WI0501065_Injection Event Record_20231115

RECEIVED
North Carolina Department of Environmental Quality — Division of.Water Resouruck 2 2023
INJECTION EVENT RECORD (IER)
Permit Number Wl0501065
1. Permit Information
Mid -Atlantic Associates
Permittee
Party Beverage
Facility Name
5200 Western Blvd. Raleigh, NC 27606
Facility Address (include County)
2. Injection Contractor Information
Blair Mitchell/ Redox Tech
Injection Contractor / Company Name
StreetAddress200 Quade Dr
Cary NC 27513
City State Zip Code
919 678-0140
Area code - Phone number
3. Well Information
Number of wells used for injection 7
Well IDs IP-01 through IP-07
Were any new wells installed during this injection
event?
X Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 7
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled A-1 Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed.
NC DEQ/DWfi
Central Office
Were any wells abandoned during this injection
event?
0 Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 7
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
OBC (Oxygen Biochem)
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 1,020 lbs. OBC in 525 gallons H2O
If the injectant is diluted please indicate the source
dilution fluid. Hydrant water
Total Volume Injected (gal) 3,675 gallons
Volume Injected per well (gal) 525 gallons
5. Injection History
Injection date(s) 11/13/23 - 11 /15/23
Injection number (e.g. 3 of 5).
Is this the last injection at this site?
❑ Yes 0 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
DARDS LAID OUT IN THE PERMIT.
0/)A 1%W5_;W 10/17/23
SIGNATURE OF INJECTION CONTRACTOR DATE
Blair Mitchell
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

RECENED
WELL ABANDONMENT RECORD
1. Well Contractor Information:
Blair Mitchell
Well Contractor Name (or well owner personally abandoning well on his/her property)
4419-C
NC Well Contractor Certification Number
Redox Tech, LLC
Company Name
2. Well Construction Permit #: W 10501065
List all applicable well construction permits (i.e. UIC, Coun)), State, Variance, etc.) ifknown
3. Well use (check well use):
❑Agricultural
❑Municipal/Public
❑Geothermal (Heating/Cooling Supply)
❑Residential Water Supply (single)
❑Industrial/Commercial
❑Residential Water Supply (shared)
❑Irritation
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
NGroundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
❑Geothermal (Heating/Cooling Return)
El Other (explain under 7g)
4. Date well(s) abandoned:
5a. Well location:
Party Beverage
11 /13/23 - 11 /15/23
Facility/Owner Name Facility fD# (if applicable)
5200 Western Blvd. Raleigh, NC 27606
Physical Address, City, and Zip
Wake 0784511432
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field, one latAong is sufficient)
35.786729275476546 N-78.71309576066118 W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(s) ifavailable. For multiple injection or non -water supply wells
ONLY with the same construction abandonment, you can submit one form.
6a.WeuID#: IP-01 through IP-07
6b. Total well depth: 28
6e. Borehole diameter: 1.5
6d. Water level below ground surface: —19
For Internal Use ONLY:
NOV 2 7 2023
WELL ABANDONMENT DETAILS FF
7a. For Geoprobe/DPT or Closed -Loop Geotherm�etts"tl ame
well construction/depth, only 1 GW-30 is needed. In ER of
wells abandoned: r
7b. Approximate volume of water remaining in well(s): (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cement Grout
A Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
140 Ibs- bentonite pellets
7g. Provide a brief description of the abandonment procedure:
Bentonite pellets to surface, packed.
8. Certification:
-u1&w�w11 /17/23
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify 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 Iniection Wells: In addition to sending the form to the address in 10a
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 Mail Service Center, Raleigh, NC 27699-1636
6e. Outer casing length (if known): (ft-) 10c. For Water Supply & Iniection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
6f. Inner casing/tubing length (if known): (ft.) abandoned.
6g. Screen length (if known): (ft-)
Form GW-30 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
Blair Mitchell
Well Contractor Name
4419-C
NC Well Contractor Certification Number
Redox Tech, LLC
Company Name
2. Well Construction Permit #: W 10501065
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ AgricultuIal
❑Geothermal (Heating/Cooling Supply)
❑ hidustrial/Commercial
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring ❑Recovery
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling
RGroundwater Remediation
El Salinity Barrier
❑ Stormwater Drainage
El Subsidence Control
❑Tracer
❑Other (explain under 421
4. Date Well(s) Completed: Well ID#
11/13/23-11/15/23 IP-01 through IP-07
5a. Well Location:
Party Beverage
Facility/Owner Name Facility ID# (if applicable)
5200 Western Blvd. Raleigh, NC 27606
Physical Address, City, and Zip
Wake
County
0784511432
Parcel Identification No: (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifweU field, one lat/long is sufficient)
35.786729275476546 N-78.71309576066118 W
6. Is(are) the well(s): ❑Permanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or ❑No
If this is a repair, fill out known well construction information and explain the nature of the
repair under 421 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: r
9. Total well depth below land surface: 28 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
If water level is above casing, use
II. Borehole diameter: 1.5
12. Well construction method: DPT
(i.e. auger, rotary, cable, direct push, etc.)
SECEI'vw
For Internal Use Only: p
No U 2 7
14. WATER ZONES
FROM
TO
DESCRH'1ION t
kIrIS#EL...,
ft
ft.
ft
15.OUTER CASING for multi -cased wells OR LINER if a Hcable t
FROM
TO DIAMETER
THICKNESS
MATERIAL
fit
ft. I in.
16. INNER CASING OR
T BING.fpeothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
ft.
im
fL
ft.
in.
17.SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS MATERIAL
ft.
ft
in.
ft.
ft
in.
1& 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
TO
Dltit k I rTION (color, hardnrs5, soiltrock Iv e, _rain size, etc.)
ft
fit.
ft
ft.
ft
ft.
ft
ft.
ft
ft.
ft
fit.
ft.
ft.
21. REMARKS
22. Certification:
11 /17/23
Signature of Certified Well Contractor Date
By .signing this form, 1 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.
SUBMITTAL INSTRUCTIONS
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
24b. For Iniection 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 Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Sunnh & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016