WI0500329_Permit (Completion)_20150128

L
-ape Lookout
K nvironrnental Sciences.
January 28, 2015
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k a`
North Carolina DENR-DWQ �
in& g^ Protection
Injection
Section
's Control ro r �n y}�k. per,
q . '@ 6 rot ctio 5 ctio 9 Vv�ate
1636 Mail Service Center
Raleigh, NC 27699®1 636
,',ration: Mr. Thomas Slusser
= a fell System and Injection Event Records
? _ � N,-wth Carolina
to. 2`. i67
PLLC (CL ), on bek.;'f of p _gin Family LLC, is
mandt
r
ins cr' ; `
this u m c mtk��i, pi(s se ooniaci e ,i �'i j b u-6601,
Cape Lookout Environmental Sciences, PLLC
David B. dis, P
Senior eologist/PrL Manager
Attachments: Status of inJeotion W-ll System
Injection U:us
Cape Lookout Environmental Sciences, PLLC
8005 Clear Brook Drive,Raleigh, NC 27615-919.880,6801

State of North Caroling
Department of Environment and Natural resources
Division of Water Resources
s,rATUS OF INJECTION WELL, SYSTEM
Permit Number W10500329
Permit tee name:Peden Family LLC
Address: _ 1859 Ca ital Boulevard
Tease check the selection which most closely describes the current status of your injection well systemn
1) ( QaVell(s)still used for injection activities.
2) ( Well(s)not used for injection but used for other purposes: a)(Water Supply
b)(Recovery
c){Monitoring
3) ® Injection discontinued and: as( 's)temporarily abandoned
l oer . �; ._ :toned
c they are used flar monitoring)
Well Abandonment
;(a)or(3'' h a copy of the CW-3f Abe_ Aon ent Recorr,l., iot avail~ .le,then be the
to,n'i �Ae well
i=
Per
It �,or(4)and will not use a well for injection on this site in the future,you should request rescission of
the permit L,- ish to rescind the permit?
,s ( o
Ce -
III 1 J _.y certify, under penalty of lam-,that 1.have personally examined and am familiar with the infonnation submitted in
this document,and that to the best of my knowledge the information is true,accurate,and complete."
1—�?-/—lS
Signature Date
Revised 6/5/2 13 W/Ui -a6

IN3ECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources—Division of Water Resources
Permit Number VY,
Were any wells abandoned during this injection
1 Pei-nflt Information event?
Peden Farnilv, LLC Yes [�]No
If yes, please provide tj-w following info rrnation,
Former Peden Steel Facility Number of Monitoring Wells
Facility NTarne
Number offlitiection Wells
'11859 Capital Boulevard, Raleigh, NC
F
Please include a etypy of the GW-30for each well
acilit y Address
4. I ec T"ontr etor I ' tlon 2. Injectant Information
Iniectant 7 ­)e: f, 1:7�5
and
3201 Spring Forest Road Coil J OT-75 <3%, & 4vatev
ess >9-
Raluj�.., NC 27616
City State Zip Code
Tot-,,"
Vo'!
1. Well Inforr
5.
:'l
jj
ari_, j�'� 2,012,
Injection number(e.g. 3 of 5)'.
Were any new wells installed during this injection
event? Is this the I 1_'r, ;-Jon at Ails st&, v __ _%x ulk
rl Yes No results of t.Yes '
❑
If yes,please provide the fol 4-ying information.- No
Number of Monitoring,
I DO -,',BY CERTIFY THAT ALL THE
INFORM.-.n a_N ON THIS F �M IS CORRECT TO
Number of Injection Wells THE P -ST OF MY KNOWL AND THAT THE
WAS P' 3 WITHIN THE
Type of We]I lnst;:,_ STANDARDS LAID 0- fl4E/PERMIT.
EJ Bored -'alled L Direct-Push
L Hand-Augured J Other(specify)
SIGNATURE OF INJECTION CONTRACTOR DATE
Please include a copy of the GW-I form for each David B. Wells, P.G., while with S&ME, Inc.
well installed. PRINT NAME OF PERSON PERT ORM[NGTHE INIJECT7
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.8/5/2013