WI0600220_Injection Event Record_20200206

TRANSMITTAL
To:
Company:
From:
CC:
Date:
ante6g roup
Antea USA of North Carolina, Inc.
3530 Toringdon Way, Suite 106
Charlotte, NC 28277 USA
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality — Division of Water
Resources
Mr. Matthew Eckmair
Mr. Robert R. Thompson, Ill, PG, RSM; Antea Group; Senior Professional
Mr. Jon Alix, PG; Antea Group; Project Manager
12 February 2020
Project Location: Former Eaton Corporation Facility (Laurinburg, NC)
Antea Group Project #: 170734296A
Enclosed:
Report Copy Prints Invoices
Specs Proposal Check Request
Shop Dwgs. Plans Payment
Change Order Correspondence X Other
These are for:
See Explanation Below As Requested Information
X Your Files Processing Review
Signature & Forwarding Resubmit
Message:
Please find the attached Injection Event Record and concurrent well construction/abandonment records for the
REDOX TECH, LLC Oxygen BioChem (OBC)T" injection (Permit No. W10600220) at the former Eaton Corporation
Facility (NONCD0001661) in Laurinburg, Scotland County, North Carolina. If you have any questions, please don't
hesitate to reach out to myself or Rob Thompson ([e-mail]).
Sincerely,
{
Matthew Eckmair
Project Professional
704 324 7036
[e-mail]
Antea Group
XI NOGENC us.anteagroup.com
The logo and ANTEA are registration trademarks of Antea USA, Inc.

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
For Internal Use Only:
Well Contractor Name
LH I Q
NC Well Contractor Certification Number
c2-60
Company Name
2. Well Construction Permit #: W OOO 2.2x,
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
DAgricultural
OGeothermal (Heating/Cooling Supply)
Q lndustriallCommercial
Et Irrigation
Non -Water Supply Well:
IjMonitoring
Injection Well:
▪ Aquifer Recharge
OAquifer Storage and Recovery
QAquifer Test
Experimental Technology
OGeothermal (Closed Loop)
1DGeothermal (Heating/Cooling Return)
OMunicipal/Public
QResidential Water Supply (single)
®Residential Water Supply (shared)
ORecovery
Groundwater Remediation
®Salinity Barrier
OStormwater Drainage
OSubsidence Control
DTracer
flOther (explain under #21 Remarks)
i°1 Well in# I -
4. Date Well(s) Completed: . 1/
5a. Well Location:
1fr"Le4- GA lrN Corrc4ior
Facility/Owner Name
Facility ID# (if applicable)
164 0o Atetheev. itck , b 3$ Z8 g 5 2-
Physical Address, City, and Zip
}
•
Sc4114Ac14 c9A,k1
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
3,4, 1-9 7- 2145 N 141 l5 6�
W
6. Is(are) the well(s) i Permanent or
emporary
7. Is this a repair to an existing well: DYes or 10
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, oil 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
1
9. Total well depth below land surface: Lig e 2a (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: (ft.)
If water level is above casing, use "+ " IS
11. Borehole diameter: 1 ' (in.)
sk'
12. Well construction method: Qom'"`
(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 applicable)
MATERIAL
FROM
TO
DIAMETER
THICKNESS
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
20 ft.
ft.
0 ft.
ft.
II 2-S in.
in.
apert466
+iv
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 I TO
ft.
ft.
ft.
ft.
ft.
ft.
DESCRIPTION (color, hardness, soil/rock type Zak
'1)(1- 1
ain size, etc.)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Si ed Well ontractor
Date
cng this form, I hereby certify that the well(s) was (were) constructo in accordance
1 5A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Stan ards 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)
construction details. You may also attach additional pages if necess
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of comp etion of well
construction to the following:
Division of Water Resources, Information Processing nit,
1617 Mail Service Center, Raleigh, NC 27699-161'7
24b. For Injection 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 Contra Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sendi g 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.
etails or well
ry
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources
Re
vised 2-22-2016

WELL ABANDONMENT RECORD
1. Well Contractor Information:
&ezi
Well Contractor Name (or well owner personally abandoning well on his/her property)
NC Well Contractor Certification Number
,c Tc&' C-LCi
Company Name
2. Well Construction Permit #:
in/ 6 (moo iZo
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.) if known
3. Well use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Water Supply Well:
DMonitoring
❑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)
lndwater Remediation
❑Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑Tracer
❑Other (explain under 7g)
4. Date well(s) abandoned:
ttlis
5a. Well location:
ThriVttr eZefrem Carpor447.7"
Facility/Owner Name
16'Wo 4rei )U. Lf1
Physical Address, City, and Zip
Scarl-kt"13 COwk-'11
County
Facility ID# (if applicable)
toc 2.E.S5
Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
S41111-NS N —11114015
CONSTRUCTION DETAILS OF WELL(S) 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#: "*" lar
6b. Total well depth:
2o
(ft.)
6c. Borehole diameter: 7-6(in.)
6d. Water level below ground surface: (ft.)
6e. Outer casing length (if known): (ft.)
6f. Inner casing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft.)
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
the same
of
(gal.)
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells Navin
well construction/depth, only 1 GW- 0 is needed. Indicate TOTAL.NUMBER
wells abandoned: q
7b. Approximate volume of water remaining in well(s):
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that appl
❑ Neat Cement Grout kl3entonite Chips or Pellets
❑ Sand Cement Grout 0 Dry Clay
0 Concrete Grout 0 Drill Cuttings
❑ Specialty Grout 0 Gravel
❑ Bentonite Slurry ❑ Other (explain under
7f. For each material selected above, provide amount of materials
650 fjraIwL1a betVivi jr---
7g)
used:
7g. Provide a brief description of the abandonment procedure:
600toies -Gild (AA grA".1,4ed bovii.14-c_
.
.f ,.
26'4 ib 5 • TO?
do.m
CAA/Lk ItitivkAlf�`, 1,,,i
"�
ktaimtirvit) brpsiLAt 0
S. Certification:
Signature of ntractor or Well Owner
B/:'gning this form, I hereby cert( that the well(s) was
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Constru
and that a copy of this record has been provided to the well owner.
Date
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 nece ' sary.
(were)
Zino
abandoned in
tion Standards
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of corn letion of well
abandonment to the following:
Division of Water Resources, Information Processing 1IJnit,
1617 Mail Service Center, Raleigh, NC 27699-1611
10b. For Infection Wells: In addition to sending the form to th address in l0a
above, also submit one copy of this form within 30 days of co letion of well
abandonment to the following:
Division of Water Resources, Underground Injection Contrill Program,
1636 Mail Service Center, Raleigh, NC 27699-163
10c. For Water Supply & Injection Wells: In addition to sendin
address(es) above, also submit one copy of this form within 30 day
of well abandonment to the county health department of the
abandoned.
the form to the
of completion
county where
Form GW-30
North Carolina Department of Environmental Quality - Division of Water Resources evised 2-22-2016

North Carolina Department of Environmental Quality —Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number Wi 060o21-o
1. Permit Information
4n4rek rb,t,te
Permittee
foie, fool torporeehael
Facility Name
16q00 teii Lam& NC 2835Z
Facility Address (include County)
5c,+14-J Co''t4ij
2. Injection Contractor nformation
I2-&h»c "Thcf.% C-LC
Fait. IA-,
Injection Contractor / Company Name
Street Address 200 Qc&c- Of.
Cit State
anD 61{; oi
Area code — Phone number
3. Well Information
Number of wells used for injection gel
Well IDs J#•
7:t613
Zip Code
Were any new wells installed during this injection
ev
7
Yes
El No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells LICI
Type of Well Installed (Check applic
❑ Bored El Drilled
❑ Hand -Augured El Other (specify)
e type):
Direct -Push
Please include a copy of the GW-1 form for each
well installed.
Were wells abandoned during this injection
eve
Yes DNo
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells ""I
ct
Please include a copy of the GW-30 for each well
abandoned
Injectant Information
C.-1,tEviA Giptirt4
Injectan4Qs) Type (can use separate additional s eets
if necessary
Concentration 25J
he
If the injectant is diluted please indicate the source
dilution fluid. INArOw.-fb
Total Volume Injected (gal) 1-1350
Volume Injected per well (gal) 60
Injection History
Injection date(s)
Injection number (e.g. 3 of 5)
Is this the last injection at this site?
EYes ENo
dal
a,d
I DO HEREBY CERTIFY THAT
INFORMATION ON THIS FORM IS CO
THE BEST OF MY KNOWLEDGE AND T
INJECTION WAS PERF e ' ED
STANDARDS LAID 0 • " IN T
SIG
OF INJECTION CONTRACTOR
PRINT NA E OF PERSON P RFORMING THE INJ
T.
L THE
CT TO
T THE
[THE
Z-I2c'zo
DAT
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
Fo
Re
UIC-IER
. 3-1-2016