WI0400091_Application_20200226

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North Carolina Department of Environmental Quality-` ivision�ar Resources
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APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELLS) FOIXINJECTION
Groundwater Rem ediation (I5A NCAC 02C.0225)/Tracer Injection, LSA `£A&02C.0229)
Do not use this form for UIC wells Permitted by Rule(ref. 15A f4CAC 02C_0217)
Permit Number(to be completed by DWR for•new projects): WI
I. APPLICATION INFORMATION
1. Project is: [I New [] Modification [X] Renewal lvithout modification [] Renewal with modification
2. If this application is being submitted for Renewal and/or Modification to an existing permit,provide:
Existing permit number WI0400091 Issued Date: May 22, 2015&Expiration Date:May 2_y 2 2020
For all Renewals, attach an updated site map and status report including monitoring results of all injection activities
to date-
For-Renewal withow modification only,fill out sections I&Honly,sign the cer lifrcation on the last page of this form,
and obtain the property owner's signature to indicate consent(f the applicant is not the owner).
II. WELL OWNER(S)/PERMIT APPLICANT(generally the responsible party)
1, Name(s): Gilbarco Inc.
2. Signing Official's Name*:_ Jama Greene Title: Vice President Operations Americas
* Signing Official must be in accordance with instructions in fart XII.
3. Mailing address of Permittee/Applicant: 7300 West Friendly Avenue
City: Greensboro State: NC Zip: 27410
4. Telephone number: (336, 547-5000 Email:
5. Status(choose one): Individual X Business/Org. Federal State County Municipality
III. PROPERTY OWNER(S)(if different than well owners)
1. Name(s): same
2. Mailing address:
City: State: Zip:
3. Telephone number: Email:
IV. PROJECT CONTACT—(generally the environmental/engineering consultant).
I. Name: Chris Ham Title: Principal
2, Company: EnviroTrac Ltd.
3. Address: 7343 West Friendly Avenue, cite J
4. City: Greensboro State: NC Zip: 27410
5. Telephone number: 336 763-6025 Email: [e-mail]
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V. FACILITY INTORMATION
1. Facility name: Phone No. (if available):
2. Physical address:
City: County: Zip:
3. Geographic Coordinates: Latitude: Longitude:
Reference Datum: Accuracy:
Method of Collection(i.e.,Google Earth, GPS,etc.):
4. Brief description of business:
V1. INCIDENT DESCRIPTION
1. Source and date of contamination:
2. List all contaminants present in soils or groundwater at the site(contaminants may be listed in groups, e.g.,gasoline,
diesel,jetfitel,fuel oil, chlorinated ethanes, chlorinated ethanes, metals,pesticides/herbicides, etc):
3. Has LNAPL or DNAPL ever been observed at the site(even if outside the injection zone)?
[] Yes If yes, list maximum measured separate phase thickness: feet
[]No If no, list maximum concentration of total VOCs observed at site: pph
4. Agency managing the contamination incident:
[]UST Section [] Superfund Section(including REC Program and DSCA sites)
[] DWR Aquifer Protection Section [] Solid Waste Section
[] Hazardous Waste Section []Other:
S. Incident manager's name: Phone No.:
6. Incident number or other incident mgmt.agency tracking number:
VII. PERMITS
List all applicable permits or construction approvals issued for the facility or incident:
1. Previous or other LIC permits issued by DWR(e.g.,NOIs)
2. Other Non-Discharge or NPDES permit issued by DWR:
3. County or DEH subsurface wastewater disposal permits:
4. Hazardous waste management or other environmental permits required by state or federal law:
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VIII. INJECTION SUMMARY
1. List all proposed injectants/additives.
NOTE: Only injectants approved by the epidemiology section of the NC Division of Pzrblic Health, Department of
Health and Harman Services can be injected. Approved injectants can be found online at
htt :Hde .ne. ov/about/divisions/water-resources/water-resources- er'mits/wastewater-branch/around-water-
rotection/ round-water-a roved-iniectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program for snore info if you wish to get approval for a different additive. However,please note
it may take 3 months or longer.
Injectant: Total Amt.to be injected(gal)/event
Injectant: Total Amt.to be injected(gal)/event
Injectant: Total Amt.to be injected(gal)levent
Injectant: Total Amt.to be injected(gal)levent
Injectant: Total Amt.to be injected (gal)/event
2. Number of separate injection events: Duration of Event:
3. Estimated Injection rate per well: gallons per minute(GPM)
4. Estimated Injection pressure: pounds/square inch(PSI)
5. Temperature at point of injection: OF
&. Injection will be via:
Existing well(s)-Total No.: ;Well Type(DPT,Permanent, etc.):
Proposed well(s)--Total No.:_ ;Well Type(DPT,Permanent,etc.):
7. NC Certified Well Drilling Contractor's Name(if known):
NC Well Contractor Certification No.:
8. Date to be constructed if proposed: attach well construction records GW-Is for
existing injection wells
9. Screened interval/Injection interval of injection wells:
Depth from to feet below land surface(BLS)(if multiple intervals, indicate shallowest
to deepest depth)
10. Well casing(leave blank if Geoprobee):
Type(PVC,stainless steel, other):
Casing depth: to ft.BLS
Type(PVC, stainless steel,other):
Casing depth: to ft.BLS
11. Grout(leave blank if Geoprobes):
Type(ceanent,bentonite,other):
Grout depth: to ft. BLS
Type(cement,bentonite, other):
Grout depth: to ft.BLS
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IX. ATTACHMENTS—provide the following information in separate attachments. The attachments should be clearly
identified and presented in the order below to expedite review of the permit application package.
1. INJECTION ZONE—Per 15A NCAC 02C.0225 3 . specify the horizontal and vertical portion of the subsurface within
which the proposed injection activity will take place and beyond which no violations of groundwater quality standards shall
result from the injection as determined by an approved monitoring plan. The determination shall be based on the hydraulic
properties of the specified zone. Provide any supporting documentation in a separate attachment.
2. HYDROGEOLOGIC EVALUATION—Per 15A NCAC 02C.0225 4 _provide a hydrogeologic evaluation of the injection
zone that includes all of the following:
(A) Regional and local geology and hydrology;
(B) Changes in lithology underlying the facility;
(C) Depth to bedrock;
(D) Depth to the mean seasonal high water table;
(E) Hydraulic conductivity,transmissivity,and storativity,of the injection zone based on tests of site-specific material,
including a description of the test(s)used to determine these parameters;
(F) Rate and direction of groundwater flow as determined by predictive calculations or computer modeling;
(G) Lithostratigraphic and hydrostratigraphic logs of any existing test and injection wells; and
(H) For systems re-injecting treated on-site contaminated groundwater only- evaluation of infiltration galleries or
injection wells.
3. INJECTANT INFORMATION--Per 15A NCAC 02C.0225(f)(6).provide information on each injectant as indicated below:
(A) MSDS,concentration at the point of injection,and percentage if present in a mixture with other injectants;
(B) The source of fluids used to dilute,carry,or otherwise distribute the injectant throughout the injection zone. If any
well within the area of review of the injection facility is to be used as the fluid source,then the following information
shall be submitted: location/113 number, depth of source,-formation, rock/sediment type, and a chemical analysis
of the water from the source well, including analyses for all contaminants suspected or historically recognized in
soil or groundwater on the site;
(C) A description of the rationale for selecting the injectants and concentrations proposed for injection, including an
explanation or calculations of how the proposed injectant volumes and concentrations were determined;
(D) A description of the reactions between the injectants and the contaminants present including specific breakdown
products or intermediate compounds that may be formed by the injection;
(E) A surnmary of results if modeling or testing was performed to investigate the injectant's potential or susceptibility
for biological, chemical, or physical change in the subsurface;.and
(F) An evaluation concerning the development of byproducts of the injection process, including increases in the
concentrations of naturally occurring substances. Such an evaluation shall include the identification of the specific
byproducts of the injection process, projected concentrations of byproducts, and areas of migration as determined
through modeling or other predictive calculations.
4. INJECTION PROCEDURE—Per 15A NCAC 02C .0225 7 . submit a table with a detailed description of the proposed
injection procedure that includes the following:
(A) The proposed average and maximum daily rate and.quantity of injectant;
(B) The average maximum injection pressure expressed in units of pounds per square inch(psi);and
(C) The total or estimated total volume to be injected.
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5. FRACTURING PLAN (if applicable)--Per 15A NCAC 02C.0225 9 . submit a detailed description of the fracturing plan
that includes the following:
(A) Material Safety Data Sheets of fracturing media including information on any proppants used;
(B) a map of fracturing well locations relative to the known extent of groundwater contamination plus all buildings,
wells, septic systems,underground storage tanks,and underground utilities located within the Area of Review;
(C) a demonstration that buildings,wells,septic systems,underground storage tanks,and underground utilities will not
be adversely affected by the fracturing process;
(D) injection rate and volume;
(E) orientation of bedding planes,joints,and fracture sets of the fracture zone;
(F) performance monitoring plan for determining the fracture well radius of influence; and
(G) if conducted, the results of geophysical testing or pilot test of fracture behavior conducted in an uncontaminated
area of the site.
b. WELL CONSTRUCTION DETAILS —Per 15A NCAC 02C .0225(f)(10). submit the following information in tabular or
schematic form as appropriate for each item:
(A) nurnber and depth of injection wells;
(B) number and depth of borings if using multi-level or"nested"well systems;
(C) indication whether the injection wells are existing or proposed;
(D) depth and type of casing;
(E) depth and type of screen material;
(F) depth and type of grout;
(G) indication whether the injection wells are permanent or temporary"direct push"points; and
(H) plans and specifications of the surface and subsurface construction details.
7. MONITORING PLAN—Per 15A NCAC 02C.0225 11 .submit a monitoring plan that includes the following:
(A) target contaminants phis secondary or intermediate contaminants that may result from the injection;
(B) other parameters that may serve to indicate the progress of the intended reactions;
(C) a list of existing and proposed monitoring wells to be used;and
(D) a sampling schedule to monitor the proposed injection.
Monitoring wells shall be of sufficient quantity and location to detect any niovernent of injection jhtids, injection process byproducts, or
forrrration fluids outside the injection zone. The monitoring schedule shall be consistent with the proposed injection schedule,pace of
the anticipated reactions, and rate of transport of the injectants and contaminants.
8. WELL DATA TABULATION—Per 15A NCAC 02C.0225[t)(12). provide a tabulation of data on all existing or abandoned
wells within the area of review of the injection well(s) that penetrate the proposed injection zone, including :monitoring
wells and wells proposed for use as injection wells. Such data shall include a description of each well's type, depth, and
record of construction or abandoru-nent.
9_ MAPS AND CROSS-SECTIONS — Per 15A NCAC 02C .0225 13 . provide scaled, site-specific site plans or maps
depicting the location, orientation,and relationship of facility components including the following:
(A) area map based oil the most recent USGS 7.5' topographic map of the area, at a scale of 1:24,000 and showing the
location of the proposed injection site;
(B) topographic contour intervals showing all facility related structures, property boundaries, streams, springs, lakes,
ponds, and other surface drainage features;
(C) all existing or abandoned wells within the area of review of the wells listed in the well data tabulation that penetrate
the proposed injection zone;
(D) potentiometric surface map(s)that show the direction of groundwater movement,existing and proposed wells;
(E) contaminant plume map(s)with isoconcentration lines that show the horizontal extent of the contaminant plume in
soil and groundwater, and existing and proposed wells;
(F) 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,major changes in lithology, and existing and proposed wells;and
(G) any existing sources of potential or known groundwater contamination, including waste storage, treatment, or
disposal systems within the area of review of the injection well or well system.
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X. UIC SYSTEMS RE-INJECTING TREATED ON-SITE CONTAMINATED GROUNDWATER ONLY
1. FEES--Per 15A NCAC 02C .0225(rn),submit/attach fees for new permits or modifications(refer to fee schedxde
at h.ttps:Hdeq.ic.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
rotection/non-discliar-e- roundwater-remediation
2. SOILS EVALUATION-Per 15A NCAC 02C .0225(f)(2), for systems with proposed discharge within seven feet
of land surface and above the seasonal high water table,a soil evaluation of the disposal site shall be provided to the
Division by the applicant. If required by G.S. 89F,a soil scientist shall submit this evaluation. This evaluation shall be
presented in a report that includes the following information:
(A) Field description of soil profile. Based on examinations of excavation pits or auger borings, the following
parameters shall be described by individual horizons to a depth of seven feet below land surface or to bedrock:
thickness of the horizon;texture;color and other diagnostic features; structure; internal drainage;depth,thickness,
and type of restrictive horizons;pH;cation exchange capacity; and presence or absence of evidence of any seasonal
high water table. Applicants shall dig pits when necessary for evaluation of the soils at the site.
(B) Recommendations concerning annual and instantaneous Ioading rates of liquids, solids, other wastewater
constituents and amendments. Annual hydraulic loading rates shall be based on in-situ measurement of saturated
hydraulic conductivity in the most restrictive horizon.
3. ENGINEERING PLANNING DOCUMENTS —Per 15A NCAC 02C .0225(f)(8), the following documents shall
be provided to the Division by the applicant(Note: if required by G.S. 89C, a professional engineer shall prepare
these documents):
(A) engineering plans for the entire system, including treatment, storage, application, and disposal facilities and
equipment, except those previously permitted unless they are directly tied into the new units or are critical to the
understanding of the complete process;
(B) specifications describing materials to be used,methods of construction,and means for ensuring quality and integrity
of the entire groundwater remediation system;
(C) plans that include construction details of recovery,injection, and monitoring wells and infiltration galleries;
(D) operating plans that include:
(i) the operating schedule including any periodic shut-down times;
(ii) required maintenance activities for all structural and mechanical elements;
(iii) a list of all consumable and waste materials with their intended source and disposal Iocations;
(iv) restrictions on access to the site and equipment;
(v) provisions to ensure the quality of the treated effluent and hydraulic control of the system at all times when
any portion of the system ceases to function,such as standby power capability,complete system-off status,
or duplicity of system components;and
(E) Completed, signed, and sealed Professional Engineer's Certification for new permit applications(form attached).
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XII. CERTIFICATION(to be signed as required below or by that person's authorized agent*)
NCAC 15A 02C .0211 e requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer
2. for a partnership or sole proprietorship: by a general partner or the proprietor,respectively
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or
ranking publicly elected official
4. for all others: by the well owner.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the applicant
that names and authorizes their agent.
"I hereby certify tinder penalty of law that I have personally examined and am familiar with the information
submitted in this document and all attachments therein, and that, based on my inquiry of those individuals
irrrrnediately responsible for obtaining said information, I believe that the information is true, accurate, and
complete. Iain alvare that there are penalties, including the possibility offines and imprisonment.for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well(s)
and all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Typed or Printed Name and Title: Jamey Greene Vice President Operations Americas
s /r�s�
Signature:. Date:,f
XIII. CONSENT OF PROPERTY OWNER(if the property is not owned by the permit applicant)
"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.
"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 YYell Construction Standards
(15A NCAC 02C.02_0."
Typed or Printed Name and Title:
Signature: Date:
Submit TWO hard copies of the completed application package with an electronic version in CD or USB Flash
Drive to:
DIVISION OF WATER RESOURCES—UIC PROGRAM
1636 MA11L SERVICE CENTER
RALEIGH,NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
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Professional Engineer's Certification (for new permit application for UIC systems re-injecting treated on-site
contaminated groundwater only
Permit No.: WI
Typed or Printed Name of Professional Engineer:
License Number:
Name of Engineering Firm(if applicable):
Mailing Address:
City: State: Zip:
Office Number: ( � Mobile Number: ( �
Email Address:
I, ,attest that this application for
has been reviewed by me and is accurate and complete to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations. Although
certain portions of this submittal package may have been developed by other professionals, inclusion of these materials
under my signature and seal signifies that I have reviewed this material and have judged it to be consistent with the
proposed design.
North Carolina Professional Engineer's Seal, Signature, and Date:
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