Injection History Injection date(s) / I g "� 13
Injection number (e.g. 3 of 5) :L
Is this the last injection at this site?
❑ Yes. ❑ No
w
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 LAID OUT IN THE PERMIT.
(3
SIGNATURE OF INJECTION CONTRACTOR DATE
Gary e rS
PRINT NAME�] OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IFR
Rev. 07/09

Figure 3. Injection Layout