WI0300447_Injection Event Record_20210419

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD fIERI
Permit Number WI0300447
Permit Information
ICI Americas, Inc.
Permittee
Former ICI Americas, Inc
Facility Name
2130 N Tryon St. Charlotte, NC 282O6
Facility Address (include County)
2. Injection Contractor Information
Arcadis
Injection Contractor / Company Name
Street Address_1O Patewood Dr. STE 375
Greenville
City
SC
State
L864J 987-3900
Area code — Phone number
29615
Zip Code
3. Well Information
Number of wells used for injection 3
Well IDs IW-1, IW-2, and IW-3
Were any new wells installed during this injection
event?
Yes LINo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
0
3
Type of Well Installed (Check applicable type):
LI Bored IZ Drilled L Direct -Push
El Hand -Augured fl Other (specify)
Please include a copy of the GW-1 form for each
well installed
Were any wells abandoned during this injection
event?
❑ Yes Z No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include a copy of the GW-30for each well
abandoned
Injectant Information
See attached.
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
3.96% v/v
If the injectant is diluted please indicate the source
dilution fluid. potable water
Total Volume Injected (gal) 13 325
Volume Injected per well (ga1)See below
IW-1 — 1,512; IW-2 — 8,659; IW-3 — 3,154
Injection History
Injection date(s)_4/19/21 — 4/27/21
Injection number (e.g. 3 of 5) 1 of 1
Is this the last injection at this site?
Yes ❑ No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THEBESTOFMYKNO J) THAT THE
INJECTION WAS PF IN THE
STANDARDS LAID O�L'�'�
I 177
URE F 1NJECT 4GT
-4 V.
�ertt�y Cr'46ivt, i� 4'(O
PRINT NAME OF PERSON
SIGNA
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
HEM
P FRN„s
'a"'M "���Form UIC-IER
Rev. 3-1-2016

Attachment 1
Injectant: Emulsified Vegetable Oil (EVO) (Lactoil or EOSPRO)
Total amount injected: 13,325 gal
Percent in mixture with other injectants: 3.96% mixture with potable water
Source of Water (if applicable): Potable water from the city of Charlotte, North Carolina.
Injectant: Bioaugmentation cultures (KB-1 Primer) flushed with a mixture of potable water and diammonium phosphate
(DAP)
Total amount injected: 6 liters of bioaugmentation cultures; 750 gallons of DAP mixture
Percent in mixture with other injectants: 0.5% mixture of diammonium phosphate with potable water
Source of Water (if applicable): Potabiewater from the city of Charlotte, North Carolina.
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)
Mt. Form
For Internal Use Only:
1. Well Contractor Information:
C Ad Dc ,
Well Contractor Name
NC/, 4C, g5'a5-4
NC Well Contractor Certification Number
Cascade Drilling, LP
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. (IIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agriculturaltunicipal/Public
Geothermal (Heating/Cooling Supply) DIResidential Water Supply (single)
Industrial/Commercial OResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring DRecovery
Injection Well:
Aquifer Recharge
'lAquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed:
5a. Well Location:
VIA
Facility/Owner Name
Groundwater Remediation
Salinity Barrier
JStormwater Drainage
DSubsidence Control
Tracer
DOther (explain under #21 Remarks)
ct-3-a!
Well ID# T W " 2
Facility ID# (if applicable)
Ln Ewvod C Ar/,'t4 / /tJ( 628.26.
Physical Address, City, and Zip
11?o t(t 1Pn jtir-t'
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3s°141'3o.3" N &° R`.22, 7"
6. Is(are) the wells) crmanent or jTcmporary
7. Is this a repair to an existing well: DYes or Et<
If this is a repair, fill out known well construction information and explain the nature of the
repair under 1121 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:
9. Total well depth below land surface: 307'
For multiple wells list all depths if different (example- 3®200' and 2®100')
(ft.)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
6tt
11. Borehole diameter: (in.)
12. Well construction method:1 i C,
(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
ft.
ft.
ft.
ft.
15, OUTER CASING ;(for '.multi -cased wells) OR LINER (if ap livable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
a2 et.
O ft.
a in.
6 (go
?VC
16 INNER CASINGOR} TUBING (geothermal
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17 SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
Q ft.
ft.
in.
3;2 ft.
22 ft.
in.
.mot
0 , 20
0. 4D
�-eia, lBSf
18. GROUT . .
FROM
TO
MATERIAL,
EMPLACEMENT METHOD & AMOUNT
17 ft.
D ft*
p.4,ti 1
-f.&tt^e. / 35 rlt9x.g.
ft.
ft.
ft.
ft.
19i.SAND/GRAVEL :PACK (if applicable) '
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3y ft.
20 ft.
.g
9'L
20 ft.
) ft.
.
//%f)�e co
ffjjtvvl'f /e oC�tars�
20.'DRILLING
:LOG '(attach 'addr'Yionatsbeeisifnecessa7y) /' i}
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: /V(i,"JG
d Well
ContractorSignalue r01'Ce
Date
By signing this .form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or ISA 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 site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information I'rocessing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this fortn 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 Sunply & lniection 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 construction to the county health department of the county
where constructed.
Fonn GW-I
North Carolina Department ofEnviromnental Quality - Division of Water Resources Revised 2-22-2016

Punt form
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
CSC -Lk `DC11 11'
Well Contractor Name
NCc,Jc - L 2 —A
NC Well Contractor Certification Number
Cascade Drilling, LP
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. tlIC, County, State, Variance, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural EMunicipal/Public
DGeothermal (Heating/Cooling Supply) DResidential Water Supply (single)
DIndustrial/Commercial °Residential Water Supply (shared)
Irri ation
Non -Water Supply Well:
Monitoring oRecovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
roundwater Remediation
Salinity Barrier
jStormwater Drainage
DSubsidence Control
°Tracer
°Other (explain under #21 Remarks)
4. Date Well(s) Completed: 4- 7-a 1 Well ID# l�1% - 3
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
Lock Loci d Ca , NV_ ct e4
Physical Address, City, and Zip
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 °I Ll ` 30, i! N Sa°t19'?2. 7,'
6. Is(are) the wells) Permanent or DTemporary
7. Is this a repair to an existing well: °Yes or 'Ergo
If this is a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form.
S. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 2
9. Total well depth below land surface: 5 3 ' 1
For multiple welk list all depths ifdierent (example- 3®200' and 2@100')
w
(ft.)
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+"
11. Borehole diameter: t9 (in.)
12. Well construction method: ..SO/VC.-
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
rr14: NWA11EtrZONES'.
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
'.:13 .f)UTER eAs1Nt; (for multt-caaell wellsj" It i1NEI (if att.
linable)
FROM
TO
DIAMETER THICKNESS
MATERIAL�r�
(-13 ft.
0 ft.
02 in.C� i(C)r
V G
t641`.4NER CASIh)G.OR TVBING`(geothermal
closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL,
ft.
ft.
in.
ft.
ft.
in.
Ali,SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
0 ft*
ft.
in.
53,1 ft. Li3 ft.
2 in.
O , 2.0
v c-( v
S'4t kss:
48 t;<IIOYJT
FROM
'10
MATERIAL
EMPLACEMENT METIIOD & AMOUNT
3 7.5ft.
o ft.
port t l if
41,,, e / 53"ci.tr4,l'
ft.
ft.
ft.
ft.
:18}.SANI %GRAVEI;'PAK(if.applicable)
..:
FROM
TO
MATERIAL
EMPLACEMENT METHOD
Sy ft.
yb,q ft.
.stre,pp t a
cysi-inefy.
q0, ft.
i
3'�.s ft.
co
I
dGitcr<.. se.,,--1/ %'.°✓'f'
20. RIBEINg:
iG(attachadaldenat.slicetli'If
TO
geeea8itkY .: -.. ..
DESCRIPTION (color, hardness, soil/rack type, groin size, etr.)
FROM
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21'.11EiMARIts: :...I
22. Certification: JVGL)C_ VS S -A
r
c or
Signature of Certified Well Con
`-1 •
Date
By signing this form, I hereby certify that the well) was (were) constructed in accordance
with ISA NCAC 02C .0100 or ISA 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 site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For 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: In addition to sending the form to the address in 24a
above, also submit one 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: 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 construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

Print Form=
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Well Contractor Name J
/VGW G 14 c2_S--A
NC Well Contractor Certification Number
Cascade Drilling, LP
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. IBC, County, Slate, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural unicipal/Public
Geothermal (Heating/Cooling Supply) OResidential Water Supply (single)
Industrial/Commercial OResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
Monitoring
['Recovery
Injection Wc1I:
Aqui fer Recharge
Aquifer Storage and Recovery
Aquifer Test
_ Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
.: roundwater Remediation
Salinity Barrier
E"Stonnwatcr Drainage
Subsidence Control
Tracer
DOther (explain under #21 Remarks)
4. Date Well(s) Completed: 1-14"`42 l
5a. Well Location:
Facility/Owner Name
r cfo.140d ('Aeslo#fe
Physical Address, City, and Zip
Well ID# 3'0 ^ t
Facility ID# (if applicable)
fh2r t Govi h
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3S9it? 30,3" N p-0o (4.22.7't w
6. Is(are) the well(s)
crmanent or OTemporary
7. Is this a repair to an existing well: Dyes or r1O
If this is a repair, fill out known well construction information and explain the nature of the
repair under 1121 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only I GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: (in.)
12. Well construction method:1+`
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use Only:
14•WATERZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15 OUTER CASING (t"or.multi-eased wells) OR LINER'(if tip' lieable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
P11L
3c ft.
O ft.
2 in.
0,Y0
16 JINNER 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,
0 ft'
ft.
in,
tyr ft.
3c ft.
in.
0,2.0
0 a
54a4'n/P_9y
18: GROUT .'';
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
tL%� �1�
ft.
ft.
/NC„
ft.
ft.
19.SAND/CRAVELPACK'(ifatiplicable) '.
FROM
TO
MATERIAL
EMPLACEMENT METHOD
49, S ft.
33 ft.
4.7
t y
9 g ft.
att, S' ft.
//%%y, UG
y,,.AI /
O fX.Ort / c AeCte- Sc..
20. DRILLING
LOG "(attach
addhionalsheets ifnecessa ) r .....
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. Certific
c WS2S -f'
Signature of Certified Well Contractor
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 1 SA 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 site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For 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 Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one 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 & Iniection 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 construction to the county health department of the county
where constructed.
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016