WI0100677_Injection Event Record_20230502

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0100677
1. Permit Information
NCDEQ/DW 4/UST/Trust Fund Branch
Permittee
Foothills Service Center
Facility Name
312 East Union St., Morganton, Burke County
Facility Address (include County)
2. Injection Contractor Information
WithersRavenel during MMPE by Advanced
Environmental Services
Injection Contractor / Company Name
Street Address-1 15 MacKenan Drive
Cary NC 27511
City State Zip Code
L919_ _469-3340_
Area code — Phone number
3. Well Information
Number of wells used for injection 3
Well IDs AS-1, AS-2, AS-3
Were any new wells installed during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
3
Type of Well Installed (Check applicable type):
❑ Bored ® Drilled ❑ 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
Please include a copy of the GW-30 for each well
abandoned.
4. Inj ectant Information
Air
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)
Volume Injected per well (gal)
5. Injection History
Injection date(s)3/6/2023 — 3/17/2023
Injection number (e.g. 3 of 5) 1
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.
4/7/2023
S ' RACTOR DATE
P RMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Numbcr
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)
❑ hrdustrial/Commercial
❑ hTigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cool
4. Date Well(s) Completed:
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100,000 GPD
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 F
02/27/23 WellID# AS-1
5a. Well Location:
FOOTHILLS SERVICE CENTER
Facility/Owner Name Facility ID# (if applicable)
312 EAST UNION STREET MORGANTON 28655
Physical Address, City, and Zip
BURKE
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 44' 52.16" N 810 41' 07.47" W
6. Is(are) the well(s): [EPermanent 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 farm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
14. WATER ZONES
FROM
TO
DESCRIPTION
rt.
rt.
rt.
rt.
15. OUTER CASING for
-cased Its) ORLINER f alicabletAMETEDI
FROM
TO
R
THICKNEi
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING eother al closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 tt•
35.0 tt•
2.0 in.
SCH 40
PVC
rt
rt
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
35.0 ft'
40.0 ft'
2.0 in.
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
30.0 ft.
PORTLANDBENTONFTE
SLURRY
rt.
rt.
rt.
rt.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
33.0 tt•
40.0 tt•
20-40
FINE SILICA SAND
rt.
rt.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 tt•
15.0 It'
BROWN/TAN SILTY CLAY
15.0 tt•
30.0 tt•
TAN SILT
30.0 tt'
40.0 ft'
TAN SILTY SAND
rt.
rt.
rt.
rt.
ft.
ft.
rt.
rt.
21. REMARKS
BENTONITE SEAL - 30.0 - 33.0 FEET
22. Certification:
"-"� 03/24/23
Signature of Certified Well Contractor Date
By signing this form, 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.
""rr"`' 24. SUBMITTAL INSTRUCTIONS
9. Total well depth below land surface: 40.0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10. Static water level below top of casing:
33.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
If water level is above casing, use
11. Borehole diameter: 8'0 (in.)
AUGER
12. Well construction method: (i.e. auger, rotary, cable, direct push, etc_.)
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Igiection Wells: Copy to DWR, Underground Injection Control (NC)
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
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
13a. Yield (gpm) Method of test: Permit Program, 1611 MSC, Raleigh, NC 27699-1611
13b. Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Numbcr
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)
❑ hrdustrial/Commercial
❑ hTigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cool
4. Date Well(s) Completed:
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100,000 GPD
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 F
02/27/23 WellID# AS-2
5a. Well Location:
FOOTHILLS SERVICE CENTER
Facility/Owner Name Facility ID# (if applicable)
312 EAST UNION STREET MORGANTON 28655
Physical Address, City, and Zip
BURKE
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 44' 52.16" N 810 41' 07.47" W
6. Is(are) the well(s): [EPermanent 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 farm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
14. WATER ZONES
FROM
TO
DESCRIPTION
rt.
rt.
rt.
rt.
15. OUTER CASING for
-cased Its) ORLINER f alicabletAMETEDI
FROM
TO
R
THICKNEi
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING eother al closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 tt•
35.0 tt•
2.0 in.
SCH 40
PVC
rt
rt
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
35.0 ft'
40.0 ft'
2.0 in.
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
30.0 ft.
PORTLANDBENTONFTE
SLURRY
rt.
rt.
rt.
rt.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
33.0 tt•
40.0 tt•
20-40
FINE SILICA SAND
rt.
rt.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 tt•
15.0 It'
BROWN/TAN SILTY CLAY
15.0 tt•
30.0 tt•
TAN SILT
30.0 tt'
40.0 ft'
TAN SILTY SAND
rt.
rt.
rt.
rt.
ft.
ft.
rt.
rt.
21. REMARKS
BENTONITE SEAL - 30.0 - 33.0 FEET
22. Certification:
"-"� 03/24/23
Signature of Certified Well Contractor Date
By signing this form, 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.
""rr"`' 24. SUBMITTAL INSTRUCTIONS
9. Total well depth below land surface: 40.0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10. Static water level below top of casing:
33.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
If water level is above casing, use
11. Borehole diameter: 8'0 (in.)
AUGER
12. Well construction method: (i.e. auger, rotary, cable, direct push, etc_.)
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Igiection Wells: Copy to DWR, Underground Injection Control (NC)
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
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
13a. Yield (gpm) Method of test: Permit Program, 1611 MSC, Raleigh, NC 27699-1611
13b. Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018

WELL CONSTRUCTION RECORD (GW-1)
For Internal Use Only:
1. Well Contractor Information:
JACOB MESSICK
Well Contractor Name
A - 4252
NC Well Contractor Certification Numbcr
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)
❑ hrdustrial/Commercial
❑ hTigation
Non -Water Supply Well:
El Aquifer Recharge
El Aquifer Storage and Recovery
El Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cool
4. Date Well(s) Completed:
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Wells > 100,000 GPD
El Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 F
02/28/23 WellID# AS-3
5a. Well Location:
FOOTHILLS SERVICE CENTER
Facility/Owner Name Facility ID# (if applicable)
312 EAST UNION STREET MORGANTON 28655
Physical Address, City, and Zip
BURKE
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
350 44' 52.16" N 810 41' 07.47" W
6. Is(are) the well(s): [EPermanent 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 farm.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
14. WATER ZONES
FROM
TO
DESCRIPTION
rt.
rt.
rt.
rt.
15. OUTER CASING for
-cased Its) ORLINER f alicabletAMETEDI
FROM
TO
R
THICKNEi
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING eother al closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 tt•
35.0 tt•
2.0 in.
SCH 40
PVC
rt
rt
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
35.0 ft'
40.0 ft'
2.0 in.
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
30.0 ft.
PORTLANDBENTONFTE
SLURRY
rt.
rt.
rt.
rt.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
33.0 tt•
40.0 tt•
20-40
FINE SILICA SAND
rt.
rt.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0.0 tt•
15.0 It'
BROWN/TAN SILTY CLAY
15.0 tt•
30.0 tt•
TAN SILT
30.0 tt'
40.0 ft'
TAN SILTY SAND
rt.
rt.
rt.
rt.
ft.
ft.
rt.
rt.
21. REMARKS
BENTONITE SEAL - 30.0 - 33.0 FEET
22. Certification:
"-"� 03/24/23
Signature of Certified Well Contractor Date
By signing this form, 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.
""rr"`' 24. SUBMITTAL INSTRUCTIONS
9. Total well depth below land surface: 40.0 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100) Submit this GW-1 within 30 days of well completion per the following:
10. Static water level below top of casing:
33.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
(ft.)
If water level is above casing, use
11. Borehole diameter: 8'0 (in.)
AUGER
12. Well construction method: (i.e. auger, rotary, cable, direct push, etc_.)
Information Processing Unit, 1617 MSC, Raleigh, NC 27699-1617
24b. For Igiection Wells: Copy to DWR, Underground Injection Control (NC)
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
FOR WATER SUPPLY WELLS ONLY: 24d. For Water Wells producing over 100,000 GPD: Copy to DWR, CCPCUA
13a. Yield (gpm) Method of test: Permit Program, 1611 MSC, Raleigh, NC 27699-1611
13b. Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 6-6-2018