WI0501064_Injection Event Record_20210120

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501064
1.
2.
3.
Permit Information
Wake County Public School System
Permittee
Willow Springs Elementary School
Facility Name
6800 Dwight Rowland Rd, Wake County
Facility Address (include County)
Injection Contractor Information
Mid -Atlantic Associates
Injection Contractor / Company Name
Street Address 409 Rogers View Ct
Raleigh NC 27610
City State Zip Code
( 919) 250-9918
Area code — Phone number
Well Information
Number of wells used for injection 4
Well IDs MW-3, RW-1, RW-3, & RW-4;
Were any new wells installed during this injection
event?
a Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells - 2 wells
Type of Well Installed (Check applicable type):
❑ Bored a 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?
n Yes ® 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
Gravity injection of approximately 250 gallons of 4% solution
of EnviroClean surfactant into existing wells MW-1 and RW-1
and new wells RW-3 and RW-4 on 12/22/20
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 4%
If the injectant is diluted please indicate the source
dilution fluid. Willow Springs municipal water
supply
Total Volume Injected (gal) 250
Volume Injected per well (gal) approx. 60
5. Injection History
Injection date(s) Sept 27-28, 2019, Dec 22, 2020
Injection number (e.g. 3 of 5) 2 of 2
Is this the last injection at this site?
❑ Yes ® No — TBD will evaluate results.
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. 3-1-2016

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1. Well Contractor information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Comport) Name
2. Well Construction Permit#:
List all applicable wet/per/nits (i.e. Calmly, Slake, Variance, Injection, etc.)
3. Well Use (check well use):
14. WATER ZO N ES
FROM
TO
DESCRIPTION
5
ft.
14
ft.
wet
ft.
ft.
15, OIt'FER CASING (for multi -clued wells) OR LINER (if applicable)
FROM THICKNESS ti1.ITERI IL
TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal rinsed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
0
ft.
4
ft.
4
m.
sch40
pvc
ft.
R.
In.
17.SCREEN
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑ industrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
ElMonitoring ' ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test Stormwater Drainage
❑ Experimental Technology El Subsidence Control
❑Geothermal (Closed Loop) 0 Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 12/16I20 Well ID# RW-3
5a. Well Location:
Wake County Board of Education Willow Springs Elementary
Facility/Owner Name Facility ID# (if applicable)
6800 Dwight Rowland Road, Willow Springs, NC
Physical Address. City, and Zip
Wake
0687007938
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one tat/long is sufficient)
35.593151 N-78.728098 W
6. Is (are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Ves or ONo
If this is a repair, Jill oat known well construction information and explain the nature tf'the
repair under 11 remarks section or on the back of this,fornt.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, von can
submit one firm.
9. Total well depth below land surface: 14
For multiple wells list all depths iJ'di/Jerem (example- 3@200' 200' and 2@)00')
10. Static water level below top of casing: 5 (ft.)
If water level is above casing, use "- "
l 1. Borehole diameter: 10 5/8
12. Well construction method: HSA
(i e auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS'
MATERIAL
4
ft.
14 rt.
4
in.
.020
sch40
pvc
ft.
ft.
in.
1& GROUT
FROM
TO
MATERLAL
EMPLACEMENT METHOD & AMOUNT
0.5 ft.
2
ft.
Portland Cem
Tremie
2
ft.
3
ft.
Bentonite Chi
Tremie
ft.
ft.
19. SAND/GRAVEL PACK (If applicable)
FROM
TO
MATERIAL
EMPLACEMENT M ETHOn
3
ft.
14
ft.
#1 Sand
Tremie
ft.
ft.
2*. DRILLING LOG Ianach additional ahrets if necessary)
FROM
ft.
TO
ft.
DESCRIPTION l catar.lIardnres, soiL'rock F.pr. exain si2r. crr.l
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
2I. REMARKS
24" sonotube with 8" FMC
22. Cerlihi[ation:
Signature o
ertitied Well Contractor
/-5 -ao 1/
Date
By signing this Prim I hereby certify that the well(s) was (were) constructed iu accordance
with I5A N('AC 02(' .0100 or I5A N('AC 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 ifnecessarv.
SUBMITTAL INSTUCTIONS
(ft,) 24a. Fur 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 Inicction Wells ONLY: In addition to sending the form to the address in
24aabove, 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 Mail 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.
Fomi G W- I
North Carolina Department of Environment and Natural Resources - Division of Water Resources
Revised August 2013

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple H ells
I. Well Contractor information:
Virgil Wilson
Well Contractor Name
4473
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Compam Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, Stale, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural ❑Municipal/Public
❑ Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑Industrial/Commercial ❑Residential Water Supply (shared)
0-Irrigation
Non -Water Supply Well:
EMonitoring ❑Recovery
Injection 'Well:
❑Aquifer Recharge El Groundwater Remediation
❑ Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑ Experimental Technology ❑Subsidence Control
❑ Geothermal (Closed Loop) ❑Tracer
❑Geothermal (Heating/Cooling Return) ❑Other (explain under#21 Remarks)
4. Date Well(s) Completed: 12/16/20 Well ID# RW-4
5a. Well Location:
Wake County Board of Education Willow Springs Elementary
Facility/Owner Name Facility fD# (if applicable)
6800 Dwight Rowland Road, Willow Springs, NC
Physical Address, City, and Zip
Wake
0687007938
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lat/long is sufficient)
35.593151 -78.728098
6. Is (are) the well(s): ©Permanent or ❑Temporary
7. Is this a repair to an existing well: Oyes or V1No
If this is a repair, fill out known well construction u(lormmion and explain the nature of the
repair under ,21 remarks .section or on the back of this form.
8. Number of wells constructed: 1
J or multiple injection or non -water supply rolls ONLY ividt the same construction, you can
.submit one farm.
9. Total well depth below land surface: 14
For multiple wells list all depths if dif ferent (example- 3 u 200' and 2 a l00')
(ft.)
10. Static water level below top of casing: 5 (ft.)
II -water level is above casing, use " - "
11. Borehole diameter: 10 5/8 (in.)
12. Well construction method: HSA
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
13b. Disinfection type: _ Amount:
1.1. WATER ZONES
FROM
TO
DFSCRIPTION
5
ft.
14
ft.
wet
ft.
ft.
15. OUTER CASING (for multi -cased wdlsl OR LINER (if ap licable)
FROM
TO
DIAM ETER
TH ICKN F_SS
MATERIAL
ft.
ft.
In.
16. INNER CASING OR TUBING (geothermal closed-lnupl
FROM
0
ft.
TO
4
ft.
DAIETER
4
in.
THICK -NE -SS
sch40
MATERIAL
pvc
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
4
ft.
14 ft.
4
in.
.020
sch40
pvc
ft.
ft.
in.
1S. GROUT
FROM
0.5 ft.
TO
2
ft.
MATERIAL
Portland Cem
EMPLACEM ENT :METHOD s .IMOt,ti '�
Tremie
2
ft.
ft.
3
ft.
ft.
Bentonite Chi
Tremie
19. SAND/GRAVEL PACK (WappUcahle)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3
ft.
14
ft.
#1 Sand
Tremie
ft.
ft.
20. DRILLING LOG (attach additional sheet, if nrcesattry)
FROM
ft.
ft.
TO DESCRIPTION {color. hardness, soil/fork type. grain sire, etr.I
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
24" sonotube with 8" FMC
22. Cert. catiun:
Signamrc of Certified Well Contractor
Date
By signing this torn, I hereby certify that the well(s) was (here) constructed in accordance
with /5A N('A(' 02(' .0100 or 15,4 N('A(' 02(' .0200 Well ('onslruclion Standards and that a
copy of this record has been provided to the aril 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.
SUBMITTAL INSTUCTIONS
24a. Fur 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 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this forth within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources- Division of Water Resources
Revised August 2013