WI0400542_Permit (Issuance)_20200228

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 individual permit when constructed in accordance
with the rules of 15A 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: February 19 , 2020 PERMIT NO. W 10400542
{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) Passive Injection System...............................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:
Natne(s): NCDEQ/DWM/UST Section/Trust fund Brand: Incident Manager- Thomas Chapman
Mailing Address: 1646 Mail Service Center,
City: _ Raleigh State: NC Zip Code:27699 County: W
Day Tele No.: 919-707-8170
EMAIL Address: Herbert.BergerAncdenr.gov
Cell No..
Fax No.:
Deemed Permitted GW Remediation NO] Rev. 3-21-2018 Page ]

0
E.
F
G.
l,1
PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Mark Davidson; Airport Director
Company Name
Mailing Address: 3801 N. Liberty Street,
City: Winston-Salem State: _NC_ Zip Code: 27105 County: Forsyth
Day Tele No.: 336-767-6361 Cell No.:
EMAIL Address: Fax No.:
PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title:
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: lbutler(a,smeinc.com Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Incident #10022 Name: Airport Exxon
Formerly 3751 N. Liberty Street (narcel merged with Airport Authority property
City: Winston-Salem County: Forsyth Zip Code: 27105
(2) Geographic Coordinates: Latitude"*:
" or 36.1360500
_
Longitude": " or-80.2300580
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 ftz 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 htm://deg.nc.izov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/eround-water-protection/eround-water-approved-iniectants.
All other substances must be reviewed by the DHHSprior to use. Contact the UIC Program 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
(1) Number of injection wells: 2 Proposed Existing (provide GW-1s)
(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 Pemutted GW Remediation NOI 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 I 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 offines and imprisonment,
for submittingfalse information. I agree to construct, operate, maintain, repair, and ifapplicable, abandon the
injection well aAd all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
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
(15A 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.
See attached NCDEO Site Access Agreement
Signature* of Property Owner (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 I (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

UNDERGROUND STORAGE TANK SECTION
May 16, 2019
Mr. Thomas Chapman
Hydrogeologist
DWM/UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Mr. Chapman
RE: Access Agreement
Airport Exxon
3751 North Liberty Street
Winston-Salem, Forsyth County, North Carolina
Incident Number: 10022
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 Environmental Quality (Department) or its contractor to enter upon said
property for the purpose of conducting an assessment and/or remediation of the groundwater and/or soils
under the authority of G.S. 143-215.94G.
I am/We are granting permission to the lands we own or control 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 borne by the Department or
its contractor. The Department or its contractor shall protect and prevent damage to the surrounding
lands. Any damages will be restored by the Department or its contractor to as close to the pre -work
condition as practicably possible.
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 will notify the land owners
48 hours prior to entry and 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 G.S. 132-1.
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 landowner. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed.
1/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
/ ✓`1 A VGk- D��•r�se...
Signature kt,,r,-r ter-+ �
Type/Print Name of Owner or Ag6nt
3'36 -76 -7 -6?fi r
Phone Number
3 8 0 i N L, c,� _C �• .- s-�-
Address ivL Zi/ o S
W,-.,J-. - S'..(., , NJc
City/State/Zip Code
9/t?//9
Date
RE: Airport Exxon
3751 North Liberty Street
Winston-Salem, Forsyth County, North Carolina
Incident Number: 10022

COMPLETION REPORT OF WELL No. SPG-1
Sheet 1 of 1
PROJECT: Airport Exxon
PROJECT NO: 1584-03-005
PROJECT LOCATION: Winston-Salem, North Carolina
DRILLING CONTRACTOR: T. Miller
DRILLING METHOD: 41/4" H.S.A.
DATE DRILLED: 7/22104
WATER LEVEL:
LATITUDE:
LONGITUDE:
TOP OF CASING ELEVATION:
DATUM:
LOGGED BY:
WELL o o
O = DETAILS w F
DESCRIPTION �, c� W <� WELL CONSTRUCTION DETAILS
co ]v J W
Sandy SILT
10
15
19.50 1 BS
22.00 1 FP
23.50 I TSC
25.50 1 BSC
25.80 TO
SAME3718 Old Battleground Road
Greensboro, NC
PROTECTIVE CASING
Diameter:
RISER CASING
Diameter: 2"
Type: PVC
Interval: 0.6-23.5
GROUT
Type: Neat Cement Grout
Interval: 1.0-19.5
SEAL
Type: Bentonite
Interval: 19.5-22.0
FILTERPACK
Type: #2 Sand
Interval: 22.0-25.8
SCREEN
Diameter. 2"
Type: 0.010"
Interval: 23.5-25.5
LEGEND
Ej FILTER PACK
■ BENTONITE
® CEMENT GROUT
® CUTTINGS / BACKFILL
= STATIC WATER LEVEL
TOC TOP OF CASING
GS GROUND SURFACE
BS SENTONITE SEAL
FP FILTER PACK
TSC TOP OF SCREEN
BSC BOTTOM OF SCREEN
TD TOTAL DEPTH
CG CEMENT GROUT
COMPLETION REPORT OF
WELL No. SPG-1
Sheet 1 of 1

COMPLETION REPORT OF WELL No. SPG-2
PROJECT: Airport Exxon
PROJECT NO: 1584-03-005 WATER LEVEL:
PROJECT LOCATION: Winston-Salem, North Carolina
LATITUDE:
DRILLING CONTRACTOR: T. Miller LONGITUDE:
DRILLING METHOD: 4 1/s" H.S.A. TOP OF CASING ELEVATION:
DATE DRILLED: 7/22/04 DATUM:
Sheet i of 1
wwcu ni: o. ware
STRATA
WELL
c
o
E�
WW
aWELL
CONSTRUCTION DETAILSDESCRIPTION
IIWDETAILS
o"
J
"
O
W
PROTECTIVE CASING
0
0.00
GS
Diameter:
Type:
Medium Brown Sandy
0.50
TOC
SILT
1.00
CG
Interval:
RISER CASING
Diameter. 2"
5
Type: PVC
Interval: 0.6.23.5
GROUT
Type: Neat Cement Grout
Pale to Medium
Brown Sandy SILT
Interval: 1.0.18.6
10
SEAL
Type: Bentonite
Interval: 18.5-22.0
III
20 18.50 I 8S I I SCREEN
Diameter: 2"
Type: 0.010"
Interval: 23.5-25.5
22.00 FP
23.50 TSC
25 25.50 BSC
25.80 TD
x S8�ME
3718 Old Battleground Road
Greensboro, NC
LEGEND
FILTER PACK
. BENTONITE
CEMENT GROUT
CUTTINGS / BACKFILL
STATIC WATER LEVEL
TOC TOP OF CASING
GS GROUND SURFACE
BS BENTONITE SEAL
FP FILTER PACK
TSC TOP OF SCREEN
BSC BOTTOM OF SCREEN
TO TOTAL DEPTH
CG CEMENT GROUT
COMPLETION REPORT OF
WELL No. SPG-2
Sheet 1 of 1

DW-1
n
I I �$ -2fIIyII
FORME y
DISPENSER
ISLANDS Qi
RW-1
SPG-1 • YMW-6
2
L--- 1
r2
r 3
L_*j
MWA
I� �I
I� it
I� �I
I� �I
FORMER ;I
BUILDING
�i LOCATION it
I� �I
I� �I
L____--J
RW-2
•
SPG-2
MW-7
MW-9 (ATC)
KEY
- MONITORING WELL LOCATION
- MONITORING WELL PRESUMED DESTROYED
OO - RECOVERY WELL LOCATION
• - AIR SPARGE WELL LOCATION
C - FORMER UST LOCATION
4fs:)
MW-3
UST DATA TABLE
TANK ID
CAPACITY
CONTENTS
1
3,000 GALLONS
GASOLINE
2
6,000 GALLONS
GASOLINE
3
6,000 GALLONS
GASOLINE
4
550 GALLONS
I FUEL OIL
5
550 GALLONS
I WASTE OIL
MW-9
0 30 60
GRAPHIC SCALE (IN FEET)
SITE MAP SCALE: I FIGURE NO.
Site ID:10022 AS SDA E
III
AIRPORT EXXON JAN. 2020 2
3751 NORTH LIBERTY STREET PROJECT NUMBER
WINSTON-SALEM. NORTH CAROLINA 4305-19-1285