The URL can be used to link to this page

Home My WebLink About20071_Howerton_PIIR_20160622 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601 June 22, 2016 Mr. Randy Bates Terwilliger Pappas Raleigh City Partner 510 Glenwood Avenue, Suite 317 Raleigh, North Carolina 27603 RE: Results of Limited Phase II Environmental Site Assessment 1001 West Main Street Parcels 103162, 103163, 103164, 103177, 103178, 103179, and 103180 Durham, North Carolina Dear Mr. Bates, ONE Environmental Group of Carolina, PLLC (ONE) appreciates the opportunity to submit this Limited Phase II Investigation Letter Report for the above referenced Property. The following scope of work was completed in accordance with the signed proposal dated June 3, 2016. The “Property” consists of 1.45 acres encompassed in Parcels 103162, 103163, 103164, 103177, 103178, 103179, and 103180. A summary of the investigation is presented below. Project Background A Phase I ESA was completed in May 2016 at the Property. The Phase I reported three (3) Recognized Environmental Conditions (RECs) in connection with the Property:  One (1) closed‐in‐place heating oil UST was identified on the south side of the chapel. According to the Property owner, the tank was drained and capped 35 years ago when the heating system at the Property was converted to natural gas. No confirmation sampling or analytical data was collected when the UST was closed and it is unknown if a release may have occurred at the tank. The Property owner was also unsure of the installation date of the UST. Based on the age and lack of closure records for the UST, the closed‐in‐place heating oil UST behind the chapel is considered a REC for the Property.  Claude M. May, Inc. at 1101 West Main Street is mapped approximately 401‐feet to the north‐northwest and cross‐gradient of the Property (on the adjacent property to the west). Soil and groundwater contamination were identified during the removal of a 2,000‐gallon heating oil tank in July 1995. During the tank removal, approximately 58 tons of contaminated soil were removed and disposed of. A Soil Cleanup Report with Site Closure Request was drafted in September 1998. This report indicates that groundwater flow direction is “generally in the easterly Mr. Randy Bates June 22, 2016 Page 2 of 8 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601 direction” at the site (towards the Property). A Notice of No Further Action (NFA) was issued in November 1998 stating the site “does not exceed industrial/commercial maximum soil contaminant concentrations established”. This NFA was conditional pending a completion of public notice and stated that as soil and groundwater impacts remained, the site was not suitable for residential use including homes, daycares, schools, recreation areas, etc. In July 2012 NCDENR (now DEQ) stated a Notice of Residual Petroleum (NORP) must be filed with the Register of Deeds as the release had not been remediated to below “unrestricted use standards”. The previous owner failed to complete the NFA requirements and to perform requested follow‐up sampling; therefore, the November 1998 NFA was deemed invalid. In June 2015 a Phase II Subsurface Investigation occurred at the site. Based on soil sampling data, it was determined that the soil excavation performed during the UST removal was successful in removing impacted soil from the site. Based on groundwater sampling data, contaminant concentrations in two (2) monitoring wells had decreased through assumed natural attenuation since 1996 and no analytes exceeding the UST Gross Contaminant Levels (GCLs) were detected; however, analytes were detected above NC 2L standards. A NFA letter was issued for the site on July 24, 2015. Based on the closure of the site with residual petroleum, direction of groundwater flow, and close proximity to the Property, this site is considered a REC for the Property.  The following incidents are associated with the service station at 1016 West Main Street: o Tops #12/Brame Specialty/Tops Texaco Mart #12 at 1016 West Main Street is mapped approximately 390‐feet to the northeast and cross‐gradient of the Property. In February 1988, hydrocarbons were detected in a monitoring well at the Tops Texaco and the site was assigned incident number 3561. In March 1992, one (1) 8,000‐gallon gasoline UST, two (2) 10,000‐gallon gasoline USTs, one (1) 2,000‐gallon diesel USTs and four (4) orphan USTs were removed from the site. Soil contamination was detected and excavated soil (approximately 2,000 tons) was disposed offsite. Concurrent with the UST removal, hydrocarbon odors were noticed in the basement of the adjacent Brame Building at 1010 West Main Street and assigned incident number 7139. The gasoline contamination at the Brame Building was assumed to be from the Tops site and the incidents were consolidated into one (1) incident number (3561). A recovery well was installed in 1989 and a groundwater remediation system using diffused air was initiated. The groundwater remediation system was ongoing until at least 1998. In November 1995, a Corrective Action Plan was drafted for the site and Mr. Randy Bates June 22, 2016 Page 3 of 8 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601 groundwater flow was expected to migrate towards the southeast (towards the Property). In May 1998, the site was assigned a “low‐risk” value and based on the cleanup standards for low‐risk sites, no further groundwater remediation was necessary. In 1998, the Maximum Soil Contaminant Concentration (MSCC) for TPH on commercial/industrial property was 12,264 mg/kg. The highest TPH concentration detected at the site was 660 mg/kg. On August 31, 1998 the site received a Notice of No Further Action and the groundwater at the site was deemed not suitable for use as a water supply or for residential use (homes, day cares, schools, recreations areas). o Trinity Park Family Far 432 at 1016 West Main Street is mapped approximately 390‐feet to the northeast and cross‐gradient of the Property. Two (2) LUST incidents have occurred at the site; however, the first incident was merged with incident 3561 at Tops, as discussed above. The second LUST incident occurred during the removal of three (3) 10,000‐gallon gasoline USTs and one (1) 2,000‐gallon diesel UST in 2008. Soil and groundwater contamination were discovered during the removal and impacted soils and free product were removed from the site (a total of 24,257‐gallons of impacted water and 997.1 tons of impacted soil was removed). Two (2) monitoring wells were installed at the site and groundwater in the vicinity was found to likely flow to the south and southwest (the Property is to the south). A Limited Site Assessment in March 2009 found that soil at the site had no concentrations of detectable compounds in excess of residential MSCC’s. Groundwater at the site was at levels above the 2L Standards but below Gross Contaminant Levels. A Notice of Residual Petroleum was filed for the site on August 21, 2009 and the site received a Notice of No Further Action on October 5, 2009. Based on the closure of the above incidents with residual petroleum, direction of groundwater flow, and close proximity to the Property, this site is considered a REC for the Property. Although not listed as a REC in the report, the following were referenced as BERs:  During the Phase I ESA site reconnaissance ONE completed a limited visual inspection of the interior and exterior of the buildings looking for older construction materials and/or suspect ACM. Based on the age of the buildings, suspect ACM is present in all buildings on the Property. No friable materials were observed; however, if the buildings are demolished, the ACM must be identified and abated prior to demolition. The presence of suspect ACM is considered a BER for the Property. Mr. Randy Bates June 22, 2016 Page 4 of 8 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601  The floor drain in the car wash area has been in use since the 1960’s. There is no oil‐water separator connected to the drain, and the drain discharges directly to the City of Durham storm water system. Based on the length of use and potential for impacts stemming from automotive washing this is considered a BER for the Property. Due to the aforementioned RECs outlined in the Phase I Report, Phase II services were completed June 7 – June 9, 2016. The scope of work was developed to further assess the impacts (if any) of the closed‐in‐place heating oil tank on the Property as well as potential off‐site impacts from three (3) nearby LUST incidents. The stormwater drain connected to the car wash area in the garage was also investigated as part of the scope of work. A Photographic Log of the Phase II activities has been provided as Attachment A. Please note the potential for asbestos‐containing material identified as a BER for the Property has been addressed as part of the Phase II scope of work; however, will be submitted to Terwilliger Pappas under separate cover. GPR Survey Prior to the introduction of soil borings and temporary wells, ONE contacted “Miss Utility” to locate any subsurface utilities that may traverse the Property. In addition, ONE completed the direct oversight of Stewart Engineering during a ground penetrating radar (GPR) survey that encompassed the general area of the former heating oil tank, the stormwater drain that runs parallel to the garage and the general locations of wells MW1, MW2, and MW3. The GPR survey marked an approximately 14’ x 4.5’ area adjacent to the chapel where the heating oil tank is located. Soil Boring and Sampling On June 7, 2016, ONE mobilized to the site to complete the installation of soil borings within the general area of the heating oil tank and the stormwater drain that runs parallel to the garage. On June 9, 2016, additional borings were installed along the northern and western property boundaries. The locations of the borings are depicted on the Boring and Monitoring Well Location Map, Figure 1. Soil borings introduced within the assumed area of the heating oil tank and the stormwater drain (SB‐1 through SB‐6) were advanced on June 7, 2016 with a Geoprobe® via direct push technology operated by Carolina Drilling, Inc. Soil cores were collected in 4‐foot Macro‐Core® sample tubes and classified by ONE personnel. The sample tubes were screened using a Photo Ionization Detector MiniRAE 2000 (PID) with an 11.7 eV lamp calibrated to isobutylene. Soil samples were collected for laboratory analysis at each boring location in the area identified with the highest PID reading. If no impacts were recorded via the PID, representative soil samples were collected at an interval below the presumed location of drains. PID readings and corresponding sample intervals are presented in Table 1. Mr. Randy Bates June 22, 2016 Page 5 of 8 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601 On June 9, 2016 soil borings were introduced along the western and northern property boundaries and to further delineate the heating oil tank via a hollow stem auger operated by Carolina Drilling, Inc. Soil was collected in approximate 2‐foot intervals and classified by ONE personnel. The samples were screened using a Photo Ionization Detector MiniRAE 2000 (PID) with an 11.7 eV lamp calibrated to isobutylene. Soil samples were collected for laboratory analysis at the boring locations along the western and northern property boundaries in the area identified with the highest PID reading. If no impacts were recorded via the PID, representative soil samples were collected at an interval above the presumed location of the water table. Please note soil borings SB‐9 and SB‐10 were screened with a PID for delineation purposes only and were not sampled. PID readings and corresponding sample intervals are presented in Table 1. One (1) soil sample was collected from each soil boring; SB‐1 through SB‐8. The samples were collected in laboratory supplied bottleware and submitted to SGS Environmental Services of Wilmington, North Carolina for analysis of Total Petroleum Hydrocarbon Gasoline Range Organics (TPH‐GRO) and Total Petroleum Hydrocarbon Diesel Range Organics (TPH‐DRO) by EPA Method 8015C. The laboratory analytical report is included as Attachment B. Soil borings SB‐9 and SB‐10 were not sampled. A summary of soil analytical data is presented in Table 2 and Figure 2 – Soil Analytical Data Map. The laboratory report has been included as Attachment B. Monitoring Well Installation and Groundwater Sampling ONE completed the oversight of Carolina Drilling, Inc. during the development of monitoring wells MW‐1, MW‐2, and MW‐3. SB‐7 was converted to MW‐1 and SB‐8 was converted to MW‐2. MW‐3 was installed along the southern boundary for groundwater elevation monitoring purposes (as per Stewart Engineering’s Guidance) and was not sampled. The monitoring wells were completed utilizing a Geoprobe® 7220DT drilling rig and a hollow stem auger. The Geoprobe® tooling was advanced to a terminal depth of 25 feet below ground surface (bgs). The wells were set with 5 feet of PVC screen from a depth of 25‐20 feet bgs. Solid PVC riser was used from 20 feet bgs to ground surface. #2 sand pack was placed in the borehole annulus to approximately 15‐25 feet bgs. Well Construction Records for MW‐1, MW‐2, and MW‐3 have been included as Attachment C. During the Phase II investigation, a groundwater monitoring well was discovered on the south side of the heating oil tank and was subsequently labeled MW‐4. The well had been patched with asphalt and was not observed during the Phase I investigation. A bailer was inserted into MW‐4, and approximately 4‐inches of free product was observed on groundwater, therefore, this well was not sampled. Representative groundwater samples were collected after MW‐1 and MW‐2 were installed. Prior to collection, water levels in the well were recorded utilizing an oil water interface probe. Initial depth to water readings are presented below. Mr. Randy Bates June 22, 2016 Page 6 of 8 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601 Well ID Initial Depth to Water (ft bgs) Depth to Water after 24 hours (ft bgs) MW‐1 5.85 4.75 MW‐2 5.1 4.3 MW‐3 ‐ 4.85 MW‐4 ‐ 3.5 Purging and sampling was completed utilizing a low‐flow peristaltic pump. The groundwater samples were placed in laboratory supplied bottleware and shipped to SGS Environmental Services of Wilmington, NC for analysis of the following constituents:  Volatile Organic Hydrocarbons (VOCs) by EPA Method 8260B;  Semi‐Volatile Organic Hydrocarbons (SVOCs) by EPA Method 625 Base/Neutrals and Acids plus 10 largest non‐target peaks;  Massachusetts Department of Environmental Protection (MADEP) Volatile Petroleum Hydrocarbons (VPH);  Massachusetts Department of Environmental Protection (MADEP) Extractable Petroleum Hydrocarbons (EPH); and,  Metals (Pb) by Method SW‐846 6010D. The locations of the monitoring wells are depicted on the Boring and Monitoring Well Location Map, Figure 1. Groundwater Analytical Data is presented in Table 3 and Figure 3 – Groundwater Analytical Data Map. Please note after the groundwater samples were collected well pads were installed. Conclusions and Recommendations ONE has completed a Phase II investigation for the Howerton‐Bryan Funeral Home facility located at 1001 West Main Street in Durham, North Carolina. The subsurface investigation was limited in nature and developed specifically to address RECs and BERs outlined in the Phase I ESA completed May 2016. Conclusions and recommendation are as follows:  Both MW‐1 (on the western border, adjacent to the daycare) and MW‐2 (on the northern border, along West Main Street) reported impacts of petroleum, chlorinated solvent and metals constituents that exceed NC2L standards. Although reported above 2L, the detections are below GCL’s (risk based screening criteria). At this point these impacts are considered reportable to the North Carolina Department of Environmental Quality (NC DEQ) for further risk evaluation. These reported detections most likely stem from one to multiple up‐ gradient/offsite sources. Mr. Randy Bates June 22, 2016 Page 7 of 8 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601  All the soil borings around the heating oil tank exceed the screening criteria of 10 mg/kg for TPH‐GRO and/or TPH‐DRO. These detections are indicators of a reportable release to the NC DEQ.  MW‐4 (well found adjacent to the heating oil tank that was previously installed) was found with approximately 4‐inches of free product on groundwater.  Considering future property use it is recommended that the heating oil tank and source material are removed to protect human health. An estimate of probable cost for heating oil tank removal and over excavation of contaminated soil/sludge/water is approximately $50,000‐$60,000. This estimate was developed under the consideration that: o The chapel will be demolished prior to heating tank removal; o Potential impacts underneath the chapel are unknown; however, the estimate assumes an excavation of 10’ off each sidewall of the existing tank to a total depth of 10’ bgs; o Water levels found in and around the heating oil tank pit are at 3’ bgs; and, o All material encountered during the remediation will be non‐hazardous.  Considering future use of the property it is recommended the magnitude of groundwater and sol impacts on the property are fully defined. This is especially true for the chlorinated solvents reported in groundwater as these are a driver for potential indoor air impacts. An estimate of probable cost for a soil gas assessment and further risk assessment is approximately $50,000‐$60,000. ONE appreciates the opportunity to provide environmental consulting services to Terwilliger Pappas. If you should have any questions or comments pertaining to the proposed scope of work, please do not hesitate to contact me at (919) 699‐7347. Sincerely, ONE Environmental Group of Carolina, PLLC Eli Holland, PG Principal Attachments: Figure 1 – Soil Boring and Monitoring Well Location Map Mr. Randy Bates June 22, 2016 Page 8 of 8 ONE Environmental Group of Carolina, PLLC 223 S. Wilmington Street, Suite 200‐D, Raleigh, NC 27601 Figure 2 – Soil Analytical Data Map Figure 3 – Groundwater Analytical Data Map Table 1 – Summary of Field Data Table 2 – Summary of Soil Analytical Data Table 3 – Summary of Groundwater Analytical Data Attachment A – Photographic Log Attachment B – Laboratory Report Attachment C – Well Construction Records FIGURES SB-3 SB-6 SB-5 SB-7 SB-8 SB-1 SB-2 SB-4 SB-9 SB-10MW-4 MW-2 MW-3 MW-1 Source: Esri, DigitalGlobe, GeoEye, Earthstar Geographics, CNES/AirbusDS, USDA, USGS, AEX, Getmapping, Aerogrid, IGN, IGP, swisstopo, andthe GIS User Community Sources: Esri, HERE,DeLorme, USGS, Intermap, ProjectManager:EF CheckedBy:EF DrawnBy:PL Figure 1 -Boring and Monitoring Well Location 1001-1005 West Main Street1006-1016 West Peabody StreetDurham, North Carolina 27701 0 40 80Feet Soil Boring Monitoring Well SB-7(10-15)TPH-DRO <7.20TPH-GRO <4.14 SB5 (2.5-5)TPH-DRO <7.16TPH-GRO <2.64 SB-8 (15-20)TPH-DRO <6.99TPH-GRO <2.98 SB-9TPH-DRO NSTPH-GRO NS SB-9 (6-8)PID - 320TPH-DRO NSTPH-GRO NS SB-10 (6-8)PID - 253TPH-DRO NSTPH-GRO NS SB2 (5-7)PID - 196TPH-DRO 6,550TPH-GRO 423 SB4 (4-5)PID - 408TPH-DRO 6,160TPH-GRO 430 SB6 (3.5-5)PID - 0TPH-DRO 23.9TPH-GRO <3.10 SB-7(10-15)PID - 0TPH-DRO <7.20TPH-GRO <4.14 SB5 (2.5-5)PID - 0TPH-DRO <7.16TPH-GRO <2.64 SB-8 (15-20)PID - 1TPH-DRO <6.99TPH-GRO <2.98 SB3 (5-7.5)PID - 352TPH-DRO 8,870TPH-GRO 471 SB1 (4-7)PID - 4TPH-DRO 1,490TPH-GRO 1,260 Source: Esri, DigitalGlobe, GeoEye, Earthstar Geographics, CNES/AirbusDS, USDA, USGS, AEX, Getmapping, Aerogrid, IGN, IGP, swisstopo, andthe GIS User Community Sources: Esri, HERE,DeLorme, USGS, Intermap, ProjectManager:EF CheckedBy:EF DrawnBy:PL Figure 2 - Soil Analytical Data 1001-1005 West Main Street1006-1016 West Peabody StreetDurham, North Carolina 27701 0 40 80Feet Notes:All units mg/kgNS- Not SampledTPH-GRO - Gasoline Range OranicsTPH-DRO - Diesel Range Organics Soil Boring MW-4~4-inches FP MW-3 MW-1EPH 0.656VPH 159Lead 0.0429PCE 373 MW-2EPH 0.220VPH 197Lead 0.161PCE 87.8DCE 34.4DPE 39.3MTBE 67.6 Source: Esri, DigitalGlobe, GeoEye, Earthstar Geographics, CNES/AirbusDS, USDA, USGS, AEX, Getmapping, Aerogrid, IGN, IGP, swisstopo, andthe GIS User Community Sources: Esri, HERE,DeLorme, USGS, Intermap, ProjectManager:EF CheckedBy:EF DrawnBy:PL Figure 3 - Groundwater Analytical Data 1001-1005 West Main Street1006-1016 West Peabody StreetDurham, North Carolina 27701 0 40 80Feet Notes:EPH and Lead mg/L all others ug/LEPH - Extractable Petroleum HydrocarbonsVPH - Volatile Petroleum HydrocarbonsPCE - TetrachloroethyleneDCE- cis-1,2-dichloroethyleneDPE - DiisopropyletherMTBE - Methy-tert,butyl ether Monitoring Well TABLES Table 1 Field Data 1001 West Main Street Durham, North Carolina Boring ID Interval PID (ppm)Field Observations / Unified Soil Classification System Designation 0‐2 5.0 Orange and gray lean clay (CL) 2‐4 0.0 Orange and gray lean clay (CL) with gravel from 3‐3.5 ft 4‐5 46.0 Orange and gray lean clay (CL) 5‐7 3.0 Orange sandy clay (SC) 7‐9 1.0 Gray lean clay (CL) 9‐10 1.0 Orange, brown, and gray lean clay (CL) 10‐12 1.0 Gray lean clay (CL) 12‐14 2.0 Dark gray sand and gray clay (SC) 14‐15 1.0 Gray and brown clay and sand (SC) 0‐5 46.0 Light gray soft sandy clay (SC) with odor 5‐7 196.0 Brown to gray clay (CL) with odor 7‐9 126.0 Light brown to gray clay (CL) with odor 9‐10 13.0 Light brown to gray clay (CL) with odor 10‐11 85.0 Light brown to gray clay (CL) with odor 11‐12 165.0 Light brown to gray clay (CL) with odor 12‐13 16.0 Light brown to gray clay (CL) with odor 13‐15 17.0 Gray to orange clay (CL) 0‐5 66.0 Brown to gray clay (CL) with odor 5‐7.5 352.0 Light brown to gray clay (CL) with odor 7.5‐10 179.0 Light brown to gray clay (CL) with odor 10.5‐13 91.0 Light brown to gray clay (CL) with odor 0‐2 0.0 Gray clay (CL) 2‐4 49.0 Gray clay (CL) with gravel layer at 2.5 ft 4‐5 408.0 Brown to gray sandy clay (SC) with a gravel layer at 4 ft and petroleum odor 5‐7 375.0 Gray and orange clay (CL) with odor and gravel from 5.5 to 6 ft 7‐9 263.0 Gray sandy clay (SC) with odor 9‐10 30.0 Gray sandy clay (SC) with odor 10‐11 290.0 Gray sandy clay (SC) with odor 11‐12 66.0 Gray sandy clay (SC) with odor 12‐13 10.0 Dark gray to orange clay (SC) with odor 0‐2.5 0.0 Dark brown to gray clay and sand (SC) 2.5‐5 2.0 Dark gray sand with clay (SC) 5‐7.5 0.0 Brown sand (SW) 7.5‐10 0.0 Gray clay (CL) 0‐3.5 0.0 Gray to orange clay and silt (CL) with gravel layer at 3.5 ft 3.5‐5 0.0 Gray clay with orange streaks (CL) 5‐7.5 0.0 Gray clay (CL) 7.5‐10 0.0 Gray clay (CL) 0‐3 1.0 Auguer sample (no soil classification) 3‐5 0.0 Auguer sample (no soil classification) 5‐10 0.0 Auguer sample (no soil classification) 10‐15 0Auguer sample (no soil classification) 15‐20 1 Auguer sample (no soil classification) 0‐5 0 Auguer sample (no soil classification) 5‐10 0 Auguer sample (no soil classification) 10‐15 0 Auguer sample (no soil classification) 15‐20 1.0 Auguer sample (no soil classification) 0‐2 0 Auguer sample (no soil classification) 2‐4 10 Auguer sample (no soil classification) 4‐6 96 Auguer sample (no soil classification) 6‐8 320 Auguer sample (no soil classification) 8‐10 159.0 Auguer sample (no soil classification) 0‐2 0 Auguer sample (no soil classification) 2‐4 8 Auguer sample (no soil classification) 4‐6 82 Auguer sample (no soil classification) 6‐8 253 Auguer sample (no soil classification) 8‐10 75 Auguer sample (no soil classification) Notes: Interval sample collected *No sample collected SB‐10* SB‐3 SB‐5 SB‐7 SB‐6 SB‐1 SB‐2 SB‐4 SB‐8 SB‐9* ONE ‐ June 2016 1 of 2 Terwilliger Pappas Ta b l e 2 So i l An a l y t i c a l Da t a 10 0 1 We s t Ma i n St r e e t Du r h a m , No r t h Ca r o l i n a TP H ‐ G a s o l i n e R a n g e O r g an i c s (GR O ) M e t h o d 8 0 1 5 C 1 0 1 2 6 0 4 2 3 4 7 1 4 3 0 B D L B D L B D L B D L TP H ‐ D i e s e l R a n g e O r g a n i c s ( D R O ) M e t h o d 8 0 1 5 C 1 0 1 4 9 0 6 5 5 0 8 8 7 0 6 1 6 0 B DL 2 3 . 9 B D L B D L No t e s : BD L B e l o w D e t e c t i o n L i m i t De t e c t i o n e x c e e d s N C D E Q A c t i o n L e v e l SB ‐8 (15 ‐20') SB ‐3 (5 ‐7. 5 ' ) S B ‐4 (4 ‐5' ) S B ‐5 (2 . 5 ‐5' ) To t a l Pe t r o l e u m Hy d r o c a r b o n s (m g / K g ) An a l y t e S B ‐1 (4 ‐7' ) NC DE Q Ac t i o n Le v e l SB ‐2 (5 ‐7' ) S B ‐6 (3 . 5 ‐5') S B ‐7 (10 ‐15') ON E ‐ J u n e 2 0 1 6 Pa g e 1 o f 1 Terwilliger Pappas Ta b l e 3 Gr o u n d w a t e r A n a l y t i c a l R e s u l t s 10 0 1 W e s t M a i n S t Du r h a m , N C 2 7 7 0 1 We l l ID D a t e Co l l e c t e d 15 4 0 0 2 0 0 1 0 0 0 0 7 0 0 7 0 0 . 4 2 0 0 . 7 15 0 0 0 ~~ ~ ~ 70 0 0 0 4 0 0 2 0 0 0 0 7 0 0 MW ‐ 1 6 / 9 / 2 0 1 6 42 . 9 1 5 9 9 3 . 7 5 2 2 4 0 . 1 ND N D N D 37 3 MW ‐ 2 6 / 9 / 2 0 1 6 A 16 1 1 9 7 ND 22 0 ND 39 . 3 3 4 . 4 6 7 . 6 8 7 . 8 No t e s : Re s u l t s r e p o r t e d i n u g / l = m i c r o g r a m s p e r l i t e r GC L = g ro s s c o n t a m i n a t i o n l e v e l ~ = s c r e e n i n g c r i t e r i a n o t l i s t e d Bo l d = i n d i c a t e s a d e t e c t i o n Bo l d & H i g hl i g ht e d = i n d i c a t e s a d e t e c t i o n a b o v e t h e 2 L s t a n d a r d NA = N o t A n l a y z e d T e t r a c h l o r o e t h e n e M e t h y l t e r t ‐ b u t y l e t h e r NC 2L St a n d a r d (u g / l ) GC L (u g / l ) L e a d Co n t a m i n a n t of Co n c e r n 1 , 2 ‐ D i c h l o r o e t h a n e D i ‐ i s o p r o p y l e t h e r C 9 ‐ C ‐ 1 8 A l i p h a t i c s C 1 1 ‐ C 2 2 A r o m a t i c s C 5 ‐ C 8 A l i p h a t i c s C 1 9 ‐ C 3 6 A l i p h a t i c s ON E ‐ J u n e 2 0 1 6 Terwilliger Pappas ATTACHMENTS ATTACHMENT A SITE PHOTOGRAPHS Site ID: 1001 West Main Street, Durham, NC Date: June 2016 ONE – June 2016 Page 1 Terwilliger Pappas 1. View of mark‐out for the closed heating oil tank 2. View of mark‐out for stormwater drain parallel to the garage Site ID: 1001 West Main Street, Durham, NC Date: June 2016 ONE – June 2016 Page 2 Terwilliger Pappas 3. View of utility mark‐out in front of the funeral home 4. View of delineation borings (SB‐9 and SB‐10) Site ID: 1001 West Main Street, Durham, NC Date: June 2016 ONE – June 2016 Page 3 Terwilliger Pappas 5. View of augering prior to installation of MW‐1 6. View of finished well plate for MW‐1 Site ID: 1001 West Main Street, Durham, NC Date: June 2016 ONE – June 2016 Page 4 Terwilliger Pappas 7. View of finished well plate for MW‐2 8. View of finished well plate for MW‐3 Site ID: 1001 West Main Street, Durham, NC Date: June 2016 ONE – June 2016 Page 5 Terwilliger Pappas 9. View of MW‐4 found on the south side of the heating oil tank 10. View of free product in MW‐4 ATTACHMENT B LABORATORY ANALYTICAL REPORT !"#$ %"# " &&'( %) *+&, - ( ) ) )) . #-) /)""$ % )0 ) 1 " )2# ) %2 ))0 #1 )"" )) #1 2 3 )4!&5 )) )% 0 # 6)0 ) %)7)(#% 48,&5!9&',8&!#$2)20 2)) )# -): %"")1 6# #$:22:%2) %# " "")1 6# ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; 7)(#% ( 7% )#%<%# (&+=,>= &,+# # ?>@, 12))"" " )==222#%# = ;;#) TPH Report Page 1 of 25 Digitally signed by: Michael Page DN: CN = Michael Page C = US O = SGS North America OU = Environmental Services Date: 2016.06.14 13:35:39 -04'00' ! ! "#$ % "& #$ "#$ ' "& #$ ( (& ) ! ( * % (& % + + # , - $ . / + % 0 0 , , ! ! 1 234 %* "& * * % " 5 6 & % / %*7 8 9 & : "* & ; % #// & < * & $ 2 ! 5 #// = !( 0' 0 $ > 9 ' , ?" #4$? % @ / ! 7 3A6826:38A ,// B 2C8 TPH Report Page 2 of 25 !"#!! ! $!$"! %& ! $!'$"! !#%& ()*+, "& !"#!!" ! $!$"! %! ! $!'$"! !#%& ()*+, &-& !"#!! ! $!$"! &%!& ! $!'$"! !#%& ()*+, & !"#!! ! $!$"! &%& ! $!'$"! !#%& ()*+, &"-&& !"#!!& ! $!$"! %!! ! $!'$"! !#%& ()*+, -&& !"#!! ! $!$"! %& ! $!'$"! !#%& ()*+, . / !"#!! ! $!'$"! !#%& ( 0 %! $$"! 1--2 3' TPH Report Page 3 of 25 ! " #$ % & ' !&" #$ ! " #$ (( & ' !&" #$ % ! ! " #$ ))* & ' !&" #$ %* % ! " #$ & ' !&" #$ % ! ! " #$ + #%#,++- '.%) TPH Report Page 4 of 25 ! "#$ % ! & '$ ($)*+, $(-./%0! 12"(323 4( 5 "(3() "(3(6 )7$ 8 (" +1+ (-8"1/ +9+ !! % : 637 . !0 % !"# : ,$%%& &,$ & ; ' ' (& <0=0)& >' =#* ) : ,$ ) &,$ (3 )( ?006 @ % TPH Report Page 5 of 25 !"# $ % &# '#()*+ #',-.$/ 01!'212 3' 4 !'2'( !'2'5 6 (7# '! *0* ', !0. *8* $/ 9+( / - / !"# : +$$$ %+#% 9 & &' (' ;/</%') =& < #* 6 ( : +$+'% 6 ( %+# '2 + 6 (', >//5 ?$ TPH Report Page 6 of 25 !"# $ % & '# (#)*+, #(-./$0 12!(323 4( 5 !(3() !(3(6 )7# 8 (! +1+ (-8!1/ +9+ %% $ : 637 % . %0 $ !"#$ : ,%&& &,# ; '' () <0=0* >' =$+ ) : ,% ) &,# (3 )( ?006 @ $ TPH Report Page 7 of 25 !" #$ % &" '"()*+ "',-.#/ 01 '212 3' 4 '2'( '2'5 6 (7" ' *0* ', 0. *8* $# 9+( :6 - $ / !"# ; +$$$ %+"% 9 && ' < /=/%( >& = #) 6 ( ; +$*% 6 ( %+" '2 * 6 ('+ ://5 ?# TPH Report Page 8 of 25 !"# $% & '# (#)*+, #(-./0 12!(323 4( 5 !(3() !(3(6 )7# 8 (! +1+ (-8!1/ +9+ $ %: 637 . 0 $ ! "#$ : ,%&& &,# ; ' '( ) <0=0 >' =$ * ) : ,%( ) &,# (3 )( %?006 @%$ TPH Report Page 9 of 25 !" #$ % &" '"()*+ "',-./ 01 '212 3' 4 '2'( '2'5 6 (7" ' *0* ', 0. *8* 9+( :6 - $/$ ! "#$ ; +%%% %+" 9 &&'(' < /=/' ) >& =$ * 6 ( ; +%+' 6 ( %+" '2 + 6 (', $://5 ?$# TPH Report Page 10 of 25 ! ! "#$ % ! & '$ ($)*+, $(-./%0 12"(323 4( 5 "(3() "(3(6 )7$ 8 (" +1+ (-8"1/ +9+ ! % : 637 . ! 0 % !" : ,# $$ &,$ ; % %& ' <0=0() >' =" * ) : ,#& ) &,$ (3 + )( ?006 @ % TPH Report Page 11 of 25 !"# $ % &# '#()*+ #',-.$/ 01!'212 3' 4 !'2'( !'2'5 6 (7# '! *0* ', !0. *8* $ 9+( :6 - / ! ; +""" %+# # 9 $ $% &% < /=/#%'( >& = ! ) 6 ( ; +"*%# 6 ( %+# '2 * 6 ('+ ://5 ? $ TPH Report Page 12 of 25 !"# $% & '# (#)*+, #(-./$%0 12!(323 4( 5 !(3() !(3(6 )7# 8 (! +1+ (-8!1/ 9 +:+ 0% $ %; 637 . 0 $ !"# ; ,$%%& &,#& < '' ( = 0>0)& ?' ># * ) ; ,$ ) &,# (3 + )( %9 006 @%$ TPH Report Page 13 of 25 !" #$ % &" '"()*+ "',-.#$/ 01 '212 3' 4 '2'( '2'5 6 (7" ' *0* ', 0. 8 *9* / :+( #/ - $/$ !"# ; +$$$ %+"% : && ' < /=/%( >& = #) 6 ( ; +$*% 6 ( %+" '2 * 6 ('+ $8 //5 ?$# TPH Report Page 14 of 25 !"# $% & '# (#)*+, #(-./$0 12!(323 4( 5 !(3() !(3(6 )7# 8 (! +1+ (-8!1/ 9 +:+ 0 $$ %; 637 . 0 $$ !"# ; ,$%% &,# < &&'( = 0>0) ?' >#* ) ; ,$' ) &,# (3 ) )( %9 006 @%$ TPH Report Page 15 of 25 !" #$ % &" '"()*+ "',-.#/ 01 '212 3' 4 '2'( '2'5 6 (7" ' *0* ', 0. *8* / $ 9+( ##/ - $/$ $ ! " #$% : +&&& %+" 9 '' ( ;/</ =& <% ) 6 ( : +& * 6 ( %+" '2 * 6 ('+ $>//5 ?$# TPH Report Page 16 of 25 ! "#"$% & '! ( ! !()*+ ,-"(.-. /( 0 (.(1 (.(2 13! 4 ( 5,5 ()4,+ 6 5"75 $8 "#"# $9 2.3 * 8 "#"# ! "# 9 :$%%& &:! & "; ''() <8"=8 >' =#* 1 9 :$( 1 &:! (. + 1( "$"6882 ?$# TPH Report Page 17 of 25 !"" ##$ % & ' (&))&()*')+,' (&% +-.%/ 0 01!""# 2 ##$ 0 %$$ !$ +&-.%/ 0 01!""# 2 ##$ 0 %$$ $ !$ %-.%/ 0 01!""# 2 ##$ $$ 0 %$$ !$ % 3$$04 ##$ $ 0 %$$ !$ % 3$$0&4 ##$ $ $ 0 %$$ !$ % 304 ##$ 5 0 % $5 !$ %$3 04 ##$ 5 0 % $5$ !$ %3 06 4 ##$ 5 5 0 % $5 !$ %3 4 ##$ $$0 0 % $5 !$ % 3$6 4 ##$ 0 0 % $5 !$ %36 4 ##$ 0 % $5 !$ 7 %8 ##$ $ 0 % $50 !$ &# #$ /66-9 TPH Report Page 18 of 25 ! " #" $%$ &'( )* +(%,%& - .(( +(%,/012 %30, 01 ".4(% 5656565656565 7% (+)(/ ) 8%97+/: ; .)) # ., (<(( ;# = !" - (48* - (4 (*$ ">#? - (4(@ .( ? - - (4 >;; ) - (4A! 8 . B& 88* 71? B& 8 (*$ ">#??17+/ % ,.( 71 B&% >" - ( ;1;1( 8 C? TPH Report Page 19 of 25 !"! # $%& ' ""(!" " ) *# ) *# !"!! # $%& ' ""(!" + ,)#, % -# . / ','%0 12# 34 # + ,)#+ *567 + ,)#+ *567 +3567 54117 +3 ) *# 54117 "!8""9"!8""!9"!8""9"!8""9"!8""9"!8""9"!8"":4 , ;, +1 <1 *,5;+<7 =" =8 !=" =8"="/""="" /4) & "8 ""="/" !" $%# *#*2 #$ $%# *- #2' ,#)4 # % $%,# 3 #*2 #&& ' 3 - #2' ' 3 # > 4 (($ ) #?#== @.#*# * ) #?#== @.#*# * 3 ## "!"== # *# A( TPH Report Page 20 of 25 !!! ""# # $ % &''&'(%')*% &$ $+,$- . /!!!" 0 "1"# 1 2 3## !2 # )+,$- . /!!!" 0 "1"# # 2 3##. !2 # $ 4##.5 "1"# 1 2 3## !2 # $ 4##.5 "1"# 1 2 3##1 !2 # $ 4.5 "1"# 1 2 3 #1 !2 # $#4 .5 "1"# . 2 3 #1# !2 # $4 .6 5 "1"# .#1 2 3 #1 !2 # $4 5 "1"# . 2 3 #1 !2 # $ 4#6 5 "1"# ## 2 3 #1 !2 # $46 5 " "# 2 3 #1 !2 # " "# -66+7 TPH Report Page 21 of 25 ! " #" $%$ &'( )* +(%,%& - .(( +(%,/012 %30, 01 ".4(% 56565656565 (%(+)(/ ) 7%8+/9 : .)) #;( 4*(& 55: :# < !" - (47* - (4 (*$ "=# - (4(; .( - - (4 =:>: ) - (4?! 7> . @& 77* A1 @& 7 (*$ "=#1+/ % ,.( A1 @&% >" - ( :1:1( 7 B TPH Report Page 22 of 25 !!" # $%& ' (!! ) *+#* % ,# - . '*'%/ 01# 23 # ) *+#) 4567 53007 !(8!(!8!(8!("8!(8!(93 * * )0 :0 4*5):7 !; ;((;. .< 1 % (;"";." !" $%# 4#41 #$ %& $%# 4, #1' *#+3 # $ $%*# ' 2 #41 ### 2 , #1' & 2 # < 3 ((% )% #=#;>; &%?-#4#> * + #=#;>; ?-#4#> 2 ## "!;; # 4# @" TPH Report Page 23 of 25 TPH Report Page 24 of 25 TPH Report Page 25 of 25 !"#$ %"# " &&'( %) *+&, - ( ) ) )) . #-) /)""$ % )0 ) 1 " )2# ) %2 ))0 #1 )"" )) #1 2 3 )4!&5 )) )% 0 # 6)0 ) %)7)(#% 48,&5!9&',8&!#$2)20 2)) )# -): %"")1 6# #$:22:%2) %# " "")1 6# ;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;;; 7)(#% ( 7% )#%<%# (&+=,+= &,+# # >?@, 12))"" " )==222#%# = ;;#) Page 1 of 68 Digitally signed by: Michael Page DN: CN = Michael Page C = US O = SGS North America OU = Environmental Services Date: 2016.06.16 09:36:26 -04'00' ! ! "#$ % "& #$ "#$ ' "& #$ ( (& ) ! ( * % (& % + + # , - $ . / + % 0 0 , , ! ! 1 234 %* "& * * % " 5 6 & % / %*7 8 9 & : "* & ; % #// & < * & $ 2 ! 5 #// = !( 0' 0 $ > 9 ' , ?" #4$? % @ / ! 7 3A68A6:38A ,// B 2C8 Page 2 of 68 !" !#$#%!&% !##%!$& '()*+ ,% !"% !#$#%!%& !##%!$& '()*+ - !" !#$#%!& !##%!$& - -% !"" !#$#%!"& !##%!$& - . / !" !##%!$& - 0 &!#!#%!1223 4", Page 3 of 68 The recovery for surrogate 2-Fluorophenol was below the QC control limits in this sample. was . !"# Page 4 of 68 !"#$% $& !"#' $(& !"# '(& !"'$ ) !"#$ * && !"% $& !"# '(& !"$% ) !"# + && !"# ,-& !"$# * && !"(%#( ., &,&/0*.-1 !"%# ""2##3 4( Page 5 of 68 !"# $ %# &#'()* #&+,-./. 01!&212 3& 4 !&2&' !&2&5 '6# 7 &! )0) &+7!0- 8 )9) / : 526 , ;/ !" : *#$$ % $*# & < ''()& =/>/ * ?% > "+ ' : *#(% ' $*# &2 '& 8//5 @. Page 6 of 68 !" # $" %"&'() "%*+,-.- /0 %101 2% 3 %1%& %1%4 5 &6" % (/( %* /, 7 (8( 9. :)& -. + . !" ; )### $ #)"$ : %%&'$$ <.=.$&( >$ =") 5 & ; )#* &+ 5 & #)" %1 * 5 &%, 7..4 ?- Page 7 of 68 !"# $ %# &#'()* #&+,-./ 0 12 !&323 4& 5 !&3&' !&3&6 '7# 8 &! )1) &+8!1- 9 ):) 0. ; 637 , /0 !" ; *#$$% $*# & < ' ' ( =0>0)*% ?% >"+ ' ; *# % ' $*# &3 ) '& 9006 @. Page 8 of 68 !" # $" %"&'() "%*+,-. / 01 %212 3% 4 %2%& %2%5 6 &7" % (0( %* 0, 8 (9( / - :)& -. /+/ - !" ; )###$ #)"$ : % % &$$ </=/$ '( >$ = ") 6 & ; )#* + 6 & #)" %2 * 6 &%, 8//5 ?- Page 9 of 68 !"# $ %& '(!)*(* +) , !)*)- !)*). -/# 0001 22 3 *4 5 6 00122 3 *4 5 6 0001 22 3 *4 5 6 00122 3 *4 5 6 0 22 3 *4 5 6 0 22 3 *4 5 6 0 2 3 *4 5 6 0012/ 3 *4 5 6 0012 3 *4 5 6 0012/ 3 *4 5 6 001 2-/ 3 *4 5 6 0 2 3 *4 6 0 2 3 *4 5 6 0 2/ 3 *4 5 6 0 22 3 *4 5 6 0 2 3 *4 5 6 00 1 2-/ 3 *4 5 6 0 2/ 3 *4 5 6 0 2 3 *4 5 6 0 2/ 3 *4 5 6 0 2 3 *4 5 6 7* 3 *4 6 2* 3 *4 5 6 8% 3 *4 6 2* 3 *4 5 6 )-* 3 *4 5 6 $2- 3 *4 6 3 *4 6 7/ 3 *4 5 6 7 / 3 *4 5 6 7 2 2 3 *4 5 6 7 . 3 *4 5 6 7 2 3 *4 5 6 7*-/ 3 *4 5 6 #)*.# 3 *4 5 6 2# 3 *4 5 6 2/ 3 *4 5 6 2# 2 3 *4 5 6 22 3 *4 5 6 2. 3 *4 5 6 2 2 3 *4 5 6 2 3 *4 5 6 355. 9: Page 10 of 68 !"# $ %& '(!)*(* +) , !)*)- !)*). -/# 2 2 3 *4 5 6 2#.* 2 3 *4 6 )0 2 3 *4 5 6 )0 2 3 *4 5 6 )-;2 3 *4 5 6 ;2-7/ 3 *4 5 6 8% 2* # 3 *4 5 6 )-/<* = 3 *4 5 6 $2-## 3 *4 5 6 $2-2# 3 *4 6 3 22 3 *4 5 6 - 3 *4 5 6 1 22*4 5 6 1* 3 *4 5 6 122 3 *4 5 6 12.* 2 3 *4 5 6 >-2# 3 *4 5 6 ?-< = 3 *4 5 6 )0 22 3 *4 5 6 0?- 3 *4 5 6 -/ 3 *4 5 6 ?- 3 *4 5 6 )7*-/ 3 *4 5 6 7*- 2-2<$17;= 3 *4 5 6 7*-/ 3 *4 5 6 )0 22 3 *4 5 6 )0 2* 3 *4 6 0 22 # @ : 5 6 7 .*/ :5 @ :5: 6 1*#: @ 65 6 7 2 $2# 1 ! ! " &5>5 # ;% > # - 7 2 $ - $2# )* %$ -) 355. 9: Page 11 of 68 !" # $% &' ()') *( + ()(, ()(- . ,/" 0.1 ()2 0 . ( 3 )2 0 .1 ( 3 )2 0 + 4 -)/ 5 67 0 4 -)/ 7 5 67 0 4 1 !"# #1" 8 $%%"$&"# %797'( :$ 9'( . , 4 1 !"# . , #1" () !) . ,( 377- ;0 Page 12 of 68 !"# $ %& '(!)*(* +) , !)*)- !)*). / -0# 11230 4 *5 6 11233 4 *5 6 1 33 4 *5 6 1 3 4 *5 6 1 * 4 *5 6 1 * 4 *5 6 3 33 4 *5 6 33 4 *5 6 43 4 *5 6 17 30# 4 *5 6 1 3-3 4 *5 6 3 3-3 4 *5 6 33-3-3 4 *5 6 / 33 4 *5 6 / 33- 4 *5 6 /3 4 *5 6 809 : 3 4 *5 6 809 :- 4 *5 6 809:.* 3 4 *5 6 8095131:- 4 *5 6 809;:.* 3 4 *5 6 8)933%-: 3 4 *5 6 8)933-:3 4 *5 6 8)93)-:3 4 *5 6 8)9<3-3%-:33 4 *5 6 8 3-3-3 4 *5 6 8*-0-33 4 *5 6 3-) 4 *5 6 *-33 4 *5 6 -33 4 *5 6 09 13: 3 4 *5 6 3-33 4 *5 6 3-33 4 *5 6 1 3-3 4 *5 6 3- 4 *5 6 ,* 3 4 *5 6 ,* 4 *5 6 =% 30 4 *5 6 =% 3* # 4 *5 6 =% 3- # 4 *5 6 =% 33 4 *5 6 #911#:- 4 *5 6 466. >? Page 13 of 68 !"# $ %& '(!)*(* +) , !)*)- !)*). / -0# )3 4 *5 6 4 33 4 *5 6 40 4 *5 6 43 4 *5 6 33 4 *5 6 3 3 4 *5 6 3 4 *5 6 - 4 *5 6 4)#- 4 *5 6 4##*5 2 112 3 @6@ A 6 ,*3- @6@ A 6@ ,*3 6 A 6? 40# ?6@ A 6? 3# ?6? A 6 23-# @6 A 6 8 3 $3# 2 !" &6B6##$ <% B$ / - 8 3 / - $3# )* % / -)%&' 466. >? Page 14 of 68 !" # $% &' ()') *( + ()(, ()(- . ,/" . ( 0 12 .3 ( 0 1 2.3 ( 0 1 4 33 1 5 1 +)3, 1 5 1 6( 1 5 1 63, 1 5 1 ! "# 4 3$$$% #3" %&'()#( 6 &))&* %171#( 8$ 7#( . , 4 3$+'% . , #3" () +'% . ,(, 911- :2 Page 15 of 68 !"# $ %& '(!)*(* +) , !)*)- !)*). / -0# # 1 2 3 4 $4# 5 &262! 7% 6! / - 3 4" / - $4# )* #" / -)" 822. 9: Page 16 of 68 !" ## $ %& '( )*(* +) , )*)- )*). -/" 0001 22 3 *4 556 7 00122 3 *4 556 7 0001 22 3 *4 556 7 00122 3 *4 556 7 0 22 3 *4 556 7 0 22 3 *4 556 7 0 2 3 *4 556 7 0012/ 3 *4 556 7 0012 3 *4 556 7 0012/ 3 *4 556 7 001 2-/ 3 *4 556 7 0 2 3 *4 56 7 0 2 3 *4 556 7 0 2/ 3 *4 556 7 0 22 *4 556 7 0 2 3 *4 556 7 00#1 2-/ 3 *4 556 7 0 2/ 3 *4 556 7 0 2 3 *4 556 7 0 2/ 3 *4 556 7 0 2 3 *4 556 7 8* 3 *4 5 7 2* 3 *4 556 7 9% 3 *4 56 7 2* 3 *4 556 7 )-* 3 *4 556 7 $2- 3 *4 56 7 3 *4 5 7 8/ 3 *4 556 7 8 / 3 *4 556 7 8 2 2 3 *4 556 7 8 . 3 *4 556 7 8 2 3 *4 556 7 8*-/ 3 *4 556 7 ")*." 3 *4 556 7 2" 3 *4 556 7 2/ 3 *4 556 7 2" 2 3 *4 556 7 22 3 *4 556 7 2. 3 *4 556 7 2 2 3 *4 556 7 2 3 *4 556 7 366. :5 Page 17 of 68 !" ## $ %& '( )*(* +) , )*)- )*). -/" 2 2 3 *4 556 7 2".* 2 3 *4 56 7 )0 2 3 *4 556 7 )0 2 3 *4 556 7 )-;2*4 556 7 ;2-8/ 3 *4 556 7 9% 2* " 3 *4 556 7 )-/<* = 3 *4 556 7 $2-"" 3 *4 556 7 $2-2" 3 *4 56 7 3 22 3 *4 556 7 - 3 *4 556 7 1 22 *4 556 7 1* 3 *4 556 7 122 3 *4 556 7 12.* 2 3 *4 556 7 >-2" 3 *4 556 7 ?-< = 3 *4 56 7 )0 22 3 *4 556 7 0?- 3 *4 56 7 -/ 3 *4 556 7 ?- 3 *4 556 7 )8*-/ 3 *4 556 7 8*- 2-2<$18;=*4 556 7 8*-/ 3 *4 556 7 )0 22 3 *4 556 7 )0 2* 3 *4 56 7 0 22 " @ 55#6 7 8 .*/ 5 6@5565 7 1*"5 6@576 7 8 2 !!"" $2" " 1 ##"$ &6>6% ;% >% - 8 2 - $2" )* & -) 366. :5 Page 18 of 68 ! "" # $% &'()') *( + ()(, ()(- . ,/! "0.1 ()2 ""3 . ( 4 )2 ""3 .1 ( 4 )2 ""3 + 5 -)/ 3 6 37 ""3 5 -)/ 007 6 37 ""3 5 1!"#$ #1! 8 % &$& % '$ %797( ) :$ 9( ) . , 5 1!"#$ . , #1! () !" . ,( 477- ;0 Page 19 of 68 !" ## $ %& '( )*(* +) , )*)- )*). / -0" 11230 4 *5 #67# 11233 4 *5 #67# 1 33 4 *5 #67# 1 3 4 *5 868 1 * 4 *5 #67# 1 * 4 *5 #67# 3 33 4 *5 #67# 33 4 *5 #67# 43 4 *5 #67# 19 30" 4 *5 6# 1 3-3 4 *5 868 3 3-3 4 *5 #67# 33-3-3 4 *5 #67# / 33 4 *5 #67# / 33- 4 *5 #67# /3 4 *5 #67# :0; < 3 4 *5 #67# :0; <- 4 *5 #67# :0;<.* 3 4 *5 #67# :0;5131<- 4 *5 #67# :0;=<.* 3 4 *5 #67# :);33%-< 3 4 *5 #67# :);33-<3 4 *5 #67# :);3)-<3 4 *5 #67# :);>3-3%-<33 4 *5 #67# : 3-3-3 4 *5 #67# :*-0-33 4 *5 #67# 3-) 4 *5 #67# *-33 4 *5 #67# -33 4 *5 #67# 0; 13< 3 4 *5 #67# 3-33 4 *5 #67# 3-33 4 *5 #67# 1 3-3 4 *5 #67# 3- 4 *5 #67# ,* 3 4 *5 #67# ,* 4 *5 #67# ?% 30 4 *5 #67# ?% 3* " 4 *5 #67# ?% 3- " 4 *5 6# ?% 33 4 *5 #67# ";11"<- 4 *5 #67# 466. @8 Page 20 of 68 !" ## $ %& '( )*(* +) , )*)- )*). / -0" )3 4 *5 #67# 4 33 4 *5 #67# 40 4 *5 #67# 43 4 *5 868 33 4 *5 868 3 3 4 *5 #67# 3 4 *5 #67# - 4 *5 #67# 4)"- 4 *5 #67# " "*5 2 2 " "*5 2 ?% " "*5 2 ' " "*5 2 112 3 76 A 6# ,*3- 7#6 A #67 ,*3 76B A 68 40"# 76 A 68 3" #6# A 6 23-" 6 A 6 !" : 3###$ $3" 2 %%& &6C6$"' >% C"' / - : 3# / - $3" )* ( / -)()* 466. @8 Page 21 of 68 ! "" # $% &'()') *( + ()(, ()(- . ,/! . ( 0 1 2 .3 ( 1 2 4 5.3 ( 0 1 2 4 6 33 42"72 +)3, 4272 8( 272 4 83, 4272 6 3 ! #3!!"#$ %&' & 8 #''#($ %292) & :$ 9 & . , 6 3*%" ! . , #3! () *%! . ,(+ 022- ;5 Page 22 of 68 !" ## $ %& '( )*(* +) , )*)- )*). / -0" " 1 2 ## 3 4 $4" 5 &262 7% 6 / - 3 4! / - $4" )* "! / -)! 822. 9: Page 23 of 68 !!"# $ %& '(!)*(* +) , )*)- )*). -/ 000"1 22 3 *4!5 !!" " 00122 3 *4!5 !!" " 00"0"1 22 3 *4!5 !!" " 00"122 3 *4!5 !!" " 0 22 3 *4!5 !!" " 0 22 3 *4!5 !!" " 0 2 3 *4!5 !!" " 0"012/ 3 *4!5 !!" " 0"012 3 *4!5 !!" " 0"012/ 3 *4!5 !!" " 0"01 2-/ 3 *4!5 !!" " 0" 2 3 *4! 5 !!" " 0" 2 3 *4!5 !!" " 0" 2/ 3 *4!5 !!" " 0" 22 3 *4!5 !!" " 0" 2 3 *4!5 !!" " 00 1 2-/ 3 *4!5 !!" " 0 2/ 3 *4!5 !!" " 0 2 3 *4!5 !!" " 0 2/ 3 *4!5 !!" " "0" 2 3 *4!5 !!" " "6* 3 *4!" 5 !!" " "2* 3 *4!5 !!" " "7% 3 *4! 5 !!" " 2* 3 *4!5 !!" " )-* 3 *4!5 !!" " $2-" 3 *4! 5 !!" " 3 *4!" 5 !!" " 6/ 3 *4!5 !!" " 6 / 3 *4!5 !!" " 6 2 2 3 *4!5 !!" " 6 . 3 *4!5 !!" " 6 2 3 *4!5 !!" " 6*-/ 3 *4!5 !!" " )*. 3 *4!5 !!" " 2 3 *4!5 !!" " 2/ 3 *4!5 !!" " 2 2 3 *4!5 !!" " 22 3 *4!5 !!" " 2. 3 *4!5 !!" " 2 2 3 *4!5 !!" " 2 3 *4!5 !!" " !!"355. 89 Page 24 of 68 !!"# $ %& '(!)*(* +) , )*)- )*). -/ 2 2 3 *4!5 !!" " 2 .* 2 3 *4! 5 !!" " )0 2 3 *4!5 !!" " )0 2 3 *4!5 !!" " )-:2 3 *4!5 !!" " :2-6/ 3 *4!5 !!" " 7% 2* 3 *4!5 !!" " )-/;* < 3 *4!5 !!" " $2- 3 *4!5 !!" " $2-2 3 *4! 5 !!" " 3 22 3 *4!5 !!" " - 3 *4!5 !!" " 1 22 3 *4!5 !!" " 1* 3 *4!5 !!" " 122 3 *4!5 !!" " 12.* 2 3 *4!5 !!" " = -2 3 *4!5 !!" " >-; < 3 *4!"5 !!" " )0" 22 3 *4!5 !!" " 0>- 3 *4!"5 !!" " -/ 3 *4!5 !!" " >- 3 *4!5 !!" " )6*-/ 3 *4!5 !!" " 6*- 2-2;$16:< 3 *4!5 !!" " 6*-/ 3 *4!5 !!" " )0" 22 3 *4!5 !!" " )0 2"* 3 *4! 5 !!" " 0" 22 " ? 9 5" !!" " 6 .*/ 9#5 ? 959 !!" " 1* 9 ? @#5 !!" " 6 2 !!""# $2 "# !1 $$"% &5!= 5& :% = & - 6 2 ' - $2 )* (' -) !!"355. 89 Page 25 of 68 ! ! "! # $%&# ''#&'(% ')*%&# )$+, -!!../ 0 ! !!!! #" . !" )$#+, -!!../ 0 ! !!! #" !" +, -!!../ 0 ! !! #" " !" !1 !"2 ! !!. #" . . !" !1 !"#2 ! !!! #" . !" ! ! !!. #" ! !! !" ! !!. #" ! !! !" 3 4 ! !! #" ! !! !" # ! !-5$5$+6! Page 26 of 68 ! "# $!% &%'(!') * +%!% &%'(!,-./"!'0-( -. 1+2%' 33 33345%! 67 %!7% 8 (9 3345 "67 %!7% 8 (9 33345%! 67 %!7% 8 (9 3345 "67 %!7% 8 (9 34"67 %!7% 8 (9 34"67 %!7%% 8 (9 34"67 2 2%% 8 (9 3345 "67 %:%% 8 (9 3345 "67 2 2% 8 (9 3345 "67 %:%% 8 (9 3345 "+%!7)%:%% 8 (9 34" +4467 2 2% 8 (9 34" +%!7% 8 (9 34"67 %:%% 8 (9 34"67 %!7% 8 (9 34"67 2 2% 8 (9 3345 "+%!7)%:%% 8 (9 34"67 %:%% 8 (9 34"67 2 2% 8 (9 34"67 %:%% 8 (9 34"67 2 2% 8 (9 4(!% 8 (9 4.7 !(%% 8 (9 4%#% 8 (9 4.7 !(%% 8 (9 4'2 2)!(%% 8 (9 4 %!7)442%!% 8 (9 ;6%!% 8 (9 %:%% 8 (9 +%:%% 8 (9 +67 +%!7% 8 (9 + + 8 (9 ++%!7% 8 (9 . <"'("<% 8 (9 . !%! 67 "<% 8 (9 .7 %:%% 8 (9 .7 <" ++%!7% 8 (9 .7 %!7% 8 (9 .7 + 8 (9 .7 +%!7% 8 (9 6"'434"67 %!7%% 8 (9 * "!!% 8.8.% !""6!"= Page 27 of 68 ! "# $!% &%'(!') * +%!% &%'(!,-./"!'0-( -. 1+2%' 33 6"'434"67 2 2%% 8 (9 " ++%!7% 8 (9 "67 ++%!7% 8 (9 "67 <"( +%!7% 8 (9 ""'2 2)>!7% 8 (9 >!7)%:%% 8 (9 %#67 (!<"%% 8 (9 '2 2)%:%%?.(+%%@ 8 (9 +324)%% 8 (9 %!7)"<"<% 8 (9 %!7)%%67 "<% 8 (9 27!7%% 8 (9 4(!)%:%% 8 (9 4* 2)%:%% 8 (9 4)%% 8 (9 '%64(!)%:%% 8 (9 1!) %% 8 (9 !% !4(!)+%!7)%!7% ? 5>@ 8 (9 !% !4(!)%:%% 8 (9 5%! 67 %!7%% 8 (9 5(%% 8 (9 ! '434"67 %!7%% 8 (9 ! '434"67 2 2%% 8 (9 ! '434"67 44(!%% 8 (9 5 "67 %!7%% 8 (9 5 "67 ( +%!7% 8 (9 ")67 "<% 8 (9 )%%?!!@ 8 (9 34"67 %!7%4< 84 A 4 +( %:%% 8 84 A 5(%%< 84 A * %2!67 * %2 %!7< 1$4 * %2!%5"+% ; * %2"!"$!88 + * %2>#! 6! + ;)!"6!67 1 ;)!"6 %!7< 1$4 '! (+%! 1 ;)'! $1 * "!!% 8.8.% !""6!"= Page 28 of 68 ! "#"" $ %&' ( #"# ) *$ ) *$ ! "#"" $ %&' ( #"# " + ,)$,!& -$ . /$ 01 $ + ,)$+ *234 + ,)$+ *234 +0234 2)54 +0 ) *$ 2)54 ####6####6####71 , 666"89 $*: $: ;## ;##;##;## ;#"##;#8<#;## 6689 *: $: ;## ;#<#;##";## ;#<#";#8<#;## 66"6"89 $*: $: ;## ;<#;;## ;;#8"<#;## 66"89 *: $: ;## ;;;## ;;#8"#;## 68 *: $: ;## ;";#;## ;#;#8#;## 68 *: $: ;## ;<;;## ;;#8"#;## 68 *: ;## ;";<;## ;<;#8"#;## 6"689 *:! ' ;## ;#;"<;## ;<;#8"#;## 6"689 *: ;## ;";;## ;<;#8"#;## 6"689 *:! ' ;## ;<";<";## ;"<";#8<#;## 6"689 1 $:&! ' ;## ;#;<;## ;<;#8"#;## 6"8 !188*: #;# ";<;"<#;# "<;<";#8##;## 6"8 !1 $: ;## ;#<#;"##";## ;##";#8<#;## 6"8 *:! ' ;## ;#;#;## ;#<;#8#;## 6"8 *: $: ;## ;"#;#;## ;#;#8<#;## 6"8 *: ;## ;#;<#";## ;#;#8"#;## 6689 1 $:&! ' ;## ;#;""<;## ;<;#8""#;## 68 *:! ' ;## ;##;"##";## ;#<#";#8"##;## 68 *: ;## ;"#";#;## ;##;#8"##;## 68 *:! ' ;## ;##;<#";## ;###;#8"#;## "6"8 *: ;## ;;<;## ;<;#8"#;## "8)$ ";# ";";"<";# ;;#8#;## "8:$) ;## ;#";"#;## ;#;#8"#;## "8 . ";# ";#";"";# ";;#8#;## 8:$) ;## ;;<;## ;<##;#8"#;## 8,&$) ;## ;"#;#<#;## ;"<#;#8"##;## 8- $:&8"8 $ ";# ;;"";# ";";#8"#;## %* $ ";# ;<";#";# ;";#8##;## ' ;## ;"#";#;## ;##";#8"#;## 1! ' ;## ;";#;## ;#;#8"##;## 1*:1 $: ;## ;;;## ;;#8"#;## 11 ;## ;;<;## ;#<";#8"#;## 0 $$ #"#;; $ *$ = Page 29 of 68 ! "#"" $ %&' ( #"# ) *$ ) *$ ! "#"" $ %&' ( #"# " + ,)$,!& -$ . /$ 01 $ + ,)$+ *234 + ,)$+ *234 +0234 2)54 +0 ) *$ 2)54 ####6####6####71 , 11 $: ;## ;"<#;## ;#;#8#;## !( ,) ( ;## ;";#;## ;##;#8"#;## !$ $*: ( ;## ;#;<;## ;<;#8"##;## :! ' ;## ;";"#<;## ;"#;#8"##;## :( !11 $: ;## ;"";<;## ;<<;#8""#;## : $: ;## ;#;"<;## ;";#8#;## :1 ;## ;<";#;## ;#;#8"#;## :1 $: ;## ;<;<;## ;#;#8"#;## * ,86"8 *: $: ;## ;<";<<;## ;<;#8"#;## * ,868 *: ;## ;#;#<;## ;<;#8""#;## !11 $: ;## ;#;<"#;## ;#<;#8"#;## *:!11 $: ;## ;";#;## ;<<##";#8"##;## *:( )1 $: ;## ";<;## <;#8##;## ,&>$: ;## ;";;## ;#";#8"#;## >$:& ' ;## ;#;<#<;## ;#;#8"#;## .*:!)$( ;## ;#";#;## ;"#<;#8"#;## ,&! ' 2)1 4 ;## ;"#;<#;## ;<;#8"##;## 168& #;# <;#;"<#;# <;<;#8"#;## - $:& ( ( ;## ;;"<;## ;";#8"#;## - $:& *: ( ;## ;;;## ;##;#8#;## :$: ;## ;<;;## ;#;#8""#;## 8)$&! ' ;## ;<#;""<#;## ;#<#;#8#;## 80&! ' ;## ;;#<;## ;<<;#8"#;## 8& ;## ;;";## ;;#8"#;## , *8)$&! ' ;## ;##;<;## ;<;#8"#;## $& ;## ;"<";;## ;;#8"#;## $ $8)$&1 $:& $: 2-9>4 ;## ;##;";## ;#;#8"#;## $ $8)$&! ' ;## ;#;""<";## ;<<";#8""#;## 9 $*: $: ;## ;#;<#;## ;#<<;#8"#;## 9) ;## ;";#;## ;#;#8"#;## $,86"8 *: $: ;## ;<";<<<;## ;<;#8#;## $,868 *: ;## ;<;<";## ;<#;#8"#;## 0 $$ #"#;; $ *$ = Page 30 of 68 ! "#"" $ %&' ( #"# ) *$ ) *$ ! "#"" $ %&' ( #"# " + ,)$,!& -$ . /$ 01 $ + ,)$+ *234 + ,)$+ *234 +0234 2)54 +0 ) *$ 2)54 ####6####6####71 , $,868 *:8"8!)$ ";# ";;<";# ";#;#8"#;## 9 *: $: ;## ;#;#;## ;#;#8"#;## 9 *:)1 $: ;## ;;;## ;<;#8#;## &*: ( ;## ;;"#;## ;<;#8#;## 6"8 *: $: 8( # #;#8" 81)! ' < <";8 9) ( # #<;8 ! " %&$ *$*: #$ %&$ *- $:( ,$)1 $ $% %&,$ 0 $*: #&&'' 0 - $:( ' 0 $ 9 1 (( ) $/$;; *>.$*$ * ) $/$;; *>.$*$ * 0 $$ #"#;; $ *$ = Page 31 of 68 !! !!" !! # $% & ' ($% $)* ($% $)*$'* # (%!+ (%) %!+ ,+$',+ -,./ 00" 0001 )2// 2 3 4 4 4"454 001)2// 2 3 4 4 444 0001 )2// 2 3 4544 001)2// 2 3 5"4 545 454"4 0)2// 2 3 54 545 45544 0)2// 2 3 444 0)2/// 3 4 "4" 444 001)2//&6 3 4 4 45 44 001)2/// 3 4544 001)2//&6 3 4 "4 444" 001 2&6 3 4 45 444 0&/ /)2/// 3 5 " 444 0&/ / 2 3 4 4 4454 0)2//&6 3 54 545 454"4 0)2// 2 3 444 0)2/// 3 4 45 45 445 00"1 2&6 3 4 4 444 0)2//&6 3 4 "4" 444 0)2/// 3 4 4 4454 0)2//&6 3 4 4 44"4 0)2/// 3 4 4 444" 7% / 3" """ " ""8 458 44 ,2// /% 3 4 4 4"454 9#/ 3" " 5" 45544 ,2// /% 3 4 4 444 // /% 3 4 48 48 4"4 2 / 3" "" " ""5 4445 ) / 3" " "8 48 44"4 76 3 554 55455 455 44" 7/ /&6 3 54 545 454"4" 7/ /)2// 2 3 444 7/ /./ 3 4 4 44"4 7/ / 2 3 "4 "4" ""44 7% &6 3 4 4 4"44 ,&/:%.: 3 54 4 454545 ,&/ )2/: 3 54 45 444 ' !!34,4, .) /; Page 32 of 68 !! !!" !! # $% & ' ($% $)* ($% $)*$'* # (%!+ (%) %!+ ,+$',+ -,./ 00" ,2//&6 3 54 545 4544 ,2//:&/ / 2 3 "4 4 4"454 ,2// 2 3 4 4 444 ,2//./ 3 5"4 545" 45"44 ,2// 2 3 54 4 4544 &/ / 2 3 5"4 545 45"44 )2//&/ / 2 3 4 "4" 444 )2//:.%// 2 3 3 344 )0)2/// 3 4 4 444 0)2/// 3 4 4 44"4 //< 2 3 4 48 48 454 < 276 3 54 48 458 44 9#)2//&% : 3 4 545 "44"4 //&6,% 3 4 548 48 44 2/:: 3 54 545 8 44 2)2/: 3 355454"" 32 2 3 4 4 4"4""4 3 4 548 4"8 44 1 )2// 2 "" "444" 1/% 3 54 545 4544 1)2// 2 3 54 545 454"4 1)2//.%// 2 3 4544 =)2/: 3 5"4 4544 )0)2// 2 3 54 545 4544 0> 3 "5 458 44 '/&6 3 4 4 4"44 /> 3 4 48 48 44 )7% &6 3 "4 4 444 7% 2 217< 3 4 "4"8 48 44 7% &6 3 4 48 48 44 0)2// 2 3 54 4 45 4"4 0)2//&% 3" " 45445 0)2// 2:55 "4 7/ /.%//&6554 1/%:54 ' !!34,4, .) /; Page 33 of 68 !! !!" !! # $% & ' ($% $)* ($% $)*$'* # (* (%) * ,+$',+ -,./ 00" )7 )2 ! ) 2/: % "! '7 )2##$$% ' 2/:$ % ' !1 & & $' 4!=/4 (<# ) =/4 ( 4!=/4 (<# ) =/4 ( ' !!34,4, .) /; Page 34 of 68 ! " # $% && % & '$ & ( )# $% " (#*"+,-. ! , "/#0 (#*"+,-. ! , "/#0 "*"+,-. ! , "/#0 /1 , "/#! ! /1 , , "/#! +22 * 3 Page 35 of 68 !" # $ %$&' &( ) *$ $ %$&' +,-! &.,' , /*0$& 1213122 45!06 !7& '8 45 * !7& '8 45!06 !7& '8 .424 *' $9$$ 2 :41 ; )424 *' $9$$ 1: :41 ; ) $0 76 ) $0 $ 6< 5=)) ) $0 $>!*$ 2 ) ) $0! !# :: 2* ) $0=" 7 2* 5( !7 76 5( !7 $ 6< 5=)) & '*$ 5(& #/ ) ! $ ::$ !!7 !?2 Page 36 of 68 ! " # $%& ' ( )( * +# * +# ! " # $%& ' ( ) , -*#-!% .# / 0# 12 # , -*#, +345 , -*#, +345 ,1345 3*65 ,1 * +# 3*65 )()7)((82 - 9$ :# +- ; ;9)); "9$2# +- ;) ";9)); "9$ :# +-( ();( )";9)); <9(92*! & ;9) 19(92*! & " ");9) $%# +#+: !"# $%# +. #:' -#*2 # $ $%-# % 1 #+: !"# 1 . #:' 1 # = 2 &'(#)( &#' #*+) #0#;; )&,>/#+# )&, * #0#;; )&,>/#+# )&, 1 ## ;; # +# ?( Page 37 of 68 !"" # $ $% #% & ' ( )'**')*+(*,-( )'& ,./&0 1 2!""$ #3 $ $% 1 1 &%% !%# ,'./&0 1 2!""$ #3 $ $% % 1 &%% !%# &./&0 1 2!""$ #3 $ $% % 1 &%% 1 !%# &14 54%% 15 $ $% % 1 &%% 1 !%# &14 54%% 1'5 $ $% % 1 &%% 1% !%# &14 5 $ $% 1 & !%# &4 %5 $ $% % 1 & % !%# '$ $% 066.7 Page 38 of 68 !" #!$#!%&% '()!*+ ,)&- &' . /) ) ,)&- 0123! &41- 12 #/5)& 6 7&!),*)0 *!8&97,0: ; /** $ /- )<)) ;$ = !" . )5 8+ . )5 ) +% #>$? . )5 )@!/) A . )5! !> ;; * . )5B" 8 / A' !8 8+ 72? A' !8 ) +% #>$??27,0 & -/) 72 A'& ># . ! ) ;2;2) !!8 !C? Page 39 of 68 ! "#" $ %&' ( #"# ) *$ ) *$ ! "#" $ %&' ( #"#" # + ,)$,!& -$ . / (,(&0 12$ 34 $ + ,)$+ *567 + ,)$+ *567 +3567 54117 +3 ) *$ 54117 ####8####"94 , :, +1 ;1 *,5:+;7 <# <#<#<# <##<#/##<## /4)! ' # ##<#/# !" %&$ *$*2 #$% %&$ *- $2( ,$)4 $ & %&,$ 3 $*2 #'' % 3 - $2( ( 3 $ = 4 ) ()$ %*$ $>$<< ?.$*$ + ) $>$<< ?.$*$ + 3 $$ #"#<< $ *$ @A Page 40 of 68 !! !! !! " # #$$%& '( ) * +'( ',- +'( ',-'*- " + !+ +(, !+ ./'*./ 0.1# 2 3#',3' 45 5 5 56 7576 55 # #1(##)875 !"#" , ,&$%& , &#$ ( ' * ,&$(( & * &#$ ) * !9 * *% +) : 5!;#5 ,'<" , ;#5 - : 5!;#5 ,'<" , ;#5 - * !!45.5. 1, #=6 Page 41 of 68 ! " # # "#$! #% & ! " '()*+,-. + /0+ % '()*+,-. /0+ 123, 4 * /0++ 12354 ++ /0+ 12 /0++ 12 +, /0+ )66 ' 7 Page 42 of 68 !" #"$%$& ' ("" #"$%)*+,$-*% *+ .(/"$ 012011 22134 56 "7"" 8 %9 212034 56 /6" 8 %9 21356 /6" 8 %9 213("6&/6" 8 %9 213 /6" 8 %9 213 %"" 8 %9 203 %"" 8 %9 3+6 /66"" 8 %9 3+6 /6" 8 %9 3 /6" 8 %9 2:356 "7;" 8 %9 1203 33("6&/6" 8 %9 13 (/6"&/6"&"6" 8 %9 13+6 33("6&/6" 8 %9 13+6 /6"&/6"&"6" 8 %9 13 /6" 8 %9 <5"/66"" 8 %9 <5"/66&"" 8 %9 <6 5"" 8 %9 "7=>6 5"" 8 %9 "7=>/& "" 8 %9 "7=>% 6"" 8 %9 "7=9262>/" &"" 8 %9 "7=>% 6"" 8 %9 $=3+6 "6 &>("6" 8 %9 $=3+6 "6&>"6" 8 %9 $=3+6 $/ /&>"6" 8 %9 $=3?6&6" &>/66" 8 %9 %&"7&/66" 8 %9 +6 &$"" 8 %9 "7=26>6 5"" 8 %9 "6&/66" 8 %9 ("6&/66" 8 %9 33%&/66" 8 %9 335&/66" 8 %9 /6"&(" 8 %9 -% 6"" 8 %9 -% "" 8 %9 " 56 "7"" 8 %9 " 56 %;"" 8 %9 " 56 5&5/";"" 8 %9 ' " 000 8+8+" 5@1 Page 43 of 68 !" #"$%$& ' ("" #"$%)*+,$-*% *+ .(/"$ 012011 " 56 "6" 8 %9 ;"=2235;>/& "" 8 %9 $/6 " 8 %9 /66"" 8 %9 "7"" 8 %9 3 $;33/ /&(" 8 %9 '"56 /6" 8 %9 '6"6 "" 8 %9 '6" 8 %9 '& "" 8 %9 212034 (/6" 8 83 A 3-% /6"& 08 83 A 3-% /6" 18 83 A "7""3; 81 1083 A '6"3;0 018 183 A 4" /6"&3;1 080 831 A ' "/56 ' "/ "6; ?'<0 ' "/"4(" 00 1 < ' "/!8B8 ( ' "/? 5B ( <&556 .0 <&5 "6; ?'<0 $ %(" . <&$ 4- ' " 000 8+8+" 5@1 Page 44 of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age 45 of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age 46 of 68 ! " #$% & !'(!' ) *+"* $ ," - ." /0 " ) *+") 1234 234 '!(!!!6'!(!!!(70 * ! #$" 1"1: "# #$" 1, ":& *"+0 " # $% #$*" $&' / "1: """ / , ":& / " 9 0 %(%(%)* ".";@; %%%+=-"1"@ + + ".";@; =-"1"@ / "" !''!';; " 1" >( Page 47 of 68 ! " #$% & '#$#() '#$#()#&) " '$ * '$($ * +*#&+* ,+-. / //0(1..%2 34 !45 !4 //0(1..1. 34 !4!!4 /(1..1. 34 64!64 /.1. 34 35 46 /..$ 34 54!646 /..$ 34 64!!45 +1..11 34 4!45 +1..1. 34 45 4 3.1. 34 !4!645 /7(1..%28 34 !44 /. 11. 34 64!45 +1.. 11. 34 64!!4! +1..111 34 46 545 (11 34 545 !!4 (11 34 64!4 1( 34 4!!!4 92.1( 34 !4!4 92. 34 54!!!4 92.%-$.1 34 545 !46 92./1/ 34 454 92.'-$.1 34 454 9+1..1." 1 34 4545 9+1..11 34 !4645 9+1....1 34 !4!!4 9:11"11 34 45545 9. .111 34 546 !4! 9$%211 34 4!6 4 +1 34 4!6 !45 %$11 34 64!45 .(11 34 454.00 146 %2/11( 34 454 111 34 64!4 111 34 64!!4 / 11. 34 45 46 1 34 46 4 ;$.1 34 54!4! & 34+4+-(.<5 Page 48 of 68 ! " #$% & '#$#() '#$#()#&) " '$ * '$($ * +*#&+* ,+-. / ;$. 34 46 564 ="(1..%2 34 54!4 ="(1..%$8 34 !4!4 ="(1..((.8 34 44 ="(1..1 34 45 4 8.//(8 34 45 54! .1.. 34 45 546 311 34 54!4 3.%2 34 45 45 3.1. 34 464 &(1..1. 34 4!4! &11 34 54!4 &1. 34 45 !6 4 & 34 !45 !4 3..8. 34 54!!4 //0%. .1. 564 ;$..%1 !544! ;$..1. 445 3.%28 546 45 &1.8 !464 018 46 4 (9(1 (1.8 $ ! "# &9(1$ &1.8 & 0 !% !%! &' 4 >.4()*+:"(>.4+ 4 >.4:"(>.4 & 34+4+-(.<5 Page 49 of 68 !"# $% &$!'('$)*+)*+$&),+$&-* .-/0 1 .. 11(200%3 4 45 11(20020 4 45 120020 4 45 1 220 4 45 1020 4 45 100 4 45 100 4 45 -20022 4 45 -20020 4 45 4020 4 45 16200%37 4 45 10 220 4 45 80 0222 4 45 -200 220 4 45 -200222 4 45 4020 4 45 22 4 45 22 4 45 2 4 45 830)+2 4 45 830)+ 4 45 830)%+/02 4 45 830)121+ 4 45 830)9+/02 4 45 8)-20020"+ 2 4 45 8)-2002+2 4 45 8)-20000+2 4 45 &45-5-/0:; Page 50 of 68 !"# $% &$!'('$)*+)*+$&),+$&-* .-/0 1 .. 8)'22"+22 4 45 8%322 4 45 -2 4 45 %3)12+2 4 45 222 4 45 222 4 45 %22 4 45 022 4 4 30.00 2 4 45 <02 4 45 <0 4 45 ="200%3 4 45 ="200%7 4 45 ="20007 4 45 ="2002 4 45 70)117+ 4 45 0200 4 45 422 4 45 40%3 4 45 40070 4 45 &20020 4 45 &22 4 45 &20 4 45 & 4 45 &45-5-/0:; Page 51 of 68 !"# $% &$!'('$)*+)*+$&),+$&-* .-/0 1 .. 82>! !207'& ! (< &45-5-/0:; Page 52 of 68 ! " #$ %% $ %&# %'(#$ ! !)*!+ ,,,- . / $" , $ '")*!+ ,,,- . , $" , $ 0 /1 $" , $ 0 / 1 $" , $ 0 21 $" , $ $" $ $" $ +3"3") 4 Page 53 of 68 !" #"$%$& ' ("" #"$%)*+,$-*% *+ .(/"$ 010 "2 3 (4 ' "/56 ' "/ "62 .!708 ' "/"9(" 00 08 ' "/!3:3 ( ' "/; 5: ( 8&556 ' 8&5 "62 .!700 $ %(" +' 8&$ '.! ' " 000 3+3+" 5< Page 54 of 68 ! " # $%& ' !(" !(( ) *+#*% # , -# ./ # ) *+#) 0123 1/43 (!!!!5(!!!!6/ * '7 " 7 ! !7!8 ! $%# 0#09 $%# 0 #9' *#+/ # ! $%*# . #09 "" . #9' # . # : / $ $% & % #-#7;7 '<,#0#; ' + #-#7;7 <,#0#; . ## !(( !(77 # 0# = Page 55 of 68 !! !! !! " #$ % & '#$ #() '#$ #()#&) " ' !* '$( !* +*#&+* ,+-. / *0 12 1 1 1 12 111 (3 (4 ( 4.0 $ ! &3 (4"" & 4.0 # & !5 $ $% & % 1!6.1 '7" ( 6.1 ' 1!6.1 '7" ( 6.1 ' & !!81+1+ -( .9: Page 56 of 68 ! "#$ %& '%"()(%* +,* +,%'*-,%'.+ /.01 2 // +3 4 4 44 56" ' "613 $! .' ' $ '56"77! '"613 $! ' ) ! ' 84.4.019! Page 57 of 68 !" #$ !" %%% " #$&" #$" $'(('(#)(*$'& &+ #&,-./%%%0 " 1 2 %1 &+ #&,-./%%%0 " 1 2 %1 + #&,-./%%%0 ." 1 2 %1 + #&,-./%%%0 ." 1 2 %1 3.4 " 1 2- %1 3.4 " 1 2- %1 354 "- 1 2 %1 354 " 1 2 %1 ." 1 2 %1 " 1 2 %1 "- 1 2 %1 " 1 2 %1 #" ,66#+ 7 Page 58 of 68 !" #"$%$& ' ("" #"$%)*+,$-*% *+ .(/"$ 012011 +3+4 (5$ 6 (7 +3+04/85$ 61 (7 +3+4/85$ 6 (7 3 (/88"" 06 1631 9 3-% /8"& 6 1631 9 3: 5$" 6 1631 9 3:" /8"& 6 1631 9 ' "/58 ' "/ "8; .!310+3( ' "/":(" 00 4 ' "/!6<6 ( ' "/= 5< ( 4&558 >+1 4&5 "8; 4='=' $ %(" >+ 4&$ <. ' " 000 6+6+" 5?1 Page 59 of 68 !" # $%& ' !"!" ( )*#) % +# , -# ./ # ( )*#( 0123 1/43 "!5!!!6"!5!!!57/ ) 8$/# 0)!9! !9"5!9!85! 8"$ :# 0)!9! !95 5!9!85! 8$ :# 0)!9!! !95 5!9!85! 8/:#: "5!9!85! 8;* : % "5 5!9!85! 8< 0) 5!9!85! 8< : % 5!9!85! $%# 0#0: !"# $%# 0+ #:' )#*/ # # $%)# $ . #0: !#%% . + #:' &'# ()!"*'%+,!+ . # < / *(,%*,"*%(%%-)! #-#9=9 %***+>,#0#= !+ * #-#9=9 >,#0#= . ## !""!"99 # 0# ?5 Page 60 of 68 !! !! " #$ % & '#$ #() '#$ #()#&) " ' !* '$( !* +*#&+* ,+-. / ++. ( 010 00 +1+2 ( 00 010 +1+32 ( 00 00 4. .2 2 00 5$..%2 0 6(. 30 .62 30 (4 (2 !"# ( 2.7 $ # $ &4 (2!#%% & 2.7 &'# ()!"*'%+,!+ & !6 *(,%*,"*%(%%-)! 0!8.0.#"+9" ( 8.0!+ 0!8.09" ( 8.0 & !!:0+0+ -( .;3 Page 61 of 68 !" #$ %# &'&#( )*( )*#%(+*#%,) -,./ 0 -- ,,/ 1 12 ,3,4 2 2 2 ,3,4 1 12 5/ /44 62 62 2 7//$4 62 62 2 '/ 2 62 22 /'4 62 62 2 5489, 4/: &%&%; 9, < %54888 % 4/: ",) ) %' %12,2,./= Page 62 of 68 !!! " "# $ % &''&'(%') *% &$ $ +,$ - . /. 0!!!" 1 " "# # 2 3 ## !2 #/ ) +,$ - . /. 0!!!" 1 " "# . 2 3 ## !2 #/ $ 4 #54## 5 " "# #. 2 3 ## . !2 #/ $ 4 #54## 5 " "# # 2 3 ## !2 #/ $ . 4 5 " "# ### 2 3 !2 #/ $ 4 #5 " "# 2 3 # !2 #/ " "# -66+7 Page 63 of 68 !"!#$# %&'() *'$+$% , -'' *'$+./01$2/+ /0 !-3'$ 45645 '$'*('. (7$8*.9 4: -(( ";' 3)'% : 5:"5 < !" , '37) , '3 ')# !="545 , '3';-' 44 , , '3=:>: ( , '3? 7> - @%77) A05 @%7 ')# !="540*. $ +-' A0 @%$ >! , ' 444 :0:0' 7B5 Page 64 of 68 ! " # $%& ' !" !" ( )*#)% +# , - ')'%. /0# 12 # ( )*#( 3456 42//6 "!7!!!8"!7!!! 92 ) ) (/ :/ 3)4(:6 " ; ;7 ;!- -< 0 % ;7 7!;!-7! !" $%# 3#30 #$ %& $%# 3+ #0' )#*2 # $ $%)# ' 1 #30 ### ( 1 + #0' ( 1 # < 2 ) )% *(( #=#;>; (%?,#3#> + * #=#;>; ?,#3#> 1 ## !"" !";; # 3# @7 Page 65 of 68 !"" !"" !"" !# $ $% %&'! ( )! * + ! ,( )!(-. ,( )!(-.(+. !# , ", ,)-! ", /0 (+/0 1/2$ 3 (- ( 45 5 5 56 56 55 $7'555 !"#" !-!-'$% &' !-!'$% !) !% !( +!-'$$$ ) +!'$%) +!"7 * *& +)) !8!5"9$5)&, :#!-!9$5 - !8!5"9$5)&, :#!-!9$5 - +!!""45/5/!2-!$; Page 66 of 68 Page 67 of 68 Page 68 of 68 ATTACHMENT C WELL CONSTRUCTION RECORDS WELL CONSTRUCTION RECORD This form can be used for single or multiple wells Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water 5HVRXUFHV Revised AXJXVW 2013 1. Well Contractor Information: Well Contractor Name NC Well Contractor Certification Number Company Name 2. Well Construction Permit #: List all applicable well permits (i.e. County, State, Variance, ,QMHFWLRQetc.) 3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single) □Industrial/Commercial □Residential Water Supply (shared) □Irrigation Non-Water Supply Well: □Monitoring □Recovery Injection Well: □Aquifer Recharge □Groundwater Remediation □Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage □Experimental Technology □Subsidence Control □Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks) 4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location: Facility/Owner Name Facility ID# (if applicable) Physical Address, City, and Zip County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N 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 #21 remarks section or on the back of this form. 8. Number of wells constructed: For multiple injection or non-water supply wells ONLY with the same construction, you can submit one form. 9. Total well depth below land surface: (ft.) For multiple wells list all depths if different (example- 3@200’ and 2@100′) 10. Static water level below top of casing: (ft.) If water level is above casing, use “+” 11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount: 14. WATER ZONES FROM TO DESCRIPTION ft. ft. ft. ft. 15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. 16. INNER CASING OR TUBING (geothermal closed-loop) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ft. ft. in. ft. ft. in. 18. 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 DESCRIPTION (color, hardness, soil/rock type, grain size, etc.) ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certification: Signature of Certified Well Contractor Date By signing this form, I 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 INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Supply & Injection Wells: Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed. For Internal Use ONLY: WELL CONSTRUCTION RECORD This form can be used for single or multiple wells Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water 5HVRXUFHV Revised AXJXVW 2013 1. Well Contractor Information: Well Contractor Name NC Well Contractor Certification Number Company Name 2. Well Construction Permit #: List all applicable well permits (i.e. County, State, Variance, ,QMHFWLRQetc.) 3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single) □Industrial/Commercial □Residential Water Supply (shared) □Irrigation Non-Water Supply Well: □Monitoring □Recovery Injection Well: □Aquifer Recharge □Groundwater Remediation □Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage □Experimental Technology □Subsidence Control □Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks) 4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location: Facility/Owner Name Facility ID# (if applicable) Physical Address, City, and Zip County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N 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 #21 remarks section or on the back of this form. 8. Number of wells constructed: For multiple injection or non-water supply wells ONLY with the same construction, you can submit one form. 9. Total well depth below land surface: (ft.) For multiple wells list all depths if different (example- 3@200’ and 2@100′) 10. Static water level below top of casing: (ft.) If water level is above casing, use “+” 11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount: 14. WATER ZONES FROM TO DESCRIPTION ft. ft. ft. ft. 15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. 16. INNER CASING OR TUBING (geothermal closed-loop) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ft. ft. in. ft. ft. in. 18. 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 DESCRIPTION (color, hardness, soil/rock type, grain size, etc.) ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certification: Signature of Certified Well Contractor Date By signing this form, I 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 INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Supply & Injection Wells: Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed. For Internal Use ONLY: WELL CONSTRUCTION RECORD This form can be used for single or multiple wells Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water 5HVRXUFHV Revised AXJXVW 2013 1. Well Contractor Information: Well Contractor Name NC Well Contractor Certification Number Company Name 2. Well Construction Permit #: List all applicable well permits (i.e. County, State, Variance, ,QMHFWLRQetc.) 3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single) □Industrial/Commercial □Residential Water Supply (shared) □Irrigation Non-Water Supply Well: □Monitoring □Recovery Injection Well: □Aquifer Recharge □Groundwater Remediation □Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage □Experimental Technology □Subsidence Control □Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks) 4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location: Facility/Owner Name Facility ID# (if applicable) Physical Address, City, and Zip County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N 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 #21 remarks section or on the back of this form. 8. Number of wells constructed: For multiple injection or non-water supply wells ONLY with the same construction, you can submit one form. 9. Total well depth below land surface: (ft.) For multiple wells list all depths if different (example- 3@200’ and 2@100′) 10. Static water level below top of casing: (ft.) If water level is above casing, use “+” 11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount: 14. WATER ZONES FROM TO DESCRIPTION ft. ft. ft. ft. 15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. 16. INNER CASING OR TUBING (geothermal closed-loop) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ft. ft. in. ft. ft. in. 18. 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 DESCRIPTION (color, hardness, soil/rock type, grain size, etc.) ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certification: Signature of Certified Well Contractor Date By signing this form, I 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 INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Resources, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells ONLY: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Resources, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Supply & Injection Wells: Also submit one copy of this form within 30 days of completion ofwell construction to the county health department of the county whereconstructed. For Internal Use ONLY: