WI0400543_Injection Event Record_20201111

AECOM
AECOM 919.461.1100 tel
1600 Perimeter Park Drive, Suite 400 919.461.1415 fax
Morrisville, NC 27560
Letter of Transmittal
UIC Program
1636 Mail Service Center
Attention: Raleigh, NC 27699-1636
Number of copies: Description:
Date: January 19, 2021
1 Hard copy
Injection Event Record
Former Chemcraft International, Inc. Facility
3950 New Walkertown Road
Winston-Salem, North Carolina
Jasen Zinna, P.E.

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400543
1. Permit Information
Akzo Nobel Coatings, Inc.
Permittee
Former Chemcraft
Facility Name
3950 New Walkertown Rd., Winston-Salem,
Forsyth County, NC
Facility Address (include County)
2. Injection Contractor Information
Redox Tech, LLC
Injection Contractor / Company Name
Street Address 200 Quade Dr.
Cary____NC 27513
City State Zip Code
( 919 ) 678-0140
Area code — Phone number
3. Well information
Number of wells used for injection 37
Well IDs 23 Throu•h 59
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 37
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 [ INo
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 36
Please include a copy of the GW-30 for each well
abandoned
4. Injectant Information
Calcium Peroxide
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 3% and 6% by weight (see table)
If the injectant is diluted please indicate the source
dilution fluid. Local Hydrant Water
Total Volume Injected (gal) 2,022
Volume Injected per well (gal) Varies (see table)
5. Injection History
Injection date(s)_ 11 / 11 /2020, 11 / 13/2020,
12/1/2020, & 12/2/2020
Injection number (e.g. 3 of 5) 2 of 2
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 .AID OUT ,THE PERMIT.
SIGNATURE OECTION ONTRACTOR fb,11ATE,
Zach Poole
PRINT NAME OF PERSON PERFORMING THE INJECTION
7'
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

Filename: C:\USERS\CAMPBELLC\DOCUMENTS\AECOM WORK\AKZONOBEL\GROUNDWATER REPORT 60618053\DWG\FIGURE 3_ACETONE ISOPLETH MAP 2019.DWG
Project Management Initials: Designer: TSH Checked: EM Approved: EM
TW-19
55—GALLON
DRUM
REMOVAL
AREA
SW-1•
‘1-18 •
`` ®MW-15
600
\`
� T .®� r
S
•
TW-16 * '- `\♦
•
TW-15
c
r0L
TW-13®
TW-12
MW-14
MW-6
6,000
60,000
MW-5®
®MW-16
SW-3
SW-4
MW-170 CRASS
IN WOODS 0MW-18
TW-8
MW®13
TW-11
TW— 7—�
—14
MW-7A
MW-8
ACETONE
SAMPLE NAME
SAMPLE DATE
CONCENTRATION
MW-2
12/3/19
<5.0
MW-4
12/4/19
5.7
MW-6
12/4/19
3.5 J
MW-13
12/4/19
6.2
MW-14
12/13/19
200,000
MW-15
12/3/19
<5.0
MW-24
12/4/19
80
TW-3
12/4/19
<500
TW-4
12/4/19
17
TW-5
12/4/19
43,000
TW-7
12/4/19
33
TW-10
12/4/19
210 E
TW-11
12/4/19
20
TW-15
12/3/19
7
TW-17
12/3/19
20
TW-18
12/3/19
980
TW-19
12/3/19
<5.0
2L STANDARD
6,000
NOTES:
1. BOLD CONCENTRATION INDICATES EXCEEDANCE OF
THE 2L STANDARD OF 6,000 ug/L.
2. ALL CONCENTRATIONS ON TABLE ARE IN MICROGRAMS
PER LITER (ug/L).
0 100
APPROX. SCALE, ft.
TW/M W
MW-9D
SW-5
LEGEND
MONITORING WELL
VERTICAL EXTENT MONITORING WELL
SURFACE WATER SAMPLE
ACETONE ISOPLETH LINE ABOVE 2L STANDARDS
(DASHED WHERE INFERRED)
ACETONE ISOPLETH LINE BELOW 2L STANDARDS
(DASHED WHERE INFERRED)
<5.0 RESULT IS LESS THAN THE INDICATED VALUE
E ESTIMATED CONCENTRATION GREATER THAN
THE INSTRUMENT CALIBRATION RANGE
J ESTIMATED VALUE
ANNUAL PROGRESS REPORT - 2019
AKZO NOBEL COATINGS INC.
WINSTON SALEM, NORTH CAROLINA
Project No.: 60618053 Date:
Figure:

41
40
51
39
28
49
50
59
52
34
58
N-22
A
56
53
54
•
26
37
55
43
44
45
FIGURE 2
CaPeroxide Injection Location Map 2020
® =6% CaPeroxide solution
injection location; December
`2020
(: =3% & ,6% CaPeroxide solution
injectiorrJocation; November
2020
-
1W-190 AS-35X
-rr-1
AS-34X P --- -` O TW-21
AS-34Rt\ .4\
\ \\
\ \\
07W-18
W-22 AS-36
A6-15R TW
,� - + °-20

Injection Summary
Former Chemcraft
3950 New Walkertown Rd., Winston-Salem, NC
Injection
Point
Depth Interval (ft
bgs)
Injection
Amount
(gal)
%wt
Date(s)
Total
(gal)
23
6.9-1.9; 10-8
80; 2
3%; 6%
11/11/2020;
11/13/2020
82
24
9.35-4.35; 13-10
25; 45; 50;
215
3%; 6%;
6%; 6%
11/11/2020;
11/13/2020;
12/1/2020;
12/2/2020
332
25
8.45-3.45; 8-5
37; 2
3%; 6%
11/11/2020;
11/13/2020
39
26
6.35-1.35; 7-4
36;3
3%; 6%
11/11/2020;
11/13/2020
39
27
8.26-3.26; 13-10
5; 65
3%; 6%
11/11/2020;
11/13/2020
70
28
9.55-4.55; 8.5-4.5
21; 3
3%; 6%
11/11/2020;
11/13/2020
24
29
12.50-2.50; 9-5
18; 2
3%; 6%
11/11/2020;
11/13/2020
20
30
6.25-1.25; 8-5
8; 2
3%; 6%
11/11/2020;
11/13/2020
10
31
9.25-4.25; 13-9
2; 30
3%; 6%
11/11/2020;
11/13/2020
32
32
7.90-2.90; 8-3
5; 20
3%; 6%
11/11/2020;
11/13/2020
25
33
6.0-1.0; 5-3
7; 3
3%; 6%
11/11/2020;
11/13/2020
10
34
6.75-1.75
2;
3%;
11/11/2020
2
35
7.90-2.90
5;
3%;
11/11/2020
5
3611.50-1.50
7;
3%;
11/11/2020
7
37
6.0-1.0
10;
3%;
11/11/2020
10
38
12.0-9.0
0; 80
3%; 6%
11/11/2020;
11/13/2020
80
39
9.0-2.0
40
6%
12/1/2020
40
40
8.0-2.0
35
6%
12/1/2020
35
418.0-2.0
25
6%
12/1/2020
25
42
9.0-2.0
30
6%
12/1/2020
30
4310.0-4.0
20
6%
12/1/2020
20
4410.0-4.0
40
6%
12/1/2020
40
45
9.0-2.0
20
6%
12/1/2020
20
4613.0-4.0
80
6%
12/1/2020
80
47
11.5.0-4.5
10
6%
12/1/2020
10

Injection Summary
Former Chemcraft
3950 New Walkertown Rd., Winston-Salem, NC
Injection
Point
Depth Interval (ft
bgs)
Injection
Amount
(gal)
%wt
Date(s)
Total
(gal)
48
7.0-1.0
20
6%
12/1/2020
20
49
7.0-1.0
10
6%
12/1/2020
10
50
14.0-5.0
120;60
6%
12/1/2020;
12/2/2020
180
5114.0-5.0
60
6%
12/2/2020
60
52
15.0-5.0
380
6%
12/2/2020
380
53
15.0-5.0
75
6%
12/2/2020
75
5415.0-5.0
40
6%
12/2/2020
40
55
10.0-4.0
35
6%
12/2/2020
35
5611.0-4.0
50
6%
12/2/2020
50
57
9.0-2.0
50
6%
12/2/2020
50
58
9.0-2.0
15
6%
12/2/2020
15
59
9.0-2.0
20
6%
12/2/2020
20
Total:
2022

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
Zachary Poole
Well Contractor Name
NCWC 4415-C
NC Well Contractor Certification Number
Redox Tech, LLC
Company Name
2. Well Construction Permit #:
WI0400543
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ lndustrial/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)
Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 11/10/2020 23 - 37
5a. Well Location:
Akzo Nobel Coatings
Facility/Owner Name
Well ID#
Facility ID# (if applicable)
3950 New Walkertown Rd, Winston-Salem, NC 27105
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.145345
N -80' 188451
6. Is(are) the well(s): ❑Permanent or EITemporary
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
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
THICKNESS
MATERIAL
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. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS '
22. Certification:
W Zachary Poole
7. Is this a repair to an existing well: ❑Yes or It No
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. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 15
9. Total well depth below land surface: 12@10 , 1 @9.5 , 1 @8', 1 @7' (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: n/a (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: 2.25 (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:
Digitally signed by Zachary Poole
Date: 2021.01.05 14:38:38 -05'00'
Signature of Certified Well Contractor
1/5/2021
Date
By signing this form, I hereby certifi, that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A 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 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 CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
Zachary Poole
Well Contractor Name
NCWC 4415-C
NC Well Contractor Certification Number
Redox Tech, LLC
Company Name
2. Well Construction Permit #:
WI0400543
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ lndustrial/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)
Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/03/2020 38-59
5a. Well Location:
Akzo Nobel Coatings
Facility/Owner Name
Well ID#
Facility ID# (if applicable)
3950 New Walkertown Rd, Winston-Salem, NC 27105
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.145345
N -80' 188451
6. Is(are) the well(s): ❑Permanent or EITemporary
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
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
THICKNESS
MATERIAL
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. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
W Zachary Poole
7. Is this a repair to an existing well: ❑Yes or It No
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. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 22
9. Total well depth below land surface: See Injection Summary for depths (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: n/a (ft.)
If water level is above casing, use "+ "
11. Borehole diameter: 1 '5 (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:
Digitally signed by Zachary Poole
Date: 2021.01.05 14:56:11 -05'00'
Signature of Certified Well Contractor
1/5/2020
Date
By signing this form, I hereby certifi, that the well(s) was (were) constructed in accordance with
15A NCAC 02C .0100 or 15A 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 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 Use ONLY:
1. Well Contractor Information:
Zachary Poole
Well Contractor Name (or well owner personally abandoning well on his/her property)
NCWC 4415-C
NC Well Contractor Certification Number
Redox Tech, LLC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
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 Retum)
MI Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 12/03/2020
5a. Well location:
Akzo Nobel Coatings
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: 14
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 s Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
375 Ibs of bentonite
7g. Provide a brief description of the abandonment procedure:
pulled the wells out of the ground, and filled the holes
with bentonite pellets, pushed down another 2', filled to surface
Facility/Owner Name Facility ID# (if applicable) 8. Certification:
3950 New Walkertown Rd, Winston-Salem, NC27105
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36.145345 N-80.188451
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: TIW 21-35
12@10', 1@9.5',1@8',1@7'
6b. Total well depth: (ft.)
6c. Borehole diameter: 2.25 (in.)
6d. Water level below ground surface: n/a (ft.)
12@10', 1@9.5',1@8',1@7'
6e. Outer casing length (if known): (ft.)
12@10', 1@9.5',1@8',1@7'
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): 51 (ft.)
1/05/2021
Si ature of Certified'4Vell Contractor or Well Owner Date
By signing this form, I hereby certify 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
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
10b. For Iniection Wells: In addition to sending the form to the address in l0a
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.
Form GW-30
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information:
Zachary Poole
Well Contractor Name (or well owner personally abandoning well on his/her property)
NCWC 4415-C
NC Well Contractor Certification Number
Redox Tech, LLC
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
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 Retum)
MI Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: 12/03/2020
5a. Well location:
Akzo Nobel Coatings
Facility/Owner Name Facility ID# (if applicable)
3950 New Walkertown Rd, Winston-Salem, NC 27105
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36.145345
N-80.188451
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) if available. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: DP 1-34
6b. Total well depth: (ft.)
6c. Borehole diameter: 1 ' 5 (in.)
6d. Water level below ground surface: n/a
(ft.)
6e. Outer casing length (if known): n/a (ft.)
6f. Inner casing/tubing length (if known): n/a (ft.)
6g. Screen length (if known): n/a (ft.)
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: 34
7b. Approximate volume of water remaining in well(s): n/a
(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 s Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
525 lbs of bentonite pellets
7g. Provide a brief description of the abandonment procedure:
Pulled dpt rods out of ground, filled hole to surface
with pellets, pushed pellets down 2', filled to surface
8. Certification:
01/05/2021
Signature of CertifiedCZIell Contractor or Well Owner Date
By signing this form, I hereby certify 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
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
10b. For Iniection Wells: In addition to sending the form to the address in l0a
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.
Form GW-30
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016