WI0400561_Other_20210122

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10400561
1. Permit Information
Gandhi & Associates, Inc.
Permittee
Eagle Mart 2 - UST Incident #44564
Facility Name
3767 Boy Wood Road, Alamance County
Facility Address (include County)
2. Injection Contractor Information
Agra Environmental, Inc.
Injection Contractor / Company Name
Street Address PO Box 5611
Cary
NC 27513
City
State Zip Code
( 919 ) 858-5350
Area code — Phone number
3. Well Information
Number of wells used for injection
6
Well IDs MW-1, MW-2, IP1, IP2, IP3, IP4
Were any new wells installed during this injection
event?
n Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
0
4
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑x 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?
❑x Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells
4
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
see attached breakdown sheet
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)
Volume Injected per well (gal)
5. Injection History
Injection date(s) see attached breakdown sheet
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
❑X 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.
1/25/21
SIGNATURE OF INJECTI®N CONTRACTOR DATE
Aaron D. Springer
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

Injectant Information Breakdown Sheet
MW-2
Injectant Information
Injectant Type(s): Ozone / Hydrogen Peroxide
Concentration: 6% / 8 % wt.
If the injectant is diluted please indicate the source dilution fluid: N/A
Total Volume Injected (gal): Continuous / 190
Volume Injected per Well (gal): Continuous / 190
Injection History
Injection Date(s): 1/11/21 to 1/19/21
IP1, IP2, IP3, IP4
Injectant Information
Injectant Type(s): Oxygen BioChem (OBC)
Concentration: 0.4 Ibs/gal
If the injectant is diluted please indicate the source dilution fluid: City of Graham Public Works
Total Volume Injected (gal): 1,000
Volume Injected per Well (gal): 250
Injection History
Injection Date(s): 1/12/21
MW-1
Injectant Information
Injectant Type(s): Hydrogen Peroxide
Concentration: 8% wt.
If the injectant is diluted please indicate the source dilution fluid: N/A
Total Volume Injected (gal): 60
Volume Injected per Well (gal): 60
Injection History
Injection Date(s): 1/19/21

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 #:
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)
❑ 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)
Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 01/12/2021 Well ID# 1 P 1,2,3,4
5a. Well Location:
Ghandi & Associates, INC
Facility/Owner Name
Facility ID# (if applicable)
3767 Boy Wood Road, Graham, NC 27253
Physical Address, City, and Zip
Alamance
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.00554 N-79.3909
6. Is(are) the well(s): ❑Permanent or ETemporary
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 LhNo
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: 4
9. Total well depth below land surface: 32
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft.)
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: 2021.01.20 09:09:50 -05'00'
Signature of Certified Well Contractor
1/13/2021
Date
By signing this form, I hereby certifi7 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: 01/12/2021
5a. Well location:
Ghandi & Associates, INC
Facility/Owner Name Facility ID# (if applicable)
3767 Boy Wood Road, Graham, NC 27253
Physical Address, City, and Zip
Alamance
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
36.00554
N-79.3909
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#: IP - 1,2,3,4
6b. Total well depth: 32 (ft.)
6c. Borehole diameter: 1 ' 5 (in.)
6d. Water level below ground surface: n/a
(ft.)
6e. Outer casing length (if known): 1 ' 5 (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: 4
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:
7g. Provide a brief description of the abandonment procedure:
Pulled direct push rods out of the ground, poured bentonite
chips down the hole, up to surface. Pushed chips down 2'
filled to surface.
8. Certification:
t
Si ature of CertifieNWell Contractor or Well Owner Date
/bd6.
01/13/2021
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