WI0600068_Injection Event Record_20141212

4
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division
Permit Number ',Jrr F;' CO 0 IA
1. Permit Information
AEC() At 4-1vaf/,•(,-&qr.
Perrnittee
rTi 'S CA-,OAA-) Hq
Facility Name (1 SC,4v�
54Djem3
Facility Address
Injection Contractor information
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Injection Contractor / Company Name
Street Address 20
City I State
( fi9) tig Orcco
Area code — Phone number
3. Well Information
Number of wells used for injection
Well names
/p-1 —
Zip Code
-9
Were any new wells installed during this injection
eve ?
[`Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applle type):
❑ Bored ❑ Drilled Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
RECEIVED/DENR/DWR
DEC 1 2 2014
Water Quality Regional
of Water I9RrJegnS Section
Were any wells abandoned during this injection
ev-nt7
[✓Yes El 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
Injectant Type
Concentration 37'3 4s n
If the injectant is diluted please indicate the source
dilution fluid. €',• /7
Total Volume Injected S / v f wl s
Volume Injected per well ,90 (caS
5. Injection History
Injection date(s)
Injection number (e.g. 3 of 5)
Is this the last injection at this site?
❑ Yes ❑ No U A-Sc.. c e
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 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

WELL e-)NSTRUCTION REO_ _ _
This form can be used for single or multiple wells
RECEIV,.
1. Well Contractor Information:
/UGt i(2> Zc,
Well Contractor Name
NC Well Contractor Certification Number
R.G -7
Company Name
For Internal Use ONLY:
/DWR
4
Water Gtu,:. t.;gio
Operant. el. ,P�tioi
2. Well Construction Permit #:
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
❑hrigation
❑Municipal/Public
❑Residential Water Supply (single)
OResidential Water Supply (shared)
Non -Water Supply Well:
❑�.4oniEc���
nr r,:ever:
injection Well:
:Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
OGeothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Weil(s) Completed: ///74f
5a. Well Location:
Facility/Owner Name
17Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well ID#
Facility IDn (if applicable)
301.0 04,44 u.t(2
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)
N W
6. Is (are) the well(s): ❑Permanent or ❑"Temporary
7. Is this a repair to an existing well: ❑Yes or Cl
If this is a repair, fill out known well construction information and explain the nature of the
repair under i111 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 5- (ft.)
For multiple wells list all depths if different (example- 3(t®200' and 2(41100')
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: l ' Z ' (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
pal
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
R,CEIVEDIDENRID A
q_c122014
14. WATER ZONES
FROM
TO
DESCRIPTION Water au""
ft.
ft.
OPeTatiOtt'S
lei ft.
ft.
j 15. OUTER CASING (for multi -cased wells) OR LiNER (if applicable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBiNG(geothermal
closed -loop)
FROM
TO
DIAMETER
THICKNESS
\L\TERIA1.
ft.
ft.
in.
ft.
ft.
in.
17, SCREEN
FROM
TO
DIAMETER
SLOT SIZE.
THICKNESS
MATEIt1AI.
ft.
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. DRILLINGLOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/lock tvpc, grain .size, etc.)
rt.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor
t Z� //ge.
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with i SA 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.
SUBMITTALiNSTUCTIONS
Regional
Section
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 Mall 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

WELLrABANDONMEN'
This form can be used for single or multiple wells
ECORD
RECEIVEDID
RitrAltF19NLY:
1. Well Contractor Information:
OE.\ 1 2YrtlVABANDONMENT DETAILS
7a.•jYut pjtyyo�7ells being abandoned:
Well Contractor Name (or well owner personally abandoning well on his/her Quay`if,,,{{wCC }}t}}iiffa w
`` injection or non -water supply wells ONLY with the same
`� ��pr�?lt(��rio knabandonment, you can submit one form.
7 7b. Approximate volume of water remaining in well(s): (gal.)
NC Well Contractor Certification Number
t-C p (:C/ ( PL C_
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothennal (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 Return)
le* oundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date wells) abandoned:
5a. Well location:
Facility/Owner Name Facility ID#(iif applicable)
3660 ®AJK.'t_J YYI�/`G� / vien,7 7_✓: lc %�I4
Physical Address, City, and Zip
County
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply).
sd Neat Cement Grout
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slum
'Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Oth:- (rynbin a-Oer 711)
7f. For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
/na% cC G.Ge C4•ZIre ,t!„
•I
8. Certification:
Signature of Certified Well Contractor or Well Owner
/2////Y-
D
By signing this form, / hereby cert161 that the well(s) was (were) abandoned in
Parcel Identification No. (PIN) 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.
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
1V W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF,WELL(S) BEING ABANDONED
Attach well construction records) if available. Fur muhipte injection or nrn-water supply
wells ONLY with the same construction/abandonment. you can submit one form.
6a. Well ID#: qq
6b. Total well depth: L. Z (ft.)
6c. Borehole diameter: / 2 5 (in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (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
106. 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
10c. For Water Supply & 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 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