WI0400545_Permit (Issuance)_20200319

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: March 3, 2020_ PERMIT NO. (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: James R. Holyfield, Jr.
Company Name -
Mailing Address: 5064 Groometown Road
City: Greensboro State: NC_ Zip Code: 27407 County: Guilford
Day Tele No.: 336-855-0197
EMAIL Address: -
Cell No.:
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 #17713 Name: Groometown Store
5064 Groometown Road
City: Greensboro County: Guilford Zip Code: 27407
(2) Geographic Coordinates:
Latitude": °
Longitude": °
Reference Datum: -
Method of Collection: Google Earth
if or 35.9737201.
if or-79.8786281
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 ff 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 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/Aoolicant: "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 submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection wegll and all related appurtenances in accordance with the 1 SA NCAC 02C 0200 Rules. "
of Applicant Print or Type Full Name and
Property Owner (if the orooerty is not owned by the Well Owner/Apnlicant):
"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 NCDEQ 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

8646 West Market St.
Suitelo5
Greensboro, NC 27409
March 19, 2018
HAND DELIVER
James Rowe Holyfield, Jr.
5064 Groometown Road
Greensboro, NC 27407
To: James Rowe Holyfield, Jr.
SUBJECT: Site Access Agreement
Enclosed is a Site Access Agreement letter for you to permit the Division of Waste Management,
or its contractor (in this case, S&ME, Inc.), to conduct groundwater and/or soil investigation on your
property located at 5064 Groometown Road In Greensboro, NC, at the facility known to us eb
Groometown Store. The investigation pertains to a petroleum release incident located on and near this
property. Please read the enclosed agreement, sign it, and return it to the Division of Waste Management
Incident Manager at the following address:
Linda L. Blalock
NC DWM-UST Section -Trust Fund Branch
1646 Mail Service Center
Raleigh, NC 27699-1646
A stamped, self-addressed envelope is enclosed for your convenience. Please call S&ME at 336-288-7180
or Linda Blalock at 919-707-8165 if you have any questions.
Sincerely,
S&ME, Inc.
P4
Lynda[ Butler
Environmental Scientist
Enclosures

Site Access Agreement, con't.
C&H Gas & Grocery/FTF-17350
Page 2
January 30, 2018
I agree not to interfere with, remove, or any way damage the Department's well($) or its
contractor's well(s) or equipment during the investigation.
Sincerely,
1
igna re -
Type/Print Name
Address
City!State/Zip Code �I V
336 -- B S-5—c>1—7
Phone Number
Date

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Guilford County, NC
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0157296
$3AGO
Parcel Mum
Total Out Buiidirg Vslue
o PIN
7831908552
Total Land Value
$63,100
r
Nei Odwhood Sales
NeiBhbarhood Sales
Total Deferred VWae
$0
Part verify
Parcel Verify
Bldg Card
1
(Amer
WXYFIELD, JAMES ROWE JR
Appraisal Mold Code
CONVENIENCE STORE
Mail Address
5064 GILOO 4ETOWN RD
Deed Date
712912010
Mail Cdy
GREENSBORO
Neighborhood
7841A01
Mail State
NC
Property Type
RETAIL
j #1ai17_ip
27407
Stnuture Sire
2016
Property Address
5064 GROOMETOWN RD
Lot Sire
0.92
Le2at Desa*tion
1 LOT "ENNIS
Year Built
1954
i Deed
007147-00252
Bedrooms
1
0
iPlat
NIA
Bathn)orns
0
t Cando
NIA
Grade
D+10 85%
Total Assessed Value
$145,700
ShortParcel ID
157286
Y«�a:, eiFdi�t
$77,600
G.zcla:m:r- irr'�ire (every
Offort s made 'o keep information provided over the k ttmet accurit;e ar.d up -to- Map Scale
dtte, Guirfcrd Cavr-ty does not certify the Autirt-itfdty oracsuracy of such information.
No warranties, 1 inch = 83 feet
express or imafied, are provided far the rocordf andlor mapping
data herein, or 1br tfis r use or
interpretation by the user.
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