WI0600074_Injection Event Record_20110722

Brown AND
Caldwell
5410 Trinity F >uite 320
Raleigh, North 27607
Tel: [phone]
Fax: [phone]
www.brownandcaldwell.com
July 20, 2011
Michael Rogers
NC DENR - Division of Water Quality
Aquifer Protection Section - UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
RECEIVED I DENT,;:, uwo
Aquifer Protection Section
'JUL 22 2011
Subject: Well Construction Record
Robeson County Solid Waste Management Facility
St. Pauls, Robeson County, North Carolina
Injection Permit WI0600074
140592-001
Dear Mr. Rogers:
In accordance with the monitoring and reporting requirements of the referenced Inject
Permit, we are submitting an Injection Event Record for the injection event on
July 18, 2011.
Very truly yours,
Brown and Caldwell
Matt Einsmann, P.E.
Project Manager
MRE:ae
cc: Steve Edge, Robeson County
Attachments (1)
1. Attachment A: Injection Event Record

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number W10600074
1. Permit Information
Robeson County
Permittee
Robeson County Solid Waste Management Facility
Facility Name
246 Landfill Road, St. Pauls, NC 28384
Facility Address
2. Injection Contractor Information
Brown and Caldwell
Injection Contractor / Company Name
Street Address5410 Trinity Road, Suite 320
Raleigh
NC 27607
City
State Zip Code
( 919) 233-9178
Area code — Phone number
3. Well Information
Number of wells used for injection
Well names IP-2
1
Were any new wells installed during this injection
event?
O Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 2
Number of Injection Wells 3
Type of Well Installed (Check applicable type):
❑ Bored E Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies ofform GW-1b 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
3DMe
Injectant Type
Concentration 10% by volume
If the injectant is diluted please indicate the source
dilution fluid. Potable Water
Total Volume Injected 492 gallons
Volume Injected per well 492 gallons
5. Injection History
Injection date(s) July 18, 2011
Injection number (e.g. 3 of 5) 1
Is this the last injection at this site?
❑ Yes ❑X 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
STANDA$DS LAID OUT IN THE PERMIT.
7-29- 'i
SIGNATURE OF INJECTION CONTRACTOR DATE
Matt Einsmann
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

NON i 3 SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
(704 ) 872-7686
NC 28625
State Zip Code
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(k applicable)
SITE WELL ID #(ifapplicable) IP-1
3. WELL USE (Check One Box) Monitoring it Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigationo Other ❑ (list use)
DATE DRILLED 06/30/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope oValley ❑Flat ❑Ridge ❑Other
LATITUDE
LONGITUDE
" DMS OR DD
' DMS OR DD
Latitude/longitude source: COPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to -
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name Facility ID# (if applicable)
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
Contact Name
246'LANDFILL ROAD
Mailing Address
ST PAULS
City or Town
(—�
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
NC 28384
State Zip Code
NC 28384
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES D NO III
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" If Above Top of Casing)
2581
d. TOP OF CASING 15 2.5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top . Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter ' Weight Material
Top 0.0 Bottom 5.0 Ft. 1 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORtuNoeENTONne SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 Ft. 1.0 In. .020 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size • Material
Top 4.0 Bottom 23.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
8.0 / 14.0
14.0 / 23.0
FINE SILICA SAND
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
12. REMARKS:
BENTONITE SFAI FROM 3 0 TO 4 0 FEFT
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
HAS BEEN PROVIDED TO LL OWNER.
9
07/06/11
SIGNATURE OF CERTIFIED WELL CONYIiACTDATE
BRIAN THOMAS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
..fr 7b[ ici. Nb'SV � � a r,^��fr r'T4Xq ry. > ns u4 vt f..ie y,
Submltwithin30 days:of comeletton,to DIvisio[I of WateiQuality Hlnfomfation Processing,
41617Mdit,Service CenteitReleigh; NC 27699 61, Phoney -[phone]
x:Sittf .rit:.,:s,
Form GW-lb
Rev. 2/09

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NIA
OTHER. ASSOCIATED PERMIT#(H applicable)
SITE WELL ID #(if applicable) IP-2
3. WELL USE (Check One Box) Monitoring 0/Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery D Injection ❑
Irigationo Other ❑ (list use)•
DATE DRILLED 06/30/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Commirnity, Subdivision Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Vattev ❑Flat ❑Ridge ❑Other
LATITUDE "DMS OR DD
LONGITUDE " DMS OR DD
Latitudellongitude source: Q3PS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name Facility ID# (if applicable)
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
Contact Name
246 LANDFILL ROAD
NC 28384
State Zip Code
Mailing Address
ST PAULS NC 28384
City or Town State Zip Code
Area d Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES p NO d
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" if Above Top of Casing)
2581
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 1 INCH SCH4o PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 3.0 Ft. PORTLAND BENTONIrE
Top Bottom • Ft.
Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 Ft. 10 in. .020 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. In. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 23.0 Ft. 20-40
Top Bottom Ft.
FINE SILICA SAND
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0.0 / 8.0 BLACK SILTY SAND
8.0 / 14.0 TAN SAND
14.0 / 33.0 WHITE SAND
33.0 / 35.0 GRAY CLAY
12. REMARKS:
BFNTONITE SFA1 FROM 3 0 TO 4 0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15 -C 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
00*itES BEEN PROVIDED TO T LOWNER.
IFIED
BRIAN THOMAS
EL
07/06/11
ACTOR
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
i R6 ova z rT4+. 4t5t . `k' 'vrW.7 kxr F PiF r" raft- lifakliZ-zt' °
f,Sybmit wlthinf30 dayntkompletto o 1Dlyeton of 1Wateratia
'rEX � W6rE r"e'1 se?s,tcik NP P7699 561 t,ge s torn a 63
yitorrriatiort Processing,$
Form GW-lb
Rev. 2/09

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(6applicable)
SITE WELL ID Of applicable) IP-3
3. WELL USE (Check One Box)Monitoring Lj Municipal/Public ❑
Industrial/Commercial ❑ Agricultural p Recovery ❑ Injection ❑
Irrigationo Other ❑ (list use)
DATE DRILLED 07/01/11'
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE
LONGITUDE
"DMS OR DD
"DMS OR DD
Latitude/longitude source: MPS Dfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
Contact Name
246 LANDFILL ROAD
Mailing Address
ST PAULS
City or Town
( 1
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
Facility ID# (if applicable)
NC 28384
State Zip Code
NC 28384
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 51
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" If Above Top of Casing)
7i.T 11kn ,r'�4sI��ii�h�aa,`=rt`�i :�i if�iF;'n'r'My ^`?,�'RCy e, }ttf; KJ r^h„'vl ,^r f3w"'1;ir't�.'�J4Y�l �r��'. �. e:�
3_ 1vz,61b M Seiyiic0 Cet err R eIgh N .2,3 91610113„ ne 919) S 7 63tipj UOS, nforr atlo Pro; essing
r r b f Y t xuva., u+da.4'.:.
2581
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 1 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material.
Top 0.0 Bottom 3.0 FL PORRAND eENIONITE
Top Bottom Ft.
Top Bottom Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 Ft. 1.0 in. .020 In. PVC
Top Bottom Ft. In. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Top 4.0 Bottom 23.0. FL 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
8.0 / 14.0
14.0 / 23.0
/
Size Material
FINE SILICA SAND
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
12. REMARKS:
BENTONITE SEAL FROM 3 0 TO 4 0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
S BEEN PROVIDED TO THE L OWNER.
'SCatt&IWIFIED EL
BRIAN THOMAS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

.NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
2581
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
(704 ) 872-7686
Area code Phone number
2. WELL. INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL IDf applicable) MP-1
3. WELL USE (Check One Box) Monitoring L( Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery D Injection 0
Irrigation Other 0 (list use)
DATE DRILLED 07/01/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Vallev ❑Flat- ❑Ridge ❑Other
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitudefongitude source: BPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name Facility ID# (if applicable)
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
Contact Name
246 LANDFILL ROAD
Mailing Address
ST PAULS
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
NC 28384
State Zip Code
NC 28384
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Li
c. WATER LEVEL. Below Top of Casing: 3.0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top . Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
Top Bottom
Material
Ft. PORr1ANe BENTONITE
Ft.
Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 Ft. 2.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 4.0 Bottom 23.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
8.0 / 14.0
14.0 / 23.0
12. REMARKS:
Material
FINE SILICA SAND
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
BENTONITE SEAL FROM 3 0 TO 4.0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
S BEEN PROVIDED TO THE W L OWNER.
07/06/11
DATE
BRIAN THOMAS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
u6mM , M a.Vi x 1v s y tCTt"tz ° rs 4h W-, 4pw ttrwtthm 30 days of aomrpletiontto D(Wsion of<WateL Quajti
elr710ail SeMce'CentepiRaleigli NC 27c699,161,Phone •:(919) 80777 6360
'.4v
a5.w.eSzituk-+u ttX fi;'r: •Y�'f_ri&i k''Li.
ormaLon Processing;;=
Form GW-1b
Rev. 2/09

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(H applicable)
SITE WELL ID #(if applicable) MP-2
3. WELL USE (Check One Box) Monitoring iMunicipa!Public ❑
IndustdaUCommercIal D Agricultural 0 Recover
y ID Injection ❑
Inigationo Other 0 (list use)
DATE DRILLED 06/30/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Sheet Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope GValley 0 Flat ❑Ridge ❑Other
LATITUDE
LONGITUDE
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: Q PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
This form if not using GPS)
5. FACILITY (Name of the business where the well Is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
Contact Name
246 LANDFILL ROAD
Mailing Address
ST PAULS
City or Town
Facility ID# (if applicable)
NC 28384
State Zip Code
NC 28384
State Zip Code
A_)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Lq/
C. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" if Above Top of Casing)
2581
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A
L DISINFECTION: Type
METHOD OF TEST N/A
N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 2INCH SCH40 PVC
Top Bottom Ft.
Top Bottom Ft:
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORUJJDSENRWE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 FL 2.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 23.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
8.0 / 14.0
14.0 / 23.0
FINE SILICA SAND
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
12. REMARKS:
BFNTONITE SFAI FROM 3.0 TO 4 0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
C 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
D HAS BEEN PROVIDED T9,7HE1IELL OWNER.
SIGNATURE`i5F CERTIFIED WELL CON
BRIAN THOMAS
RACT
07/06/11
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ro." a'`x` y.yr't<Y h^-1}�^s .R + i�S# aAre g3ii. 3i tfc rTii-ii a >k t:
,Submttiwtth n 30zdaysoLc9rnpletton to•Divlston ofWaterQual1,.
1617pailServtcet"Centrir Raleigh;NC27899181¢Phsti q919)8g716300'.
+Information Processtng;
Form GW-lb
Rev. 2/09

Of
RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2581
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE _ NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID Mir applicable) IP-1
3. WELL USE (Check One Box) Monitoring [1y Municipal/Public ❑
Industrial/Commercial 0 Agricultural'0 Recovery 0 Injection 0
Irrigation0 Other 0 (list use)
DATE DRILLED 06/30/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384 .
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValley ❑Flat 0Ridge ❑Other
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: COPS Cropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located)
ROBESON COUNTY LANDFILL N/A
Facility Name Facility ID# (if applicable)
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
NC 28384
State Zip Code
Contact Name
246 LANDFILL ROAD
Mailing Address
ST PAULS
City or Town
NC 28384
State Zip Code
•
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p/
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7.,CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 1 INCH • SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORTLwoeemoNRE SLURRY
Top
Top
Bottom Ft.
Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 Ft. 1.0 in. .020 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 23.0 FL 20-40
Top Bottom Ft.
FINE SILICA SAND
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
Formation Description
BLACK SILTY SAND
8.0 / 14.0 TAN SAND
14.0 / 23.0 WHITE SAND
12. REMARKS:
BFNTONITE SFAL FROM 3 0 TO 4 0 FEFT
I DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
HAS BEEN PROVIDED TOV6�LL OWNER.
"liseat
SIGNATURE O RTIFIED WELL CO AC
BRIAN THOMAS
07/06/11
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
z 0,1; +.x.. x't rt&y�""p F� `G 4154aC" rams , [ Al r 3tE, cry
Lirnitwithinn30days'ofoompletlon,to Division ofWatexQuab
/ 617 Mail Service Center`Raleigh Nett276994 61Phone '(919) 8d7 6300
S _s
.i3'v,�:'; .... � r ,.3.,r.. 1".,+._ xaa, ie.o a -,.rot...,.: �'r'frz ....1':.�..s.✓`... xu_v'3z?:s.�L .�l.
nformaLon Prdcessmg
Form GW-1 b
Rev. 2/09

.NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
NC 28625
State Zip Code
OTHER ASSOCIATED PERMIT#(a applicable)
SITE WELL ID Cif applicable) IP-2
3. WELL USE (Check One Box) Monitoring /Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Inigaiono Other ❑ (list use)
DATE DRILLED 06/30/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope DValleu El Flat 0 Ridge ❑Other
LATITUDE " DMS OR DD
LONGITUDE " DMS OR DD
Latitude/longitude source: IJPS (]Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
Contact Name
246 LANDFILL ROAD
Mailing Address
ST PAULS
City or Town
Facility ID# (if applicable)
NC 28384
State Zip Code
NC 28384
State Zip Code
Area code Phone number
6.. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO cl
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" If Above Top of Casing)
2581
d. TOP OF CASING IS 2.5 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top . Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 1 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. PORTUWD BENTONITE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 Ft. 1.0 in. .020 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 23.0 Ft. 20-40
Top Bottom Ft.
FINE SILICA SAND
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
8.0 / 14.0
14.0 / 33.0
33.0 / 35.0
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
GRAY CLAY
12. REMARKS:
BENTONITE SEAL FROM 3.0 TO 4 0 FFFT
I D0 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
mop WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
orniRECOR S BEEN PROVIDED TO TL OWNER.
��
IFIED
BRIAN THOMAS
07/06/11
ELL CONiFFACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
iars1Xlir'Y`i.%11 .1E4, ` 1?!'`tl'k",,,,,6 ie<err ,,,1„�i'"rr.c+.izw`"w'.r ,k
t,tit-W gtitIkOun, O daytrati rnplefronto 14,:A(9Lon, vvratOr -wc4- ty
ki61 it Seil�LcekCenter 281etgh,=NC 23699'�61 Phorie" �999a°807 6300
''ic...'
t;informatro ProcgsSIII
Form GW-lb
Rev. 2/09

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2581
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#Qtapplicable)
SITE WELL ID #tif applicable) IP-3
3. WELL USE (Check One Box) Monitoring [Municipal/Public 0
IndustriallCommerdal ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation0 Other 0 (list use)
DATE DRILLED 07/01/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope OVallev ❑Flat ❑Ridge GOther
LATITUDE "DMS OR DD
LONGITUDE " DMS OR DD
Latitudefongitude source: ID33PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name Facility ID# (if applicable)
246 LANDFILL ROAD
Street Address
ST PAULS NC 28384
City or Town State Zip Code
ROBESON COUNTY LANDFILL
Contact Name
246 LANDFILL ROAD
Mailing Address
ST PAULS NC 28384
City or Town State Zip Code
Area a Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO p1
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use °+" if Above Top of Casing)
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top
7. CASING: Depth Diameter
Top 0.0 Bottom 5.0 Ft. 1 INCH
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
Top Bottom
9. SCREEN: Depth
Top 5.0 Bottom 23.0
Top Bottom Ft.
Top Bottom Ft.
10. SAND/GRAVEL PACK:
Depth
Top 4.0 Bottom 23.0
Bottom
Thickness/
Weight Material
SCH 40 PVC
Material
Ft. PORLAND eemoNlm
Ft.
Ft.
Method
SLURRY
Diameter Slot Size Material
Ft. 1.0 in. .020 In. PVC
in. in.
in. ' in.
Size Material
Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.o
8.0 / 14.0
14.0 / 23.0
FINE SILICA SAND
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
12. REMARKS:
BFNTONITF SEAL FROM 3 0 TO 4 0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
BEEN PROVIDED TO THE L OWNER07/06/11
'S
BRIAN THOMAS
FIED'WEL
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
7..v: i tW.i9,il iw.aleK, 5 51.Smp rF"t��+d i ft3 h ¢, - iat+�%,Th.iv
FFw8ubmtt w thi 30O days, corrlp1etlon to yDnrisiomof�Waterr9ualiry,
617 lgath5caC{Qn_tet,{Ra�1SIghr C27 99 6latglacaL 9)kB0itram
>h .3 r ,
} r' P '� 'i a;; Form GW-1b
nfOrlflahOn ProDeS$In
9,;, Rev. 2/09

NONKESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE. NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(6 applicable)
SITE WELL ID Of applicable) MP-1
3. WELL USE (Check One Box) Monitoring d Municipal/Public ❑
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection ❑
Irrigation: Other 0 (list use)
DATE DRILLED 07/01/11
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope :Vailev ❑Flat :Ridge ❑Other
LATITUDE
LONGITUDE
" DMS OR
" DMS OR
DD
DD
Latitude/longitude source: IJ3PS ['Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name Facility ID# (if applicable)
246 LANDFILL ROAD
Street Address
ST PAULS
City or Town
ROBESON COUNTY LANDFILL
Contact Name
246 LANDFILL ROAD
NC 28384
State Zip Code
Mailing Address
ST PAULS
City or Town
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
NC 28384
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ty
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" if Above Top of Casing)
2581
d. TOP OF CASING IS 2.5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f; DISINFECTION: Type N/A Amount N/A g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 2 INCH SCH40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0.0 Bottom 3.0 Ft. P°RnANDBEN1LINRE SLURRY
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 Ft. 2.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 23.0 Ft. 20-40 FINE SILICA SAND
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
8.0 / 14.0
14.0 / 23.0
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
12. REMARKS:
BENTONITE SEA' FROM 3 0 TO 4 0 FFET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RE(RSR&I{AS BEEN PROVIDED TO THE W L OWNER.
IFIE
BRIAN THOMAS
ELL NOW06/11
4FSlCT(SR. 07/DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
?a- i!&�§"S"`F�'>,�s..+, ay,"eSr�"uR',, 'rX"�1
f 8> bmlt th(rn30 daystof Com tSltto Dlvlsioproft�llater00uah
1617 Mail SerJice1,Ce tier, Ralet h tNC 27699`I6,1,Phone4 (919) 80Z 836
'rocess(ri
Form GW-1b
Rev. 2/09

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
BRIAN THOMAS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION -PERMIT# N/A
OTHER ASSOCIATED PERMIT#(d applicable)
SITE WELL ID #(d applicable) MP-2
3. WELL USE (Check One Box) Monitoring Municipal/Public 0
Industrial/Commercial 0 Agricultural 0 Recovery 0 Injection 0
Irrigationo Other 0 (list use)
DATE DRILLED 06/30/11.
4. WELL LOCATION:
246 LANDFILL ROAD 28384
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: ST PAULS COUNTY ROBESON
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope (Valley 0 Flat El Ridge ❑Other
LATITUDE i. ."DMS OR DD
LONGITUDE 0 I
"DMS OR ' DD
LatitudeAongitude source: EGPS (]topographic map
(locatf000f well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
ROBESON COUNTY LANDFILL N/A
Facility Name Facility JD# (if applicable)
246 LANDFILL ROAD
Street Address
ST PAULS NC 28384
City or Town State Zip Code
ROBESON COUNTYLANDFILL
Contact Name
246 LANDFILL ROAD
Mailing Address
ST PAULS NC 28384
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 23.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO 4"
c. WATER LEVEL Below Top of Casing: 3.0 FT.
(Use "+" if Above Top of Casing)
ear 1 yH "r rvztj.y
ubmtt wlthm430 daysp compjet onto x. WIP,ADn of�V atelet,,I
16ttMar SenlibC f%riRaletgh�'Nc 7699 1611 Phone 9t9) 807 30.
2581
d. TOP OF CASING IS 2:5 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top. Bottom_ Top Bottom
Top Bottom Top -.. Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 Bottom 5.0 Ft. 2 INCH SCH 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth
Top 0.0 Bottom 3.0
Top Bottom
Top Bottom
Material
Ft. PORTLAN.D BEHIONm_
Ft.
Ft.
Method
SLURRY
9. SCREEN: Depth Diameter Slot Size Material
Top 5.0 Bottom 23.0 FL 2.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4.0 Bottom 23.0 Ft. 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 8.0
8.0 / 14.0
14.0 / 23.0
FINE SILICA SAND
Formation Description
BLACK SILTY SAND
TAN SAND
WHITE SAND
12. REMARKS:
BENTONITE SEAI FROM 3 0 TO 4 0 FEET
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
C 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE D HAS BEEN PROVIDED TQJJS ELL OWNER.
SIGNATURE'OF CERTIFIED WELL CONTRACT
BRIAN THOMAS
07/06/11
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
z. iV.W3.fik:.. '3`r}j'? fii
orm tron nacessmg`
Y.
Form GW-lb
Rev. 2/09