WI0100230_Injection Event Record_20200915

North Carolina Department of Environmental Quality — (Wilton of Water
INJECTION EVENT RECORD (IERj
Permit Number wi010O230
r—
I Permit Information
L'hcintrtmics, Inc,
Penn ittee
chciniroflics Supi rttwsl Sac,APiA - I'-5 (flack Valley I'I1
Facility Name
180 Old Bee Tree Road, Swannanoa, NC 28778
Facility Address (include County)
2. Injection Contractor Information
Geosi ntec Consultants of NC, P.C.
Injection Contractor ' Company Name
Street Address 1255 Roberts Boulevard, Suite 200
Kennesaw GA _ _ 30144
City State Zip Code
0781386-9507
Area code — Phone number
3. Well Information
Number of wells used for injection 7
Well IDs: IP-BV-I.,-3, -4, -5, MW265-N25CD.
MW279-M25CD
Were any new wells installed during this injection
event?
❑Yes ZINo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable type):
0 Bored ❑ Drilled ❑ Direct -Push
0 Hand -Augured ❑ Other (specity)
Please include a copy of the GW-1 form for each
well installed.
Were any wells ahandone
event"
U Yes
SEP 16 2020
Z No
inn
If yes, please provide the following information.
Number of Monitoring Wells _
Number of Injection Wells_
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
ELS' Liauid Concentrate and EIJC' t.iquld Mix. Nutrmult'ats sod=
lactate. sodium bicarbonate. diainmonium nho5phate WAN. rhodamig4
car the
Injectant(s) Type (can use separate additional sheets if
necessary
Concentration I°u EU' Liauid Conccntratr itd Et1C' Liquid Mix. 25
el. Nutnsulfate 13 0 ¢ L as sulfate). 16 a/ sodium !amts. 477 mgrk
sodium bicarbonate. jrngll. DAP_ 31 mglL rhodaminc WT
If the injectant is diluted please indicate the source
dilution fluid. City water (18,733 gallons] and extracted
eroundwater (26.466 Cal l ons l
Total Volume Injected (gal) 45.199
Volume Injected per well (gal)
IP-BV-1 (5528), IP-BV-2 (4 419),IP-BV-3111.1331. IP-BV-417.8821.
II'-BV-5110.7781 MW265-N25CD(5.335).MW2779-M25CD(123)
5. Injection History
Injection date(s) July 7-10, 13-17, 21-24, 27-31, August 3-5, 2020
Injection number (e.g. 3 of 5) 3 of 3
Is this the last injection at this site?
❑ 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.
.ti4•1tAci 9t YI Zo tv
,NARE OF INJECTION CONTRACTOR DATE.
Qe,ya,N K b41 z 3 /
PRINT NAME OF PERSON PERFORMING THE INJECTION
PIN* 1.4 • 6-)e- 346 - 9So
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 U1C-IER
Rev. 3-1-2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Randy Phillips
Well Contractor Name
1096-A
NC Well Contractor Certification Number
A.E.Drilling Services
FlECEIVED
SEP 15 2o7Q
Company Name
2. Well Construction Permit #: i' DEQ/Dwitl
List all applicable well permits (i.e. County, State, Varso0Iif'raliohty6e
3. Well Use (check well use): �� %%�Ilfll
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑lrrieatton
❑MunicipaUPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
i3Monitoring
❑Recovery
Injection Weil:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
Cl Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating Cooling Return)
DGroundwater Remediation
❑Salinity Barrier
❑Stonnwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
For Internal Use ONLY:
14. WATER ZONES
FROM ` TO
ft.
ft.
DESCRIPTION
ft.
ft_
15. OUTER CASING (for multi -eased wells) OR LINER (ir applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0 ft. 72 it_ 2 i" • sch 40 PVC
16. INNER CASING OR TUBING geothermal closed -loop!
FROM
ft.
TO
ft.
DIAMETER THICKNESS
in.
MATERIAL
ft.
in.
17. SCREEN
FROM TO
DIAMETER
SLOT SIZE
rmctesEss
MATERIAL
72 ft.
92
ft.
2
in.
.010
sch 40
ft.
ft.
in.
PVC
18. GROUT
FROM TO
65.9 ft 69.4
ft.
MATERIAL
chips
EMPLACEMENT METHOD & AMOUNT
tremmie
0
ft.
65.9 it
neat cement
tremmie
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM I TO MATERIAL
EMPLACEMENT METHOD
69.4 ft• '92
ft.
#1 sand
tremmie
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DuiCift TION , cedar, hardness, soillreck type, grain size, etc.)
R.
ft.
4. Date Well(s) Completed: 11 /20/14
Sa. Well Location:
Chemtronics
Weil m# IP-BV-1
Facility/Owner Name Facility ID# (if applicable)
180 Old Bee Tree Rd. Swannanoah
Physical Address, City, and Zip
Buncombe
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
6. Is (are) the well(s): l3Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or ElNo
If this is a repair, fill out known well construction information and esplain the nature of the
repair under #21 remarks section or on the back of this form.
S. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, yen can
submit one form.
9. Total well depth below land surface: 92 (It)
Fur multiple wells list all depths if different fexample- 3 r(200' and 40trf)
1
10. Static water level below top of casing: 22.1 7 (ft.)
If water level is above casing rise "+'•
11. Borehole diameter: 6 (in.)
12. Well construction method: Auger / Core
(i.e. auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _. Method of test:
13b. Disinfection type: Amount:
ft.
ft.
ft.
ft.
ft.
ft.
R.
ft.
ft.
ft.
tt.
21. REMARKS
22. Certification:
2�.
12/18/14
Signature oft tificd Well Contractor Date
By signing this form. I hereby certify that the wells) was (were) constructed in accordance
with 15.4 NC/C 02C .0100 or 15,4 NC4C 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 INSTUCTIONS
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 Injection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a 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:
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 Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
L. Well Contractor Information:
Randy Phillips
Well Contrac ter Name
1096-A
NC Well Contractor Certification Number
A.E.Drilling Services
Company Name
2. Well Construction Permit /t:
List all applicable well permits (i.e. County, State, Variance. byes
3. Well Use (check well use):
n, etc)
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
Ii7Monitoring
❑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)
4. Date Well(s) Completed: 11 / 13/ 14
5a. Well Location:
Chemtronics
❑Groundwater Remediation
°Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under fee Remarks)
WeBIDN �P-BV-2
Facility/Owner Name Facility ID# (if applicable)
180 Old Bee Tree Rd. Swannanoah
Physical Address, City, and Zip
Buncombe
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one iat/long is sufficient)
N W
6. Is (are) the well(s): /Permanent or OTemporary
7. Is this a repair to an existing well: ❑Yes or ®No
Phis is a repair, fill old known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of t
wells constructed: E
For multiple injection or non -water supply welLs ONLY with the same construction. you con
submit one form.
9. Total well depth below land surface: 92
For multiple wells list all depths if different (example- 3O200' and 2C 1(H)')
10. Static water level below top of casing: 18.02
(ft.)
(ft)
filmier level is above casing. use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Auger I Core
(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
ft.
DESCRIPTION
ft.
ft. st.
15. OUTER CASING (for multi -cased wells) OR LINER Of applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0 f`' r72 2 sch 40
16. INNER CASING OR TUBING (geothermal closed -loop/
OM U TO : DIAMETER
THICKNESS
PVC
MATERIAL
f. In.
ft.
ft.
17.SC.REEN
FROM T TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
72 f` 92
ft.
2
in.
.010
sch 40 PVC
ft.
ft.
in.
18, GROUT
FROM TO
MATERIAL.
EMPLACEMENT METHOD & AMOUNT
67
ft.
70
ft.
chips
tremmie
0
ft.
67
ft.
neat cement
tremmie
ft.
ft-
19. SAND/GRAVEL PACK rif applicable)
FROM TM- MATERIAL
EMPLACEMENT METHOD
70 "t_92
ft.
ft.
ft.
#1 sand
tremmie
20. DRILLING LOG (attach additional sheets if necessary]
FROM TO De3t.h;PTION (color, hardness, solFroek nix, emu, sin, Oct,
ft.
ft.
ft.
ft.
ft.
It
ft.
ft.
rt.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature of rtiftcd Well Contractor
12/18/14
Date
By signing this form. f hereby certify that the 'rell('s) was (were) constructed in accordance
with I5A NCAC 02C.0700 or 75,4 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 welt site details or well
construction details. You, may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
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 ONLY: hi addition to sending the form to the address in
24a above, also submit a 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:
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.
Forma OW-1
North Carolina Department of Environment an
d Natural Resources — Division of Water Resources Revised August 201

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Randy Phillips
Well Contractor Name
1096-A
NC Well Contractor Certification Number
A.E.Drilling Services
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, Stare, Variance, lnje
3. Well Use (check well use):
it, et
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
D Industrial/Commercial
❑lrriattion
❑Municipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
IdMonitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating Cooling Return)
4. Date Well(s) Completed: 1 1 /7/14 Well1➢# IP-BV-3
Sa. Well Location:
Chemtronics
Facility/Owner Name
Facility 1138 (if applicable)
180 Old Bee Tree Rd. Swannanoah
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (exrlain under #21 Remarks)
Physical Address, City, and Zip
Buncombe
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
N
6. Is (are) the well(s): 21Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out laconic well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form_
S. Number of wells constructed: 1
For multiple infection or non -water supply wells ONLY udlh the same construction, you can
submit one form,
9. Total well depth below land surface: 91.5
For multiple wells list all depths i f different (example- 3(4200' and 2(000')
(R.)
10. Static water level below top of casing: 21 -96 (ft.)
If water level is above casing: tire "+"
H. Borehole diameter: 6
12. Well construction method: Auger / Core
(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
ft.
ft.
TO
f4
ft.
DESCRIPTION
15. OUTER CASING (for multi -cased wells) OR LINER (if ap Beside)
FROM
0
TO DIAMETER THICKNESS
e. 71.5 ft 2 In ' sch 40
lb. INNER CASING OR TUBING (geothermal closed-l000p)
THICKNESS
FROM
ft.
TO
ft.
r
17. SCREEN
FROM TO
71.5 ft 91.5 ft
DIAMETER
R in,
L in
DIAMETER I SLOT SIZE
2 In. .010
MATERIAL
PVC
FMA.TERIAL
THICKNESS MATERIAL
sch 40
PVC
ft. ft.
in,
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
66.5 It
ft.
ft.
69.5
66.5
ft,
ft.
ft.
chips
neat cement
tremmie
tremmie
19. SAND/GRAVEL PACK Qf applicable)
FROM
TO i MATERIAL
EMPLACEMENT METHOD
69.5 ft.
ft.
91.5 rt. ;
ft.
#1 sand
tremmie
20. DRILLING LOG (attach additional sheets if necessary)
FROM
et.
TO
ft.
D ESCRt mint leoler, hardness, soil/rock [rise,.grain site, etc.)
ft.
ft.
ft.
ft
ft.
ft.
ft.
ft.
ft.
ft.
ft.
It.
21. REMARKS
22. Certification:
12/18/14
Signature of C ill Well Contractor Date
By signing this form. r hereby certh that the nell(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 site details or well
construction details. Yon may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
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 Matz Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a 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
24e. For Water Supply & injection Wells:
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 Environment and Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Randy Phillips
Well Contractor Name
1096-A
NC Well Contractor Certification Number
A.E.Drilling Services
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use);
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industria l/Commercia l
❑lrri,ation
❑Mu nicipal/Public
DResidential Water Supply (single)
❑Residential Waler Supply (shared)
Non -Water Supply Well:
<@Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heati» .Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stomiwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1 "13/14
5a. Well Location:
Chemtronics
Well ID# IP-BV-4
FacilityiOwner Name Facility 1D# (if applicable)
180 Old Bee Tree Rd. Swannanoah
Physical Address, City, and Zip
Buncombe
County Parcel Identification No. (PIN)
5h. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N
6. Is (are) the well(s): llPermmzient or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or FIND
If this is a repair, fill ant ;mown well construction information and explain the nature of the
repair tinder #21 remarks section or on the back alibis Arm.
8. Number of wells constructed: `
For multiple it jection or non -water supply wells ONLY with the same construction. you cam
submit one form.
9. Total well depth below land surface: 92 (ft.)
For multiple wells list all depths if different (example- 3l
F 20L)' and 2@101Y)
10. Static water level below top of casing: 22.01 (ft.)
If water level is above casing. use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Auger / Core
(i.e. auger, rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
N,
TO
ft.
DESCRIPTION
ft.
It.
15. OUTER CASING tfor multi -cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
0
ft.
72 It 2 in- sch 40 PVC
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
ft.
ft.
17, SCREEN
FROM
72 ft.
TO 1 DLSMETER THICKNESS
ft r In.
TO
92
ft.
DIAMETER
2 in.
MATERIAL
SLOT SIZE THICKNESS
.010 sch 40
MATERIAL
PVC
ft.
ft.
in.
18. GROUT
FROM TO
67 ft. 70 rt.
MATERIAL
chips
EMPLACEMENT METHOD & AMOUNT
tremmie
0
ft.
ft.
67 ft
neat cement
tremmie
ft
19. SAND/GRAVEL PACK (if applicable)
FROM TO
MATERIAL
EMPLACEMENT METHOD
70
ft.
92
ft.
#1 sand
tremmie
ft.
ft.
20. DRILLING LOG (attach additional sheets if neteasary)
FROM TO DESCRIPTION (color, hardness, soil/rock typr. grain size, gnat
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
IZ
ft.
ft.
21. REMARKS
22. Certification:
12/18/14
Signature of Cer ed Wall Contractor Date
By signing this farm, I hereby certh• that the well(s) was (were) constructed in accordance
with 154 NCAC 02C .0100 or 15A NCAC 02C.02(10 Well C'snsrntction 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 welt
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For AB 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
241). For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a 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:
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-1
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Randy Phillips
Well Contractor Name
1096-A
NC Well Contractor Certification Number
A.E.©rilling Services
Company Name
2. Well Construction Permit g:
List all applicable well permits (i.e. Counts, Stare. Variance, Injection, etc_)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑hruation
❑MunicipalPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
EMonitoring
❑Recovery
Injection Well;
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
❑Groundwater Remediation
❑Salinity Barrier
❑Stortnwater Drainage
❑Subsidence Control
❑Tracer
I }then (explain under n21 Remarks)
For lotermal Ilse ONLY:
14. WATER ZONES
FROM rO E DESCRIPTION
ft. I ft. f1
ft.
ft.
l5. OUTER CASING (for multi -cased wells) OR LINER_lif applicable)
FROM TO
0 rt. 171 rT' 2
DIAMETER
iR
THICKNESS I MATERIAL
sch 40
PVC
16. INNER CASING OR TUBING (geothermal closed -leapt
FROM TO
ft.rt.
DIAMETER
in.
THICKNESS MATERIAL
ft. ft.
in.
17. SCREEN
FROM
71 ft-
TO_
91 ft-
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
2 in.
.010 sch 40
PVC
ft.
in.
18. GROUT
FROM TO
MATERIAL EMPLACEMENT METHOD & AMOUNT
66 ft.
69
0
ft.
ft.
66
ft.
R.
ft.
chips
tremmie
neat cement
tremmie
19. SAND/GRAVEL PACK (if applirablel
FROM TO MATERAI.
69 ft- 91 ft. #1 sand
EMPLACEMENT METHOD
tremmie
ft.
ft. .
20. DRILLING LOG (attach additional sheets if necessary5
FROM
ft.
TO
ft.
TIE-4( ktt'TIIrs' (color, hardness, soil/rock rep%grain flan, Ole.)
4. Date Well(s) Completed: 11 /10/14
5a. Well Location:
Chemtronics
WellID# IP-BV-5
Facility/OwwnerName Facility lDi (if applicable)
180 Old Bee Tree Rd. Swannanoah
Physical Address, City, and Zip
Buncombe
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minntes/seconds or decimal degrees:
(Swell field, one tatllong is sufficient)
6. is (are) the well(s): ®Permanent or ['Temporary
7. Is this a repair to an existing well: ['Yes or ElNo
If this is a repair, fill out knownwell construction information and explain the nature of the
repair under 112 h remarks .section or on the back of this form.
8. Number of wells constructed: 1
For multiple injection or non -water supply welts ONLY with the same construction, you can
form. submit one rm.
9. Total well depth below land surface: 91
For multiple wells list all depths if diffrrent (example- 3@200' and 2(1(XY)
10. Static water level below top of casing: 22.1
limier level is above casing, use "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Auger / Core
(ft.)
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
I FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm)
13b. Disinfection type:
Method of test:
Amount:
ft.
ft.
ft.
ft.
ft.
ft
ft.
tG
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
12/18/14
Signature of C fied Well Contractor Date
By signing this farm. I hereby cerlifp that the calks) was (were) constructed in accordance
with T5.4 NC4C 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 INSTUCTIONS
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 Injection Well: ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health depattment of the county where
constructed.
Form GW-1
North Carolina Department of Environment and
Natural Resources- Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used far single or multiple wells
I. Well Contractor Information:
Randy Phillips
Well Contractor Name
1096-A
NC Well Contractor Certification Number
A.E.Drilling Services
Company Name
Z. Well Construction Permit #:
List all applicable well permits (i.e. County, State. Variance, Injection, etc.)
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
@Monitoring
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
DAquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
❑Geothermal (HeatineiCooling Return) ,t
4. Date Well(s) Completed: 1 1 /4/ 1 4
5a. Well Location:
Cherntronics
Facility/Owner Name
❑Groundwater Remediation
❑Salinity Barrier
DStormwater Drainage
OSubsidence Control
OTracer
°Other (exr lain under #21 Remarks)
Well ID# MW279-M25CD
Facility IDS (if applicable)
180 Old Bee Tree Rd. Swannanoah
Physical Address, City, and Zip
Buncombe
county
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. is (are) the well(s): la Permanent or ❑Tetuporary
7. Is this a repair to an existing well: ❑Yes or LENo
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 hack of this farm.
K. Number of wells constructed: i
For multiple infection or non -water supply wells ONLY with the same construction. you can
submit one form.
9. Total well depth below land surface: 93.5
For multiple wells list all depths ifdij5erent (example- 300' and 44100)
10. Static water level below top of casing:
If water level is above casing. sue "+"
11. Borehole diameter: 6 (in.)
12. Well construction method: Auger / Core
(ft.)
(ft.)
(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 limbic)
FROM
0 ft.
TO DIAMETER
72 ft, 2
in
eppI
THICKNESS MATERIAL
sch 40 PVC
16. INNER CASING OR TUBING Geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
72 ft.
ft_
TO DIAMETER ! SLOT SIZE
92 it ' 2 in- i .010
ft.
in.
THICKNESS
sch 40
MATERIAL
PVC
18. GROUT
FROM
TO l MATERIAL
EMPLACEMENT METHOD & AMOUNT
70 ft.
tremmie
19. SAND/GRAVEL PACK iif applicable,
FROM
TO
MATERIAL I EMPLACEMENT METHOD
70 rt.
93.5 ft.
#1 sand tremmie
ft.
ft.
20. DRILLING LOG (attach addltiaaal sheets if necessary)
FROM TO DF_SCRIPTIONi color, hardness, sail/rock type, again size, ;KG]
ft. ft.
ft. ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
rt.
ft.
21. REMARKS
22. Certification:
Sigma/lure of led Well Contractor
12/18/14
Date
8y signing this form. f hereby certi/p that the wrll(s) was (were) constructed in accordance
with 15A NC4C 02C .0100 or 15A NCAC 02C _0200 Well Constriction 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 INSTUCTIONS
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 ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
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.
87 ft. chips
0 ft. f 67 ft. neat cement tremmie
ft. ft.
Form G W-I
North Carolina Department of Environment and Natural Resources — Division of Water Resources Revised August 2013

4, Date Wei)(s) Completed: 4' L
Sa. Well Location:
16. INNNER CASING OR TUBING geothermal elosed•loup)
FROM 1 TO i DL°CIETER t TRICKNESS I bLATERLI.L
ft. ft. ' in. I
1 Pt. ft. ~t
1 I
i7. SCREEN
FROM TO DTAbrSTER SLOT SIZE TIIIC}.mESs MprERruL
Municipal/PtrblicI I ' S' ft. 1g3.5' ft 2"
❑Groundwater Remcdiation
OSalinity Barrier
OStormwatcr Drainage
CI Subsidence Control
°Tracer
J Facility,Oo,eee Name Foeility ID? (if eppfe)cabl
Physical Address, City, and Zip
County Parcel identification No. (PLY)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(it vicil aeld. one latlong is suffieiertt)
N W'
6. is (are) the well(s): OKinanent or ❑Temporary
7. is this a repair to an existing well: °Yes or Wirf'-
/fthis is a repair. fellow longest or11 rewstreetiott information and explain the nature of the
repair under 021 remorlo section or an the back of this fan.
S. N umber of wells constructed:
Per multiple inieclioo or non -meter stipple wells ONLY with the sane construction, you can
subsoil one form.
9. Total well depth below Sand surface:
For rwritiple wells list all depths ifdifferent (example- 3(rg200' and 7(a31007
(ft.)
10. Static water level below top of casing: (ft.)
If water level is above casing. use
11. Borehole diameter: (in-)
II. Well construction method: flan fe.. eel a'
(i.e. auger, rotary, cable, direct push, etc.)
L
FOR WATER SUPPLY WELLS ONLY:
13a. Yield tgpm) Method of test:
13 b. Disinfection type: —
Pore OW -1
L -
Amount:
WELL CONSTRUCTION RECORD
This fonn can be used for single or multiple wells
1. Well Contractor Information:
{{mil:
We:I Conn. etor Name
7C?/
NC Well Counselor Certification Number
Company Name
Fob- Tnte:nal Use ON-.Y..
rF
14. WATER ZONES
FROM I TO T DESCRIPt'ION
ft. ft.
R ft
IS. OUTERCASING r for multi -cased ocelot OR LINER Of apQlicablo)
FROM ' 1'0 DIAMETER THICKCESS MATERIA1.
ft i ft. m.
2. Well Construction Permit X:
List all applicable uo1l permits (1, Cmunry Stare, Varirn+ce. Infection, etc./
3. Well Use (check well use):
Water Supply Wells
❑Agricultural
❑Geothermal (Heoting,'Cooling Supply) ORcsidential Water Supply (single) IL_ —[t� I — R. 1 in. i
_ 7
CLtdustria]1Cownercial :Residential Water Supply (shared) ILrA7l.OTOUT To
T
°irrigation
Non -Water Supply Well:
glblonitoring ORecovery
Ifnjectioo Well:
OAquifer Recharge
DAquifer Storage and Recovery
IAquifer Test
°Experimental Technology
❑Geothermal (Closed Loop I
rt. 1
ft, ft ,
} ft. El. 1
It.SAND/GRAVEL PACK of applicable)
_PROM O _ _ MATERLV._ T EMPLACLM&VP MGTilOn
le Sft 1tc--"
Pt. I ft. -�
20. DRILLING LOC'attach additional sheets tI necessary)
Fr5M TO
OGtnthctmal (HcatinglCoolinp Reoma) °Other (explain under #21 Remarks] 0. ft.i
e at.s— 1 ft. 1
'WellID1 /y's,)- ll)2SLa3
1_ ft.
I_— ft.
f— b.
I ft.
MATERIAL 1 EMPLACEMENTMe-etIOD SiAMOUN
J
ft.
ft.
It. f
rL
DESCRIPTIONLtor hardness, seiVrook lal1c, ruin alto, etc.,
22. Certiticatiula• ,
Siyman=_rtrGed rNe:l Concacto:
Date
By signing this fwvn, ! hereby ccat;S• that the _-el!(sl was (were) constructed in accordance
with CLI NC4C 02C.0100 or 194 NCG(C 02C .02110 Well Cnnenuctien Standards and that a
ropy of this record has been provided to the well oemter.
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 INSTUCTIONS
24a. For Ail Wells: Snhrnit 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. Fnr Injection Wells ONLY: lit addition to sending the form to the address in
2.4a above, also submit a copy of this torm 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. Fur Water Supply 5: Injection Wells:
Also submit one copy of this fomr within 30 days of completion of
well coastrue6on to the county health department of the county where
.. constmcted.
North Carolina Deportment of Environment and Natural Resources - Division of Water Resources Revised August 2013