WI0501065_Injection Event Record_20210608

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501065
1. Permit Information
Party Beverage
Permittee
Party Beverage (now Kenzy Mart)
Facility Name
5200 Western Blvd, Raleigh, Wake County
Facility Address (include County)
2. 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
3. Well Information
Number of wells used for injection 6
Well [Ds RW-2; borings GP-1, 3, 5, 8, and 10A
(direct push, temporary well constructed)
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 - 1 well, 5 temp wells
Type of Well Installed (Check applicable type):
❑ Bored A/ Drilled a 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 ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 5 (temp wells)_
Please include a copy of the GW-30 for each well
abandoned
4. Injectant Information
Gravity injection of approximately 250 gallons of 2% solution
of EnviroClean surfactant into well RW-2 and temp wells GP-
1, 3, 5, 8, and 10A
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 2%
If the injectant is diluted please indicate the source
dilution fluid. City of Raleigh municipal water
supply
Total Volume Injected (gal) 250
Volume Injected per well (gal) RW-2, 125 gal;
temp wells 10 to 25 gal each
5. Injection History
Injection date(s) March 25, 2021
Injection number (e.g. 3 of 5) 1 of 1
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.
S A 5/27/21
SIGNATURE OF INJECTION CONTRACTOR DATE
Gary A. Fischer
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:
JEREMY RINGLER
Well Contractor Name
A - 4422
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
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)
Elndustrial/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: 03/24/21 Well ID#
5a. Well Location:
PARTY BEVERAGE
Facility/Owner Name
RW-2
Facility ID# (if applicable)
5200 WESTERN BLVD RALEIGH 27606
Physical Address, City, and Zip
WAKE
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
35° 47' 12.57" N 78° 42' 46.72"
W
6. Is(are) the well(s): OPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
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:
9. Total well depth below land surface: 28'0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 15.0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 10•0 (in.)
12. Well construction method: AUGER
(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. 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
0.0 ft'
13.0 ft•
4.0 in-
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
13.0 ft'
28.0 ft•
4.0 in.
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
10.0 ft.
PORTLANDBENTONITE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
11.0 ft.
28.0 ft.
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 ft'
28.0 ft.
SILTY CLAY
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL - 10.0 - 11.0 FEET
22. Certification:
03/26/21
Signature of Certified Well Contractor Date
By signing this fonn, I 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 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)
1. Well Contractor Information:
JEREMY RINGLER
Well Contractor Name
A - 4422
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION
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)
Elndustrial/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: 03/23 24/21 We11 ID# GP-1, 3, 5, 8, 10A
5a. Well Location:
PARTY BEVERAGE
Facility/Owner Name
Facility ID# (if applicable)
5200 WESTERN BLVD RALEIGH 27606
Physical Address, City, and Zip
WAKE
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lat/long is sufficient)
35° 47' 12.57° N 78° 42' 46.72"
W
6. Is(are) the well(s): ❑Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or ONo
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: F1Ve
9. Total well depth below land surface: 24'0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100)
10. Static water level below top of casing: 15.0 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 2 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:
For Internal Use Only:
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
0.0 ft.
9.0 ft.
1.0 in.
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
9.0 ft'
24.0 ft
1.0 in'
.010
SCH 40
PVC
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.)
0.0 ft'
24.0 II'
SILTY CLAY, CLAYEY SILT
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
03/26/21
Signature of Certified Well Contractor Date
By signing this fonn, I 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 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
This form can be used for single or multiple wells
For Internal Use ONLY:
1. Well Contractor Information:
GARY FISCHER
Well Contractor Name (or well owner personally abandoning well onhis/her property)
3339
NC Well Contractor Certification Number
MID -ATLANTIC ASSOCIATES, INC.
Company Name
2. Well Construction Permit 4: NA
List all applicable well construction permits (i.e. County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Indu stria l/Commercial
❑Irrigation
Non -Water Supply Well:
['Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
['Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
[Aquifer Storage and Recovery
❑Aquifer Test
['Experimental Technology
['Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
EGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned: 03/25/21
5a. Well location:
PARTY BEVERAGE
Facility/Owner Name Facility ID# (if applicable)
5200 WESTERN BLVD RALEIGH 27606
Physical Address, City, and Zip
WAKE
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° 47' 12.57" N -78° 42' 46.72"
W
CONSTRUCTION DETAILS OF WELLS) 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#: GP-1, 3, 5, 8, 10A
6b. Total well depth: 24.0
(ft.)
6c. Borehole diameter: 2'0 (in.)
6d. Water level below ground surface: 15 (ft)
6e. Outer casing length (if known): N/A (ft.)
6f. Inner casing/tubing length (if known): 9'0 (ft.)
6g. Screen length (if known): 15' 0 (ft.)
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned:
For multiple injection or non -water supply wells ONLY with the same
consnuction/abandonnzent, you can submit one form.
5
7b. Approximate volume of water remaining in well(s): 0
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
)(Bentonite Chips or Pellets
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
0 Other (explain under 7g)
0 Neat Cement Grout
0 Sand Cement Grout
0 Concrete Grout
0 Specialty Grout
0 Bentonite Slurry
7f. For each material selected above, provide amount of materials used:
10 pounds
7g. Provide a brief description of the abandonment procedure:
BORINGS ABANDONED BY FILLING HOLE WITH
BENTONITE CHIPS (HOLEPLUG)
S. Cer "cat'tn:
eofCertifieIWell ontract.r Well Owner
3/26/21
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 Quality, 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 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
l0c. 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 Environment and Natural Resources — Division of Water Quality Revised March 2013