WI0800528_Injection Event Record_20211004

-ELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
George 'tsnagei
Well Contractor Name
2393A
NC Well Contractor Certification Number
OCT 04 2021
ii
Carolina Drilling•DFQ/Dwj
Company Name
2. Well Construction Permit #:
List all applicable well con.1racl,an permits (r.c. U/C, County. State, !balance. etc.)
3. Well Use (check well use):
= s•- fry li.ftr.:. •
U IC#W10800528
Water Supply Well:
°Agricultural
°Geothermal (Heating/Cooling Supply)
❑lndustrial/Commercial
❑Irri ation
°Municipal/Public
°Residential Water Supply (single)
°Residential Water Supply(shared)
°Wells > 100.000 GPD
Non -Water Supply Well:
°Monitoring
Injection 11'e,l:
°Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal; Heating/Cooling Return)
Augu
4. Date Well(s) Completed: m gym'
Sa. Well Location:
fount u.t«n Dry etr.nea eti uwm usratatawa.nr.
°Recovery
t IGroundwater Remediation
°Salinity Barrier
DStormwatcr Drainage
°Subsidence Control
°Tracer
DOther(exnlain under#21 Remarks)
2021 Well IN N/A
DSCA ID #65-0001
Facility/Owner Name Facility IDk (if applicable)
3750 Oleander Drive, Wilmington, NC 28403
Physical Address. City. and Zip
New Hanover
County Parcel Identification No, (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one laUiong is sufficient) 22. Certification:
171013.833 N 2331802.645
w
6.1s(are) the well(s): °Permanent or C1Temporary
7. Is this a repair to an existing well: °Yes or elNo
((this is a repair,fill out knave well construction inforatation andtuplaat the nature (tithe
repair ;ruder 421 remarks section or on the back of this farm.
8. For GeoprobeJDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: to
9. Total well depth below land surface; 19@30'
For multiple wells lest all depths if different (example- 3{i�200' and 2 @leer)
10. Static water level below top of easing:
If water level is above casing, use "• "
11. Borehole diameter: 2 (in.)
6'
ft.)
(ft.)
12. Well construction method: direct push
(i.e. auger. rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) N/A A Method of test: NIA
13b. Disinfection type: NIA Amount: NIA
ofCertiWell nir for
For Internal Use Only:
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19 geoprobe borings were drilled to a depth of 30 feet
3)uz
Date
ysigning this/arm.' hereby ceny)i that the well(s)was (here) earvracvai in accordance with
13A NCA(.' 02C..0/00 or MA NCA(' 02(' .0200 Well Construction nsrructios Stm,dards and that a copy
of lhLe recntd 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 or 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 Infection Wells: Copy to DWR, Underground Injection Control (IUC)
Program. 1636 MSC, Raleigh, NC 27699-1636
24c. For Water Supply and Open -Loon Geothermal Return Wells: Copy to the
county environmental health department or the county where installed
24d. For Water Wells producing over 1004100 GPD: Copy to DWR, CCPCUA
Permit Program, 1611 MSC, Raleigh, NC299-1611
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources
Revised 6.6.2018

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0800528
I. Permit Information
Brookfield Properties
Permittee
Former Modern Dry 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
Wilminston
City
NC
State
( 910J 799-0493
Area code — Phone number
3. Well Information
Number of wells used for injection
Well ]Ds 1-19 geoprobe borings
28409
Zip Code
19
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 I9
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled X Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-I form for each
well installed.
Were any wells abandoned during this injection
event?
X Yes 0 No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 19
Please include a copy of the GW-3ij for each well
abandoned.
4. Injectant Information
Sodium Lactate (willClear+],
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 50%
If the injectant is diluted please indicate the source
dilution fluid. Uppradient Qroundwater from MW-
WSP-1 D.
Total Volume Injected (gal). —5,000 gallons
Volume Injected per well (gal) 19 borings (" 264
gallons each.
5. Injection History
Injection date(s) 2/2020,8/2020.5/2021,8/2021
Injection number (e,g. 3 of 5) 4 of 5
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 WAS PE ORMED WITHIN THE
STANDARD A UT N THE PERMIT.
r L�• c
FGTU5?RE OF INJECTIOIONTRACTOR DATE
George 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 ABANDONMENT RECORD
For Internal Use ONLY:
1. Well Contractor Information:
George Bridger
Well Contractor Name for well owner personally abandoning well on his/her property)
2393A
NC Well Contractor Certification Number
Carolina Drilling
Company Name
2. Well Construction Permit #:
tur all apphcabte well commutate permits (i.e. UIC, County, State, 1•anance, eic.) ;(&mown
3. Wen use (check well use):
U IC#WI0800528
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑industrial/Commercial
❑irrigation
Non -Water Supply Weil:
❑Monitoring
Injection Well
❑Aquifer. Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
IRGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g
4. Date wells) abandoned: August 25-31, 202
1
So. Well location:
na..l u,a.ro on dune.. n tl t„e.pap,mu a,;..e..
DSCA ID#65-0001
Facility/Owner Name Facility ID 1(if applicable)
3750 Oleander Drive, Wilmington 28403
Physical Address, City, and Zip
New Hanover
County
Parcel Identification No. (NN)
5b. Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field, one 1st/long is sufficient)
171013.833 N 2331802.645
W
CONSTRUCTION DETAILS OF WELL(S1 BEING ABANDONED
Attac1 well eans;r.tioareeard;.$)iforaaiilabic. For multiple Oxalate ornon-water slpplywcll:
ONLY with the saute construction abandonment. you cat snbtna one fame.
6a. Well ID#: 1 - 19 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): N/A (ft.)
6E Inner easing/tubing length (if known): N/A (ft.)
6g. Screen length (it known): N/A (ft.)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth. only 1 G W-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
7b. Approximate volume of water remaining In weU(s):
N/A
(gal.)
FOR WATER SUPPLY WELLS ONLY:
7e. Type of disinfectant used: N/A
7d. Amount of disinfectant used: N/A
7e. Sealing materials used (check all that apply):
❑ Neal Cement Grout 0 Bentonite Chips or Pellets
❑ Sand Cement Grout 0 Dry Clay
0 Concrete Grout 0 Drill Cuttings
0 Specialty Grout ❑ Gravel
0 Bentonite Scurry ❑ Other (explain under 7g).
7f. For each material selected above, provide amount of materials used:
10 bags
7g. Provide a brief description of the abandonment procedure:
Filled geoprobe hob with bentonite chips, compacted and then sealed with asphalt patch
8. Certification:
Si :rT' rCertified Well Cont or or
-CD:14-(5) 2e2
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.
IBA3YTTAL 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 tniection 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 ibilowing:
Division of Water Resources, Underground .Injection Control Program,
1636 Mail Service Center, Raleigh. NC 27699-1636
10c. For Water Sunni,/ & tnieetion 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 CW-30
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016