WI0501094_IER & GW-1_20240312

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0501094
Were any wells abandoned during this injection
1. Permit Information event?
❑ Yes ® No
Eaton Cop2oration
Permittee If yes,please provide the following information:
_Eaton Roxboro Facility Number of Monitoring Wells
Facility Name
Number of Injection Wells
_2564 Durham Road,Roxboro,NC 27573
Facility Address (include County) Please include a copy of the GW-30 for each well
abandoned.
2. Injection Contractor Information 4. Injectant Information
Draper Aden Associates/TRC EOS Pro and BAC-9
Injection Contractor/Company Name Injectant(s)Type(can use separate additional sheets
if necessary
Street Address114 Edinburjzh South Drive Suite 200
Concentration EOS Pro: 5:1 (Potable
Ca NC 27511 Water:Produci),BAC-9: 10^10 DHC/Liter
City State Zip Code If the injectant is diluted please indicate the source
[phone] dilution fluid. Tap water from a spigot on site
Area code—Phone number Total Volume Injected(gal) 4,020 gal
3. Well Information Volume Injected per well (gal),IW-29B: 1,287;
IW-3013: 1,413; IW-3113: 1,320
Number of wells used for injection 3
5. Injection History
Well IDs IW-29B,IW-30B and IW-3IB
— Injection date(s) 2/26/2024 -3/1/2024
Were any new wells installed during this injection In number(e.g. 3 of 5) 1 of 1
event?
® Yes ❑ No Is this the last injection at this site?
® Yes ❑ No
If yes,please provide the following information:
I DO HEREBY CERTIFY THAT ALL THE
Number of Monitoring Wells 1 INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Number of Injection Wells 3 INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
Type of Well Installed(Check applicable type):
❑ Bored ® Drilled ❑Direct-Push
❑ Hand-Augured ❑ Other(specify)_ 4L
Please include a copy of the GW-1 form for each 3/11/2024
well installed. SIGNATURE OF INJECTION CONTRACTOR DATE
Sean Jarvah
PRINT NAME OF PERSON PERFORMING 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

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John C. SCihappell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2332-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if applicable)
M&W Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name i -
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,Coun)4 State,Parlance,etc.) 0 ft 13.5 ft- 2 in SCh 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3Municipal/Public 13.5 ft. 28.5 ft. 2 t"• 0.010 Soh 40 PVC
Geothermal(Heating/Cooling Supply) [IResidential Water Supply(single) ft. ft. in.
Industrial/Commercial [)Residential Water Supply(shared) 18.GROUT
hTl ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 9.5 ft. Portland Cement MIX&Pour(133 Ibs)
Monitoring Recovery 9.5 ft. 11.5 ft. Bentonite Chips Pour 1 -501b bag
Injection Well:
ft. ft.
Aquifer RechargeGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [IStormwater Drainage 11.5 ft. 28.5 ft. #2 Medium Sand Pour w/Water(6-501b bags)
Experimental Technology [Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) M Other(explain under#21 Remarks) FROM To ft. DESCRIPTION color,hardness,soil/nick e, rain size,etc.
ft.
4.Date Well(s)Completed:7/20/23 Well ID#IW 29B ft. ft.
5a.Well Location:
Eaton Corporation ft. ft.
Facility/Owner Name Facility ID#(if applicable)
2564 Durham Road, Roxboro, NC 27573
Physical Address,City,and Zip
Person 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Ce lion:
36.359955 N -78.985057 W rtifi
_ 9-25-23
!X
6.Is(are)the well(s) Permanent or [)Temporary Signa of Cefied rti Well Co ctor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: []Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
tf this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 28.5 ft
A ( ) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Sonic above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,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 Supply&Injection 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-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John C. Schappell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2332-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(forulti-cased wells)OR LINER if a licable
M&W Drilling, L LC FROM m
TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal dosed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 ft. 15 ft' 2 in. Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural QMunicipal/Public 15 It. 30 ft. 2 in. 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 11 ft. Portland Cement MIX&Pour(154 Ibs)
Monitoring QRecovery 11 ft. 13 ft. Bentonite Chips Pour 1 -501b bag
Injection Well:
ft. ft.
Aquifer RechargeGroundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery Ql Salinity Barrier FROM TO I MATERIAL EMPLACEMENT METHOD
Aquifer Test 0Stormwater Drainage 13 ft. 30 ft. #2 Medium Sand Pour w/Water(6-501b bags)
Experimental Technology D Subsidence Control ft. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM ft. ft.To DESCRIPTION color,hardness,soil/mck type,grain size,etc.
4.Date Well(s)Completed.7/21/23 Well ID#I W-30B ft. ft.
5a.Well Location: ft. ft.
Eaton Corporation ft. I
ft.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
2564 Durham Road, Roxboro, NC 27573 ft. ft.
Physical Address,City,and Zip ft. ft.
Person 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certifi O
36.359941 N -78.985245 W /-
l 9-25-23
6.Is(are)the well(s)oPermanent or [DTemporary Signature of tertified Well Contractor Date
By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: QYes or JNo with 15A NCAC 02C.0100 or 15A NC'AC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GWA is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd erent(example-3@Z00'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfivater level is above casing,use"+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
i Sonic above,also submit one copy of this form within 30 days of completion of well
Well construction method: construction to the following:
(i.e
.auger,rotary,cable,direct push,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 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
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

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John C. Schappell 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
2332-A ft. ft.
ft. I ft.
NC Well Contractor Certification Number 15.OUTER CASING for mu1H-cased wells)OR LINER if a licable
M&W Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e. UIC,County,State,Variance,etc) 0 ft. 15 ft. 2 in' SCh 40 PVC
3.Well Use(check well use):
ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural DMunicipal/Public 15 ft- 30 ft. 2 in- 0.010 Sch 40 PVC
Geothermal(Heating/Cooling supply) DResidential Water Supply(single) ft. ft. in.
Industrial/Commercial QlResidential Water Supply(shared) 18.GROUT
ItTi ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft• 11 ft• Portland Cement Mix&Pour(154 Ibs)
Monitoring ORecovery 11 ft. 13 ft. Bentonite Chips Pour 1 -501b bag
Injection Well:
ft. fL
Aquifer Recharge E)Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3 Stormwater Drainage 13 ft. 30 ft. #2 Medium Sand Pourw/Water(6-501b bags)
Experimental Technology Subsidence Control ft. fL
DIGeothermal(Closed Loop) [3Tracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) 13 Other(explain under#21 Remarks) FROM ft. To ft. DESCRIPTION color,hardness,soil/mck type,grain size,etc.
4.Date Well(s)Completed:7/21/23 Well ID#I W-31 B ft. ft.
5a.Well Location: ft. ft.
Eaton Corporation ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. fL
2564 Durham Road, Roxboro, NC 27573 ft. ft.
Physical Address,City,and Zip ft. ft.
Person 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one latllong is sufficient) 22.Certifiea• n•
36.359941 N -78.985318 W (Aczdez 9-25-23
6.Is(are)the well(s)Ex Permanent or DTemporary Signature of CIrtified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: nYes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under 421 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 30 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@1001 Construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use••+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Sonic above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,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 SunDly&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

Print Form
WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
John C. Schappell 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
2332-A ft. ft.
ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER rf a licable
M&W Drilling, LLC FROM TO DIAMETER THICKNESS MATERIAL
ft. ft. in.
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) 0 It- 12 ft. 2 in' Sch 40 PVC
3.Well Use(check well use): ft. ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural [3MunicipaVPublic 12 ft. 27 ft. 2 in' 0.010 Sch 40 PVC
Geothermal(Heating/Cooling Supply) ID Residential Water Supply(single) ft. ft. in.
Industrial/Commercial DResidential Water Supply(shared) I8.GROUT
_11hri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 8 ft* Portland Cement Mix& Pour(94 Ibs)
x Monitoring Recovery 8 ft. 10 ft- Bentonite Chips Pour 1 -501b bag
Injection Well: ft. fL
Aquifer Recharge rl Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery [3 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
:)Aquifer Test E)Stormwater Drainage 10 ft. 27 ft. #2 Medium Sand Pour(2.25-501b bags)
Experimental Technology [3 Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG(attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) FROM TO Other(explain under#21 Remarks) ft ft. DESCRIPTION(color,hardness,soil/rock type,grain size,etc.
4.Date Well(s)Completed:8/16/23 Well ID#MW-56D ft. ft.
5a.Well Location: ft. ft.
Eaton Corporation ft. ft
Facility/Owner Name Facility iD#(if applicable)
ft. ft.
2564 Durham Road, Roxboro, NC 27573 ft. ft.
Physical Address,City,and Zip ft. ft.
Person 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22,Certif fin:
N w �- 9-25-23
6.Is(are)the well(s) x Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: 0Yes or E)No with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 27 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:4 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
HQ Rock Core above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,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 Supply&Injection 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