WI0400555_Permit (Issuance)_20201015

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. This form shall be submitted at least 2 WEEKS prior to injection.
AQUIFER TEST WELLS (15A NCAC 02C .02201
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.
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: October 5, 2020 PERMIT NO. (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) 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) X 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: Business/Organization
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:
Company Name Speedway LLC
Delegated Signatory Authority: Mr. John M. Helms, Manager of Environmental Remediation
Mailing Address: 500 Speedway Drive
City: Enon State: OH Zip Code: 45323 County: Clark
Day Tele No.: 937-864-3000 Cell No.: 937-206-2431
EMAIL Address: jmhelms(a)speedway.com
Deemed Permitted GW Remediation NOI Rev. 3-1-2016
Fax No.: 937-863-6722
Page 1

D. PROPERTY OWNER(S) (if different than well owner)
E.
F.
G.
Company Name Same as Well Owner
Mailing Address:
City:
Day Tele No.:
EMAIL Address:
State: _ Zip Code: County:
Cell No.:
Fax No.:
PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Troy L. Holzschuh / Project Manager
Company Name Mid -Atlantic Associates, Inc.
Mailing Address: 1125 E. Morehead Street
City: Charlotte State: NC Zip Code: 27610 County: Mecklenburg
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address: jyoungnmaaonline.com
PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Speedway 6929
4019 Reynolda Road
Fax No.: [phone]
City: Winston Salem County: Forsyth Zip Code: 271
(2) Geographic Coordinates: Latitude": 360 9' 59.21"
Longitude": -80' 19, 58.92"
Method of Collection: Goo,gle Earth Pro Software
"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
The site is currently regulated by the North Carolina Department of Environmental Quality (NCDEQ), Division
of Waste Management (DWM), Underground Storage Tank (UST) Section. The site is ranked intermediate risk
and, therefore, the current groundwater cleanup goals are the North Carolina Gross Contamination Levels
(GCLs) and removal of free product. Weathered free product characteristic of gasoline remains present on the
water table at monitoring well MW-6 and dissolved -phase benzene concentrations exceed the NCGQS (NC
Groundwater Quality Standards) at several wells. As such, the "area of the contaminant plume" indicated below
refers to the approximate area of contaminants exceeding NCGQS standards.
Land surface area of contaminant plume: 2,460 square feet
Land surface area of inj. well network: 25 square feet (< 10,000 W for small-scale injections)
Percent of contaminant 3plume area to be treated: 1 % (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 2

H. INJECTION ZONE MAPS — Attach the following to the notification. Provided in Attachment A
(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.
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.
Residual weathered gasoline free product (approximate thickness of 0.95 ft) remains present on the water table
at the site at monitoring well MW-6. High levels of petroleum contamination are also present in several wells.
Based on previous conversations with NCDEQ and State Trust Fund Branch personnel, Mid -Atlantic proposes
to inject EnviroClean at the site to enhance free product recovery at monitoring well MW-6. EnviroClean (EC-
165) is a common cleanup/mitigation agent that can be applied as both an emulsifying agent for free product
recovery and biosurfactant for dissolved -phase groundwater remediation. It is estimated that up to 250 gallons
of a 2.5% solution of EnviroClean will be gravity -injected into the above -referenced well over an estimated
period of up to 8 hours on -site. An 8-hour AFVR event will then be conducted at the site approximately one- to
two weeks following completion of the surfactant injection event, with post-AFVR free product gauging and
well sampling activities conducted approximately two to four weeks following completion of the AFVR event.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant. Attach additional sheets if necessary.
Provided in Attachment B
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 http:Hdeq.nc.gov/about/divisions/water-
resources/water-resources-hermits/wastewater-branch/ground-water-Drotection/eround-water-aDDroved-ini ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Inj ectant:
EnviroClean EC-165
Volume of injectant: 250 Gallons
Concentration at point of injection: 2.5%
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA Provided in Attachment C
(1) Number of injection wells: 0 Proposed 1 Existing (provide GW-ls)
(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
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 3

Only existing wells will be used (none are proposed). The injection event is currently scheduled for the week of
October 27, 2020, followed by an 8-hour AFVR event within 2-3 weeks after the injection event. The surfactant
injection will take approximately 8 hours for completion and the AFVR is expected to run for approximately 8
hours. Post-AFVR free product gauging and well sampling will be conducted approximately two to four weeks
following completion of the AFVR event.
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,
The site is currently regulated by the NCDEQ DWM UST Section. Sampling of 9 site monitoring wells (MW-
1, MW-1D, MW-2R, MW-3R and MW-4 through MW-8) are performed on a 6-month schedule with results
reported to the UST Section. Please note that EnviroClean is a proprietary blend of water -based, biodegradable
surfactants that was specifically engineered as a cleanup/mitigation agent and vapor suppressant for use on a
wide range of hydrocarbon products. EnviroClean, in and of itself, does not cause or catalyze specific chemical
reactions, nor does it contain any bacteria cultures. The basic principle of EnviroClean is to emulsify and
encapsulate hydrocarbon particles. As such, the injection activity is not anticipated to result in violations of the
NCGQS for additional compounds other than those already noted from the previous gasoline releases release.
N. SIGNATURE OF APPLICANT AND PROPERTY 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 of fines and imprisonment, for submitting false
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all relapdwMurtenancesIbi-Vccordance 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 permit 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.
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 farm.
Submit the completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 4

ATTACHMENT A
DRAWINGS
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 6

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APPROVAL:
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DATE:
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JOB NO:
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DWG NO: 1

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LIGHT POLE
ESTIMATED LATERAL EXTENT OF FREE PRODUCT
ESTIMATED ISOCONCENTRATION CONTOUR FOR BENZENE (ug/L)
BENZENE CONCENTRATION AT LOCATION (ug/L)
NOT DETECTED AT OR ABOVE LABORATORY'S METHOD DETECTION LIMIT
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ATTACHMENT B
INJECTANT INFO
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 7

ENVIRO�CU
SAFETY DATA SHEET
SECTION 1 MATERIAL IDENTIFICATION
PRODUCT NAME / DESCRIPTION: EnviroClean
DISTRIBUTED / MANUFACTURED BY:
ENVIRO CLEAN PRODUCTS & SERVICES DATE: 05/18/2015
PO BOX 721090 PHONE: [phone]
OKLAHOMA CITY, OK 73172 EMERGENCY PHONE: [phone]
FUNCTION: Industrial Cleaner and Remediation Agent
SECTION 2 HAZARD IDENTIFICATION
CLASSIFICATION:
Acute Toxicity- Oral
Category 4
Skin Corrosion/Irritation
Category 3
Eye Damage/Irritation
Category 2B
Target Organ Specific Toxicity: Single
I Category 3
Target Organ Specific Toxicity: Chronic
I Category 2
SIGNAL WORD:
WARNING!
HAZARD STATEMENTS:
Harmful if swallowed
Causes mild skin irritation
Causes eye irritation
May cause respiratory irritation
May cause damage to organs through prolonged or repeated exposure
> <s !Rr"04
PRECAUTIONARY STATEMENTS:
Obtain special instructions before use
Do not handle until all safety precautions have been read and understood
Use personal protective equipment as required
Avoid breathing dust/fume/gas/mist/vapors/spray
Use only outdoors or in a well ventilated area
Wash all exposed skin thoroughly after handling
Avoid release to the environment

ENVIRO�CU
Store in a well ventilated place
TOXICITY INFO:
See Section 11.
SECTION 3 HEALTH HAZARDS
CHEMICAL NAME
(Proprietary Formula)
%WIW CAS NUMBER
Proprietary Blend of Ethoxylated Octylphenolic Surfactants
Non-ionic water based liquid blend, concentrate
This product does not contain any hazardous ingredients as defined by CERCLA and California's Prop. 65.
SECTION 4
Potential acute health effects:
FIRST AID
Eyes: May cause irritation with redness and pain.
Skin: May cause irritation with redness and pain.
Inhalation: Inhalation may cause irritation.
Ingestion: Ingestion may cause severe irritation, corrosion/ulceration, nausea, and vomiting.
Medical Conditions Aggravated by Exposure:
None known.
Eye Contact: In case of contact, immediately flush eyes with cool running water. Lift and
separate eyelids while flushing with plenty of water for at least 15 minutes. Get
medical attention.
Skin Contact: Wash with soap and water. Get medical attention if irritation occurs. Wash
clothing before reuse. Destroy contaminated shoes.
Inhalation: Remove victim to fresh air and keep at rest in a position confortable for breathing.
If not breathing, give artificial respiration. If breathing is difficult, give oxygen.
Seek medical attention if symptoms develop.
Ingestion: Do NOT induce vomiting unless directed to do so by medical personnel. Never
give anything by mouth to an unconscious person. If large quantities of this
material are swallowed, call a physician immediately. Give plenty of water.
SECTION 5 FIRE FIGHTING MEASURES
Fire Hazard Classification (OSHA/NFPA): 0
Extinguishing Media: As required for fire being fought.
Special Fire Fighting Procedures: Use self-contained breathing apparatus.
Hazardous combustion products: No known.

ENVIRO�CU
SECTION 6 ACCIDENTAL RELEASE MEASURES
Personal Precautions, PPE, and Emergency Procedures:
Wear protective clothing as described in Section 8 of this safety data sheet.
Containment Procedures: Stop the flow of material, if this is without risk. Wear appropriate protective
equipment and clothing during clean-up. Do not allow the spilled product to enter
public drainage system or open water courses.
Clean -Up Procedures: Sweep up or gather material and place in appropriate container for disposal.
Wash spill area thoroughly. Wear appropriate protective equipment during
cleanup. Dispose of collected material according to regulations.
SECTION 7 HANDLING AND STORAGE
Handling: Avoid contact with eyes, skin and clothing. Do not take internally. For industrial
use only. Wash after handling. Don't breathe dust, vapor, or gas. Keep this and
all chemicals out of reach of children.
Storage: Keep away from heat, sparks, and open flames. Prevent spills. Keep container
tightly closed and in a cool, well -ventilated place away from incompatible
materials. Empty product containers may contain product residue, do not reuse.
SECTION 8
PERSONAL PROTECTION / EXPOSURE CONTROLS
Ventilation System:
Always keep exposure below permissible exposure limits. In general, dilution
ventilation is a satisfactory health hazard control for this substance. However, if
conditions of use create discomfort to the worker, a local exhaust system should
be considered.
Airborne Exposure Limits: None Established.
Personal Protection:
As prescribed in the OSHA Standard for Personal Protective Equipment (29 CFR
1920.132), employers must perform a Hazard Assessment of all workplaces to
determine the need for, and selection of, proper protective equipment for each
task performed.
Eyes:
Wear face shield, safety glasses, or chemical goggles.
Hands & Skin:
For prolonged or repeated handling, use impervious gloves. Gloves should be
tested to determine suitability for prolonged contact. Use of impervious apron
and boots are recommended.
Respiratory:
If ventilation is not sufficient appropriate NIOSH/MSHA respiratory protection
must be provided.
Work Practices:
Eye wash fountain and emergency showers are recommended.
SECTION 9 TYPICAL PHYSICAL AND CHEMICAL PROPERTIES
Physical Form: Liquid
Color: Red

ENVIRO�CU
Odor:
Wintergreen
Odor Threshold:
NE
pH:
8.5+/-0.5
Boiling Point:
NE
Melting Point:
N/A
Flash Point:
>200 deg F
Evaporation Rate (Butylacetate = 1)
NE
Flammability:
Non -Flammable
UEL:
NE
LEL:
NE
Vapor Pressure:
NE
Vapor Density:
NE
Specific Gravity (Water =1):
1.03 +/- .05
Solubility Water:
Complete
Partition Coefficient:
NE
Auto -ignition Temperature:
NE
Decomposition Temperature:
NE
Viscosity (CPS):
NE
SECTION 10 STABILITY AND REACTIVITY
Stability: This product is stable under normal temperatures and pressures.
Incompatibility: Strong Oxidizers and strong acids.
Decomposition Products: No Known hazardous products.
Conditions to Avoid: Sparks/flames/high heat.
SECTION 11 TOXICOLOGICAL PROPERTIES
Raw Material Test Result Route Species
N/A
See Section 4 for symptoms.
CARCINOGENICITY:
No known carcinogens, mutagens, or reproductively toxic ingredients
SECTION 12 ECOLOGICAL INFORMATION
Raw Material Test Result Time Species
N/A
PERSISTENCE & DEGRADABILITY:
NE

ENVIRO�CU
BIOACCUMULATION:
NE
MOBILITY
NE
SECTION 13 DISPOSAL CONSIDERATIONS
Whatever cannot be saved for recovery or recycling should be managed in an appropriate and approved
waste disposal facility. Processing, use, or contamination of this product may change the waste
management options. State and local disposal regulations may differ from federal disposal regulations.
Dispose container and unused contents in accordance with federal, state, and local requirements.
SECTION 14 TRANSPORT INFORMATION
Not Regulated by DOT or IATA.
SECTION 15 REGULATORY INFORMATION
US FEDERAL REGULATIONS
SARA (SUPERFUND AMENDMENTS AND REAUTHORIZATION ACT):
SARA 302 EXTREMELY HAZARDOUS SUBSTANCES LIST: NA
SARA 312 HAZARD CATEGORY:
SARA 313 TOXIC CHEMICALS LIST:
M
NA
CERCLA (COMPREHENSIVE ENVIRONMENTAL RESPONSE. COMPENSATION AND
LIABILITY ACT): NA
RCRA (RESOURCE CONSERVATION AND RECOVERY ACT) LISTED HAZARDOUS WASTES:
NA
CWA (CLEAN WATER ACT) LISTED SUBSTANCES: NA
FDA (FOOD AND DRUG ADMINISTRATION): NA
TOXIC SUBSTANCES CONTROL ACT (TSCA): NA
IATA: NA

ENVIRO�CLEAN
NFPA HAZARD INFORMATION SIGN
101
4 - DEADLY
3 - EXTREME DANGER
2 - HAZARDOUS
1 - SLIGHTLY HAZARDOUS
0 - NORMAL MATERIAL
[0]
FLASH POINTS:
4
- BELOW 73 F
3
-BELOW 100 F
2
- BELOW 200 F
1
- ABOVE 200 F
0
- WILL NOT BURN
[01 REACTIVITY HAZARD (YELLOW DIAMOND)
4 - MAY DETONATE
3 - SHOCK AND HEAT MAY DETONATE
2 - VIOLENT CHEMICAL CHANGE
1 - UNSTABLE IF HEATED
0 - STABLE
[] SPECIFIC HAZARD (WHITE DIAMOND)
OXY
OXIDIZER
ACID
ACID
ALK
ALKALI
COR
CORROSIVE
W
USE NO WATER
SECTION 16 OTHER INFORMATION
THIS INFORMATION IS OFFERED IN GOOD FAITH AS TYPICAL VALUES AND NOT AS A
PRODUCT SPECIFICATION. NO WARRANTY, EXPRESSED OR IMPLIED, IS HEREBY MADE. THE
RECOMMENDED INDUSTRIAL HYGIENE AND SAFE HANDLING PROCEDURES ARE BELIEVED
TO BE GENERALLY APPLICABLE. HOWEVER, EACH USER SHOULD REVIEW THESE
RECOMMENDATIONS IN THE SPECIFIC CONTEXT OF THE INTENDED USE AND DETERMINE
WHETHER THEY ARE APPROPRIATE.

ATTACHMENT C
WELL CONSTRUCTION DATA
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 8

WELL CONSTRUCTION RECORD (GW-1)
For
Use
Print Form
1. Well Contractor Information:
Alan Brown
Well Contractor Name
3185-A
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural [:)Municipal/Public
Geothermal (Heating/Cooling Supply) QlResidential Water Supply (single)
Industrial/Commercial Residential Water Supply (shared)
Irrieation
Non -Water Supply Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling
4. Date Well(s) Completed: 2/27/18
5a. Well Location:
Speedway
Groundwater Remediation
01 Salinity Barrier
01 Stormwater Drainage
Subsidence Control
❑I Tracer
❑I Other (explain under #21 1
Well ID# MW-6
6929
Facility/Owner Name Facility ID# (if applicable)
4019 Reynolda Road Winston-Salem, NC
Physical Address, City, and Zip
Forsyth
County
6808-62-4079.00
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.166470 N-80.333063 W
6. Is(are) the well(s)�Ix Permanent or [31'emporary
7. Is this a repair to an existing well: Yes or )No
If this is a repair, fall out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
9. Total well depth below land surface: 35 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing:
Ifwater level is above casing, use
11. Borehole diameter: 8
(in.)
12. Well construction method: hollow Stem auger
(i.e. auger, rotary, cable, direct push, etc.)
14. WATER ZONES
FROM
TO
DESCRIPTION
24 ft.
26 ft.
Wet silty clay
ft.
ft.
15. OUTER CASING for multi -cased wells OR LINER if a licable
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING(geothermal closed400
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
5 ft.
2 i°
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
5 ft
35 ft
2 in-
.010
SCH 40
PVC
ft.
ft
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
3 ft.
4 ft.
Bentonite Chips
Gravity
0 ft.
3 ft.
Portland Cement
Tremie
ft.
ft.
19. SAND/GRAVEL PACK if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
4 ft
35 ft
#1 filter pack
gravity
ft.
ft.
20. DRILLING LOG attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.
Ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Digitally signed by Todd Muench
Todd Muench ou=PWNCae mlle[muench@pwiOloml a=US 3/5/18
Date: 2018.03.05 15:14:46-05'00'
Signature of Certified Well Contractor Date
By signing this form, I hereby certijy' that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
(ft.) Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center, Raleigh, NC 27699-1636
13a. Yield (gpm) Method of test: 24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016

LOG OF BORING: MW-6
Mid Atlantic 125E o24Suie104.
Charl.lone, NC 8204
Ift
Engineering & Environmenxal Solutions Ph: [phone]
Page: 1 of 2
Hand uger Hollow Stem
Site Name: Speedway 6929 Drilling/Boring Method: Auger Total Boring Depth (ft): 36
Project Number: R1039.00 Sampling Method: N/A Well Depth (ft): 36
Location: Winston-Salem NC Subcontractor/Drillers: Parratt-Wolff Screen Depth (ft): 26-36
Date Started: 2/27/2018 Driller: DTW (ft): 30.85
Date Completed: 2/27/2018 Monitoring Equipment: N/A MAA Field Staff: Gary Fischer
�
c �
a
Sampling
5
a >r
SOIL DESCRIPTION (color, texture, moisture, etc.)
Construction Details
A
w
Interval, Odors
t«.
Light brown silty CLAY. Petroleum staining at 1.5' to 3'
2
2
298
X
4
Light brown and light orange silty CLAY
4
19.8
6
6
8
8
10
39.6
X
Light brown silty clay
10
12
12
14
14
49.8
X
Light brown slightly clayey SILT with greenish grey petroleum staining
16
16
�
18
18
118
Dark brown clayey silt. Petroleum on outside of split spoon. Core totally saturated.
20
20
COMMENTS: in - indicates inches N/A - indicates not applicable to this boring
DTW - Depth to Water ft - indicates depth in feet plan - indicates parts per million
ft-bgs - indicates feet below ground surface TD - Total Depth of Boring for Sampling

LOG OF BORING: MW-6
Mid Atlantic 125E o24Suie104.
Charl.lone, NC 8204
Ift
Engineering & Environmental Solutions Ph: [phone]
Page: 2 of 2
Hand uger Hollow Stem
Site Name: Speedway 6929 Drilling/Boring Method: Auger Total Boring Depth (ft): 36
Project Number: R1039.00 Sampling Method: N/A Well Depth (ft): 35
Location: Winston-Salem NC Subcontractor/Drillers: Parratt-Wolff Screen Depth (ft): 25-35
Date Started: 2/27/2018 Driller: DTW (ft): 30.85
Date Completed: 2/27/2018 Monitoring Equipment: N/A MAA Field Staff: Gary Fischer
�
c �
a
Sampling
5
a >r
SOIL DESCRIPTION (color, texture, mixture, etc.)
Construction Details
A
w
Interval, Odors
.
118
Dark brown clayey SILT. Petroleum on outside of split spoon. Core totally saturated.
22
22
24
24
168
Dark brown slightly sandy silty CLAY
26
--
26
28
28
30
321
Light brown, greenish grey slightly clayey sandy SILT
30
32
32
34
34
211
Light brown, greenish grey slightly clayey sandy SILT
36
36
Boring terminated at 36'
38
38
40
40
COMMENTS: in - indicates inches N/A - indicates not applicable to this boring
DTW - Depth to Water ft - indicates depth in feet plan - indicates parts per million
ft-bgs - indicates feet below ground surface TD - Total Depth of Boring for Sampling

TABLE 4.1
MONITORING WELL CONSTRUCTION DATA
SPEEDWAY #6929
4019 REYNOLDA ROAD
WINSTON-SALEM, NORTH CAROLINA
MID -ATLANTIC JOB NO. 00OR1039.04
WELL
TOTAL WELL
SCREENED
INSTALLATION
WELL I.D.
DIAMETER
DEPTH
INTERVAL
DATE
(INCHES)
(FEET)
(FEET BLS)
M W-1
2
1 /24/2001
36.0
16.0-36.0
MW-1 D
2
5/29/2001
58.0
53.0-58.0
MW-2
2
5/24/2001
36.0
21.0-36.0
MW-2R
2
6/19/2019
30.0
15.0-30.0
MW-3
2
5/24/2001
36.0
21.0-36.0
MW-3R
2
6/19/2019
30.0
15.0-30.0
MW-4
2
5/24/2001
40.0
25.0-40.0
MW-5
2
2/27/2018
37.0
27.0-37.0
MW-6
2
2/27/2018
35.0
5.0-35.0
M W-7
2
11 /26/2018
40.0
23.0-38.0
MW-8
2
6/19/2019
35.0
20.0-35.0
NOTE:
BLS = Below Land Surface