WI0800528_Injection Event Record_20210818

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (TER)
Permit Number WI0800528
1. Permit Information
Brookfield Properties
Permittee
Former Modern DIN Cleaners and Laundry
Facility Name
3750 Oleander Drive, Wilmington. New Hanover
Facility Address (include County)
2. Injection Contractor Information
Carolina Drilling
Injection Contractor / Company Name
Street Address 114 Chimney Lane
Wilmin 'ton
City
NC
State
28409
Zip Code
L910 ) .799-0493
Area code — Phone number
Well Information
Number of wells used for injection _20
Well IDs_1-18 geoprobe borings, MW-WSP-1XD
and MW-WSP-2D
Were any new wells installed during this injection
event?
x Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 18
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.
RECEIVED
S E P 2 2 2020
Were any wells abandoned during this injection
event? NC DEQ/DWR
x Yes ❑ No Central Office
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 18
Please include a copy of the GW-30for each well
abandoned
Injectant Information
sodium lactate (w i11C1ear+)
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 50%
If the injectant is diluted please indicate the source
dilution fluid. Upgradient groundwater from MW-
WSP-1D
Total Volume Injected (gal) 3,570_
Volume Injected per well (gal) 18 borings A 160
eal each. MW-WSP-1XD w 345 u.allons and MW-WSP-
2D A 345 gal.
5. Injection History
Injection date(s) 8/18/20 to 8/22/20
Injection number (e.g. 3 of 5), 5 of 6 days
Is this the last injection at this site?
❑ Yes x No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WS PERFORMED WITHIN THE
STAND A Ft Sal$ jUT IN THE PERMIT.
E OF INJEJI ION CONTRACTOR DATE
eorge Bridger
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 (GW-1)
1. Well Contractor Information:
George Bridger
Well Contractor Name
NC Well Contractor Certification Number
Carolina Drilling
RECEIVED
SEP 2 2 707
DECCM
'Central Othc
Company Name
2. Well Construction Permit #:
UIC#W10800528
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothemial (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
❑Municipal/Public
DResidential Water Supply (single)
❑Residential Water Supply (shared)
❑Webs > 100,000 GPD
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
DAquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothenmal (Closed Loop)
Geothermal (Heating/Cooling Retum)
inGroundwater Remediation
❑ Salinity Barrier
❑ Stolmwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under 1121 Remarks)
4. Date Well(s) Completed: 8/22/20
5a. Well Location:
Former Modem Dry Cleaners end Laundry /&ookfield Properties
Well ID# N/A
DSCA ID #65-0001
Facility/Owner Name Facility ID# (if applicable)
3750 Oleander Drive, Wilmington 28403
Physical Address, City, and Zip
New Hanover
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
171013.833 N 2331802.645
6. Is(are) the well(s): ❑Permanent or C1Temporary
7. Is this a repair to an existing well: ❑Yes or fnNo
If this is a repair, fell 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: 25
9. Total well depth below land surface: 18@3CY
For multiple wells list all depths ifdit 1rent (example- 3@200' and 2@100')
(ft.)
1
10. Static water level below top of casing: (ft.)
Ifwater level is above casing. use "+"
11. Borehole diameter: 2 (in.)
12. Well construction method: direct push
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A
Method of test: NIA
13b. Disinfection type: N/A Amount: N/A
For Internal Use Only:
14. WATER ZONES
!I FROM
TO
DESCRIPTION
6 ft
30 ft.
ft.
J
ft.
OUTER
CASING (for
multi -cased wells) OR LINER (f a licable)
�15.
FROM
TO
1 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.
lit.
In
ft.
ft.
in
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
f.
ft
ft
ft.
ft.
19. SAND/GRAVEL
PACK
(if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft
ft.
ft.
f.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, ,palm size, etc)
ft.
ft.
ft.
ft.
f.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft
ft.
21. REMARKS
18 geoprobe borings were drilled to a depth of 30 feet.
22. Certification:
45-54/ . 4 2d
e of Certified We Con. it Date
5y signing this form,1 hereby certify 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 Supplv and Open -Loop Geothermal Return Wells: Copy to the
county environmental health department of the county where installed
24d. For Water Wells producini 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:
George Bridger
Well Contractor Name (or well owner personally abandoning well on his/her property)
Vi
NC Well Contractor Certification Number
Carolina Drilling
Company Name
2. Well Construction Permit #:
UIC#W10800528
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
DAgricultural
❑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
DExperimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
•Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑ Other (explain under 7g)
4. Date well(s) abandoned: $/1 8/2020 8/22/2020
5a. Well location:
Former Modern Dry Cleaners and Laundry/Brookfield Properties
Facility/Owner Name
3750 Oleander Drive,
Physical Address, City, and Zip
New Hanover
County
DSCA ID #65-0001
Facility ID# (if applicable)
Wilmington 28403
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latilong is sufficient)
171013.833 N 2331802.645
W
CONSTRUCTION DETAILS OF WELLS) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction/abandonment, you can submit one form.
6a. Well ID#: 1 - 18 borings
6b. Total well depth: 30 (ft.)
6c. Borehole diameter: 2 (in.)
6d. Water level below ground surface: 6 (ft.)
6e. Outer casing length (if known): NA (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: 18
7b. Approximate volume of water remaining in well(s): N/A
(gal.)
FOR WATER SUPPLY WELLSA/� ONLY:
7c. Type of disinfectant used: N/A
Id. Amount of disinfectant used: NA
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
❑ Sand Cement Grout
❑ Concrete Grout
0 Specialty Grout
0 Bentonite Slurry
II Bentonite Chips or Pellets
❑ Dry Clay
0 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:
Filled geoprobe hole with bentonite chips, compacted and then sealed with asphalt patch.
8. Certgiication:
of Certified Well Conctor or Well Owner Date
[v signing this form, 1 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 Ixell
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection 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 & Infection 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 healtitEti tt of the county where
abandoned. 6'iCliCl V CU
SEP 2 2 2020
Form GW-30
North Carolina Department of Environmental Quality - Division of Water Resources
NC DEQ/DWRt
Central ate Revised 2-22-2016

Map Location
Drawn: ZT 11/18/2019
Approved: MA 11/18/2019
Project #: 31402113.000
rd:Q:kranakinv SLwm...wal /V7A}.0 asrt
INDEPENDENCE MALL
0 50
Feet
Legend
Soil Boring (2 Zones)
• 15. Zone - 8o Gallons
3o' Zone - 8o Galons
Q Deep Monitor Well (345 Gallons)
O Shallow MonitorWell
• Deep MonitorWell
Groundwa
El Injection
Site Parce
Property F