WI0501061_GW1 Well Construction_20201116

WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
Vince Federle
Well Contractor Name
A - 3552
NC Well Contractor Certification Number
Geologic Exploration, Inc.
Company Name
2. Well Construction Permit#: W10501061
Lis, all apphrabk u'eli consiruciinn permits (i.e. UI(; County. State Variance, etc )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Wells> 100,000 GPD
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)
I1Groundwater Remedietion
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #21 Remarks)
10/27/20 to 10/28120 2020.DAA-1 to 2020.OAA-20
4. Date Well(s) Completed: Well MN
Sa. Well Location:
Sepro
Facility/Owner Name Facility ID# (if applicable)
1245 Atlantic Avenue, Rocky Mount, NC 27801
Physical Address, City, and Zip
Edgecombe
3860088740
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35/57/47.29 N 77/46/54.75
6. Is(are) the well(s): f7Permanent or t9Temporary
W
7. Is This a repair to an existing well: : NYes or In No
hJ this is a repair, fill out known 'veil construction infarmalnw' and explain the nature oI the
repair under u2i remarks section or on the back of this farm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 20
9. Total well depth below land surface: 16
nruiuple well iist ail depths ifdiiJerent (example- 30200' anti 2QI00)
(ft.)
10. Static water level below lop of easing:-6 (DJ
if ....cliff level is above casing. use "
I I. Borehole diameter: 1 '75 (in.)
12. Well construction method: Direct Push
(i.eauger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14. WATER ZONES
FROM
TO
DESCRIPTION
n.
R.
rt.
R.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap Ilcable)
FROM
TO
DIAMETER
THICKNESS q MATERIAL
ft.
ft.
in
16. INNER
CASING OR TUBING (geothermal elmed-coop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
n.
n.
in.
rI.
n.
in.
17. SCREEN
FROM
TO ...
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
n.
in.
r
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.
n.
n.
n.
20. DRILLING LOG (attach additional sheets ifnecessary)
_FROM
TO
DESCRIPTION (color, hardness, sail/reek type, grain size, art.)
0 D.
15 ft.
ft.
ft.
n,
ft.
n.
n.
ft.
ill
ft.
ft.
ft.
ft.
21. REMARKS
20 DPT injection points installed for injection
22. Certification:
Signature of Certified Well Contractor
11 /11 /2020
Date
13y signing this farm. 1 hereby certify that the walks) was (were) consrrrrred in accordance with
15A NCA(' OA' 0100 or 1SA NCA(' 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 construction info
(add 'See Ove? in Remarks Box). You may also attach additional pages if necessary
24. SUBMITTAL INSTRUCTIONS
Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wells: Copy to DWR, Underground Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply. and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC 27699-1611
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 6-6-2018

WELL ABANDONMENT RECORD
For Internal I se ONLY
1. Well Contractor Information:
Vince Federle
Well Contractor Name 'or well owner personally abandoning well on his/her progeny)
A - 3552
NC Well Contractor Certification Number
Geologic Exploration, Inc.
Company Name
2. Well Construction Permit Of: W10501061
List till applicable leen constnrNron permits (Le. UIC, Cmmry, State, Variance etc) ifknown
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:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
MI Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 10/27/20 to 30128120
5a. Well location:
Sepro
Face irr/Owner \a+ic Facility IDII (if applicable)
1245 Atlantic Avenue, Rocky Mount, NC 27801
Phys'_,il Address, { ity, -,nd 2 ip
Edgecombe 3860088740
Cou iiv Parcel Identification Na. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well Crld, one ha/long is sufficient)
35/57/47.29 N 77/46/54.75 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction reconl(s) ifa ailable. rot multiple injection oriwn-natersupply wells
ONLY with the some cwrsrructian abandonment. you can submit one form.
2020-DAA-1 to 2020-DAA-20
6a. Well IDN:
6b. Total well depth: 16 (ft.)
6c. Borehole diameter: 1.75 (in.)
6d. Water level below ground surface: �6 (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
Form •: W-30
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned.
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
D Bentonite Slurry
NI Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
Tremie piped bentonite from bottom to top of borehole
S. Certification:
44.i
Signa w c of emeed Well Contractor or Well Owner Date
11/11/20
By signing this form, 1 hereby certify that the well(sJ 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 detal Is. You may also attach additional pages if necessary
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of wel,
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 I0a
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
addresses) 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 Environmental Quality - Division of Water Resources Revised 2-22-2016

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10501061
I . Permit Information
Phillips 66 Company
Perm ittee
Former Phillips Fibers
Facility Name
1245 Atlantic Avenue, Rocky Mount, Edgecombe,
NC 27801
Facility Address (include County)
2. Injection Contractor Information
Geologic Exploration Inc.
Injection Contractor / Company Name
Street Address 176 Commerce Blvd
Statesville
City
NC
State
[phone]
Area code — Phone number
28625
Zip Code
3. Well Information
Number of wells used for injection 20
Well [Ds 2020-DAA-1 thru 2020-DAA-20
Were any new wells installed during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 20
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 Q
Number of Injection Wells 20
Please include a copy of the GW- 0 for each well
abandoned.
4. Injectant Information
PlumeStop, Oxygen Release Compound
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration —10 to 30%
If the injectant is diluted please indicate the source
dilution fluid. Potable Water
Total Volume Injected (gal) —4,260 gallons
Volume Injected per well (gal) —295 a1R Ions
5. Injection History
Injection date(s)10/27/20 to 10/28/20
Injection number (e.g. 3 of 5) 1 of 1
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
7
II f s s ao
SIGNATURE OF INJECTION CONTRACTOR ATE
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