WI0700518_Injection Event Record_20211105

FELL ABANDONMENT RECORD
For Internal Use ONLY:
Physical Address, City, and Zip
�i E?21r1�1��
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.654180 N
-77.362643 w
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#:
6b. Total well depth: I (ft-)
6c. Borehole diameter: / 4 (in.)
6d. Water level below ground surface: AppY OX. 10 ft. (ft)
6e. Outer casing length (if known): /1/ / A (ft.)
6f. Inner casing/tubing length (if known): `(ft-)
6g. Screen length (if known):
N/p
(ft.)
1. Well Contractor information:
11AID
Web Contractor Name (or well owner personally abandoning well on his/her progeny)
NC Well Conlraelor Certification Number
Company Name
0
2. Well Construction Permit#: Di I 0 7 00 5 (
List all applicable ur11 construction permits (Le. County, Sate, arrant. etc.) !f known
�• Well use (check web use):
Water Supply Web:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑lndustriaUCommerciat
❑ IrfiRation
Non -Water Supply Web:
❑Monitoring
Injection Web:
❑Aquifer Recharge
Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geotherrnal(Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date well(s) abandoned:
5a. Well location:
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
VaCTose zone soils
Groundwater Remediation
❑Salinity Barrier
❑Stomtwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under 7g)
lDJ 2 7 I /
E_ 1 pi' it fw41 Rci"
Facility/eater Name Facility ID/0 (if applicable)
WELL ABANDONMENT DETAILS
7a. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
well consttuctio&deplh, only 1 OW-30 is needed Indicate TOTAL NUMBER of
wells abandoned: 1 D I -
7b. Approximate volume of water remaining in well(s): ipL)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
i
7e. Sealing materials used (check all that apply):
19 Neat Cement Grout "El Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Concrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
❑ Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
ZelItoytI to Gf urHb.124
G`oo SuftoCO_
7g. Provide a brief description of the/abandonment procedure: t_
;2✓1+00; }
Cf V 1Nl CXao_ ckc c ) I ►l£M
to VI �(0 t.—to Su Ida C12
S. Certification:
2y00 N t('tttrtoflg1 Of►4,t Ga7%r10,I(e NC- F�-�-L�
Signature of Certified Web Contractor or Well Owner
Date
By signing this form, I hereby cert115) 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 Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Infection Wells: In addition to sending the form to the address in l0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form totheaddress(es) above, also submit one copy of this form within 30 days of completion
of web abandonment to the county health department of the. -coat where
abandoned
s
Form OW-30
North Carolina Department of Environmental Quality - Division of Water Resources
Revised 2-22-20.

WELL CONSTRUCTION RECORD (GW-11
1. Well Contractor Information:
12,CAw11n6 E C-kceCe_ :EL
Well Contractor Name
Ling -
NC Well Contractor Certification Number
oK Tc
Company Name I Q
2. Well Construction Permit it: w+ O.? O D S I
List all applicable well cons(rucrlon permits (i.e. UiC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Wen:
❑Agricu 11ural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Wells > 100,000 GPD
❑Recovery
For Internal Use Only:
14 WATER ZONES
FROM TO DESCRIPTION
ft
IS. OUTER CASING (far multi -eased wets) OR LINER Of suable))
DIAMETER Ttll('K.YFS9
In
ft
rt
FROM TO
ft rt.
16 INNER CASING OR TUBING (verbena d dosed -loop)
TTIICKNESS
FROM TO
It.
ft.
17 SCREEN
It.
ft.
DIAMETER
in
FROM TO DIAMETER SLOT stir
ft I ft
ft ft
18. GROUT
FROM
ft
TO MATERIAL
ft
MATERIAL
TNICKNLSS
MATERIAL
EMPIACEMENT METHOD & AMOUNT
ft
R.
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geother al (Closed Loop)
❑Geothermal (Heating/Cooling Return)
'JGroundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 111 121)2.)
Sa. Wen Location:
Er, pr1r BrU5 h Fttlu'17
Facibty/OwnerName Facility 113# (if applicable)
2 406 iv. Mein) Of ci) Dr' IN 6r ,0;d( lac
Well ID#
Physical Address, City, and Zip
Gi Q..,u1l\r ,w,
County
Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.654180 N-77.362643 w
6. Is(are) the well(-): ❑Permanent or sISITempontry
7. Is this a repair to an existing well: ❑Yes orTo
If this is a repair, Jill out known well construction bfornation and e...plait the nature of the
repair under #21 remarks section or on the back of this form
& For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: I 0
�7 !
9. Total well depth below land anrfaee: i 1 e 9 3 @ g (f1.)
For multiple wells list al! depths ifdi erenl (example- 3@200' and 2@!001
10. Static water level below top of casing: C)
If water !evens above casing use "+ "
11. Borehole diameter. y (m.)
12, Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
PI) •
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
ft
R
19. SANDIGRAVEL PACK (if applicable)
FROM
ft.
TO MATERIAL
ft
EMPLACEMENT METHOD
ft.
Ft.
20. DRILLING LOG (attach additional sheets if necessary)
DESCRIPTION (color, hardness. soli/rock type, grain du, etc.)
FROM
ft
TO
ft
ft
R.
ft.
ft
ft
ft.
ft
ft.
ft
ft.
ft
ft.
21. REMARKS
Not applicable.
22. Certification:
Si of Certified Well Contractor
111 5,21
Date
Bysignbrg this form, I hereby centfy that the well(s) was (were) constructed in accordance with
ISA NCAC 02C.0100 or 13A NCAC 02C .0200 Well Ccvts noc lo» Standards and that a copy
ofiMs recordhas 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 wen completion per the follow ing:
24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Injection Wens: Copy to DWR, Undergrotmd Injection Control (IUC)
Program, 1636 MSC, Raleigh, NC 27699-1636
24e. nr Water Supper and Open -Loop Geothermal Rehm Welts: Copy to the
county environmental health department of the county where installed
24d. For Water Wells aroduclni 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

North Carolina Department of Environmental Quality— Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI 0700 51 46
Permit Information
Newell Brands (contact: Kristin Jones)
Permittee
ei dal /'
Facility Name
via N 401;0 0/
Facility Address (include County)
2. Injection Contractor Information
Pa LA in& CIA(ee)exTec,
Injection Contractor / Coinpany Name
Street Address WC) Qof t
City State
Z75/.6
Zip Code
(91 j 678-0140
Area code — Phone number
3. Well Information
Number of wells used for injection lb 1
Well IDS 4///1
Were any new wells installed during this injection
event?
Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells /Uvrt.C_
Number of Injection Wells 10
Type of Well Installed (Check aliccable type):
❑ Bored 0 Drilled hd Direct -Push
❑ Hand -Augured 0 Other (specify)
Please include a copy of the GW-1 form for each
well installed
Were any wells abandoned during this injection
event?
IDYes ❑No
If yes, please provide the following information:
Number of Monitoring Wells 1W j A
Number of Injection Wells 101
Please include a copy of the GW-30 for each well
abandoned
4. In jectant Information
?MVO 5►yr✓l P2IMaui()Ard+-
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration l '5 1105 pe( 4Z) 541166 Wes(
If the injectant is diluted please indicate the source
dilution fluid. ?D-t-A taccfof
Total Volume Injected (gal) $ 4 00
Volume Injected per well (gal) $ q
5. Injection History
Injection date(s) io//$ J v - /0/ 2.6/
Injection number (e.g. 3 of 5) N/A
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
STA ARDS LAID OUT IN THE PERMIT.
SIGNACTi1RE QF TION CONTRACTOR
ZwliAL, C Claf iI
PRINT NAME_OF PERSON PERFORMING THE INIFCTION
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