WI0600047_Injection Event Record_20190619

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Groundwater Management Associates, Inc.
4300 Sapphire Court, Suite 100
Greenville, North Carolina 27834
Telephone: [phone]
www.gma-nc.com
June 13, 2019
Mr. D. Michael Rogers
NCDWQ, DWR, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
RECEIV �. r,
CilDWR
JUN 19 2019
Watts Quality
Regional Operations Section
Re: UIC Permit (#WI0600047) — Injection Event Record No. 1
NCDOT Priority Site #32, (Johnson Brothers Utility & Paving Company)
1924 North Main Street, Lillington, Harnett County, North Carolina
Dear Mr. Rogers,
Groundwater Management Associates, Inc. (GMA) completed and attached two hard copies of
the first injection event record (an electronic copy was sent via email also). A table with an
updated injection schedule is attached. Please call me at [phone] or email me
([e-mail]) if you have any questions.
Sincerely,
Groundwater Management Associates, Inc.
Katie T. Hackney, PG
Senior Hydrogeologist
Enclosures: 1) In -Situ Groundwater Remediation Injection Event Record — sent via email:
6/13/2019 and mailed (2 hard copies); includes figures, table, and GW-1
cc: DWR, FRO, Water Quality Operations Section (hard copy)
Mr. John Wise, PE, GMA-Apex (email)
Mr. Jason Prosser, PG, NCDOT Roadside Environmental Unit (email)
Z:\GMA\1605xa-NCDOT\160502_Site#32_Lillington\UIC Injection WIC Injection Event
Records\UICIERCover_Site# 32_Lillington_20190613.doa
The Groundwater Experts

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0600047
1. Permit Information
NCDOT Priority Site #32 Lillington
Permittee
Johnson Brothers Utility and Paving
Facility Name
1924 N. Main St, Lillington, NC 27546, Harnett Co.
Facility Address (include County)
2. Injection Contractor Information
Groundwater Management Associates, Inc. (GMA)
Injection Contractor / Company Name
Street Address 4300 Sapphire Court. Ste. 100
Greenville, NC 27834
City State Zip Code
( 252 Z 758-3310
Area code — Phone number
3. Well Information
Number of wells used for injection 5
Well IDs: 32-MW1, 32-MW8, 32- MW10, 32-
MW17, 32-MW18
Were any new wells installed during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 2
Number of Injection Wells 0
Type of Well Installed (Check applicable 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
Number of Injection Wells
Please include a copy of the GW-30 for each well
abandoned
4. Injectant Information
See Attached Table I
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration See Attached Table 1
If the injectant is diluted please indicate the source
dilution fluid.: Lillington Municipal Water System
Total Volume Injected (gal)See Attached Table 1
Volume Injected per well (gal)See Attached Table 1
5. Injection History
Injection date(s)_Mav 14-20, 2019
Injection number (e.g. 3 of 5) 1 of 20
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.
SIGNA 1U RE O JEC I [ON NTRACTOR't 3JDATE
Katie T. Hackney, PG, GMA
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016

1 THIS MAP IS
/ REVIEWED
WITH ANY APPLICABLE
,'
THIS PRODUCT
ONLY AND IS
WHICH IT WAS
NOT A CERTIFIED SURVEY AND HAS NOT BEEN
BY A LOCAL GOVERNMENT AGENCY FOR COMPLIANCE
LAND DEVELOPMENT REGULATIONS.
U . ._ a s - - _ �-
IS FOR REFERENCEAND ILLUSTRATION PURPOSES
ONLY AS ACCURATE AS THE SOURCE DATA FROM -- _
COMPILED _
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—
LEGEND 0 1000 2000 Feet
•
• SITE LILLINGTON QUADRANGLE
NORTH CAROLINA-HARNETT COUNTY
7.5 MINUTE SERIES (TOPOGRAPHIC)
CONTOUR INTERVAL = 10 FEET
MAP DATED 1997
GMA S
File. DRAWINGS/160502/
TOPO
TOPOGRAPHIC MAP
DATE 5/11/2017
Project No. 160502
NCDOT PRIORITY SITE #32, LILLINGTON, HARNETT CO., NC
FIGURE 1

4-3Aft tit
iTHIS MAP IS NOTA CERTIFIED SURVEY AND HAS NOT BEEN
REVIEWED BY A LOCAL GOVERNMENT AGENCY FOR COMPLIANCE
WITH ANY APPLICABLE LAND DEVELOPMENT REGULATIONS
a
THIS PRODUCT IS FOR REFERENCE AND ILLUSTRATION PURPOSES
ONLY AND IS ONLY AS ACCURATE AS THE SOURCE DATA FROM
WHICH IT WAS COMPILED. ..'��+►/ �i
32-MW14
�S+
2 M'tiN 12 *
•i?org,
32-MVV2
T V,
41111.4., *if
32-M W 19
32-MW1 32-DW1
32-M W20
32-MW23
4
32-MW24
32-MW25
32-MW16R
32-MW13R
4
LEGEND
ROAD
BUILDING
MONITORING WELL
PARCEL BOUNDARY
SCALE IN FEET
0 80'
GMA
File: DRAWINGS/160502/
SITEMAP-2019
SITE MAP WITH AERIAL BASE
DATE: 5/21/2019
Project No. 160502
NCDOT PRIORITY SITE #32, LILLINGTON, HARNETT CO., NC
FIGURE 2
F-2

Table 1. Injectint Information for Injection Event Record
NCDOT Prior ty Site #32, Johnson Brothers Paving & Utility Co , Llllington, Harnett County, NC GMA Project #160502
Injectant Type
Total Per Injection Event
Volume Solution Injected Per Well (gallo
s)
Volume Potable H2O Injected Per Well (gallons)
Injection
Event ID
HFCS
(gallons)
NaHCO3
(pounds)
(NaPO3)2
(pounds)
Potable
H2O
(gallons)
Total Volume
Soultlon Injected
(gallons)
Volume Potable
H20 Flush
(gallons)
32-MW1
32-MW8
32-MW30
32-MW17
32-MW18
32-MW1
32-MW8
32-MW10
32-MW17
32-MWIB
1
(5/14-20/19)
637
1550
38
3240
3960
1545
585
820
1285
440
830
215
275
505
275
275
2
3
4
5
HFCS = High Fructos Corn Syrup
NaHCO3 = Sodium Bicarbonate
(NaPO3)6= Hexamataphosphaste
H2O= Water

Table 2. Anticipated Schedule of Injection Related Activities - Year One
NCDOT Priority Site #32, Johnson Brothers Paving & Utility Co., Lillington, Harnett County, NC GMA Project #160502
Activity
Anticipated Start Date (subject to future
modification)
Monitoring Well Installation
3/12-14/2019
Develop New monitoring Wells
3/14/2019
Antecedent (Pre -Injection) Sampling Event
5/2-3/2019
Initial Injection Event
5/14-20/2019
1st Quarterly Sampling Event
between 7/8/19 & 7/26/19
Second Injection Event
8/12/2019
2nd Quarterly Sampling Event
between 10/7/19 & 10/25/19
Third Injection Event
11/11/2019
3rd Quarterly Sampling Event
between 1/6/20 & 1/24/20
Forth Injection Event
2/10/2020
4th Quarterly Sampling Event
between 4/6/2020 & 4/24/2020
Report of Findings and Schedule of Additional Activities
5/11/2020

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Daniel Summers
Well Contractor Name
2579-A
NC Well Contractor Certification Number
Carolina Soil Investigations, LLC
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Slate, Variance, Infection, etc.)
3. Well Use (check well use):
Water Supply Wen:
°Agricultural
°Geothermal (Heating/Cooling Supply)
°Industrial/Commercial
°Irigation
DMunicipal/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Retum)
°Recovery
❑Groundwater Remediation
°Salinity Barrier
DStormwater Drainage
❑Subsidence Control
❑Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 03-14-19 Well ID#
5a. Well Location:
Johnson Bros. Utility & Paving
Facility/Owner Name
MW-26D
Facility ID# (if applicable)
1924 North Main St Lillington, NC
Physical Address, City, and Zip
Harnett
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.42186 N-78.79782
6. Is (are) the we0(s): ©Permanent or °Temporary
7. Is this a repair to an existing well: °Yes or EINo
If this is a repair, fill out Mown 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: 1
For multiple infection or non -water supply wells ONLY with the same constracdon, you can
submit one form
9. Total well depth below land surface: 50 (ft )
For multiple wells list all depths if different (example- 3@200' and 2(100')
10. Static water level below top of casing: 15 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 4 (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:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
40 ft
50 fL
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap Usable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
0 ft'
40 ft:
2 '°'
sch 40 pvc
16. 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
THILnnESS
MATERIAL
40 ft:
50 ft
2 in*
010
sch 40
pvc
ft
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 R
5 ft
portland
mix & Pour
5 ft'
38 ft
bentonite
tremie
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
38 ft
50 ft
10/30 silica sand
tremie
ft.
ft.
20. DRILLING
LOG (atta
h additional sheets if nee ssary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain sire, etc)
0 ft:
50 it
brown silt loam / brown silty clay / saprolite
ft.
ft
ft.
ft
ft
ft
ft
ft
ft
ft.
ft.
ft
21. REMARKS
Contact: GMA Katie Hackney 252-402-5283
22. Certification:
7Z7a zrzu Sean. ne
03-14-19
Signature ofCertifie VelI Contractor Date
By signing this form, I hereby cent& that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or /5A 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 OW-1
North Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Daniel Summers
Well Contractor Name
2579-A
NC Well Contractor Certification Number
Carolina Soil Investigations, LLC
Company Name
2. Well Construction Permit #:
List all applicable well permits (Le. County, State, Variance, injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
Dlndustrial/Commercial
Olrigation
Non -Water Supply Well:
MMonitoring
❑MunicipaVPublic
❑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)
4. Date Well(s) Completed: 03-14-19
5a. Well Location:
Johnson Bros. Utility & Paving
Facility/Owner Name
o Groundwater Remediation
o Salinity Barrier
oStormwater Drainage
°Subsidence Control
°Tracer
°Other (explain under #21 Remarks)
Well ID#
MW-26D
Facility ID# (if applicable)
1924 North Main St Lillington, NC
Physical Address, City, and Zip
Harnett
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one 'at/long is sufficient)
35.42186 N-78.79782
w
6. Is (are) the well(s): I2lPermanent or °Temporary
7. Is this a repair to an existing well: ❑Yes or EINo
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: 1
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one farm.
9. Total well depth below land surface: 50 (ft.)
For multiple wells list all depths fdierenl (example- 3@200' and 2@100)
10. Static water level below top of casing: 15 (ft.)
If water level Is above casing, use "+"
11. Borehole diameter: 4 (in.)
12. Wellconstruction 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:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
40 ft.
50 ft
ft.
ft.
15. OUTER CASING (for multi -cased wens) OR LINER (if ap Neale)
FROM
0 ft
TO
40 ft
DIAMETER
2
is
THICKNESS
sch 40 pvc
MATERIAL
TN
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
ID.
ft
im
17. SCREEN
FROM
TO
DIAMETER
SLOT SEE
THICKNESS
MATERIAL
40 ft
50 ft
2 is
010
sch 40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
5 •
portland
mix & Pour
5 ft
38 ft
bentonite
tremie
ft.
ft
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
38 ft.
50 ft.
10/30 silica sand
tremie
ft.
ft.
20. DRILLING LOG (atta h additional sheets if necessary)
FROM
TO
0 ft
ft
50 ft
ft
DESCRIPTION (color. hardness, sail/rock type. grain
etc)
brown silt loam / brown silty clay / saprolite
ft
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Contact: GMA Katie Hackney 252-402-5283
22. Certification:
T%an#tei Sutxlsta44.
Signature of Certified W14t Contractor
03-14-19
Date
By signing this form, I hereby cerlifi, that the well(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
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For A11 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 contraction 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