WI0400539_Permit (Issuance)_20200225

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule" and do not require an individualpermit when constructed in accordance
with the rules of I5A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale_ Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: January 29 , 2020_ PERMIT NO. W10400539 (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) x
Air Injection Well......................................Complete
sections B through F, K, N
(2)
Aquifer Test Well.......................................Complete
sections B through F, K, N
3
O
Passive Injection System ...................
J y ............Complete
sections B through F, H-N
(4)
Small -Scale Injection Operation ......................Complete
sections B through N
(5)
Pilot Test.................................................Complete
sections B through N
(6)
Tracer Injection Well...................................Complete
sections B through N
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): NCDEQ/DWM/UST Section/Trust Fund Brand: Incident Manager- Herbert Berger
Mailing Address: _ 1646 Mail Service Center,
City: Raleigh _ State: _NC_ Zip Code:27699 County: Wake
Day Tele No.: 919-707-81
Cell No.:
EMAIL Address: Herbert. Betger,ncdenr.jZov Fax No.:
Deemed Permitted GW Remediation NO] Rev. 3-21-2018 Page 1

ra
E.
F
50,
PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Shaikh Amiad Masoud on behalf of Abid Masoud
Company Name
Mailing Address: 225 West Ridge Drive
City: Burlington State: NC_ Zip Code: 27215 County: Alamance
Day Tele No.: 336-512-2044
EMAIL Address:
Cell No.: 336-512-2044
Fax No.:
PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Lyndal Butler
Company Name S&ME, Inc.
Mailing Address: 8646 West Market Street, Suite 105
City: Greensboro State: _NC_ Zip Code:27409 County: Guilford
Day Tele No.: 336-288-7180 Cell No.: 336-312-0276
EMAIL Address: lbutlernn,smeinc.com Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Incident #24248 Name: Former Country Cupboard
9681 NC Highway 700
City: Pelham County: Rockingham Zip Code: 27311
(2) Geographic Coordinates: Latitude":
or 36.5173 °_
Longitude": " or-79.5477 °
Reference Datum: Accuracy:
Method of Collection: Google Earth
"FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
TREATMENT AREA
Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated:_ (must be < 5% of plume for pilot test injections)
INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 2

I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at httt)://deg.nc.eov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/around-water-approved-iniectants
All other substances must be reviewed by the DHHS prior to use. Contact the UICProgram for more info (919-
807-6496).
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(I) Number of injection wells: 1 Proposed 1 Existing(provideGW-Is)
(2) For Proposed wells or Existing wells not having GW-Is, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Deemed Permitted GW Remediation NOl Rev. 3-21-2018 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby certify, under penalty of law, that 1 am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility offtnes and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
Signature of Applicant Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(I SA NCAC 02C .0200). "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
Signature* of Property 9kner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of his NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone- [phone]
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 4

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
A
DIVISION OF WASTE MANAGEMENT
��
MICHAEL F. EASLEY, GOVERNOR
NCDENR
William G. Ross Jr., SECRETARY
Dexter R. Matthews, DIRECTOR
.Mo' „ M" wU� �eM OF
Mm nei i
N -n- -
UNDERGROUND STORAGE TANK SECTION
Herb Berger
Hydrogeologist
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
RE: State Lead Referral Notification
Former Country Cupboard
9681 NC Highway 700
Pelham, NC 27311, Rockingham County, NC
DWM Incident # 4- 9 � 4 a44
Dear Mr. Berger:
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and hereby
permit the Department of Environment and Natural Resources (Department) or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of G.S. 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be home by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and is
a public record, in accordance with North Carolina G.S. 132-1.
DIVISION OF WASTE MANAGEMENT/UST SECTION
1637 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA 27699-1637
PHONE: [phone] \ FAX: [phone]
INTERNET: http://www.wastenot.enr.state.nc.us
AN EQUAL OPPORTUNITYIAFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/10% POST -CONSUMER PAPER

6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the land owner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
gn e
.S/#AS/rN - AI'IJAA-/9Soo.(D
Type/Print Name of Owner or Agent
336
Phone Number
07;S — YvFS%-��%lCj�-ac�TvE - ,B,4 je rfy ro1J
Address � - .y >P t j -
City/State/Zip Code
3 - / 7 — a 6
Date

a
NONRESIDENTL4L WELL CONSTRUCTION RECORD
North CarolinaDepartment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2907
1. WELL CONTRACTOR:
Thomas Whitehe
Well Contractor (Individual) Name
SWE. Inc.
Well Contractor Company Name
3201 SDrina Forest Road
Street Address
Raleigh NC 27616
City or Town State Zip Code
9( 19 ) 872-2660
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(it applicable) N/A
SITE WELL ID #(if applicable) AS-1
3. WELL USE (Check One Box) Monitoring 51" Munidpal/Public ❑
IndustrialtCommerrial❑ Agricultural Recovery[:] Injection
Inigationo Other ❑ (list use)
DATE DRILLED 7/1 8/14
4. WELL LOCATION:
9681 Hiahwav 700
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Pelham COUNTY Rockingham
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VlFlat ❑Ridge ❑Other
LATITUDE 86 - a1 - 7,M.000D ^ DMS OR 3X.XXXX)0000( DD
LONGITUDE 79 ° 64 ' 7,500.0000 " DMS OR 7X.XXXXX)COO( DD
Latitudellongitudesource: MPS Dropographicmap
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
Fnrmer Cmintry Cimbnard
Facility Name Facility ID# (if applicable)
96A1 Hinhwav 700
Street Address
Pelham NC 97311
City or Town State Zip Code
Ahid Masnitd
Contact Name
225 West Ridne Drive
Mailing Address
Rurlinotnn NC 27215
City or Town State Zip Code
L)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 55 feet
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO W
d. TOP OF CASING IS 0 FT. Above Land Surface -
*Top of casing terminated atlor below land surface may require
a variance in accordance with ISA NCAC 2C .0118.
e. YIELD (III NIA METHOD OF TEST
I. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thlckneasl
: 7. CASING: Depth Diameter Weight Material
Top 0 Bottomy5D-- Ft. 2" _ sch 40 _ PVC
Top Bottom Ft.
Top Bottom Ft.
• 8. GROUT: Depth Material Method
i Topes_ Bottom 4_5 Ft. Portland Pour
:Top 45 Bottom 48 Ft._bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 50 Bottom 55 Ft. 2 in. .010 in. sch40 Dvc
Top Bottom Ft.in. _ In.
Top Bottom Ft.in. in.
10. SANDIGRAVEL PACK:
Depth Size Material
Top 48 Bottom 55 Ft. Coarse Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
• ,r•-
• -r. -I-
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
lSkNCAC2,WELLCONSTRUCTIONSTANDA AND THAT A COPY OF THIS
RECORD EEN PROVIDED TOT LL ER.
GNATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: N/A FT. :Thomas Whitehead
(Use °+° If Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Form GWA b
y p kY - Information Proeeetting, Rev. vos
1617 Mall Service Center, Raleigh, NC 27699-161, Phone; [phone]

COMPLETION REPORT OF WELL No. AS-1
Sheet 1 of 1
c
c
i
3
u
z
c
PROJECT: Country Cupboard
PROJECT NO:
PROJECT LOCATION: Pelham, Rockingham County, NC
DRILLING CONTRACTOR: T. Whitehead
DRILLING METHOD: 41/4" H.S.A.
DATE COMPLETED: 7/17114
WATER LEVEL:
LATITUDE:
LONGITUDE:
TOP OF CASING ELEVATION: 99.36
DATUM:
LOGGED BY: L. Butler
STRATA
IWELL
=
0
0
m
DETAILS
W
g
WELL CONSTRUCTION DETAILS
DESCRIPTION
o_ e
o
Lu
LU
PROTECTIVE CASING
0
0.00
GS
99.62
Diameter:
TOPSOIL
0.26
0.75
TOC
CG
99.36
98.87
Type:
Interval:
FILL: FINE SANDY
SILT
brown orange, d
5
RISER CASING
FILL: CLAYEY SILT
gray green, moist, with
rock fragments and
Diameter: 2-Inch
or anic debris fuel odor
10
Type: SCH 40 PVC
Interval: 0.26-50.0
GROUT
%I
15
Type: Cement grout
orange tan, damp,
Interval: 0.75-45.0
oddation staining; fuel
odor
20
SEAL
Type: Bentonite
25
Interval. 45.0-49.0
FILTERPACK
30
Type: #2 Sand
SANDY SILT
Interval: 49.0-55.2
gray tan, moist
35
SCREEN
Diameter: 2-Inch
Type: 0.010
40
Interval: 50.0-55.0
45
45.00
54.62
SANDY SILT
gray tan, moist, difficult
49.00
BS
50.62
LEGEND
drilling at 52 feet
60
-
50.00
TSC
49.62
FILTER PACK TOC TOP OF CASING
BENTONITE GS GROUND SURFACE
■ BS BENTONITE SEAL
55.00
BBC
44.62
® CEMENT GROUT BOC BASE OF OUTER CASING
55
55.20
TO
44.42
TSC TOP OF SCREEN
® CUTTINGS / BACKFILL BSC BOTTOM OF SCREEN
1 STATIC WATER LEVEL TO TOTAL DEPTH
CG CEMENT GROUT
COMPLETION REPORT OF
WELL No. AS-1NMO
#SME
ETTIINGG Sheer 1 Of 1
Nh1EMAL