WI0501062_GW1 Well Construction_20201116

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
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#: W10501062
List all applicable well construction permits (Le. WWlC', ('ounty, Stare. 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
❑AquiTer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Retum)
(Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under #21 Remarks)
10/29120 to 10♦30/20
4. Dale Well(s) Completed:
5a. Well Location:
Charles Duckworth
Well ID# 2020-FLA-1 to2020-FLA-20
Facility/Owner Name Facility I D6 (if applicable)
1301 Atlantic Avenue, Rocky Mount, NC 27801
Physical Address, City, and Zip
Edgecombe
3860088196
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/tong is sufficient)
35/57/55.74 N 77/46/42.77
6. Is(are) the well(s): ❑ Permanent or OTemporary
W
7. Is this a repair to an existing well: ❑Yes or dNo
fthis is a repair, Jill out known well construction it formation and explain the nature oflhe
r<pair under 021 remarks .section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: an
9. Total well depth below land surface 20
(ft.)
(or multiple wells lost all depths if different (example- 3©200' and 2e l00)
10. Static water level below top of casing: -8 (ft.)
if -water levels abort casing use "•
11. Borehole diameter: 1-75
(in.)
12. Well construction method: Direct Push
(i.e. auger, rotary. cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
h.
h.
ft.
h.
15.OUTER CASING (for multi -cased wells) OR LINER (irapplicable)
FROM
TO
DIAMETER
THICKNESS j MATERIAL
h.
h.
in.
16. INNER
CASING OR TUBING
(geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
h.
ft.
in.
h.
rt.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
h.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEM ENT M ETH OD & AMOUNT
ft.
ft.
h.
f1.
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EM PLACEMENT METHOD
ft.
ft.
h.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/wit type. gain rise. etc.)
0 ft.
20 h.
ft.
ft.
h.
ft.
h.
h.
h.
ft.
h.
n.
n.
h.
21. REMARKS
20 DPT injection points installed for injection
22. Certification:
IL-
Signature of Certified Well Contractor
11 /11 /2020
Date
I/y signing this form. 1 hereby certify (hat die well(s) was (were) constructed in accordance with
ISA NCAC 02C 0100 or ISA 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 Over' 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-1 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 property)
A - 3552
NC Well Contractor Certification Number
Geologic Exploration, Inc.
Company Name
2. Well Construction Permit #: W10501062
List all applicable well construction permits (l. e. 11/C, County,. Stare. Variance, ere.) ifknoen
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commercial
❑Irrigation
DMunicipal/Public
OResidential 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 Retum)
IBGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 10I29120 to 10/30/20
5a. Well location:
Charles Duckworth
Facility.+Owns N'enic Facility IDf(tfapp:ica`.de
1301 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 lalllong is sufficient)
35/57/55.74
N 77/46/42.77
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(-) ifarailable Fix nndtipte injection or non -water supply welt
ONL F with the sane construction abandonment. you can submit one form
6a. Well ID11: 2020-FLA-1 to 2020-FLA-20
6b. Total well depth: 20
(ft.)
6c. Borehole diameter: 1 ' 75 (in.)
6d. Water level below ground surface: -8 (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): - (ft.)
Fonn GA -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 m
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
e 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
8. Certification:
11/11/20
Signature of Certified Well Contractor or Well Owner Date
By signing this form. 1 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
lOa. 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 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
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 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 W10501062
1. Permit Information
_Phillips 66 Company
Permittee
_Former Phillips Fibers
Facility Name
_1301 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 NC 28625
State Zip Code
City
[phone]
Area code Phone number
3. Well Information
Number of wells used for injection 20
Well 1Ds 2020-FLA-1 thru 2020-FLA-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 0
Number of Injection Wells 20
Please include a copy of the GW-30 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)—7,900 gallons
Volume Injected per well (gal) —400 gallons
5. Injection History
Injection date(s) 10/29/20 to 10/30/20
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
® Yes ❑ No
1 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
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-1ER
Rev. 3-1-2016