WI0500448_Injection Event Record_20040324

WELL
, T
'ABANDONMEN>. RECORD
Thi; form can be used for single or multiple wells
1. Well Contractor Information:
/ci a[c kt
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
/2-G i%13--,c C C-
LL¢-�
Company Name
2. Well Construction Permit #: c
List all applicable well permits (i.e. County, State, Variance, Injection, etc.) ijknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water "apply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
DAquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
OGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 3 A t.l '7 -
5a. Well location:c/7
(K4; k / ' ��/L.)[/
�1,-6.S iv'
046,
Facility/Owner Name / Facility lD#(if applicable)
lqc
Physical Address, Chi, and Zip
%� v 2
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply
wells ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: 1
6b. Total well depth: Z 0 (ft.)
6c. Borehole diameter: % S (in.)
6d. Water level below ground surface:
P
6e. Outer casing length (if known): N (ft.)
6f. Inner casing/tubing length (if known): I (ft.)
6g. Screen length (if known): isit((ft.)
Form OW-30
NA (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For multiple injection or non -water supply wells ONLY with the same
construction/abandonment, you can submit one form.
7b. Approximate volume of water remaining in well(s):
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
C Neat Cement Grout
C Sand Cement Grout
❑ Concrete Grout
0 Specialty Grout
❑ Bentonite Slurry
kd'Bentonite Chips or Pellets..
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
Za llam. Petit
7g. Provide a brief description of the abandonment procedure:
fu its /otoil,dc.t e(• l 66_ .t>
CO AS a ic-te e A of cC f. 1�.,)..,-,2-
1°141.3- A &. Q ; 'r)„ t S LJ—LS
'
�I & c �Q --b s�4
8. Certification:
7 /0? i .�-
Signature of Certified Well Contractor or Well Owner
Da3 2 f y
By signing this form, 1 hereby certtfr that the well(s) was (were) abandoned in
accordance with ISA NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 abandonment to the county health department of the county
where abandoned.
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

INJECTION EVENT RECORD
North Carolina Department of Environment and `Natural Resources — Division of Water Resources
Permit Number U' / U s a 0 '?4- $'
Permit Information
/�4w , r-e
Permittee
Facility Name I
Facility Ad ess'
Injection Contractor Information
Injection Contractor / Company Name
Street Address 7 uc,.L<
LL
City
State
Area code — Phone number
. Well Information
27 t._2
Zip Code
Number of wells used for injection ( 1
Well names 1 `� C L -pi s (s-(. es r
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 Installed (Check applic ble type):
❑ Bored ❑ Drilled Direct -Push
❑ Hand -Augured 111 Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
[Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells /Cit4
Number of Injection Wells / `3
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
)4, G
Injectant Type
Concentration
If the injectant is diluted lease indicate the source
dilution fluid. cr c
Total Volume Injected %am L (, c
7 .,
Volume Injected per well S 6
5. Injection History
Injection date(s) J 1— 3 i 2,
Injection number (e.g. 3 of 5) j-- •
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 LAD OUT IN THE PERMIT.
-- J
SIGNAT U R r•: OF INJECTION CONTRACTOR
Z1‘ /(
DATE
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 8/5/2013

I'm fi rce
WILL CONSTRUCTION REC jRD
This form can be used for single or multiple wells
1. Well Contractor Information:
41r47../
C._ 4' G ( 'v( r4 of
Well Contractor Name
I - [ c - 4/1 7 - i3
NC Well Contractor Certification Number
/�L E
(- (
LLCM
Company Name
2. Well Construction Permit #: tl S.- CI'
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irrigation
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑Recovery
Injection Well:
Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (i leating/Cooling Return)
4. Date Well(s) Completed: -CA,
5a. Well Location:
%
Facility/Owner Name jam)
y 4 02} it r fj; Are_
Physical Address, City, and Zip
County
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under #21 Remarks)
Well ID#
f,Cs{ o 6"
Facility ID# (if applicable)
aid 9`-(4*-
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iatllong is sufficient)
N W
6. Is (are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ❑No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #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: Z-v (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@l00')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: / (in.)
12. Well construction method:
(ft.)
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
rt.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING,lgeothermal closed -loop)
FROM
TO DIAMETER
THICKNESS
MATERIAL
ft
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
1
lb. GROUT.
FROM
— TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACKSif applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additional sheets if neeessery)
FROM
TO
DESCRIPTION (color. hard nen. ,slLevee k hpe, Brain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
2I. REMARKS
22. Certification:
,tom 3/2 /
Signature of Certified Well Contractor Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A 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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sur & In; ection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

'I

WELL ABANDONMEN . RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
71/4tY /� �._- (a
Well Contractor Name (or well owner personally abandoning well on his/her property)
,lC C--
NC Well Contractor Certification Number
L,L G—
Company Name
1 00 c0D �—�
2. Well Construction Permit #:
C6
List all applicable well permits (i.e. County, State, Variance, Injection, etc) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal(Closed Loop)
❑Geothermal (Heating/Cooling Retum)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: _) A ^t 1 — `3 7 ) )
5a. Well locations
Wei
Facility/Owner Name " Facility ID# (if applicable)
Physical Address, Cify, and Zip
// r
County
For lntetnal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For multiple injection or non -water supply wells ONLY with the same
construction/abandonment, you can submit one form.
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
04entonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
� 7 141 %?etZ.(i
to /43 C4_'F,S_
7g. Provide a brief description of the abandonment procedure:
/21l? Ore 9 Z`. / ( c •
o S o / ece. %e P.- . /, , S /;fit •1v,r e�� e c / �/I`� . .
L(La
(Li 0 e.Q. e_,C F. ,e—C—
8. Certification:
/ (at
Signature of Certified Well Contractor or Well Owner
gt-
D e
By signing this form, I hereby certfy that the well(s) was (were) abandoned in
Parcel Identification No. (PIN) accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
�i abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELLI S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply
wells ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth:
(ft.)
6c. Borehole diameter: / ( (in.)
6d. Water level below ground surface: 1 (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): r (ft.)
6g. Screen length (if known): NA' (ft.)
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
lOb. For Iniection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
l0c. 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 abandonment to the county health department of the county
where abandoned.
Form GW-30
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION REC.JRD
This form can be used for single or multiple wells
1. Well Contractor Information:
/(O&t e
Well Contractor Name
N- 4L/61-R
NC Well Contractor Certification Number
/2E 'U7G ( 6 (-(
LL
Company Name
2. Well Construction Permit #: /" Dv
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):.
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑ Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
DAquifer Recharge
DAquifer Storage and Recovery
DAquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Coolil g Retum)
4. Date Well(s) Completed: JAW t /S6
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID#
5a. Well Location:
11 (47
L(
Facility/Owner Name Facility ID# (if applicable)
(zr.b/l/^/ A7 , d )_9,, Re,
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
6. Is (are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or DNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this farm.
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: Z a (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@I00')
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter:
12. Well construction method:
MF�
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Intemal Use ONLY:
11. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased weds) OR LINER,(if applicable) _
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
I6:INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
In.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
111. GROUT
FROM
TO /
MATERIAL r EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
_ FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING
LOG (attach additlanil sheets if ncecssnry)
FRO+I
TO
DESCRIPTION (ceinr. bard..., soil'rock hpe, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
rt.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor
3 ./ l/
Dal
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or I SA 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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply- & Infection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources —Division of Water Resources Revised August 2013

L
wi

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Permit Number 1,f/ a n S6 4` k."
1. Permit Information
Permittee
Facility Name
Facility Address
2. Injection Contractor Information
Injection Contractor / Company Name
Street Address L (.1/1:'(.t
City I State Zip Code
( `7(`1) Ci'1 � 6(q
Area code — Phone number
3. Well Information
Number of wells used for injection /
Well names I'(ue- ((wSl (See '
Were any new wells installed during this injection
eve t?
Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells t &e
Number of Injection Wells / L
Type of Well Installed (Check applica le type):
❑ Bored ❑ Drilled Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
[Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells A( 4
Number of Injection Wells / `l
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
A
Injectant Type
a
Concentration�'-
If the injectant is diluted please indicate the source
dilution fluid. .i
Total Volume Injected
Volume Injected per well / / -. 's
5. Injection History
Injection date(s) Sot- A-
-t— 31 2_0tc_f
Injection number (e.g. 3 of 5)
Is this the last injection at this site?
❑ Yes ❑ No
3
{
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.
SIGNATURE OF INJECTION CONTRACTOR/DA: E
/ IA /�: 2( 41 ;U
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 8/5/2013

WELL ABANDONMEN1,; RECORD
For internal Use ONLY:
Ye (/:)d
This form can be used for single or multiple wells
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #: t S `� �{ b�
List all applicable well permits (i.e. County, State, Variance, Injection, etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (I-Ieating/Cooling Supply)
❑ Indu strial/Commercial
❑Irrigation
Non -Water Supply Well:
❑ Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
73(lroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
r4 it J e�� da 6
Facility/Owner Name Facility ID# (if applicable)
4- Z ern ;?Jrt r, did it/d, C! / t i-t C
Physical Address, City, and Zip
LJI /.3 uw
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For multiple injection or non -water supply wells ONLY with the same
construction/abandonment, you can submit one form.
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
0 Neat Cement Grout he-Bentonite Chips or Pellets
O Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
/9ezei
% CC
7g. Provide a brief description of the abandonment procedure:
J A
i
Ca�tS6/'L ei.-J1 C,1, s 511� c(. ae
a14•( I we aY.r 1_e�
e- rs A):2dj Sigr-{
8. Certification:
�-Z
.t..�
Signature of Certified Well Contractor or Well Owner
By signing this form, I hereby cert fy that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
�1 abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL+SI BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply
wells ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
6b. Total well depth: - (ft.)
6c. Borehole diameter: (in.)
6d. Water level below ground surface: /' A- (ft.)
6e. Outer casing length (if known): / (ft-)
6f. Inner casing/tubing length (if known): t-lf� (ft.)
6g. Screen length (if known): /h84' (ft.)
Form GW-30
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. 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 abandonment to the county health department of the county
where abandoned.
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Permit Number Litt) S73c - 4G gr
1. Permit Inf/ormation
Permittee
Facility Name
', Peer ( i?zu ttL
Facility Address
2. Injection Contractor Information
Injection Contractor / Company Name
Street Address 2 v
(V�
State
Zip Code
Area code — Phone number
3. Well Information
Number of wells used for injection / l
Well names Y o cs C[ (4 d-E r C 117
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 f /
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled El Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
['Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 7(/
Number of Injection Wells / I
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
ge_ -F
Injectant Type
Concentration ,44?(a
(
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected / 6 -()
Volume Injected per well / 5-0
S
5. Injection History
Injection date(s) -�
1 37 20 (c{.
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 QUT IN THE PERMIT.
SIGNATURE OF INJECTION CONTRACTOR DATE
/v
Al 7Z z AeLc_ /-1 4.,k_.1
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 8/5/2013

y
VV" ;LL CONSTRUCTION REC+:JI D
This form can be used for single or multiple wells
1. Well Contractor Information:
4/4A Zj1 ceta_ 'lPLti1
Well Contractor Name
Wec--1f(67 - l3
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #: ! S ' K-fig
List all applicable well permits (i.e. County, State, Variance, Injection, 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:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
.❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 541 Well ID#
5a. Well Location:
It I
Facility/Owner Name Facility ID# (if applicable)
/ i
Physical Address, Ci(y, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is (are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or 0-No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #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: 2- ' (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
N (ft.)
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: (in.)
12. Well construction method:
(Le. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM 1 TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (ifapp [cable):
FROM
TO
DIAMETER
THICKNESS 1
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geethrrmal elnsrd-Soap)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM i TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft. f ft,
in.
ft. '
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILL4'YGLOG
(attach additlonM sheets if necessary)
FROM
TO
DESCRIPTION i color, hardness, soiVrock n pr. p rain size, ete.l
rt.
R.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
n.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
f
G - CCU L`i-e—�
Signature of Certified Well Contractor
/ /(
Date ••
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with I SA 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 necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells ONLY: 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised August 2013

.6

t;_
WELL ABANDONMENJ_ RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning well on his/her property)
1i,�•fc!c It(- g
NC Well Contractor Certification Number
• 'e
Company Name
2. Well Construction Permit ft: LiU GO ‘.,z_ ��✓
List all applicable well permits (i.e. County, State, Variance, Injection, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
DMonitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal ;Heating/Cooling Return)
4. Date well(s) abandoned: 3,l a. 7
5a. Well location:
G/1/1,4 71ez 4/5f-e_a r
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
El Tracer
DOther (explain under 7g)
Facility/Owner Name
ZU0 /f.'�_
Physical Address City, d Zip
�S-r
3( f/
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
CONSTRUCTION DETAILS OF WELLS} BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply
wells ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#:
T
6b. Total well depth: (ft.)
6c. Borehole diameter: r . ' (in.)
6d. Water level below ground surface: /V A (ft.)
6e. Outer casing length (if known): / ' P4 (ft.)
6f. Inner casing/tubing length (if known): WI- (ft.)
6g. Screen length (if known): 14 'a (ft.)
Fonn GW-30
Facility ID# (if applicable)
4/L Ul is&k.
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For multiple injection or non -water supply wells ONLY with Me same
construction/abandonment, you can submit one form.
7b. Approximate volume of water remaining in well(s):
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
Er Bentonite Chips or Pellets
0 Dry Clay
❑ Drill Cuttings
❑ Gravel
0 Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
o ( )k r,
•�.
7g. Provide a brief description of the abandonment procedure:
/04-- .' 1 �� � A 4. 6-
�-�� r'eaef‹. 1-e� c-k'SczeC.i
r
8. Certification:
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certi that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & 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 abandonment to the county health department of the county
where abandoned.
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECuAID
This form can be used for single or multiple wells
1. Well Contractor Information:
Well Contractor Name
jVLLIL ( 7-(
NC Well Contractor Certification Number
t' t7 t37c' 'TC C t—(
Company Name
2. Well Construction Permit #: U) 0 J 0 U 4' g
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industria1ICommercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: �)AN /
Well ID#
5a. Well Location:
i
1161 i" )-eI X r� �i 2d3lor)t�G (.or-
Facility/Owner Name I Facility ID# (if applicable)
44- v . r l� -. ;) U1 (doot
Physical Address, City, and Zip, r
Li; l�Sv
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is (are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or ❑No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #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: (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: A! _ (ft.)
If water level is above casing, use "+"
11. Borehole diameter: f ' (in.)
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:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO DESCRIPTION
ft.
ft.
ft.
ft.
15.OUTER CASING (for multi -cased wells) OR LINER (if ap licable).
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO 1 DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVELPACK of applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
.20. DRILLING
LOG (snatch additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, sail/rack tree, drain nee. etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS.
22. Certification:
Signature of Certified Well Contractor
3/z�/
Date
By signing this form, 1 hereby certify that the ',miffs) 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
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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells ONLY: 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 Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013