WI0400544_Permit (Issuance)_20200311

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 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to infection)
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 24 , 2020_ PERMIT NO. W10400544 (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:
Name(s): NCDEQ/DWM/UST Section/Trust Fund Brand: Incident Manager- Linda Blalock
Mailing Address: 1646 Mail Service Center,
City: Raleigh State: NC Zip Code:27699 County: Wake
Day Tele No.
919-707-8165
Cell No.:
EMAIL Address: Linda.Blalockgncdenr.gov Fax No.:
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 1

D.
E.
F.
G.
H.
PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Brent W. Groce
Company Name Hatchgro LLC
Mailing Address: 103 Miranda Lane
City: Roxboro State: NC_ Zip Code: 27574 County: Person
Day Tele No.: 336-597-2207 Cell No.: 336-592-1121
EMAIL Address:
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: lbutlerAsmemc.com Fax No.:
PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Incident # 30792 Name: The Country Store
4807 NC Highway 57 N
City: Semora County: Caswell Zip Code: 27343
(2) Geographic Coordinates: Latitude":
Longitude*
Reference Datum:
Method of Collection: DeLorme®
it or 36.4993 °.
if or-79.1530 °
Accuracy:
"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 hgp://deg.nc.g_ov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-inj ectants.
All other substances must be reviewed by the DHHS prior 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: 1 Proposed 1 Existing (provide GW-1s)
(2) For Proposed wells or Existing wells not having GW-1s, 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 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 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
(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 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

2014 SEP 22 PF1 f � 5fl
Ms. Linda Blalock
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Blalock:
RE: Site Access Agreement
The Country Store
4807 NC Hwy 57 N
Semora, Caswell County
Incident #: 30792
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 soil and groundwater under the authority of G.S.
143-215.3(a)2.
I am/We are granting permission with the understanding that:
I. 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.
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 G.S. 132-1.
DENR/WASTEMANAGEMENT
UST SECTION
ATTN: LINDA BLALOCK
1637 MAIL SERVICE CENTER
RALEIGH NC 27699-1637

The Country Store
Incident #: 30792
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.
Me 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,
Type/Print Name of Owner or Agent
10.3 01"IypW LSE
Address
Address
,6AdWQZM--17,75-3 ¢
ity/Sta e/Zip Code
Phoneber
20l0
Date

Well ID
WELL
CONSTRUCTION DETAIL
Project Name
Project Number
4305-19-034E A
I FI=
Proposed AS-1 30792-The Country Store
S&ME Staff
Installation Date
County
City
Well Permit Number
L. Butler
Scheduled 2/27/2020
Caswell
Semora
Not applicable
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Geologic Exploration, Inc.
TBD
Flush Monitor Well
Water Level at TOB (0.01 ft-
BTOC)
Date/Time
Northing (0.1 ft)
Land Surface Elev. (0.01 ft)
Drilling Method
Hollow Stem Auger
Depth to Water (0.01 ft-
BTOC)
Date/Time
Easting (0.1 ft)
Total Well Depth (0.1 ft-bgs)
Borehole Diameter (1 in)
55.0
8.25-inch
TOC Relative to Ground
0.25
ft
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
Depth Below Ground Surface (ft-bgs
2-in Sch 40 PVC
Top of Seal - 45.0 0.1 ft-bgs
Casing Interval (0.1 ft-bgs)
0.25
1 to
1 49.8
Screen Type
2-in Sch 40 PVC (0.010)
Screen Interval (0.1 ft-bgs)
49.8
1 to
I 54.8
Grout Type
Top of Filter Pack - 48.0 0.1 ft-bgs
Portland Cement T2
Grout Interval (0.1 ft-bgs)
Top of Screen - 49.8 0.1 ft-bgs
0.5
to
45.0
Seal Type
Screened Interval - 5.0 0.1 ft-bgs
Bottom of Screen - 54.8 0.1 ft-bgs
3/8 in. Holeplug®
Seal Interval (0.1 ft-bgs)
45.0
1 to
1 48.0
Filter Pack
#2 Silica Sand
Filter Pack Interval (0.1 ft-bgs)
48.0
to
55.0
Development
Bottom of Filter Pack -
Cave In -
Total Boring Depth -
55.0
55.0
0.1 ft-bgs
0.1 ft-bgs
0.1 ft-bgs
Yes
Development Volume (gal)
-
Notes:
BTOC - Below Top of Casing
TBD - To Be Determined
For lithologic information
see attached boring log
Form Revision Date: 9/1/17 2:10 PM