WI0800491_More Information (Received)_20230502

UNITED STATES MARINE CORPS
MARINE CORPS INSTALLATIONS EAST -MARINE CORPS BASE
PSC BOX 20005
CAMP LEJEUNE NC 28542-0005
UIC Program
North Carolina Department of
Environmental Quality
Division of Water Resources
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
To Whom It May Concern:
5090.10.1
G-F/BEMD
APR 2 6 2023
�ECEN�
MAY 02NZ3
grDeaOoffice
Marine Corps Base Camp Lejeune respectfully submits the
enclosed Notice of Intent (NOI) for approval to conduct a small-
scale injection operation at petroleum remediation site Building
820 (North Carolina Department of Environmental Quality
Incidents #23135 and 43105). The proposed injection event is
being completed to attempt to reduce dissolved phase 2L
groundwater quality exceedances at the site. No new wells will
be installed. One event is proposed and will be conducted upon
approval of the NOI. The proposed injection event will be
followed up with an electronically submitted Injection Event
Record.
If you have any questions or comments, please contact Mr.
David Towler, Environmental Quality Branch, Environmental
Management Division, G-F, at [phone]. Please reference
document number 27540 in your reply.
cere1y(
RWERT A. LOG ER, P . E .
Directo , vironmental Management
By direction of
the Commanding General
Enclosure: 1. Notification of Intent (NOI) to Construct or
Operate Injection Wells - Building 820
Copy to:
File (ODI #27540)

NC Department of Environmental Quality — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an individualpermit when constructed in accordance
with the rules of 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to infection)
AQUIFER TEST WELLS (15A NCAC 02C .02201
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
INSITU REMEDIATION (15A NCAC 02C .0225] or TRACER WELLS (15A NCAC 02C .0229 :
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells is located within an area that does not exceed five percent of the land surface
above the known extent of groundwater contamination. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
5) In -Situ Thermal Wells (IST] — Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: March 22 32023
PERMIT NO.
(to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
A.
B.
Permit No. WI Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
Air Injection Well .......................................
Complete sections B through F, J, M
(2)
Aquifer Test Well .......................................
Complete sections B through F, J, M
(3)
Passive Injection System ...............................
Complete sections B through F, H-M
(4) X
Small -Scale Injection Operation ......................
Complete sections B through M
(5)
Pilot Test .................................................
Complete sections B through M
(6)
Tracer Injection Well ...................................
Complete sections B through M
(7)
In -Situ Thermal (IST) Well ...........................
Complete sections B through M
STATUS OF WELL OWNER: Federal Government
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 1
Enclosure (1)

C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): MCB Camp Lei eune, Environmental Management Division. Attn : Robert Lowder
Mailing Address: 12 Post Lane
City: _MCB Camp Leieune State: NC_ Zip Code: 28542 County: Onslow
Day Tele No.: _ [phone] Cell No.:
EMAIL Address: robert.a.lowder(a,usmc.mil Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Same as above ___ .
Company Name
Mailing Address: —
City: T_ __ State: __ Zip Code:_—___ .,County:__
Day Tele No.: _ Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Mike Stoehr. PG, Assistant Pro iect Manager
Company Name Rhea Engineers & Consultants. Inc.
Mailing Address: 333 Rouser Road, Suite 301
City: _Moon Township State: PA_ Zip Code: 15108_ County: -Allegheny
Day Tele No.: _724-443-4111 Cell No.:_412-335-8196
EMAIL Address:, mike. stoehr(a)rhea.us Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: —Building 820 Incident #23135 and 43105
City: MCB Camp Leoeune County: Onslow Zip Code: 28542
(2) Geographic Coordinates: Latitude": 3A2 42' _0.04" or 34 0.700011
Longitude": 771 21' 15.98" or 77 0.354439
Reference Datum: —Accuracy:
Method of Collection: GPS
"FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: _-23,000 square feet
Land surface area of inj. well network:—5,000..square feet ` 10,000 W for small-scale injections)
Percent of contaminant plume area to be treated: 100%_(must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 2

Total Amt. to be injected (gal/event): 1.400 pal
No. of separate injection events:1 Total Amt. to be injected (gal): 1,400 gal
Source of Water (if applicable):_ Public water
L. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
Groundwater sampling at wells MW02, MW09D. MW12, MW26, MW38, MW45, and MW47 for volatile
organic compounds (VOCs) using United States Environmental Protection Agency (USEPA) Method 6200 is
scheduled to occur in July 2023 to track performance.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: `I hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aw re that there are significant penalties, including the possibility of fines and imprisonment,
for submitting fr se * ormation. I agree to construct, operate, maintain, repair, and if applicable, abandon the
v 'etyt pn well nd all elated appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
Robert A. Lowder. P.E.: Director. Environmental Manaeement Divisi
of Appycant Print or Type Full Name and Title
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(I5A NCAC 02C .0200�. "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1(one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 4

H.
I.
J.
K.
INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
Wells MW02. MW09D. MW12, MW26, MW38. MW45, and MW47 will receive a total of 700 pounds of CBN
mixed with 1,400 gal of water and 70 pal of PetroBac. Each individual well will receive 100 pounds of CBN, 10
gal of PetroBac, and approximately 200 pal of water. The injection rate is no more than 3 gallons per minute.
WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 7 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): MW02: —7 ft BLS; MW09D: —94 ft BLS; MW12: —11 ft BLS; MW26:
—10 ft BLS; MW38: —7 ft BLS; MW45: —7 ft BLS; and MW47: —7 ft BLS.
(3) For Proposed wells or Existing wells not having GW-1s, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
INJECTION SUMMARY
NOTE: Only iniectants aunroved by the epidemiolory section or the NC Division o1'Public Health, Department
of Health and Human Services can be injected. Approved iniectants can be found online at
hUp:Hdeg.ne.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection%ground-water-approved-iniectants. All other substances must be reviewed bi the DHHSprior to use.
Contact the UIC Pro am for more info i ' ou wish to get a roval for a different additive. However, please
note it may take 3 months or lonjter. If no iniectants are to be used use N/A.
Injectant: CBN Total Amt. to be injected (gal)/event: 700 pounds
Injectant PetroBac
Injectant:
Inj ectant:
Injectant:
Total Amt. to be injected (gal)/event: 70 pal
Total Amt. to be injected (gal)/event:
Total Amt. to be injected (gal)/event:
Total Amt. to be injected (gal)/event:
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

Injection Zone Maps

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Well Construction Data

r DAVENPORT I WELL INSTALLATION DIAGRAM
RHEAA,
WELL IDENTIFICATION: UST820-MW02
PROJECT: Building 820 DATE: 8/27/1991
DRILLER:
DRILLING METHOD:
NORTHING COORDINATE: 3842285 EASTING COORDINATE: 284394.62
FIELD REPRESENTATIVE: I DEPTH TO WATER:
(1) Well Vault
(2) Grout
(3) Seal
(4) Well Casing
(5) Screen
(6) Screen Filter
- i . Installation 1 .
Top of Casing Elevation: 32.26
Ground Elevation: 30.48
(1) Well Vault
Dimensions
2 Grout
e Cement
Placement
e of Seal Bentonite
41 Well Casin
Schedule 40
Material PVC
Diameter 2 inch
(5) Screen
Schedule 40
ryy2e PVC
Slot Size 0.01 inch
6 Screen Filter
Tvue I Sand
Development Method:
Comments: Type II Well

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone[phone]
WELL CONSTRUCTION RECORD
�.1 W-9D
DRILLING CONTRACTOR: MANN DRILLING CO.
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO.
Lat Long. RO
Minor Basin
Basin Code
Header Ent GW-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 2196 PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: CAMP LEJFUNF M B County: ONSLOW
BERKLEY MANOR BLDG 820
(Road Community, or Subdivision and Lot No.) DEPTH DRILLING LOG
2.OWNER: COMMANDING GENERAL From To Formation Description
ADDRESS AC/S, EMD, PSC BOX 20004
(.Street or Route N o. )
CAMP LEJEUNE NC 28542-0004
City or Town State Zip Code
J. DATE DRILLED 9/20/01 USE OF WELL: MONITOR_
4 TOTAL DEPTH 98,
5. CUTTINGS COLLECTED YES N
6. DOES WELL REPLACE EXISTING WELL? YES Q NO®
7. STATIC WATER LEVEL Below Top of Casing: 22 FT
(Use "+" it Above Top o asing
8. TOP OF CASING IS -.5 FT. Above Land Surface*
*Casing Terminated at/or below land surface is Illegal unless a variance Is issued
In accordance with 15A NCAC 2C .Oils
9. YIELD (gpm) METHOD OF TEST
10. WATER ZONES (depth):
1 1. CHLORINATION:
12. CASING:
Type A Mount if additional space rs nee ed use back of form
Wall Thickness
Depth Diameter or Weight(Ft. Material
From 1.5 To 80 Ft 4 SCD 40 PVC
From I_ To 28 F
From To Ft
13. GROUT:
Depth Material Method
From 84.5 To_$2 Ft. BENTONITE HAND
From 3 To 84.5 Ft. GROUT TREMIE
From-9-- To-7- Ft:
14. SCREEN:
Depth Diameter Slot Size Material
From 93 To 98 Ft 2 in. .01 in PVC
From To — Ft. _ in. in.
From To— Ft— in. in.
15. SAND/GRAVEL PACK:
Depth Size
From 89 To 98 Ft. #2
From To Ft
16. REMARKS:
Material
SAND
LOCATION SKETCH
(Show direction and distance from at east two State
Roads, or other map reference points)
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
C�
SIGNATU' ON CTOR OR AGENT DATE
Submit ginal to Division of Environmental Management and copy to well owner.
GWA REV. 9/91

North Carolina - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone]
WELL CONSTRUCTION RECORD
FOR OFRCE USE ONLY'
OUAO. NO: SERIAL NM
Let Long.. R?'
Mirror Basin
Basin Code
DRILLING CONTRACTOR: Law Engineering I Headw Ent. GW-1 Ent..
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 332 PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) M4-12
Nearest Town: Jacksonville County:
Camp Le'eune North Carolina
(Road, Community, or Subdivision and Lot No.)
2. OWNER, U.S. Marine Corns -
ADDRESS
(Street or Route No.)
Camp Lejeune North Carolina
City or Town State Zip Code
3. DATE DRILLED 3/18/94 USE OF WELL Monitoring__
4. TOTAL DEPTH 24'
5. CUTTINGS COLLECTED YES XCI NOC
6. DOES WELL REPLACE EXISTING WELL? YES Cj NOff--1
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated at/or below land surface is Illegal unless a variance is Issued
in accordance with 15A NCAC 2C .0118
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): 13.0 - 24.3
DEPTH
From To
See Appendix A
DRILLING LOG
Formabon Description
11. CHLORINATION: Type n /a - — Amount —n1a� If additional space is needed use back of form
12. CASING:
Wall Thickness LOCATION SKETCH
Depth Diameter or Weight/Ft. Material (Show direction and distance from at least two State
From 0 To 9 Ft. 2" Sch 40 PVC Roads, or other map reference points)
From To Ft.
From To Ft. See Drawing 2.1
13. GROUT:
Depth Material Method
From 0 To 5 Ft. BE oni fP-Portl anrt T =,ie
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From 8.5 To 23.5 Ft 2 in. 0--QJ-O_ in. PVC: -
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 6.5 To 5 Ft. f/1 TnrppdQ Sand
From To Ft.
16. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND. THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
f &i( - 9
SKWATI.hiE OF OON*ACTOR & AGENT DATE
rou � enr nn� .-.i�__�r... n=s.:�� r e -- - ' ��....•�....r..rin.... r.....Yn�rrr.

North Carolina - Department of Environment. Health. and Natural Resources FOR OFFICE USE ONLY
Division of Environmental Management - Groundwater Section OUAD NO: SERIALNO:
P.O. Box 29535 - Raleigh, N.C. 27626-0535
Phone [phone] Lat Long R�
Motor Basin
WELL CONSTRUCTION RECORD Basin Code
DRILLING CONTRACTOR: Law Engineering Header Ent t3Uf-1 Ent.
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER: 332 PERMIT NUMBER:
1. WELL LOCATION: (Show sketch of the location below) MW-26
Nearest Town: Jacksonville County: OBSlOW
Camp Lejeune North Carolina
(Road. Community, or Subdivision and Lot No.)
2. OWNER U.S. Marine Corte
ADDRESS
(Street or Route No.)
Camp Lejeune North Carolina
City or Town State Zip Code
3. DATE DRILLED 4 4194 USE OF WELL Monitoring
4. TOTAL DEPTH 23.5
5. CUTTINGS COLLECTED YES XD NO❑
6. DOES WELL REPLACE EXISTING WELL? YES r' NOR-1
7. STATIC WATER LEVEL Below Top of Casing: FT.
(Use -+- if Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surface'
Casing Terminated attar below land surface is Illegal unless a variance is issued
In accordance with 15A NCAC 2C .0118
9. YIELD (gpm): METHOD OF TEST
10. WATER ZONES (depth): I '• --
11. CHLORINATION: Type
12. CASING:
DEPTH
From TO
See Appendix A
_ DRILLING LOG
Formation Deaaipdon
Amount -- If additional space is needed use back of form
Wall Thickness
Depth
Diameter or WeighuFt. Material
From — 0
To 8.0 Ft.
2" S i 40 PVC
From
To Ft.
From
To Ft.
—
13. GROUT:
Depth
Material Method
From 0 To 3-5 Ft.
fl ntnn-I tP—PnrtjanriTTetllie
From
- To R.
14. SCREEN:
Depth Diameter Slot Size Material
From 8.0 To 23.0 Ft _2— in. 0-.OlO in. PVC.
From To Ft. in. in.
From To Ft. in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 6.0 To ,24_0 Ft. # 1 Tf)rppdn Sant From To Ft.
16. REMARKS:
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
See Drawing 2.1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SXMTURE & CCNrP. TOR ORfoENT DATE
^Idt 4 or%# A A%4 ! . i_.L -_� —A - f V. 'rL- w/ W-A- r W-1 69-- .. -- �w,i Mwv M W�a AtYrI

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
D.T. Chalmers, Jr.
Well Contractor Name
4146A
NC Well Contractor Certification Number
CATLIN Engineers and Scientists
Company Name
2. Well Construction Permit #: N/A
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
❑ Agricultural ❑ Municipal/Public
❑ Geothermal (Heating/Cooling Supply) ❑ Residential Water Supply (single)
❑ Industrial/Commercial ❑ Residential Water Supply (shared)
❑ Irrigation
Non -Water Supply Well:
N Monitoring ❑ Recovery
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (1Ieating/Coolin
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under #21 1
4. Date Well(s) Completed: 03/01/18 Well ID#: UST8204M38
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
SITE 820. JACKSONVILLE. NC
Physical Address, City, and Zip
ONSLOW
County Parcel Identification No. (PIN)
i For Internal Use ONLY:
14. WATER
ZONES
FROM
I DESCRIPTION
ft
ft
ft.
ft
15. ENNER CASING OR TUBING eeeheemal ctosed-
FROM
TO DIAMETER THICKNESS
MATERIAL
0 ft.
5 ft 4 tn. Sch. 40
PVC
16.OUTER CASING for multi
-cased wed ORLINER
if ticabk
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft
io
ft
ft
in
17. SCREEN
FROM I
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 ft
15 ft
4 in.
Slot .010
Sch. 40
PVC
ft
ft
..
18. GROUT
FROM
TO
MATERIAL.
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
1 ft
3ft
Bent. Pellets
Surface Pour
ft
ft
19. SAND/GRAVEL
PACK
agip1ka61
FROM
TO
MATERIAL EMPLACEMENT METHOD
3 rt.
15 ft
Torpedo Sand
ft
ft.
20. DRILLING
LOG attach
odditiooat sbeetr if necenr
FROM
TO
I ❑FSCRfPTrQN(c434ur, ha.d�5. soiVrockryw. gr4n size. etc.
ft
ft.
ft G
ft. G G
it
It.
ft
ft
ft
ft.
ft.
21. REMARKS
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Certification: /n
(if well field, one lat/long is sufficient) d;
l
N W r- 9/28/2018
Signature of Certified Well Contractor ' Date
6. Is (are) the well(s): ®Permanent or OTemporary 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
7. Is this a repair to an existing well: O Yes or ®No this record has been provided to the well owner.
If this is a repair, fill nut known well construction information and explain the nature of
the repair under #21 remarks section or on the back of this farm. 23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8. Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non -water supply wells OAT Ywith the same construction, you SUBMITTAL INSTRUCTIONS
can submit one form
9. Total well depth below land surface: 15 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths in different (example- 3@200' and 2@100) construction to the following:
10. Static water level below top of casing:
If water level is above casing, use "+"
11. Borehole diameter: 10
(ft.) 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
12. Well construction method: HSA completion of well construction to the following:
(i.e. auger, rotary, cable, directpush, etc)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water SvDDIy & Infection Wells:
Also submit one copy of this form within 30 days of completion of well
13b. Disinfection type: Amount: construction to the county health department of the county where constructed.
(in.)
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
D.T. Chalmers, Jr.
Well Contractor Name
4146A
NC Well Contractor Certification Number
CATLIN Engineers and Scientists
Company Name
2. Well Construction Permit #: N/A
List all applicable well permits (i.e. County, State, Variance, Injection, etc)
3. Well Use (check well use):
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Non -Water Supply Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heatincr/Cooline Return:
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under #21
4. Date Well(s) Completed: 05/08/18 Well ID#: UST820-MW45
5a. Well Location:
Facility/Owner Name Facility ID# (if applicable)
SITE 820 JACKSONVILLE. NC
Physical Address, City, and Zip
ONSLOW
County
Parcel Identification No. (PIN)
For internal Use ONLY:
14. WATER
ZONES
FROM
TO
DESCRIPTION
ft.
ft
&I
ft
15. INNER CASING OR TUBING eothermal closed
l
FROM
TO ➢IAN=
THICKNESS MATERIAL
O ft
5 ft 2 in
Sch. 40 PVC
16.OUTER CASING for multi
-eased weUsl OR LINER
Of soulicablel
FROM
I TO
DIAMETER
THICKNESS
MATERIAL
fc
ft
tn.
ft
ft
in
17. SCREEN '
FROM
TO DIAMETER
I SLOT SIZE
I THICKNESS
I MATERIAL
5 ft
15 fc 2 in.
Slot .01Tjh.
40
PVC
ft
ft in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft
ft
1 ft
3 ft
Bent. Pellets
Surface Pour
ft
ft.
19. SAND/GRAVEL
PACKM
oin0cablel
FROM
TO
MATERIAL EMPLACEMENTMETHOD
3 ft
15 &
Torpedo Sand
ft
ft
20. DRfi.JXNG
t,OC attach additional
sheets ifnecesury
FROM
TO
DESCRIPTION color hardness. soillrockDo, main mm etc
ft
ft
%
ft
%
ft�
��
ft
ft
ft
ft
ft
ft
21. REMARKS
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Certification:
(if well field, one lat/long is sufficient) �r
Signature of Certified Well Contractor f
77.3543229285 N 34.69962653
6. Is (are) the wll(s): ®Permanent or OTemporary
w
7. Is this a repair to an existing well: OYes or ®No
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. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you
can submit one form.
9. Total well depth below land surface: 15 (ft.)
Far multiple wells list all depths in different (example- 3@200' and 2@1009
10. Static water level below top of casing: 10.06 (ft.)
Ifwater level is above casing, use "+"
11. Borehole diameter: 8 (in.)
q/2s/2nl R
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 site details or well
construction details. You may also attach additional pages if necessary.
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 24a above, also submit a copy of this form within 30 days of
12. Well construction method: HSA completion of well construction to the following:
(i.e. auger, rotary, cable, directpush, etc.)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water St liph & Injection Wells:
Also submit one copy of this form within 30 days of completion of well
13b. Disinfection type: Amount: construction to the county health department of the county where constructed.
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
D.T. Chalmers, Jr. _
Well Contractor Name
4146A
NC Well Contractor Certification Number
CATLIN Engineers and Scientists
Company Name
2. Well Construction Permit #: N/A
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)
❑ Industrial/Commercial
00 Monitoring
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heatim/Coolie_ Return•
❑ Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Recovery
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑ Other (explain under 9211
4. Date Well(s) Completed: 06/28/18 Well ID#: USTS204Y W47
5a. Well Location:
Facility/Owner Name
Facility ID# (if applicable)
SITE 820, JACKSONVILLE. NC
Physical Address, City, and Zip
ONSLOW
County Parcel Identification No. (PIN)
Internal Use ONLY:
14. WATER
ZONES
FROM
TO
DESCRIPTION
ft.
ft
ft.
ft.
15. E14MR CASING OR TUBING
eothermsl cbsed-loo
FROM TO
DIAMETER
THICKNESS
MATERIAL
0 ft. 1 5 It.1
2 in
Sch. 40
PVC
16.OUTER CASING for mdh
eased Welty OR LINER
ifs Icabk
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft
ft.
in.
17. SCREEN
FROM
TO I
DIAMETER
SLOT SIZE THICKNESS
MATERIAL
5 ft
15 ft
2 ln.
Slot .010 Sch. 40
PVC
fLi
ft
1& GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft
ft.
1 ft
3 ft
Bent. Pellets
Surface Pour
M
ft.
19. SAND/GRAVEL.
PACK
dzpphmblej
FROM
TO
MATERIAL
EMPLACEMENT METHOD
3 ft
15 ft
Torpedo Sand
ft
ft
20. ➢R1I.1.IiYG
1.OG Wtwli
addition sl sheets If "ccwary
FROM
TO
DESCRE TION <alar, hardness wtvr t L3pc. F7wn Soo ctc
ft.
ft.
ft G
ft. Alp
ft.ft
ft.
%
ft.
ft.
21. REMARKS
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Certification•
(if well field, one lat/long is sufficient)
77.3543229285
N 34.69962653 w t-,[
Signature of Certified Well Contractor
6. Is (are) the well(s): ®Permanent or OTemporary
7. Is this a repair to an existingwell: OYes or ®No
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. Number of wells constructed: 1
For multiple injection or non -water supply wells ONLY with the same construction, you
can submit one form.
9. Total well depth below land surface: 15
For multiple wells list all depths in different (example- 3@200' and 2@100)
10. Static water level below top of casing:
If water level is above casing, use "+"
7.25
rriY 1 9/28/2018
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with
I5A 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. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: 8 (in.) 24b. For Iniection 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
12. Well construction method: HSA completion of well construction to the following:
(i.e. auger, rotary, cable, directpush, etc) Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Sy pply & Iniection Wells:
Also submit one copy of this form within 30 days of completion of well
13b. Disinfection type: Amount: construction to the county health department of the county where constructed.
Adapted from Form GW-1 North Carolina Department of Environment and Natural Resources - Division of Water Resources Revised 2-22-2016