WI0700473_Staff Report_20230829

DocuSign Envelope ID: BC2970D7-E1E1-4FB8-B2B1-1DECA3BDA6E8
North Carolina Department of Environmental Quality - Division of Water Resources
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Permit No. WI0700473
Date: _8/29/23_ County: _Camden _
To: _Blake Butcher_ Perm ittee/A p plic ant: Michael Colson & Denise Dickinson
Central Office Reviewer Blake Butcher Facility Name: _Colson & Dickinson Return Well_
L GENERAL INFORMATION
1. This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification
a. Date of Inspection: 8/28/23
b. Person contacted and contact information: Michael Colson (757-717-1780)
c. Site visit conducted by: R. Sipe & B. Sherman
d. Inspection Report Printed from BIMS attached: ® Yes ❑ No.
e. Physical Address of Site including zip code: No change since last inspection
f. Driving Directions if rural site and/or no physical address: No change since last inspection
g. Latitude: Longitude: NA No change since last inspection
Source of Lat/Long & Accuracy (i.e., Google Earth, GPS, etc.):
IL DESCRIPTION OF INJECTION WELL AND FACILITY
1. Type of injection system: -.
® Geothermal Heating/Cooling Water Return
❑ In situ Groundwater Remediation
❑ Non -Discharge Groundwater Remediation
❑ Other (Specify:
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system only:
Were samples collected from Influent/Effluent sampling ports? ® Yes ❑ No.
Provide well construction information from well tag: See attached GW-1
b. Does existing or proposed system use same well for water source and injection? ❑ Yes ® No
If No, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section IV of this Staff Report. Note: Pre-existing_ supply well's total depth from well tag is
58 feet.
3. Are there any potential pollution sources that may affect injection? ❑ Yes ® No
What is/are the pollution source(s)?
What is the distance of the injection well(s) from the pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary?
5. Quality of drainage at site: ® Good ❑ Adequate ❑ Poor
6. Flooding potential of site: ® Low ❑ Moderate ❑ High
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7. For Groundwater Remediation Injection Systems only, is the proposed and/or existing groundwater monitoring
program (number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ❑ No.
If No, attach map of existing monitoring well network if applicable and recommend any changes to the
groundwater -monitoring program.
8. Does the map included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ❑ Yes ❑ No. If No, or no map, please attach a sketch of the site, Show property boundaries,
buildings, wells, potential pollution sources, roads, approximate scale, and north arrow. (See attached Map)
9. For Non -Discharge Groundwater Remediation systems only (i.e., permits with WQ prefix):
a. Are the treatment facilities adequate for the type of waste and disposal system? ❑ Yes ❑ No ❑ NIA.
If No, please explain:
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist and/or Professional Engineer? ❑ Yes ❑ No ❑ NIA. If no, please explain:
III. EVAL UATIONAND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If Yes, explain.
2. List any items that you would like WQROS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item Reason
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
4. Recommendation
❑ Deny. If Deny, please state reasons:
❑ Hold pending receipt and review of additional information by Regional Office
❑ Issue upon receipt of needed additional information
® Issue
5. Signature of Report Preparer(s): DV41 R"Oty 54t
Signature of WQROS Regional Supervisor: l;aGvia Tea."
Date: 8/29/2023
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IV ADDITIONAL REGIONAL STAFF REVIEW COMMENTS/ATTACHMENTS (Optional II Needed
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WELL CONSTRUCTION RECORD
tins form can be used for single or nwillple wells
1. Well Contractor Information:
Woll Contractor Name
a 55,E - a
NC Well Contractor Certification Number
W F LL `5 -PU Y ke
Company Name t / ,
2. Well Construction Permit #; V� /0 -7 all 7/73
psi all applicable irellpernrus f-e. Caunly, State, Variance, Infealon, etc.)
3. Well Use (check well use):
Water Supply Well:
OAgricultural ❑Municipal/Public
❑Greothermal (HeatinglCooling Supply) ❑Residential Water Supply (single)
❑IndustrialiCommercial f]Residential Water Supply (shared)
Supply Well:
❑Aquifer Recharge 0Gmundtivatcr Remediation
❑Aquifer Storage and Recovery ❑Salinity Barrier
DAquifer Test ❑Stormwater Drainage
LlExperiinonlal Technology ❑Subsidence Control
OGeothennal (Closed loop) ❑Tracer
00ther (explain under #21
4. Date Well(s) Completed: , W ell ID# N 19
5a. Well L&ation:
1JV_1_Kr Cot SbAI
Facility/Owner Name Facility 1134 (ifapplicable)
1-2±?-DO 61 wOtib h&—CAtn,iLN, N•.C. a7Ro-�,I
Physical Address, City, and Zip
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, out latllwg is suficieut)
2 N- -?-6 $Si_ 9 3 W
6. Is (are) the well(s): Kermanent or ❑Temporary
7. Is this a repair to an existing well: *cs or ❑No
If ibis a a repair, fill out known well comirrrctian fnfarmalron and explain the narnre afthe
relmir mnirr 42i rcrrmrna teciion or ou dw back of fhlsform.
$. Number of wells constructed: t
Far maniple inj"tion or non-waicr supply irells ONI Y with /lie sable consfrvction, ywu can
suborn onefarm,
9. Total well depth below land surface: _ - _90 F-r
For nnrhiple wells list aft depiks if therein (example- JW 00' and 2Q100')
For interest Use ONLY:
22. Certification:
�+
Sig ra ofCeni$ed Well Contrauo, Date I
By signing this form, 1 hereby terrify that the well(s) was (wen) constructed in occordance
with 15A NCAC 61C .0100 or 15A NCAC 02C.0260 Well Consimetion Srartdrrrdv acid ihar a
copy of this record hav 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
constntction details. You may atso attach additional pages if necessary.
SUBMIITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
W. Static water level below top ofeasing: to rT- (ft.) Division of Water Resources, Information Processing Unit,
!f water level is above caving, use "+ " 1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: (in.) 24b. FoL 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
12. Well construction method' hl iJ-_- p:w /; _ construction to the following:
Ox. Sager, rotary, cable; direct Pt &14 eta)
Division of Water Resources, Underground Injection Content Program,
FOR WATER SUPPLY WELLS ONLY: _ 1636 Mail Service Center, Raleigh, NC 27699-1636
ear
13a. Yield ($pm)r'jD Method of test: I
24c. For Water Supply & Injection Wells:
�'Vti/l� •
ST 1C4�N rr Also submit one copy of this fonn within 30 days ofwnipletionof
13b. Disinfection type: Amount: .t0 6Z r well construction to the county health department of the county where
constructed.
Form GNW1 Norib Carolina Dapartmont ofEnviionment and Natural Resources - Division of Water Rosotmoea Revised August 2013