WI0300512_GW-1 & GW-30_20240320

North Carolina Department of Environmental Quality—Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300512
Were any wells abandoned during this injection
1. Permit Information event?
® Yes ❑ No
NCDEQ-DWM-UST-State Lead Program_
Permittee If yes,please provide the following information:
Best Stop#2 Number of Monitoring Wells
Facility Name
Number of Injection Wells 39
10014 Lancaster Hwy,Waxhaw,Union Co.,NC
Facility Address(include County) Please include a copy of the GW-30 for each well
abandoned.
2. Injection Contractor Information
4. Injectant Information
DeepEarth Technologies,Inc.
Injection Contractor/Company Name _Cool-Oxe
Injectant(s) Type(can use separate additional sheets
Street Address 51425 219th Ave. if necessary
Bemidji MN 56601 Concentration: 200 gal water, 3 gal liquid
City State Zip Code oxidizer, 551b Cool-Ox®
(708) 396-0100 If the injectant is diluted please indicate the source
Area code—Phone number dilution fluid: Water from Davis Water Service
Total Volume Injected(gal)_4,992
3. Well Information
Volume Injected per well (gal)_128
Number of wells used for injection 39
5. Injection History
Well IDs IW-1 through IW-39
Injection date(s)_2/6/2024 through 2/9/2024
Were any new wells installed during this injection
event? Injection number(e.g. 3 of 5) 1 of 1
® Yes ❑ No
Is this the last injection at this site?
If yes,please provide the following information: ® Yes ❑ No
Number of Monitoring Wells
I DO HEREBY CERTIFY THAT ALL THE
Number of Injection Wells 39 INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
Type of Well Installed(Check applicable type): INJECTION WAS PERFORMED WITHIN THE
❑ Bored ❑ Drilled ®Direct-Push STANDARDS LAID OUT IN THE PERMIT.
❑ Hand-Augured ❑ Other(specify) 3/20/24
Please include a copy of the GW-1 form for each SIG TURF OF MECTIOWCONTRACTOR DATE
well installed. James Gainey
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

WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
rt. rt.
A - 4459
NC Well Contractor Certification Numbci 15.OUTER CASING for multi-cased wells OR LINER if a licable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
ft. in.
Company Name
16.INNER CASING OR TUBING eother at closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc) R R in.
3.Well Use(check well use): ft ft in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. fit. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑IITI ation ❑Wells>100,000 GPD, FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: fit. fit.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
rt. rt.
El Aquifer Recharge [EGroundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
El Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stonnwater Drainage fit. fit.
❑Experimental Technology El Subsidence Control ft. fit.
El Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0.0 rt• 45.0 IL DIRECT PUSH
4.Date Well(s)Completed: 02/06/24-02/09/24 Well ID# IW-1 - IW-39
fit. fit.
5a.Well Location:
BEST STOP - 2 rt rt
Facility/Owner Name Facility ID#(if applicable) ft fit
10014 LANCASTER HIGHWAY WAXHAW 28173
Physical Address,City,and Zip ft. ft.
UNION 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.Certification:
340 50' 12.00" N 800 43' 41.61" W 02/14/24
6.Is(are)the well(s): ❑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 with
7.Is this a repair to an existing well: ❑Yes or ONo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this farm.
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 construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 39 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 45.0
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:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use^+"
11.Borehole diameter: 2.25 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: DPT RODS
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) 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 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018

WELL ABANDONMENT RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: WELL ABANDONMENT DETAILS
DAVID HALL 7a.Number of wells being abandoned: 39
Well Contractor Name(or well owner personally abandoning well on his/her property) For multiple injection or non-water supply wells ONLY with the same
A - 4459 construction/abandonment,you can submit one form.
NC Well Contractor Certification Number 7b.Approximate volume of water remaining in well(s): (gal.)
GEOLOGIC EXPLORATION FOR WATER SUPPLY WELLS ONLY:
Company Name 7c.Type of disinfectant used:
2.Well Construction Permit#:
List all applicable well construction permits(i.e.County,State, Variance,etc.)ifknown 7d.Amount of disinfectant used:
3.Well use(check well use):
Water Supply Well: 7e.Sealing materials used(check all that apply):
❑Agricultural ❑Municipal/Public ❑Neat Cement Grout 0 Bentonite Chips or Pellets
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ❑ Sand Cement Grout ❑ Dry Clay
❑hidustrial/Commercial ❑Residential Water Supply(shared) ❑ Concrete Grout ❑ Drill Cuttings
❑Irrigation ❑ Specialty Grout ❑ Gravel
Non-Water Supply Well: ❑ Bentonite Slurry ❑ Other(explain under 7g)
❑Monitoring ❑Recovery
Injection Well: 7f.For each material selected above,provide amount of materials used:
El Aquifer Recharge 0 Groundwater Remediation 7.0 GALLONS
❑Aquifer Storage and Recovery El Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control 7g,Provide a brief description of the abandonment procedure:
❑Geothermal(Closed Loop) ❑Tracer ABANDONED VIA BENTONITE CHIPS
❑Geothermal(Heating/Cooling Return) El Other(explain under 7g)
4.Date well(s)abandoned: 02/06/24 — 02/09/24
5a.Well location:
MCCAIN GROCERY
Facility/Owner Name Facility ID#(if applicable) g•Certification:
10014 LANCASTER HIGHWAY WAXHAW 28173 02/14/24
Physical Address,City,and Zip Signature of Certified Well Contractor or Well Owner Date
UNION By signing this form, I hereby certify that the well(s) was (were) abandoned in
County Parcel Identification No.(PIN) 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.
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 9.Site diagram or additional well details:
340 50' 12.00" 800 43' 41.61" You may use the back of this page to provide additional well site details or well
N W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S)BEING ABANDONED SUBMITTAL INSTRUCTIONS
Attach well construction record(s)if available. For multiple injection or non-water supply
wells ONLY with the same construction/abandonment,you can submit one form. 10a. For All Wells: Submit this form within 30 days of completion of well
6a.Well ID#:
IW-1 - IW-39 abandonment to the following:
Division of Water Quality,Information Processing Unit,
6b.Total well depth:
45.0 ft.) 1617 Mail Service Center,Raleigh,NC 27699-1617
(
10b.For Iniection Wells: In addition to sending the form to the address in 10a
2.25 above, also submit one copy of this form within 30 days of completion of well
6c.Borehole diameter: (in.) abandonment to the following:
Division of Water Quality,Underground Injection Control Program,
6d.Water level below ground surface: (ft.) 1636 Mail Service Center,Raleigh,NC 27699-1636
10c.For Water Supply&Iniection Wells: In addition to sending the form to
6e.Outer casing length(if known): (R•) 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
6L Inner casing/tubing length(if known): (ft.) where abandoned.
6g.Screen length(if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised March 2013