WI0400098_APPLICATION FOR PERMIT_20110426

North Carolina Department of Environment and Natural Resources
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
In Situ Groundwater Remediation rtsA tiCA o2c g2251 I Tracer Injection 115A NCAC Q2C.Q229i
Do not use this form for the Following:
■ in situ rernediation, tracer, or aquifer test injection wells permitted by rule (ref. N AC 2 217
■ reruediation systems that reinject treated contaminated groundwater {ref. 15A NCAC 02T .1 j
Application Number (to be completed by DWR):
1. APPLICATION INFORMATION
I. Project is: [ ] New [ ] Modification PQ Renewal without modification [ ] Renewal with modification
2. If this application is being submitted for renewal or modification to an existing permit, provide;
existing permit number WIQ49M and the issuance date April 25. 2011
Far renewal withon modifications, fill out sections 1 do 11 only, sign the certification on the lost page of this form, and obtain the
propert3 owner's signarure to indicate consutt (if the applicant is not the owner]
Forte renewals, submit a stains report including monitoring results of all urjecrion activities to date-
H.
WELL OWNER (generally the responsible party)
I. Name: ABB.Ing.
2. Signing Official's Name*: R. Keith XpaugrhgM __ Ttle: Chief ounsel
* Signing Official must be in accordance with instrucdons in Part IX on page 5.
3. Mailing address of applicant:_ 5 Waterside Qgssing
City: Windsor State. CT Zip:
4. Telephone number: 860-285-9494 — Email: �[e-mail]
5. Status (choose one): Individual X Business/Org. Federal State County Municipality
W. PROPERTY OWNER (if different than well owner)
1. Name:
2. Physical address:
City: State: Zip:
3. Mailing address:
City: _
4. Telephone number: Email:
State: Zip:
I1111. PROJECT CONTACT — Person who can answer technical questions about the proposed injection project.
1. Name: Title:
2. Company:
3. Address:
4. City: State: Zip:
5. Telephone number:__ Email:
Revised 1111912013 UIC-514T Pa 1 of 5
+��, 8e

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
In Situ Groundwater Remediation I Tracer Nection
V. FACILITY INFORMATION
1. Facility name: Ph#:
2. Mailing address:
City: County: State.NC Zip:
3. Geographic Coordinates: Latitude: Longitude:
Reference Datum: Accuracy:
Method of Collection:
4. Brief description of business:
VI, INCIDENT DESCRIPTION
1. Source and date of contamination:
2. List all contaminants present in soils or ,groundwater at the site (romandnaws mays be listed in groups, e.g., gasoline.
diesel, jer fuel, fired oil, chlorinated erhenes, chlorinated erhanes, nierals, pesricid&Ojerbicides, 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 ❑SCA sites)
(] DWR Aquifer Protection Section [ ] Solid Waste Section
(] Hazardous Waste Section [ ] Other:
Incident manager's name: Ph#:
6. Incident number or other incident m;mt. agency tracking number:
V II. PERMITS
List all applicable permits or construction approvals issued for the facility or incident:
I . Hazardous Waste Management program pe, mstS under RCRA:
_. DWR Dion -Discharge or NPDES permits:
3. County or DEH subsurface wastewater disposal permits:
4. Other environmen tal permits required by state or federal law:
Revised 11119r?013 )TIC-5II5T Page 2 of 5

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
In Situ Groundwater Remediation I Tracer Injection
VIII. 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 i.SA ,tiC,j_Q o2C .U;25{en 21 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. HYDROGF.OLOGIC EVALUATION - Per 1 5A NCAC 02C .0225w0) 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 deterrrdne these parameters;
(F) Rate and direction of groundwater flow as determined by predictive calculations or computer modeling; and
(G) Li thostrati graphic and hydroscmd graphic logs of any existing test and injection wells.
3. INI JEC'TANT INFORMATION - Per ISA NCAC 02C .¢225t_LiL5j list each injectant in the space below and provide the following
information for each 'injectant. NOTE: Approved injecrants can be fowid online at lotto:l/PorraL►rcden orglweGlwerlrrtig vnrn.
All other substances must be reviewed by the Division of Public Health, Deparrmenr of Health and Human Services. Conraer the
UIC Program for more infannatio►i (Ph# 919-807-6496).
(A) MSDS, concentration at the point of injection, and percentage if present in a rnixture with other injectants;
(B) The source of fluids used to dilute, carry, or otherwise distribute the injectant throughout the injection zone. If an}
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: locationllD 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 summary 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 byproduct; 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. ENJECTION PROCEDURE - Per 15A NCAC 02C .D225seaL6] 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 ❑restimated total volume to be injected.
Revised i t119r_013 UIC-5II5T Page 3 of 5

APPLICATION FOR PERMIT TO CONSTRUCT AND10R USE A WELLS) FOR INJECTION
In Situ Groundwater Remediation J Tracer Injection
5. FRACI`L1Rf_NG PLAN cif applicable? — Per im NCAC c submit a detailed description of the Fracturing plan
that includes the following:
(A) Material Safety Data Sheets of fracturing media including information on any proppanis 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 uncontanunated
area of the site.
6. WELL COIySTRAXTION DETAILS — Per 15A NCAC fl2C .o225jeO submit the following information in tabular or
schematic form as appropriate for each item:
(A) number 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 welts are permanent or temporary "direct push" points; and
(H) plans and specifications of the surface and subsurface construction details.
7. MON1TOR13NI i PLAN — Per 15A�CAC Q2CLo225LgA-gj subrrut a monitoring plan that includes the %!lowing:
(A) target contaminants plus 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.
Moniroring svells shall be of suj`icieni quantity• and location to detect am niovemenr of injecrion fluids, injection process byproducrs. or
forniarion 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 injeciants and contaminants.
S. WELL DATA TAB Ui ATION — Per 15A NCAC Q2C .0225tev ins provide a tabulation of data on a]I 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 abandonment_
9. MAPS AND CROSS-SECT(OIvS — Per ,�_ c_ :fit_ w o225� k provide scaled, site -specific site plans or maps depicting
the location, orientation, and relationship of facility components including the following:
(A) area map based on 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 -sections) 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 lithoiogy. 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.
Revised 1 lll9r2013 UIC-51157 Page 4 of 5

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
In Situ Groundwater Rcmediation ! Tracer Injection
IX. CERTIFICATION* (to be signed as required below or by that person's authorized agent)
NCAC 15A 02C .0211[e! requires that a]I permit applications shall be signed as follows:
1- 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 behair of the upplicant. then suppi)• a letter signed by the applicant
that names and authorizes their agent.
"I hereby certify under 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
ininrediately responsible for obtaining said information, I believe that the information is true, accurate, and
complete. I am aware that there are penalties, including the possibility of fines and imprisonment, for submitting
false information. 1 agree to construct, operare, 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. "
Printed Name and Title: R th I{nauerha a Chief Counsel
Signature: Date:
X. 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 const acted. 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 uvell(s) are to be constructed and operated, 1 hereby consent to
allow the applicant to construcr each injection v.,ell as outlined in this application and agree that it shall be the
responsibility of the applicant ro ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C , 02W), "
Printed Name and Tit] 5'Tumer. Assistant ►--anager, it of Winston-Saleni
Signature: _ Dater
Submit TWO copies of the completed application package, including al attachments, to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
ttcvised 1111912013 UIC-5I/5T Page 5 of 5

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR
INJECTION
Type 5I Wells — In Situ Groundwater Remediation [Type 5T Wells —Tracer Injection
■ Do not use this form for remediation systems that extract contaminated groundwater, treat it, and reinject the
treated groundwater.
■ Submit TWO copies of the completed application and all attachments to the address on the last page of this
form.
• Any changes made to this form will result in the application package being returned.
Application Number (to be completed by DWQ):
1. GENERAL INFORMATION:
1. Applicant's Name (generally the responsible party): Flakt Products. Inc. ti
2. Signing Official's Name*: Mr. John Conant Title: Dir.- Nuclear En . & Compliance
* Signing Official must be in accordance with instructions in part VI on page 7.
3. Mailing address of applicant:_ 5 Waterside Crossing
City:
Windsor
State: CT Zip:
06095
Telephone number: [phone] Fax number: [phone]
4_ Property Owner's Name (if different from Applicant): Mr. Fred Godley
5. Property Owner's mailing address: P.O. Box I ] 40
City: Cornelius State: NC Zip: 28031
6. Name and address of contact person who can answer questions about the proposed injection
project:
Name: Mr. Ricky A. Ryan Title: Sr. Principal _Project_Manager_
Company: MACTEC Engineering and Consulting
Address: 9725 Cogdill Road _
City: Knoxville State: TN Zip: 37932
Telephone number: (,865) 588-8544 Fax number: [phone]
Email Address: [e-mail]

APPLICATION FOR PEz%,..IT TO CONSTRUCT AND/OR USE A rrELL(S) FOR INJECTION
Type 51 Wells — In Situ Groundwater Remediation 1 Type 5T Wells — Tracer Injection
It. PERNUT IITTFORMATION:
1. Project is: ( )New () Modification of existing permit ( )Renewal of existing permit without
modification
( X ) RenewaI of existing permit with modification
2. If this application is being submitted for renewal or modification to an existing permit, provide:
existing permit number W10400098 and the issuance date 3/30/2009
For renewal without modifications, fill out sections I & II only, sign the certification on the
last page of this form, and obtain the property owner's signature to indicate consent (if the
applicant is not the owner).
For all renewals, submit a status report including monitoring results of all injection activities
to date.
Note: Injection event report for original permit # WI0400098 was submitted to the Division of
Water Quality on June 28, 2010 (MACTEC, 2010).
Revised 6/09 UIC-51l5T Page 2 of 56

APPLICATION FOR PEP mlIT TO CONSTRUCT AND/OR USE b rr ELL(S) FOR INJECTION
Type SI Wells —In Situ Groundwater Remediation 1 Type 5T Wells — Tracer Injection
M. INCIDENT & FACILITY DATA
A. FACILITY INFORMATION
1. Facility name: Farmer Flakt Products Site
2. Complete physical address of the facility:_ 2000 Lowery Street
City: Winston-Salem County:Fors h State: NC Zip: 27101
B. INCIDENT DESCRIPTION
1. Describe the source of the contamination:
The facility used metal product degreasing baths at 2 locations within the building: north and
south pits, as shown on Figure 2. The baths consisted of open steel tanks (—I I ' deep, 6' wide,
and I2' long,) located in concrete pits. The tanks were filled with degreasing solvents, either
trichloroethene (TCE)or 1. 1, 1 -trichloroethane (TCA). at various times, pumped from a 7,000 gal.
aboveground storage tank (AST) through overhead pipes. A 1988 assessment concluded that the
stored solvents had been released onto the ground surface and subsurface. It was later concluded
from a soil investigation assessment that the north and south pits and the AST were sources
contributing to the presence of volatile organic compounds (VOCs) in soils located beneath the
pits and AST system. An evaluation of the historical use of the site revealed reported surface
releases of TCE and TCA near the former UST area. A 2006 focused soil investigation indicated
that the persistent groundwater contamination in the former UST area may be indicative of
residual contamination in the saturated zone (MACTEC 2006).
2. List all contaminants present in soils or groundwater at the site (contaminants may be listed in
groups, e.g., gasoline, diesel, jet fuel, fuel oil, chlorinated ethenes, chlorinated ethanes, metals,
pesticides/herbicides, etc):
Primarily chlorinated ethanes, chlorinated ethenes. 1,4-dioxane, and other volatile organic
3. Has LNAPL or DNAPL ever been observed at the site (even if Outside the injection zone)?
4
() Yes If yes, list maximum measured separate phase thickness feet
( X)No If no, list maximum concentration of total VOCs observed at site: 144,506 ppb
Agency managing the contamination incident:
{} UST Section (X) Superfund Section (including REC Program and DSCA sites)
[) DWQ Aquifer Protection Section [) Solid Waste Section
(} Hazardous Waste Section (} Other:
5. Incident managers name Kim Caulk and phone number [phone]
6. Incident number or other site number assigned by the agency managing the contamination
incident: NONCD 0000017
Revised 6109 UIC-5115T Page 3 of 56

APPLICATION FOR PEP-milT TO CONSTRUCT AND/OR USE A wELL(S) FOR INJECTION
Type 5I Wells — In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
C. PERMITS
List all permits or construction approvals that have been issued for the facility or incident, including
those not directly related to the proposed injection operation:
1. Hazardous Waste Management program permits under RCRA:
2. DWQ Non -Discharge or NPDES permits: NCO085871
3. County or DEH subsurface wastewater disposal permits:
4. Other environmental permits required by state or federal law: Administrative Order on Consent
(Docket Number 97-SF098), Authorization to Construct for Permit NO. NCO085871 (letter dated
November 6, 1997), Injection Permit WI0400098 (NC DENR 2009, issued March 30, 2009).
IV. INJECTION DATA
A. INJECTION FLUID DATA
1. List all proposed injectants.
NOTE: Any substance to he injected as a tracer or to promote in situ remediation must be
reviewed by the Occupational and Environmental Epidemiology Section (GEES) of the Division
of Public Health, Department of Health and Human Services. Review the list of an)roved
tgj!e tints or contact the IIIC Program to determine if the injectants you are proposing have
been reviewed 6v OEES
Hydrogen peroxide, ferrous sulfate, and phosphoric acid are GEES approved additives for
CHIP , and sulfuric acid was approved for the subject site in a September 30, 2008 letter
from the North Carolina Department of Health and Human Services to Mr. Qu Qi with the
Aquifer Protection Section (NCDHHS, 2008).
1njectant: Catalyzed Hydrogen -Peroxide (CH.P)(HO-,) (Geo-Cleanse)
Concentration at point of injection: 11.3% 14102
Percent if in a mixture with other injectants: NA
lnjectant: CHP: Ferrous Sulfate (FeSO4 7HA catalyst) [Geo-Cleanse]
Concentration at point of injection: Dissolved at up to 500 ppm aqueous solution (typically
100-200 mg/L)
Percent if in a mixture with other injectants: NA
Injectaot: Phosphoric Acid HPO4 as part of the catalyst) Geo-Cleanse
Concentration at point of injection:/-5% (approx. 0.002M). as needed to lower pH to <6
Percent if in a mixture with other injectants: NA
Injectant: Sulfuric Acid (HIS04), as part ofcatalyst Geo-Cleanse
Concentration at point of injection: as needed (approx. 0.002M), as needed to lower pH to c6
Percent if in a mixture with other injectants: NA
Revised 6/49 U1C-51/5T Page 4 of 56

APPLICATION FOR PEtuvi.IT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 51 Wells — In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
K
Source of fluids used to dilute or chase the injectants listed above:
( ) None
(X) Municipal water supply
{ } Groundwater from private well or any well within % mile of injection site
(} Air
{ } Other:
3. If any well within '/a mile of injection site, a private well, or surface water is to be used as the
fluid source, supply the following information:
a. Location/113 number of source: none
b. Depth of source:
c. Formation:
d. Rock/Sediment type:
e. In Attachment C, provide a current, complete 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.
NOTE_ If contaminated groundwater is to be used as the dilution or chase fluid, this is not
the proper permit application form. You must apply for a closed -loop groundwater
remediation permit using tWlicationform Gi RS.
PROPOSED OPERATING PARAMETERS
1. Duration of Injection: 8 to 9 weeks per event
a. Maximum number of separate injection
b. Expected duration of each injection event: 8 to 9 weeks
c. Expected duration between events (if more than one event): 3-6 months
2. Injection rate per well: 0.5-1.2 gallons per minute (gpm)
3. Total Injection volume: 3,368 gallons per day (gpd). 143.160
separate events)
4. Injection pressure: 10-40 pounds/square inch (psi)
5. Temperature at point of injection: (GW) 80-120°F
6. Briefly describe how the above parameters will be measured and controlled:
gallons per event (if
Groundwater
temperature is measured each morning. Pressure and rate are monitored/optimized con_tinuousiy
in response to site conditions. Temperature and pressure are controlled by adjusting peroxide
concentrations, catalyst mixture. and injection rate. Injection rate is controlled with calibrated
totalizers and flow valves.
7. Estimated hydraulic capacity of the well: 2.0 gpm
Revised 6/09 UIC-5115T Page 5 of 56

APPLICATION FOR P)EtuvAT TO CONSTRUCT AND/OR USE A wELL(S) FOR INJECTION
Type 51 Wells —In Situ Groundwater Remediation / Type 5T Wells —Tracer Injection
C. INJECTION WELL CONSTRUCTION DATA
1. Injection will be via:
(X) Existing well(s) proposed for use as an injection well. Provide the data in (2) through (6)
below to the best of your knowledge.
(X) Proposed well(s) to be constructed for use as an injection well. Provide the data in (2)
through (6) below as proposed construction specifications.
2. Well Drilling Contractor's Name: SAEDACCO, INC
NC Well Contractor Certification number:
3. Date to be constructed: TBD Number of borings: 41 new borings
contain ing 80 new injection wells and 7 existing borin gs contain ing 9 existin g infection wells.
See Attachments E and G for details.
Approximate depth of each boring (feet): Proposed: 34 at 70' and 7 at 80"
Existing: 4 at 60' and 3 at 70' See Attachments E and G for details._
4. Screened interval/Injection interval of injection wells:
Depth: 55 to 80 feet below ground surface (if multiple intervals. indicate shallowest and
deepest depth).
5. Well casing (N/A if injection is through direct push rods):
Type: () PVC 0 Stainless steel ( X) Other: Schedule 80 CPVC
Casing depth: 60 to 80 ft.
6. Grout (N/A if injection is through direct push rods):
Type: (X) Cement (X) Bentonite
Grout depth: 0 to 73 ft.
() Other:
Revised 6/09 UIC-51/5T Page 6 of 56

APPLICATION FOR PExivilT TO CONSTRUCT AND/OR USE A wELL(S) FOR INJECTION
Type 5I Wells — In Situ Grou ndwater Remediation / Type 5T Wells — Tracer Injection
V. ATTACHMENTS
Provide the following items as separate attachments with the given headings:
A. SITE HISTORY
Provide a brief description of the site history including-
(1) site usage historically and present,
(2) origin of the contamination,
(3) previous remedial action(s).
NOTE. G.S. 89E-18 requires that any geologic plans, reports, or documents in which the performance is
related to the public welfare or safeguarding of the environment he prepared by a licensed geologist or
subordinate under their direction. G.S. 89E-13 requires that all drawings, reports, or documents
involving geologic work prepared or approved by a licensed geologist, or a subordinate under their
direction, be signed and sealed by the licensed geologist.
B. HYDROGEOLOGIC DESCRIPTION
Provide a hydrogeologic description, soils description, and cross section of the subsurface to a depth that
includes the known or projected depth of contamination. The hydrogeologic description shall include:
(1) the regional geologic setting;
(2) significant changes in lithology;
(3) the hydraulic conductivity, transmissivity, and specific yield of the aquifer to be used for injection.
including a description of the test(s) used to determine these parameters; and
(4) the depth to the mean seasonal high water table.
C. INJECTION FLUID COMPOSITION
Describe the chemical, physical, biological and radiological characteristics of each injectant. Attach the
Material Safety Data Sheet (MSDS) for each injectant. If a private well or a well within 'A mile of the
injection site is used as the source well, include chemical analysis of source fluid here-
D
. INJECTION RATIONALE
Attach a brief description of the rationale for selecting the injectants and concentrations proposed for
injection, including:
(1) goals of the injection project;
(2) explanation and/or calculations of how the proposed injectant volume and concentration were
determined;
(3) 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; and
(4) summary results of modeling or testing performed to investigate the injectant's potential or
susceptibility to change (biological, chemical or physical) in the subsurface.
E. INJECTION PROCEDURE AND EQUIPMENT
Provide a detailed description of all planned activities related to the proposed injection including but not
limited to:
(1) construction plans and materials;
(2) operation procedures;
(3) a detailed diagram of the surface and subsurface portions of the system; and
a planned injection schedule.
Revised 6/09 U1C-51/5T Page 7 oi56

APPLICATION FOR PExu.JT TO CONSTRUCT AND/OR USE A wELL(S) FOR INJECTION
Type SI Wells —In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
F. MONITORING PLAN
Provide a plan for monitoring the results of the injection, including:
(1) a Iist of existing and proposed monitoring wells to be used;
(2) a list of monitoring parameters and analytical methods to be used; and
(3) a schedule for sampling to monitor the proposed injection.
NOTE.- The selected monitoring wells must be located so as to detect any movement of injection fluids,
process by-products, or formation fluids outside the injection area or zone. The monitoring parameters
should include the target contaminants as well as secondary or intermediate contaminants which may
result from the ii jection chid other parameters which may serve to indicate the progress of the intended
reactions, such as pH, ORP, dissolved oxygen, and other electron acceptors and donors. The monitoring
schedule should be consistent with the pace of the anticipated reactions and rate of transport of the
injectants and contaminants.
G. WELL DATA
Provide a tabulation of data on all existing or abandoned wells within '/4 mile of the injection well(s)
which penetrate the proposed injection zone, including, but not limited to, monitoring wells and wells
proposed for use as injection wells. Such data shall include a description of each well's use (water
supply, monitoring, etc), total depth, screened or open borehole depth interval, and well construction or
abandonment record, if available.
I:� 35I1 a1
Attach the following scaled, site -specific maps:
(1) Area map based on 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.
(2) Site map including:
a. all property boundaries;
b. all buildings within the property boundary;
c. existing and proposed injection wells or well field(s)
d. any existing sources of potential or known groundwater contamination, including
waste storage, treatment or disposal systems within '/a mile of the injection we] I or
well system;
e. all surface water bodies within'/e mile of the injection well or well system; and
f. all existing or abandoned wells within''/4 mile ofthe injection well(s) which penetrate
the proposed injection zone, including, but not limited to, monitoring wells and wells
proposed for use as injection wells.
(3) Potentiometric surface map(s) including:
a. direction of groundwater movement
b. existing and proposed monitoring wells
c. existing and proposed injection wells
(4) Contaminant plume map(s) including:
a. the horizontal extent of the contaminant plume, including isoconcentration lines
b. existing and proposed monitoring wells
c. existing and proposed injection wells
(5) Cross-section(s) to the known or projected depth of contamination, including:
a. horizontal and vertical extent of the contaminant plume, including isoconcentration lines
b. major changes in iithology
c. existing and proposed monitoring wells
d. existing and proposed injection wells
Revised 6/09 UIC-51/5T Page 8 of56

APPLICATION FOR PE. _IT TO CONSTRUCT AND/OR USE A "ELL(S) FOR INJECTION
Type 51 Wells —In Situ Groundwater Remediation 1 Type 5T Wells — Tracer Injection
Vl. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .0211(b) requires that all permit applications shall be signed as follows:
1- 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 under 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 immediately responsible for obtaining said information, I believe that the
information is true, accurate, and complete. I am aware that there are penalties, including the
possibility of' 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.
Printed NWme and Title:
Signature:,
Date: E7 1 v
V11. CONSENT OF PROPERTY OWNER (if the property is not owned by the 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 he 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
wells) conform to the Well Construction Standards (Title 15A NCAC 2C .0200).
Printed Name and
Signature:
Date. AO 13? Z 0
r -
Submit TWO copies of the completed application package, including all attachments, to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
TF
Revised 6109 UIC-5115T Page 9 of 56

ATTACHMENT A
SITE HISTORY
Revised 6/09 UIC-5U5T Page 10 of 56

1.0 Site Usage Historically and Present
Site usage information is located in the original application for permit # WI0400098 (MACTEC, 2008),
2.0 Origin of Contamination
The origin of site contamination is located in the original application for permit #W10400098
(MACTEC, 2008).
3.0 Previous Remedial Actions
March 1990 In -situ volatilization (ISV) systems at the two solvent pits were put into
operation. Periodic sampling of the soils beneath the pits was conducted to
evaluate the effectiveness of the ISV systems. Once soil sample results indicated
that the concentrations of target VOCs beneath the pits were below clean up
levels, operation of the systems was discontinued; the ISV systems in the north
and south pits were discontinued in July 1991 and January 1993, respectively,
June 1998 A 7-well groundwater recovery system was put into operation. The operation
continues to present day, with site -wide groundwater monitoring performed on
an annual }oasis.
October 2009 An in -situ chemical oxidation pilot test near the former UST area was performed
to demonstrate the effectiveness and efficiency of CHP and to enhance ongoing
remediation actions. A part of the pilot test, nine injection wells and four vent
wells were installed near the former UST area, and 4,380 gallons of 34 percent
hydrogen peroxide which was diluted and injected over a 10-day period.
Sampling of performance monitoring wells following the injection revealed that
the individual contaminants of concern (COCs) were reduced between 34 and 88
percent. The average reduction for the site COCs was 63 percent.
Revised 6/09 UIC-5I/5T Page i I of 56

ATTACHMENT S
I I Ill 11:11Ie3 all)1C1I!! Col 11 aI.N R 131 Y CORI
Revised 6/09 UIC-5I15T Page 12 of 56

The hydrogeological description is located in the original application for permit #WI0400098
(MIACTEC, 2008).
Revised 6/09 UIC-5I15T Page 13 of 56

ATTACHMENT C
INJECTION FLUID COMPOSITION
Revised 6/09 UIC-5I15T Page 14 of 56

A copy of the GEES of the Division of Public Health, Department of Health and Human Services' list of
approved injectants, as well as, the Material Safety Data Sheets for the listed injectants was previously
provided in the October 10, 2008 application for permit 4WI0400098 (MACTEC. 2008).
Revised 6/09 UIC-5I15T Page 15 of 56

1_%WKTal:l►•►ID1ad 17
INJECTION RATIONALE
Revised 6109 UIC-5I15T Page 16 of 56

1.0 Goals of the Injection Project
The goal of this injection is to conduct an expanded application of the in -situ chemical oxidation
(ISCO) based on results from the pilot test performed in October 2009, in the form of CHP. The
goals of the injection are to: 1) reduce overall contaminant mass and 2) to continue to assess the site -
specific saturated zone soil physical characteristics that may affect oxidant distribution and injection
procedures. CHP was selected because it has, on many sites and in the pilot test, effectively oxidized
chlorinated ethenes and ethenes, such as those present at this site,
2.0 Explanation and/or Calculations of how the Proposed Injectant Volume and Concentration were
Determined
MACTEC's subcontractor, GeoCleanse, has determined the proposed peroxide volume and
concentration from past experience with similar contaminants (including using contaminant mass
calculations) from site -specific conditions, and from observations from the ISCO pilot test, as well as,
using contaminant mass calculations. The concentration of all reagents is modified to ensure proper
chemistry (mildly acidic pH and presence of elevated iron concentration), distribution of oxidant, and
a safe and controlled reaction based upon process monitoring.
3.0 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
Because CHP is able to oxidize the parent products TCA and TCE without generating other
breakdown chlorinated compounds, generation of daughter products is not expected to occur. A
specific breakdown pathway has not been determined for 1,4-dioxane. Some residual metals,
acetone, and/or methyl -ethyl keytones (MEK) may be generated by the process however, it is
anticipated that once the pH stabilizes to pre -injection condition, the residual metals will precipitate
and the acetone and methyl -ethyl keytones will dissipate from the groundwater. MACTEC notes that
acetone and MEK were not detected in performance monitoring following a CHP application at the
site in 2009. Carbon dioxide and water are also expected to be generated during oxidation; 12 vent
wells [screened from 3 to 60 feet below ground surface (bgs)] will be constructed to allow the
generated carbon dioxide gases to vent to controlled locations. Four existing vent wells screened
from 3 to 65 feet bgs will also be utilized.
4.0 Summary results of modeling or testing performed to investigate the injectant's potential or
susceptibility to change (biological, chemical, or physical) in the subsurface
MACTEC's subcontractor, GeoCleanse, will conduct daily groundwater sampling in the treatment
area, to assess whether appropriate geochemical conditions are established in the aquifer, reagents are
distributed effectively, and efficient oxidation reaction is occurring. The parameters to be measured
are groundwater pH, alkalinity, dissolved iron, chloride. hydrogen peroxide, and temperature. From
the results obtained, it can be assessed whether a conducive environment (e.g., low pH, sufficient
iron, distribution of peroxide, etc.) has been established to oxidize the COCs utilizing CHP.
Revised 6/09 UIC-51/5T Paee 17 of 56

ATTACHMENT E
INJECTION PROCEDURE AND EQUIPMENT
Revised 6/09
Ul C-5I15T Page 1$ of 56

1.0 Construction plans and materials
Following NCDENR issuance of the permit to construct and use the subject injection wells, the
injection will begin with the installation of 80 injection wells and 12 vent wells, as shown an Figure
?A (Attachment H). Hollow stem auger drilling is proposed for the injection and vent well
installation. The injection wells will be constructed of I.25-inch diameter Schedule 80 chlorinated
poly vinyl chloride (CPVC) pipe with a 0.010-slot screened interval of 5 feet. Thirty-five of the wells
will have a total depth of 60 feet bgs; 38 of the wells will have a total depth of 70 feet bgs; and seven
of the wells will have a total depth of 80 feet bgs. Most of the injection wells will be installed as
nested well pairs in the same boring. The 12 new vent wells will be constructed of 2-inch diameter
Schedule 80 CPVC with a 0.010-slot screened interval of 57 feet with a total well depth of 60 feet
bgs. The filter sand will be size 20/30 or similar for all injection wells, and will be overlain by a layer
(1 to 2 feet thick) of barrier fine grain sand. The grout collar will consist of 95% Portland cement and
5% bentonite powder,
2.0 Operation procedures
Upon completion of the well installation, MACTEC will submit to NCDENR a notice of completion
of construction and allow sufficient time (up to 10 days following receipt of notice) for the Director to
send notice of intent to inspect the installation or otherwise review the injection wells. MACTEC will
then commence injection of the materials described in Attachment C.
3.0 A detailed diagram of the surface and subsurface portions of the system
The surface layout of the new wells is shown on Figure 2A (Attachment H). The subsurface
diagrams of the proposed wells are illustrated in the Well Construction Diagrams included in this
Attachment.
4.0 A planned injection schedule
Construction of the proposed wells will be scheduled following issuance of the injection permit. We
anticipate commencing drilling approximately 4 weeks following issuance of the permit. Well
construction will take place over the course of 40 work days. After well construction is complete,
MACTEC will submit a notice of completion to NCDENR.
Injection will commence once NCDENR has inspected or otherwise reviewed the wells and found
them to be in compliance with the permit conditions. In accordance with subsection I5A NCAC 02C
.021 I(h) of the North Carolina Administrative Code, Subchapter 2C -- Well Construction Standards,
if MACTEC does not receive notice from the Director of intent to inspect or otherwise review the
injection well within 10 days after receiving the notice, the injection will commence and will proceed
over the course of approximately 50 workdays.
Revised 6/09 UIC-5I15T Paue 19 of 56

PROPOSED WELL CONSTRUCTION RECORDS
Revised 6/09 UIC-5115T Page 20 of 56

PROPOSED DUAL INJECTION WELL CONSTRUCTION DETAILS
jos NAME FORMER ABB FLAKT PRODUCTS
WELLS 33 EACH
TOTAL DEPTH
MACTEC ENGINEERING
FIELD REPRESENTATIVE
6`
7p.❑'
I
70. D'
m
JOB NUMBER 303 t — 05 —200 7— ? 2
INSTALLATION DATE
DRILLED Br
RISERJSCREEN:
MATERIAL:
DIAMETER:
SLOT SIZE:
(NOT TO SCALE)
TBD
SAEDACCO
SCHEDULE 80 CPVC
1.25"
0.010"
ANT STEEL
'BETE PAD
PVC RISER
PORTLAND/BENTONITE
GROUT
FINE SAND SEAL
BOREHOLE WALL
SAND FILTER PACK
PVC SCREEN
PVC END CAP
FINE SAND SEAL
PVC RISER
SAND FILTER PACK
PVC SCREEN
PVC END CAP
BOTTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
OMACTEC.
IN-SITU CHEMICAL OXIDATION
WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and Consulting, inc. ❑RAFTING BY: PREPARED BY: (,�[,J CHECKED BY: �r
9725 Cogdill Road ,1
Knoxville, Tennessee 37932 JOB NUMBER: DATE: SCALE:
865-588-8544 ■ Fax. [phone]
3031-05-2007-12 SEPTEMBER 23, 2010 NOT TO SCALE

PROPOSED DUAL INJECTION WELL CONSTRUCTION DETAILS
JOB NAME FORMER ABB FLAKT PRODUCTS
WELLS 4 EACH
TOTAL DEPTH
MACTEC ENGINEERING
FIELD REPRESENTATIVE
80.0
JOB NUMBER
INSTALLATION DATE
DRILLED BY
RISER/SCREEN:
MATERLAL:
DIAMETER:
SLOT SIZE:
(NOT TO SCALE)
3031-05-2007-12
TBD
SAEDACCO
SCHEDULE 80 CPVC
1.25"
0.010"
r, i,ri+n'JNT STEEL
'RETE PAO
PVC RISER
PORTLAND/BENTONITE
GROUT
FINE SAND SEAL
BOREHOLE WALL
SANG FILTER PACK
PVC SCREED
PVC END CAP
FINE SAND SEAL
PVC RISER
SAND FIL
ITER PACK
PVC SCREEN
PVC END CAP
BOTTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
IN -SITU CHEMICAL OXIDATION
O MACTEC WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and Consulting, Inc. flRAf=PING BY: PREPARED BYCHECKED BY: CRW
9725 Cogdlll Road
Knoxville, Tennessee 37932 JOB NUMBER; DATE: SCALE:
865-588-8544 • Fax: 865-SB8-8426
3031-05-207-12 OCTOBER 1, 2010 NOT TO SCALE

PROPOSED SHALLOW INJECTION WELL CONSTRUCTION DETAILS
JOB NAME FORMER ABB FLAKT PRODUCTS
WELLS I EACH
TOTAL DEFTN S O.
MACTEC ENGINEERING TBD
FIELD REPRESENTATIVE
JOB NUMBER
INSTALLATION DATE
DRILLED BY
RISER/SCREEN:
MATERIAL:
DIAMETER:
SLOT SIZE:
3031 -05-2007- 12
TBD
SAEDACCO
SCHEDULE 80 CPVC
1.25"
0.010"
�r r rrrI—MUUNi JfCEL
CONCRETE PAD
?OUND SURFACE
PVC RISER
RTLAND/BENTONITE
OUT
BOREHOLE WALL
FINE SAND SEAL
SAND FILTER PACK
PVC SCREEN
PVC END CAP
(NOT TO SCALE) BOTTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
OMACTEC
IN-SITU CHEMICAL OXIDATION
WINSTON-SALEM, NORTH CAROLINA
MACTEC Engi?�SrCpgdiildiZOddsulting, Inc. DRAFTING BY: '.-%g, PREPARED BY: CHECKED 6Y: CRW
Knoxville, Tennessee 37932 JOB NUMBER: DATE SCALE:
865-588-8544 + Fax: [phone]
3031-05-2007-12 OCTOBER 1, 2010 NOT TO SCALE

PROPOSED DUAL INJECTION WELL CONSTRUCTION DETAILS
JOB NAME FORMER A68 FLAKT PRODUCTS
WELLS 2 EACH
TOTAL DEPTH 80.0'
MACTEC ENGINEERING T8D
FIELD REPRESENTATIVE
8C
JOB NUMBER
INSTALLATION DATE
DRILLED BY
RISERISCREEN:
MATERIAL:
❑IAMETER:
SLOT SIZE.
(NOT TO SCALE)
303 t-U5-2QO7--- 12
TRD
SAEDACCO
SCHEDULE 80 CPVC
t .25"
O.o 10"
r, JNr SILLL
FRET£ PAD
PVC RISER
PORTLAND/BENTONITE
GROUT
FINE SAND SEAL
BOREHOLE WALL
SAND FILTER PACK
PVC SCREEN
PVC END CAP
FINE SAND SEAL
PVC RISER
SAND FILTER PACK
PVC SCREEN
PVC END CAP
BOTTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
J IN -SITE] CHEMICAL OXIDATION
MACTEC
WINSTON-SALEM, NORTH CAROLINA
MACTEC Engincc ng and Consulting, Inc-
9725 Cogdill Road a DRAFTEIVG BY; RS} PREPARED BY. ,! CHECKED BY: CRW
Knoxville. Tennessee 37932 JOB NUMBER: DATE: SCALE:
855-588.8544 9 Fax: [phone]
3031-05-2007-12 SEPTEMBER 23, 2010 NOT TO SCALE

PROPOSED SHALLOW INJECTION WELL CONSTRUCTION DETAILS
JOBNAME FORMER AB13 ELAKT PRODUCTS
WELLS
TOTAL DEPTH
MACTEC ENGINEERING
FIELD REPRESENTATIVE
I EACH
70.0,
Ci
4tNiACTEC
MACTEC Englneenng and Consulting. Inc.
9725 Cogdlll Road
Knoxville, Tennessee 37932
86S-588.8544 0 Fax: 86S-588.8026
JOB NUMBER
INSTALLATION DATE
DRILLED BY
RISERISCREEN:
MATERIAL:
DIAMETER:
SLOT SIZE:
[IVUI rV JSALrj
3031 -05-2007- 12
T13D
SAEDACCO
SCHEDULE 80 CPVC
I.25"
0.010"
CI IC'f�-fy -MU
M 3TELL
7CONCRETE PAD
?OUND SURFACE
PVC RISER
RTLAND/BENTONITE
OUT
BOREHOLE WALL
FINE SAND SEAL
SAND FILTER PACK
PVC SCREEN
PVC END CAP
UVI IVm OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
IN -SITU CHEMICAL OXIDATION
WINSTON-SALEM, NORTH CAROLINA
DRAFTING BY: PREPARED BY: CHECKED BY: CRW
]DB NUMBER: DATE: SCALE:
3031-05-2007-12 OCTOBER 1, 2010 NOT TO SCALE

PROPOSED VENT WELL CONSTRUCTION DETAILS
108 NAME FORMER ABB FL4KT PRODUCTS
WELLS 12 EACH
TOTAL DEPTH 50.0
MACTEC ENGINEERING TBD
FIELD REPRESENTATIVE
JOB NUMBER
INSTALLATION DATE
DRILLED BY
RISERISCREEN:
MATERIAL:
DIAMETER:
SLOT SIZE:
()VU( ry DUMLE)
3031-05-2007-12
TBD
SAEDACCO
SCHEDULE 80 CPVC
2 10
0.010"
ri n.J_Muurgl .])EEL
CONCRETE PAD
?OUND SURFACE
PVC RISER
RTLAND/BENTONITE
OUT
BOREHOLE WALL
FINE SAND SEAL
SAND FILTER PACK
PVC SCREEN
PVC END CAP
U V I F v,<+I OF BOREHOL E
FORMER FLAKT PRODUCTS SITE
111 IN -SITU CHEMICAL OXIDATION
MACTEC WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and Consulting, Inc. DRAFTING BY: PREPARED BY: J CHECKED BY: CRW
9725 CogdHI Road
Knoxville, Tennessee 37932 ]OS NUMBER: DATE: SCALE:
865-588.8544 ■ Fax: [phone]
3031-05-2007-12 OCTOBER 1, 2010 NOT TO SCALE

EXISTING WELL CONSTRUCTION RECORDS
Revised 6109 UIC-5I15T Page 26 of 56

JOB NAME
WELL NUMBER
SHALLOW INJECTION WELL CONSTRUCTION RECORD
ABB FLAKT
S1W-1
BOREHOLE DIAMETER 8.5 J'
TOTAL DEPTH 60.0'
MACTEC ENGINEERING A. ADAMS
FIELD REPRESENTATIVE
C
108 NUMBER JOJ 1- 05 - 200 7-12
INSTALLATION DATE 07 22 2009
DRILLED BY SAEOECCO
RISERISCREEN:
MATERIAL. PVC SCH SO
DIAMETER: 314
SLOT SIZE: 0.01
IflUI IV JLMLL/
r, , .11i-muum Si EEL
OLE COVER
70UND SURFACE
PVC RISER
RTLAND/BENTONITE
OUT
BOREHOLE WALL
#00 SAND
# I SAND
PVC SCREEN
PVC END CAP
-I I- OF pVREHQLC
FORMER FLAKT PRODUCTS SITE
4 /,Jj "It MACTEC
IN -SITU CHEMICAL OXIDATION
WINSTON-SALEM, NORTH CAROLINA
MACTEL Engineering and Con5ulting, Inc. ❑RAFTING BY: PREPARED BY: CHECKED BY: CRW
9725 Cogdlll Road
Knoxville, Tennessee 37932 JOB NUMBER; DATE: SCALE:
865-588-8544 0 Fax:[phone]
3031-05-2007.12 OCTOBER 1, 2010 NOT TO SCALE

SHALLOW INJECTION WELL CONSTRUCTION RECORD
108 NAME ABB FLAKT
WELL NUMBER SIW-2
BOREHOLE DIAMETER 8.5 „
TOTAL DEPTH 60.0
MACTEC ENGINEERING A. ADAMS
FIELD REPRESENTATIVE
r
108 NUMBER .303 1 - 05 - 200 7- 12
INSTALLATION DATE Q 713/2009
DRILLED BY SAFDFCCO
RISERJSCREEN:
MATERIAL: PVC
SCH
80
3141J
DIAMETER:
0.010
SLOT SIZE:
(IVVI 1 U _)UALt/
r, ,-,I—MUI1NT ') LL
OLE COVER
SOUND SURFACE
PVC RISER
RTLAND/BENTONITE
)UT
BOREHOLE WALL
100 SAND
11 SAND
PVC SCREEN
PVC END CAP
ra■m+iL RPM waimMCI Lai
FORMER FLAKT PRODUCTS SITE
4rMACTEC TN -SITU CHEMICAL OxIDATIDN
WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and Consulting, Inc. 9725 Cflgdlll Road pRgFTjNG 8Y; PREPARED BY: CRW CHECKED BY:
Knox"le, Tennessee 37932 106 NUMBER: DATE: SCALE;
$65-588-8544 ■ Pax:865-588-8026
3031-05-2007-12 SEPTEMBER 28, 2010 NOT TO SCALE

SHALLOW INJECTION WELL CONSTRUCTION RECORD
306 NAME ABB FLAKT
WELL NUMBER
S!W-3
BOREHOLE DIAMETER
8.5 "
TOTAL DEPTH
60.0'
MACTEC ENGINEERING
A. ADAMS
FIELD REPRESENTATIVE
C
OMACTEC
JOB NUMBER 3O31 — 05 - 200 7— 12
INSTALLATION DATE 07122 2009
DRILLED BY _ SAEDECCO
RISER/SCREEN:
MATERIAL:
DIAMETER:
SLOT SIZE:
PVC SCH 80
3 4"
0.010"
r' "r'i—MOUNT STEEL
OLE COVER
SOUND SURFACE
PVC RISER
RTLAND/BENTONITE
OUT
BOREHOLE WALL
100 SAND
11 SAND
PVC SCREEN
PVC END CAP
(NOT TO SCALE)�� BOTTOM OF BOREHOLE
ABB FLAKT
MACTEC Engineering and Consutdng, Inc. ❑RAFTING BY: PREPARED BY: CRW CHECKED BY: 3T
9725 Cogdlll Road
Kno"Ilk, Tennessee 37932 JOB NUMBER: DATE: SCALE:
865-588-8544 ■ Fax:[phone]
3031-05-2007-12 SEPTENBER 29, 2010 NOT TO SCALE

JOB NAME
SHALLOW INIECTION WELL CONSTRUCTION RECORD
ABB FLAKT
WELL NUMBER
51W-4
1 1. D r,
BOREHOLE DIAMETER
TOTAL DEPTH
65, Q'
MACTEC ENGINEERING
A. ADAMS
FIELD REPRESENTATIVE
I
]OB NUMBER .30J I-05--2007-12
INSTALLATION DATE 0712112009
DRILLED BY SAEDECCO
RISERISCREEN:
MATERIAL: PVC SCH 80
DIAMETER: 314 r0
SLOT SIZE: 0.0 I 0 "
I-MUUNI 3;rCL
OLE COVER
?OUND SURFACE
PVC RISER
RTLAND/EENTOWE
OUT
BOREHOLE WALL
JOO SAND
jI SAND
PVC SCREEN
PVC END CAA
(NOT TO SCALE)�� BOTTOM OF 60REHOLE
FORMER FLAKT PRODUCTS SITE
0 ;01A IN -SITU CHEMICAL OXIDATION
MACTEC
WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and Consulting, trx. DRAFTING BY: PREPARED BY: CRW CHECKED BY:
9725 COgdlli Road L•'
Kno"Ille, Tennessee 37932 JOB NUMBER: DATE: SCALE'
865.588-8544 ■ Fax; 86S-588-8026
3031-05-2007-12 SEPrEMBER 28, 2010 NOT TO SCALE

DUAL INJECTION WELL CONSTRUCTION RECORD
JOB NAME ABB FL4KT
WELL NUMBER DLIW-1
BOREHOLE DIAMETER_
TOTAL DEPTH
MACTEC ENGINEERING
FIELD REPR ESENTA LIVE
Z
8.5 "
70.0'
A. ADAMS
JOB NUMBER 3031-05-2007-12
INSTALLATION DATE 07
22 2009
DRILLED BY SAEDECCO
RISERISCREEN:
MATERIAL: CPVC
SCH 80
314 IF
DIAMETER:
0. 010 "
SLOT SIZE:
-MUUfVT STEEL
OLE COVER
ROUND SURFACE
PVC RISER
RTLAND/BENTONITE
OUT
BOREHOLE WALL
100 SAND
I? SAND
PVC SCREEN
100 SAND
# I SAND
PVC END CAP
(NOT TO SCALE)-'--- BOTTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
MACTEC IN -SITU CHEMICAL OXIDATION
WINSTON-SALEM? NORTH CAROLINA
h1ACTEC Engineering and Consulting, Inc. DRAFTING 6Y: PREPAREfl BY: CRW CHECKED BY:
9725 Co9dill Road
Knoxville, Tennessee 37932 JOB NUMBER: DATE: SCALE:
865-588-8544 • Fax: [phone]
3031-05-2007-12 SEPTEMBER Z4, 2�16 NOT TO SCALE

DUAL INIECTION WELL CONSTRUCTION RECORD
108 NAME AB8 Frr AKT
WELL NUMBER err IW-2
BOREHOLE DIAMETER 5.5 "
TOTAL DEPTH 72, 0
MACTEC ENGINEERING A. ADAMS
FIELD REPRESENTATIVE
71
JOB NUMBER 3031 - C5 - 20 7- 12
INSTALLATION DATE 0712312009
DRILLED BY SAEDECCO
RISER/SCREEN
MATERIAL: CPVC
SCH SC
DIAMETER:
3L4 "
SLOT SIZE:
0' 01 C 1
(iYVI iV DumLCj
r' '1'-1-MUUNI STEEL
OLE COVER
?OUND SURFACE
PVC RISER
RTLAND/BENTONITE
OUT
BOREHOLE WALL
100 SAND
# I SAND
PVC SCREEN
100 SAND
11 SAND
PVC END CAP
UW.IV! OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
j 4ji(A MACTEC IN -SITU CHEMICAL OxIDATION
WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and Consulting, Im-
9725 Cogdill Road DRAFTING BY: PREPARED BY: CRW CHECKED BY:
Knoxville, Tennessee 37932 308 NUMBER: DATE: SCALE:
885-588-8544 • Far: 855.508-8026
3031-05-2007-12 SEPI BER 29, 2010 NOT TO SCALE

Jab NAME
WELL NUMBER
DEEP INJECTION WELL CONSTRUCTION RECORD
A88 FLAKT
DIW-18
BOREHOLE DIAMETER
8.5„
TOTAL DEPTH
70. D'
MACfEC ENGINEERING
A. ADAMS
FIELD REPRESENTATIVE
1
OMACTEC
MACTEC Engineering and Consulting, Im- DRAFTING BY:
97z5 CagdiO Road
Knaxvilie, Tennessee 37932 JOB NUMBER:
BSS-508-8544 ■ Fax;865-588-8025
3031-05-2007-12
106 NUMBER J031 - D5 -200 7- 12
INSTALLATION DATE 012512009
DRILLED BY SAFDECCD
RISER/SCREEN:
MATERIAL: CPvC
SCH 80
DIAMETER:
314 "
SLOT SIZE:
0.010 „
((VU! I U JUALt f
r' "'i-MUUM STEEL.
IOLE COVER
ROUND SURFACE
RTLAND/BENTONITE
OUT
PVC RISER
BOREHOLE WALL
)0 SAND
PVC SCREEN
1 2 SAND
PVC END CAP
�V 7 I %J OF BOREr-IOLF
PREPARED BY: CRW CHECKED BY:
DATE: SCALE:
SEPTEMBER 29, 2010 1 NOT TO SCALE

VENTILATION WELL CONSTRUCTION RECORD
306 NAME
WELL NUMBERyw— 1
BOREHOLE DIAMETER 8,511
TOTAL DEPTH 65. d'
MACTEC ENGINEERING A. ADAMS
FIELD REPRESENTATIVE
no
ABB FLAKT
108 NUMBER 3631—05-2Q07— 12
INSTALLATION DATE 0712412009
DRILLED BY SAEDFCCC
RISER/SCREEN:
MATERIAL: PVC SCH Sa
DIAMETER: 2
SLOT SIZE: Q. C 1 D
(IVU; IU -DUA-
r, r i`-1—AMOUNT .JrTFEL
'OLE COVER
ROUND SURFACE
RTLAND/BENTONITE
OUT
]O SAND
PVC RISER
BOREHOLE WALL
1 2 SAND
PVC SCREEN
PVC END CAP
„u,.V41 QF BOREHOLE
FORMER FLAKT PRODUCTS SITE
AMACTEC WININ-ST
INST
MACTEC Engineering and Consulting, Inc. DRAFTING BY:
9725 Cogdllf Road
Knoxville. Tennessee 37932 JOB NUMBER-
865-588-8544 • Fax: [phone]
U CHEMICAL OXIDATION
ON-SALEM, NORTH CAROLINA
b� PREPARED BY:CRW CHECKED BY-
3031-05.2007.12
kTE: SCALE:
SEPTEMBER 29, 2010 NOT TO SCALE

VENTILATION WELL CONSTRUCTION RECORD
108 NAME ABB FLAKT
WELL NUMBER
VW-2
BOREHOLE DIAMETER
8.5"
TOTAL DEPTH
65. D
MACTEC ENGINEERING
FIELD REPRESENTATIVE
A. ADAMS
r
i
JOB NUMBER 3031 — 05-200 7— 12
INSTALLATION DATE 071
DRILLED BY SAEDECCO
RISERISCREEN:
MATERIAL: CP11C SCH Sa
DIAMETER: 2 "
SLOT SIZE: a_ 0 1 a "
(fYuf fu "A'ALtf
ri it H—MQum 5EL
(OLE COVER
ROUND SURFACE
,RTLAND/BENTONITE
'OUT
)0 SAND
PVC RISER
BOREHOLE WALL
# i SAND
PVC SCREEN
PVC END CAP
DUI i� OF 80REHOCE
FORMER FLAKT PRODUCTS SITE
0 A/6
AIA IN -SITU CHEMICAL OXIDATION
MACTEC
WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and ConwlGng, Inc. DRAFTING BY: PREPARED BY: CRW CHECKED BY:
97ZS CcWIP Road
Kno"gle,Tennessee 37932 JOB NUMBER: DATE: SCALE:
865-598-6544 ■ Fax: [phone]
3031-05-2007-12 SEPTEMBER 26, 2010 1 NOT TO SCALE

VENTILATION WELL CONSTRUCTION RECORD
JOBNAME ABB ELAKT
WELL NUMBERyw_.
BOREHOLE DIAMETER 8, 5
TOTAL DEPTH 65. 5
MACrEC ENGINEERING A. ADAMS
FIELD REPRESENTATIVE
Is
103 NUMBER
.3031-05-2007-12
INSTALLATION DATE
07123/2009
DRILLED BY
SAEDECCQ
RISERISCREEN:
MATERIAL:
CPVC
SCH 80
2 "
DIAMETER:
0' 0 1
SLOT SIZE:
r, 'r11—MVL'NT STEEL
SOLE COVER
ROUND SURFACE
RTIANDIBENTONITE
our
)0 SAND
PVC RISER
BOREHOLE WALL
1 SAND
PVC SCREEN
PVC END CAP
(NOT TO SCALE)�� 90TTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
OMACTEC
IN -SITU C
WINSTON-
MACTEC Engineering and Consul[Ing, Inc.
QRAFTING BY:
9725 Cagdil! Road
Kno"ViRe, Tennessee 37932
106 NUMBER:
665-588-8544 • Fax; 865-588-W26
3031-05-2007-12
HEMICAL OXIDATION
SALEM, NORTH CAROLINA
I PREPARED BY: CRW I CHECKED BY:
SEPTEMBER 28, 2010 I NOT TO SCALE

VENTILATION WELL CONSTRUCTION RECORD
JOB NAME ABB FLAKT JOB NUMBER JOJ I - C5 -200 7- 12
WELL NUMBER
VW-4
S. 5
BOREHOLE DIAMETER
TOTAL DEPTH
65, C
MACTEC ENGINEERING
A. ADAMS
FIELD REPRESENTATIVE
r
6
f MACTEC
MACTEC Engineering and Consulting, Inc.
9725 Cagdill Road
Knoxville, Tennessee 37432
86S-588-8544 ■ Fax:[phone]
INSTALLATION DATE 0712412009
DRILLED BY
SAEBFCCO
RISER/SCREEN:
MATERIAL:
CPVC SCH SO
2 „
DIAMETER:
a. C 1 O
SLOT SIZE:
r' "`'1-h UUM STEEL
OLE COVER
MND SURFACE
RTLANDIBENTONITE
OUT
)0 SAND
PVC RISER
BOREHOLE WALL
# I SAND
PVC SCREEN
PVC END CAP
(IYU I I U 24,14U)
FORMER FLAKT PRODUCTS SITE
IN -SITU CHEMICAL OXIDATION
WINSTON-SALEM, NORTH CAROLINA
DRAFTING BY: PREPARED BY: CHECKED BY: J
JOB NUMBER: DATE: SCALE:
3031-05-2007-12 SEPTEMBER 29, 2010 NOT TO SCALE

ATTACHMENT F
MONITORING PLAN
Revised 6/09 UIC-5I15T Page 38 of 56

1.0 A list of existing and proposed monitoring wells to be used
Performance monitoring will be conducted from monitoring wells MW-112, MW-129, MW-132S,
MW-132D, MW-I33S, MW-133D, MW-134S, MW-134D, MW-135, along with approximately eight
of the proposed injection wells. Select vent wells will be used for process monitoring during
injection.
2.0 A list of performance monitoring parameters and analytical methods to be used
Parameter Analytical Method
VOCs 8260 (EPA)
pHIDOIORPITemp I Horiba field flow -through cell
1,4-dioxane 8260 (EPA)
Ferrous Iron 3500D (EPA)
Alkalinity SM2320B
3.0 RCRA Metals will be sampled from monitoring wells MW-112, MW-129, MW-132S, MW-132D,
MW-133S, MW-133D, MW-134S, MW-134D, MW-135. Samples will be collected prior to injection
(baseline) and thereafter until concentrations return to baseline concentrations.
Revised 6109 U1C-5I15T Page 39 of 56

4.0 A schedule for sampling to monitor the proposed injection
Mon
Well ID
Baseline (Performance
MW-1 12
List A, Metals
M W-129
List A, Metals
MW-132S
List A, Metals
M W-132D
List A, Metals
MW-133S
List A, Metals
MW-133D
List A, Metals
MW-134S
List A, Metals
MW-134D
list A, Metals
MW-135
List A, Metals
Selected Injection Wells
List A
Proposed Vent Wells
---
The parameter listed refers to the lists below.
Methods
Parameter List A - Groundwater
Vacs
8260 (EPA)
pH/DO/ORP/Temp
Horiba field flow -through cell
1,4-dioxane
8260 (EPA)
Ferrous Iron
3500D (EPA)
Alkalinity
SM2320B
Parameter List C Offgas
Carbon Dioxide Meter
Oxygen Meter
VOCs PID
.g Event (Type of Monitoring)
During Injection 1 34 Days After Injection
List B
List A, Metals
List B
List A, Metals
List B
List A, Metals
List B
List A, Metals
List B
List A, Metals
List B
List A, Metals
List B
List A, Metals
List B
List A, Metals
List B
List A. Metals
---
List A
List C
--
Parameter List B — Groundwater and/or Offgas
pH/Temp
Field kit
Total Iron
Field kit
Hydrogen Peroxide
Field kit
Chloride
Field Kit
VOCs
PID
Other — Groundwater
RCRA Metals 601 OB (EPA)
Notes: DO = dissolved oxygen Prepared by/Date: CRW 6/22/1 O
EPA = Environmental Protection Agency
ORP = oxygen reduction potential Checked by/Date: K3D 9/28/1 O
PID = photoionization detector
VOC = volatile organic compound
Revised 6/09 UIC-5I/5T Page 40 of 56

ATTACHMENT G
11,13ma17_10
Revised 6/09 UIC-5II5T Page 41 of 56

Appendix G
Well Construction Information
ABB Flakt Products Site
Winston-Salem, North Carolina
Well IQ
Date
Installed
Well Purpose/TypeUtilit
of Well
Boring
Depth
Well
Depth
Screen Interval
Surve Coordinates
Well Material
Completion
Top
Bottom
Easting
Northing
Elevation
Riser/Screen
Flush-
mount
Vault
Stick -
u
DP-2
12/10/97
Monitor
Not used
105.0
85 0
75
85
1641500,76
854468.04
830.66
PVC
X
DP-4
12/08197
Monitor
Not used
93.5
80.0
70
80
1650604.10
854456.22
818.71
PVC
X
❑P-5
12/06197
Monitor
Not used
80.0
70.0
60
70
1641220,00
854422.10
816.97
PVC
X
DP-22
03/24/97
Monitor
Not used
78.0
78.0
73
78
1641423.46
854493.21
835.38
PVC
X
SP-23
03124/97
Monitor
Not used
64.0
64.0
49
64
1641401.69
654512.16
835.61
PVC
X
RW-2
01/13/98
Recovery
O&M program
100.0
100.0
80
100
1641474,25
854470.33
826.75
PVCIStainless
X
RW-3
01124/98
Recovery
O&M program
110.0
110.0
80
110
1641407.64
854458.30
821.9
PVC/Stainless
X
RW-6
01/25/98
Recovery
O&M program
115.0
115.0
85
115
1641543,73
854473.80
832.99
PVC/Stainless
X
RW10
01/26/98
Recovery
O&M program___
115.0
115.0
85
115
1641611,96
854485.32
833.54
PVCIStainless
X
RW-13
12/17/97
Recovery
O&M program
77.6
77.0
57
77
1641236,39
854426.36
816.9
PVCIStainless
X
RW-14
12/20/97
Recovery
O&M program
100 0
100.0
80
100
1641684.44
B54499.19
834.16
PVCIStainless
X
PRW-2
01113/98
Recovery Well Water Level
water level 2auging
100.0
100.0
60
100
1641474.53
854470.00
826.8
PVC
X
PRW-3
01/24/98
Recovery Well Water Level
water level gauging
110.0
110.0
80
110
1641407.81
854458.42
821.73
PVC
X
PRW-6
01/25198
Recovefy Well Water Level
water level gauging
115.0
115.0
85
115
1641543,72
854473.34
833.22
PVC
X
PRW-10
01126198
Recovery Well Water Level
water level gauging
115.0
115.0
85
115
1641612.11
854485.47
834
PVC
X
PRW-13
12/17/97
Recoveg Well Water Level
water level gauging
77.0
77.0
57
77
1641236.67
854426.18
817.36
PVC
X
PRW-14
12/20/97
Recovery Well Water Level
water level gauging
100.0
100.0
80
100
1641684.36
854498.87
834.48
PVC
X
MW-E
06/23/88
Monitor
Sample - all.
56.5
54A
44
54
1642023.38
854621,83
835.79
PVC
X
MW-104
12/19/88
Monitor
Sample
68.0
68.0
57.6
67.6
1641374.24
854677.78
839.69
PVC
X
MW-106
12/20/88
Monitor
Sample
67.4
66.9
56.5
66.5
1641259,77
854492.02
835.47
PVC
X
MW-i D7
12/15/88
Monitor
Sample
69.4
69.4
64.9
69A
1641442,37
854465,30
825.09
PVC
X
MW-110
03/22/89
Monitor
Sample
65.0
65.0
54.6
64.6
1641830.59
854539.23
835.34
PVC
X
MW-112
D3124189
Monitor
Sample
55.2
55.2
44.8
54.8
1641633.29
854498.83
834.16
PVC
X
MW-113
03/27189
Monitor
water level gauging
52.9
51.9
41.5
51.5
1641288.78
854495.73
835.56
PVC
X
MW-118
04/19/89
Monitor
water level gauging
51,0
50.8
40.4
50.4
1641571.06
854624.68
839.64
PVC
X
MW-119D
MUM
Monitor
water level gauging
59.0
59.0
49
59
1640877.57
854511.59
842.35
PVC
X
MW-121 D
11/13193
Monitor
water level gauging
84.0
84.0
79
84
1641320.53
854694.10
839.77
PVC
X
MW-123
D4104195
Monitor
Sample
56.5
56.5
41.5
56.5
1640468.80
854087.00
818.43
PVC
X
MW-127
03124/97
Monitor
Sample - alt.
99.5
99.5
39.5
99.5
1641898,29
854565,25
835.28
PVC
X
MW-128
03/24/97
Monitor
Not used
104.0
104.0
39
104
1641423.27
854489,95
834.85
PVC
X
MW-129
04/23/04
Monitor
Sample
67.0
65.5
55
65
1641598,75
854494,55
834.13
PVC
X
MW-130
041271D4
Monitor
Sample
57.0
55.5
45
55
1641455.29
854466.31
825.68
PVC
X
MW-131D
04/27/04
Monitor
water level gauging
84.0
81.5
76
81
1641396.16
854506.36
635.52
PVC
X
SIW-1
07/22/09
ISCO Injection
Injection
60.0
60.0
55
60
NS
NS
NS
CPVC
X
SIW-2
07/23/09
ISCO Injection
In ection
60.D
6D.0
55
60
NS
NS
NS
CPVC
X
SIW-3
07/22/09
ISCOInjectionInjection
60.0
60.0
55
60
NS
NS
NS
CPVC
X
SIW4
07/21/09
ISCO Injection
65.0
60.0
55
60
NS
NS
NS
CPVC
X
QIW-1 B
1 07/25/09.1
ISCO Injection
-injection
Injection
70.0
70.D
65
70
NS
NS
NS
CPVC
X
Revised 6J09 U1C-51l5T Page 42 of 56

Appendix G [Continued]
Well Construction Information
ABB Flakt Products Site
Winston-Salem. North Carolina
Well ID
1DLIW-1D
Cate
Installed
Well Pu ose1T a
Utilityof Weil
Boring
Depth
Well
Depth
Screen Interval
Surve Coordinates
Well Material
Com letion
Top
Bottom
Easting
Northing
Elevation
Riser/Screen
Flush-
mount
Vault
Stick -
u
DLIW-1S
07/22/09
ISCO Injection
-Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
07/22/09
ISCO Injection
Injection
70.0
MO
65
70
NS
NS
NS
CPVC
X
DLIW-2S
07/23109
ISCOInjection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
DLIW-2D
07/23/09
ISCO Injection
Injection
72.0
70.0
65
70
NS
NS
NS
CPVC
X
VW-1
07/24109
ISCO Injection
Vent
65,0
65.0
3
65
NS
NS
NS
CPVC
X
VW-2
07/23/09
ISCOInjectionVent
65.0
65.0
3
65
NS
NS
NS
CPVC
X
VW-3
07/23/09
ISCO Injection
Vent
65.5
65.0
3
65
NS
NS
NS
CPVC
X
VW-4
07/24/09
ISCO Injection
Vent
65.0
65.0
3
65
NS
NS
NS
CPVC
X
MW-132S
07/20/10
Monitor
Sample
77.0
77.0
48
58
1641554.23
806854506.92
835.23
PVC
X
MW-132D
07/20/10
Monitor
Sample
77.0
77.0
67
77
1641553,98
807854507,07
835.21
PVC
X
MW-133S
07/22/10
Monitor
Sample
81.0
81.0
52
62
1641605.37
809854543,33
839,76
PVC
X
MW-133D
07/22/10
Monitor
Sample
81.0
81.0
71
81
1641605,02
810854543.33
839.76
PVC
X
MW-134S
07/19/10
Monitor
Sample
77.0
77.0
48
58
1641675.94
802854518.68
834,64
PVC
X
MW-134D
07119/10
Monitor
Sample
77.0
77.0
67
77
1641675.68
801854518.97
834.66
PVC
X
MW-135
07121/10
Monitor
Sample
80.0
80.0
70
80
1641604.66
8D4854496.44
834.07
PVC
X
IW-1A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVG
X
IW-1B
TBD
ISCO Injection
Injection
70.o
70.0
65
70
NS
NS
NS
CPVC
X
IW-2A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-2B
TB❑
ISCO Injection
Injection
70.6
70.0
65
70
NS
NS
NS
CPVC
X
1W-3A
TBD
ISCOIn'echon
Injection
70.D
60.0
55
60
NS
NS
NS
CPVC
X
IW-3B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW4A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW413
TBD
ISCO Injection
In ection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-5A
TBD
ISCO Injection
Injection
70.0
MO
55
60
NS
NS
NS
CPVC
X
IW-5B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
1W-6A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-6B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
1W-7A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-7B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-8A
TB❑
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-813
TB❑
ISCO Injection
Injection
7D.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-RA
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-9B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-10A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-106
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-11A
TBD
ISCOInjectionInjection
7D.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-11B
TB❑
ISCO In ection
Injection
70.0
70.D
65
70
NS
NS
NS
CPVC
X
IW-12A
TBD
ISCO Injection
Injection
7D.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-12B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-13A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
NV-13B
TBD
ISCOln'eclion i
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
Iw-14A I
TBD I
ISCOIn'ection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
Revised 6/09 UIC-51/5T Page 43 of 56

Appendix G (Continued)
Well Construction Information
ABB Flakt Products Site
Winston-Salem. North Carolina
Well ID
Date
Installed
Well Pu ose(T a
Utilityof Well
Boring
De th
Well
De th
Screen Interval
Su ey Coordinates
Well Material
Completion
Top
Bottom
Easting
Northing
Elevation
Riser/Screen
Flush-
mount
Vault
Stick -
u
RN-14B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-15A
TBD
ISCO Injection
injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-15B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-16A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-15B
TBD
ISCOInjectionInjection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
NV-17A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-17B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-18A
TBD
ISCO Injection
Injection
80.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-1 BB
TBO
ISCO Injection
Injection
80.0
80.0
75
8o
NS
NS
NS
CPVC
X
IW-19A
TBD
ISCO Injection
Injection
70,0
60.0
55
60
NS
NS
NS
CPVC
X
IW-19B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-20A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-20B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-21A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-21B
TBD
ISCO Injection
Injection
70.0
70.0
55
70
NS
NS
NS
CPVC
X
IW-22A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-22B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-23A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-23B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-24A
TBD
ISCO In ection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-24B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-25A
TBD
ISCOInjectionInjection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-25B
TBD
ISCO 1n ection
ljnjection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-26A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-26B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-27A
TBD
ISCOInjectionInjection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-27B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-28A
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-28B
TBD
ISCO Injection
Inection
BOA
60.0
55
60
NS
NS
NS
CPVC
X
IW-28C
TBD
ISCO Injection
Inection
80.0
80.0
75
80
NS
NS
NS
CPVC
X
IW-29
TBD
ISCO Injection
Injection
80,0
80.0
75
80
NS
NS
NS
CPVC
X
IW-30A
TBD
ISCOInjection
Inection
80.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-30B
TBD
ISCO Injection
to ecbcin
80.0
80.0
75
B0
NS
NS
NS
CPVC
X
IW-31A
TBO
ISCO lNection
Injection
80,0
70.0
65
70
NS
NS
NS
CPVC
X
IW-318
TBD
ISCO injection
Injection
80.0
80.0
75
80
NS
NS
NS
CPVC
X
IW-32A
TBD
ISCO Injection
Injection
80.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-32B
TBD
ISCO Injection
Injection
80.0
80.0
75
80
NS
NS
NS
CPVC
X
IW-33A
TBD
ISCOInjectioninaction
8CW
70.0
65
70
NS
NS
NS
CPVC
X
iW-33B
TBD
ISCO Injection
Injection
80.0
80,0
75
80
NS
NS
NS
CPVC
X
IW-34A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-34B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-35A
TBD
ISCO Inject' in
Injection
70.0
1 60.0
55
60
NS
NS
NS
CPVC
X
Revised 6/09 U IC-5 i15T Page 44 of 56

Appendix G (Continued)
Well Construction Information
ABB Flakt Products Site
Winston-Salem, North Carolina
Well I❑
Date
Installed
Well Pu ose1T a
Utilityth of Well
Boring
De
Well
De th
Screen Interval
Su ey Coordinates
Well Material
Com letion
Tap
Bottom
Easting
Northing
Elevation
Riser/Screen
Flush
mount
Vault
StiGt-
o
IW-35B
TBD
ISCO Injection
injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-36A
TBD
ISCO Injection
injection
7D.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-36B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-37A
TBD
ISCO Injection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-37B
TBD
ISCO Injection
tn'ection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
IW-3aA
TBD
ISCO injection
injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
NV-38B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
I1N-39A
TBD
ISCO Injection
Injection
7D.0
60.0
55
60
NS
NS
NS
CPVC
X
IW39B
TBD
ISCO Injection
Injection
70.0
70.0
65
70
NS
NS
NS
CPVC
X
RN-40A
TBD
ISCOIriection
Injection
70.0
60.0
55
60
NS
NS
NS
CPVC
X
IW-408
TBD
ISCO Injection
Injection
70,0
70.0
65
70
NS
NS
NS
CPVC
X
VW-5
TBD
ISCO Injection
Vent
60.0
60.0
3
60
NS
NS
NS
CPVC
X
VW_6
TBD
ISCO Injection
Vent
60,0
60.0
3
60
NS
NS
NS
CPVC
X
VW-7
T13D
ISCO Injection
Vent
60.0
60.0
3
60
NS
NS
NS
CPVC
X
VW-8
TBD
ISCO Injection
Vent
60.0
60-0
3
60
NS
NS
NS
CPVC
X
VW-9
TBD
ISCO Injection
Vent
60.0
60.0
3
60
NS
NS
NS
CPVC
X
VW-10
TBD
ISCO Injection
Vent
60.0
60.0
3
60
NS
NS
NS
CPVC
X
VW-11
TBD
ISCO Injection
Vent
6D.0
60.0
3
60
NS
NS
NS
CPVC
X
VW-12
TBD
ISCO Injection
Vent
60.0
60.0
3
60
NS
NS
NS
CPVC
X
VW-13
TBD
ISCO Injection
Vent
60.0
60A
3
60
NS
NS
NS
CPVC
X
VW-14
TBD
ISCO Injection
Vent
60.0
60.0
3
60
NS
NS
NS
CPVC
X
VW-15
TBD
ISCOInjectionVent
60.0
1 60.0
3
60
NS
NS
NS
CPVC
X
VW-16
TBD
ISCOl2ction
Vent
60.0
1 60.0
3
60
NS
NS
NS
CPVC
X
Nate: Only monitoring wells MW-112, MW-129, MW-132S, MW-132D, MW-133S, MW-133D, VW-134S, MWA 34D, MW-135, and the proposed injection and Prepared bylDate: CRW 6/23/10
vent wells are expected to be impacted by this injection.
Checked by/Date. KJD 9/28110
CPVC = Chlorinated Polyvinyl Chloride O&M = Operations & Maintenance CRW 9129l10
DIW = Deep Injection Well PRW = Piezometer in Recovery Well
DLIW = Dual Injection Well PVC = Polyvinyl Chloride
DP = Deep Piezometer RW = Recovery Well
ISCO = In -Situ Chemical Oxidation SIW = Shallow Injection Well
NV = Injection Well SP = Shallow Piezometer
MW = Monitoring Well TBD = To Be Determined
NS = Not Surveyed VW = Vent Well
NS = Not Surveyed
Revised 6/09 UIC-5115T Page 45 of 56

REFERENCES
Revised 6/09 UIC-5I15T Page 55 of 56

References
MACTEC Engineering and Consulting, Inc., 2006. Groundwater Recovery Hvdraulic Control System,
Annual Report 2005 and Focused Soils Investigation (February).
MACTEC Engineering and Consulting, 2008. Application for Permit to Construct and/or Use a Well(s)
for Injection — Former Flakt Products Site, Winston-Salem, North Carolina (October 10).
MACTEC Engineering and Consulting, 2010. Injection Event Report. Former Flak Products Site,
Winston-Salem, North Carolina (June 28).
NC DENR, 2009. Issuance of Injection Permit WI0400098, Former Flak Products Site, Winston-Salem,
North Carolina (March 30).
NCDHHS, 2008. Memorandum to Mr. Qu Qi with the North Carolina Division of Water Quality.
September 30.
Revised 6109 UIC-5115T Page 56 of 56

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells —In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
• Do not use this form for remediation systems that extract contaminated groundwater, treat it, and reinject the treated groundwater.
• Submit TWO copies of the completed application and all attachments to the address on the last page of this form.
• Any changes made to this form will result in the application package being returned.
Application Number (to he completed by DWQ}:
I. GENERAL INFORMATION:
1. Applicant's Name (generally the responsible party): Flakt Products, Inc,
K
Signing Official's Name: Mr. John Conant
3. Mailing address of applicant: 2000 Day Hill Road, CEP 880-1911
City: Windsor
Title: Dir., Nuclear Engr. & Compliance
State: CT
Zip- 06095
Telephone number: [phone] Fax number: [phone]
4. Property Owner's Name (if different from Applicant): Mr. Fred
Property Owner's mailing address: P.O. Box 1140
City: Cornelius
State: NC
Zile: 28031
6. Name and address of contact person who can answer questions about the proposed injection project:
Name: Mr. Ricky A. Ryan Title: Sr. Principal Project Manager
Company: MACTEC Engineering and Consulting
Address: 9725 Cogdill Road, Knoxville, TN 37932
City: Knoxville State: TN Zip: 37921
Telephone number: [phone] Fax number: [phone]
Email Address: [e-mail]
REf;OVEO I DENR 10Q
AQUtifqa vRnTF('�T:nN qFCTId�f
H. PERMIT INFORMATION:
OCT 14. Mg
1. Project is: © New ❑ Modification of existing permit ❑ Renewal of existing permit without modification
❑ Renewal of existing permit with modification
2. If this application is being submitted for renewal or modification to an existing permit, provide:
existing permit number and the issuance date
For renewal without modifications, fill out sections I & II only, sign the certification on the Iast page of this
form, and obtain the property owner's signature to indicate consent (if the applicant is not the owner).
For all renewals, you must submit a status report including monitoring results of all injection activities to
date.
Revised 9/07 UIC-51/5T Page 1 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells —In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
III. INCIDENT & FACILITY DATA
A. FACILITY INFORMATION
1. Facility name: Former Flakt Products Site
2. Complete physical address of the facility: 2000 Lowery Street
City: Winston-Salem County: Forsyth State: NC Zip: 27101
B. INCIDENT DESCRIPTION
1. Describe the source of the contamination:
The facility used metal product degreasing baths at 2 locations within the building: north and south pits, as
shown on Figure 2. The baths consisted of open steel tanks (-1 V deep, 6' wide, and 12' long) located in
concrete pits. The tanks were filled with degreasing solvents, either trichloroethene (TCE) or 1,1,1-
Wchloroethane (TCA), at various times, pumped from a 7,000 gal. above ground storage tank (AST) through
overhead pipes. A 1988 assessment concluded that the stored solvents had been released onto the ground
surface and subsurface. It was later concluded from a soil investigation assessment that the north and south pits
and the AST were sources contributing to the presence of volatile organic compounds (VOCs) in sails located
beneath the pits and AST system. An evaluation of the historical use of the site revealed reported surface
releases of TCE and TCA near the former UST area. A 2006 focused soils investigation indicated that the
persistent groundwater contamination in the former UST area may be indicative of residual contamination in the
saturated zone (MACTEC 2006).
2. List all contaminants present in soils or groundwater at the site (contaminants may be listed in groups, e.g.,
gasoline, diesel, jet fuel, fuel oil, chlorinated ethenes, chlorinated ethanes, metals, pesticides/herbicides, etc):
Primarily chlorinated ethanes, chlorinated ethenes, 1,4-dioxane, and other volatile organic compounds.
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
N No If no, list maximum concentration of total VOCs observed at site: 152,926.8 ppb
4, Agency managing the contamination incident:
❑ UST Section ® Superfund Section (including REC Program and DSCA sites)
❑ DWQ Aquifer Protection Section ❑ Solid Waste Section
❑ Hazardous Waste Section ❑ Other:
5. Incident managers name Kim Caulk and phone number [phone]
6. Incident number or other site number assigned by the agency managing the contamination incident:
NONCD 000 0017
C. PERMITS
List all permits or construction approvals that have been issued for the facility or incident, including those not
directly related to the proposed injection operation:
1. Hazardous Waste Management program permits under RCRA:
2. DWQ Nan -Discharge or NPDES permits: NCO085871
3. County or DEH subsurface wastewater disposal permits:
4. Other environmental permits required by state or federal law: Administrative Order on Consent (Docket
Number 97-SF-098), Authorization to Construct for Permit No. NCO085871 (letter dated November 6, 1997).
Revised 8/07 UIC-5I/5T Page 2 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 51 Wells — In Situ Groundwater Remediation 1 Type 5T Wells — Tracer Injection
TV. INJECTION DATA
A. INJECTION FLUID DATA
I . List all proposed injectants.
NOTE: Any substance to be injected as a tracer or to promote in situ remediation must be reviewed by the
Occupational and Environmental Epidemiology Section (GEES) of the Division of Public Health, Department of
Health and Human Services. Review the list of aWroved iniectantsT or contact the UIC Program to determine if
the injectants you are proposing have been reviewed by OEES
Injectant: Fenton's Reagent: Hydrogen Peroxide (H0 ) (Geo-Cleanse)
Concentration at point of injection:11.3% H2O_2
Injectant: Fenton's Reagent: Ferrous Sulfate (FeSO4 ZH20, catalyst) (Geo-Cleanse)
Concentration at point of injection: Dissolved at up to 500 ppm aqueous solution
Injectant: Phosphoric Acid (H3PO4), as part of the catalyst (Geo-Cleanse)
Concentration at point of injection: ) -5% (approx. 0.002M), as needed to lower pH to --4
Injectant: Sulfuric Acid (H2504), as part of the catalyst (pending OEES approval)
Concentration at point of injection: as needed (approx. 0.002M) to lower pH to —4
Injectant:
Concentration at point of injection;
Source of fluids used to dilute or chase the injectants listed above:
❑ None
B Municipal water supply
❑ Groundwater from private well or any well within %4 mile of injection site
❑ Air
❑ Other:
3. If any well within %4 mile of injection site, a private well, or surface water is to be used as the fluid source, supply
the following information:
a. Location/)]) number of source: none
b. Depth of source:
c. Formation:
d. Rock/Sediment type:
e. In Attachment C, provide a current, complete 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.
NOTE: lfcontaminated groundwater is to be used as the dilution or chase fluid, this is not the proper permit
application form. You must apply far a closed -loop groundwater remediation permit using application form
G9 S
Revised 8107 U1C-5115T Page 3 of

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells — In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
B. PROPOSED OPERATING PARAMETERS
1. Duration of injection:
Maximum number of separate injection events: t
Expected duration of each injection event: 9 days
Expected duration between events (if more than one event):
2. Injection rate per well: 0-5-1-2 gallons per minute (gpm)� {_ /
3. Total Injection volume: ,800 gallons per day (gpd); lid gallons per event (if separate events)
4. Injection pressure: 10 - 40 pounds/square inch (psi)
5. Temperature at point of injection: (GR 80 - 420 °g
6. Brieflv describe how the above parameters will be measured and controlled:
Groundwater temperature is measured each morning. Pressure and rate are monitored/optimized continuously in
response to site conditions. Temperature and pressure are controlled by adjusting peroxide concentration,
catalyst mixture, and injection rate. Injection rate is controlled with calibrated totalizers and float valves.
7. Estimated hydraulic capacity of the well: 2 gpm
C. INJECTION WELL CONSTRUCTION DATA
I. injection will be via:
❑ Existing well(s) proposed for use as an injection well, Provide the data in (2) through (6) below to the best of
your knowledge.
® Proposed well(s) to be constructed for use as an injection well. Provide the data in (2) through (6) below as
proposed construction specifications.
2. Well Drilling Contractor's Name: SAEDACCO, INC.
NC Well Contractor Certification number: 2332
3. Date to be constructed: TBD Number of borings: 7 ASS 4�z pa; r3 of ►teS& 06�♦s
Approximate depth of each boring (feet): 4 at 55' and 3 at 65'
4. Screened interval/Injection interval of injection wells:
Depth: 50 to 65 feet below ground surface (if multiple intervals, indicate shallowest and deepest depth).
5. Well casing (NIA if injection is through direct push rods):
Type: ❑ PVC ❑ Stainless steel 9 Other: Schedule 80 CPVC
Casing depth: 50 to 60 $.
6. Grout (N/A if injection is through direct push rods):
Type: ® Cement ® Bentonite ❑ Other:
Grout depth: 0 to 56 ft.
Revised 9/07 U1C-51/5T Page 4 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 51 Wells — In Situ Groundwater Remediation I Type 5T Wells — Tracer Injection
V. ATTACHMENTS
Provide the following items as attachments with the given headings:
A. SITE HISTORY
Provide a brief description of the site history including:
(1) site usage historically and present,
(2) origin of the contamination,
(3) previous remedial action(s).
NOTE: G.S. 89E-18 requires that any geologic plans, reports, or documents in which the performance is related to the
public welfare or safeguarding of the environment be prepared by a licensed geologist or subordinate under his or her
direction. G.S 89E-13 requires that all drawings, reports, or documents involving geologic work which shall have been
prepared or approved by a licensed geologist or a subordinate under his or her direction be signed and sealed by him or
her.
B. HYDROGEOLOGIC DESCRIPTION
Provide a hydrogeologic description, soils description, and cross section of the subsurface to a depth that includes the
known or projected depth of contamination. The hydrogeologic description shall include:
(1) the regional geologic setting;
(2) significant changes in lithology;
(3) the hydraulic conductivity, transmissivity, and specific yield of the aquifer to be used for injection, including a
description of the test(s) used to determine these parameters; and
(4) the depth to the mean seasonal high water table.
C. 1NJECTION FLUID COMPOSITION
Describe the chemical, physical, biological and radiological characteristics of each injectant. Attach the Material Safety
Data Sheet (MSDS) for each injectiot. If a private well or a well within '/A mile of the injection site is used as the source
well, include chemical analysis of source fluid here.
D. INJECTION RATIONALE
Attach a brief description of the rationale for selecting the injectants and concentrations proposed for injection, including:
(1) goals of the injection project;
(2) 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; and
(3) summary results of modeling or testing performed to investigate the injectant's potential or susceptibility to change
(biological, chemical or physical) in the subsurface.
E. INJECTION PROCEDURE AND EQUIPMENT
Provide a detailed description of all planned activities related to the proposed injection including but not limited to:
(1) construction plans and materials;
(2) operation procedures;
(3) a detailed diagram of the surface and subsurface portions of the system; and
(4) a planned injection schedule.
F. MONITORING PLAN
Provide a plan for monitoring the results ofthe injection, including:
(1) a list of existing and proposed monitoring wells to be used;
(2) a list of monitoring parameters and analytical methods to be used, and
(3) a schedule for sampling to monitor the proposed injection.
NOTE: The selected monitoring wells must be located so as to detect any movement of injection fluids, process by-
products, or formation fluids outside the injection area or sane. The monitoring parameters should include the target
contaminants as well as secondary or intermediate contaminants which may result from the injection and other
parameters which may serve to indicate the progress of the intended reactions, such as pH, ORP, dissolved oxygen, and
Revised 8107 UIC-5115T Page 5 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 51 Wells — In Situ Groundwater Remediation I Type 5T Wells — Tracer Injection
other electron acceptors and donors. The monitoring schedule should be consistent with the pace of the anticipated
reactions and rate of transport of the injectants and contaminants.
G. WELL DATA
Provide a tabulation of data on all existing or abandoned wells within '/4 mile of the injection well(s) which penetrate the
proposed injection zone, including, but not limited to, monitoring wells and wells proposed for use as injection wells.
Such data shall include a description of each well's use (water supply, monitoring, etc), total depth, screened or open
borehole depth interval, and well construction or abandonment record, if available.
H. MAPS
Attach the following scaled, site -specific maps:
(1) Area map based on 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.
(2) Site map including:
a all property boundaries;
b. all buildings within the property boundary;
c. existing and proposed injection wells or well field(s)
d. any existing sources of potential or known groundwater contamination, including waste storage,
treatment or disposal systems within `/. mile of the injection well or well system;
e. all surface water bodies within '/ mile of the injection well or well system; and
f. all existing or abandoned wells within '/� mile of the injection well(s) which penetrate the proposed
injection zone, including, but not limited to, monitoring wells and wells proposed for use as injection
wells.
(3) Potentiometric surface map(s) including:
a. direction of groundwater movement
b. existing and proposed monitoring wells
c. existing and proposed injection wells
(4) Contaminant plume map(s) including:
a. the horizontal extent of the contaminant plume, including isoconcentration lines
b. existing and proposed monitoring wells
c. existing and proposed injection wells
(5) Cross-section(s) to the known or projected depth of contamination, including:
a. horizontal and vertical extent of the contaminant plume, including isoconcentration lines
b. major changes in lithology
Revised 8/07 U1C-51/5T Page 6 of 7

VI.
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells -In Situ Groundwater Remediation / Type ST Wells - Tracer Injection
CERTIFICATION
I John Conant . r; , ,i �.,..,F �;. hereby certify under penalty of law that
I have personally examined and 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(s) and all related appurtenances in
accordance with the approved specifications and conditions of the Permit.
Signature: Date: ' 1 C, FJ
Title: e
If authorized agent is acting on behalf of the applicant, supply a letter signed by the applicant authorizing the
above agent.
VH. CONSENT OF PROPERTY OWNER (if the property is not owned by the 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 laird shall be deemed to vest ownership in the land owner, in the absence of
contrary agreement in writing.)
1, Mr. Fred Godley_,,,,_,.., , j, as owner of the property on which the
injection well(s) are to be constructed and operated, 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 Well Constructiop Standards (Title 15A NCAC 2C .0200)
Sig nature' Datc: - 4 s�
Title:_�C�h1�
Submit TWO copies of the completed application package, including all attachments, to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
RECEIVED t DENR I DWO
Ao UtFFR PPnTprTION CFCT10N
OCT 14 2009
Revised 8/07 UIC-51/5T Page 7 of 7

ATTACHMENT A
SITE HISTORY

1.0 Site Usage Historically and Present
The FU-t Products, Inc. (Flakt) Lowery Street site consists of a 570,000-square-foot former
manufacturing plant on a 52-acre property located in an area of industrial and residential
development near Interstate 40 Business in Winston-Salem, North Carolina. Manufacturing
operations were conducted at the facility from. 1965 to 1986; the facility has been mostly
vacant and inactive since 1986. Metal fabrication activities at the site included the production
of air pollution control equipment, large diameter fans, industrial air-conditioning units, and
dust collectors; which involved processes such as sand blasting, plasma arc machining,
solvent degreasing, painting, and assembly (Rust, 1995). Presently the northeast corner of the
building is leased to a cardboard recycling company; the rest of the facility remains vacant.
2.0 Origin of the Contamination
The facility used metal product degreasing baths at 2 locations within the building: north and
south pits, as shown on Figure 2. The baths consisted of open steel tanks (—I I feet deep, 6
feet wide, and 12 feet long) Iocated in concrete pits. The tanks were filled with degreasing
solvents, either trichloroethene (TCE) or 1.1,1-trichloroethane (TCA), at various times,
pumped from a 7,000 gal. above ground storage tank (AST) through overhead pipes. A 1988
assessment concluded that the stored solvents had been released onto the ground surface and
subsurface. It was later concluded from a soil investigation assessment that the north and
south pits and the AST were sources contributing to the presence of volatile organic
compounds (VOCs) in soils located beneath the pits and AST system. An evaluation of the
historical use of the site revealed reported surface releases of TCE and TCA near the former
UST area. A 2006 focused soils investigation indicated that the persistent groundwater
contamination in the former UST area may be indicative of residual contamination in the
saturated zone (MACTEC, 2006).
3.0 Previous Remedial Actions
March 1990 In -situ volatilization (ISV) systems at the two solvent pits were put into
operation. Periodic sampling of the soils beneath the pits was conducted
to evaluate the effectiveness of the ISV systems. Once soil sample
results indicated that the concentrations of target VQCs beneath the pits
were below clean up levels, operation of the systems was discontinued;
the ISV systems in the north and south pits were discontinued in July
1991 and January 1993, respectively.
June 1998 A 7-well groundwater recovery system was put into operation. The
operation continues to present day, with sitewide groundwater
monitoring performed on an annual basis.
Attachment A — Page 1

ATTACHMENT B
HYDRGGEQLOGIC DESCRIPTION

1.0 Regional Geologic Setting
Forysth County is near the western edge of the Piedmont physiographic province.
Approximately 85 percent of the county is underlain by gneiss which primarily consists of
quartz -mica -feldspar gneiss, quartz -mica schist, and quartz -feldspar schist, along with some
feldspar -hornblende gneiss and hornblende schist. Most of this unit appears to be of
sedimentary origin, but metamorphism has altered the rock almost completely from its
original character. The bedding is prominent in many places, it strikes generally
northeastward and at most places dips southeastward at a moderate angle (Mundorff, 1948).
A porphyritic granite unit is present south of Winston-Salem. The granite is intruded into the
gneiss at many places with stringers of the granite ranging from a few inches to many feet
thick., cutting across or following along the structure. The granite is light to medium gray
coarse rock with many large feldspar phenocrysts (Rust, 1995),
The Piedmont is characterized by rolling hills and fairly steep stream valleys. Relief is
greater near the larger streams and topography in those areas commonly has relief of 150 to
250 feet. Locally the relief is about 50 to 75 feet with elevations ranging from about 750 to
950 feet above mean sea level (Rust, 1995).
2.0 Significant Changes in Lithology
The Flalct site is underlain by four distinct lithologic units. The uppermost unit consists of a
mix of sand, silt and clay fill of varying content from the surface to depths of 20 feet below
ground surface (bgs). Beneath the fill layer is a sandy unit with varying amounts of silt and
clay that is first encountered at depths from 5 to 30 feet bgs and ranges from 20 to 60 feet
thick. The overburden layer grades downward to a saprolite, characterized by fractures
(variably open, lined, or filled by clay and oxides), with variable degrees of weathering,
fractured quartz and feldspar veins, variable hardness and clay content. Fracture frequency is
highly variable with zones of intense fracturing being present. Generally the degree of
weathering appears to decrease with depth, with infilling of fractures decreasing, and matrix
hardness increasing, though some soft highly weathered saprolite does occur down to depths
of 100 feet. The saprolite is encountered at depths ranging from 40 to 60 feet bgs, and is
approximately 20 feet thick in the vicinity of monitoring wells MW-1 12 and MW-l. The
dense saprolite unit is encountered at an approximate depth of 100 feet in the vicinity of
MW-120D (MACTEC. 2004).
At the western end of the remediation well line, contact with fresh hard bedrock is abrupt and
sharp. Near the middle of the line the contact is gradational, with frequent changes between
soft weathered saprolite and hard fresher bedrock. At the eastern end of the line, fresh
bedrock was not encountered. Fracturing occurs in the hard fresh bedrock as well as in
saprolite with some zones of intense fracturing_ Bedrock was identified as schist.
granodiorite and some diorite. Depths to fresh bedrock deepened from 70 feet at the western
end of the rem ediation line to at least l 10 feet at the eastern end (MACTEC, 2004).
3.0 Aquifer Characteristics
Slug tests were conducted on April 11, 1995 on three monitoring wells (MW-107.
MW-120D, and MW-125) located on the Site. Both falling mead and rising head tests were
conducted. The tests were performed by quickly adding and removing a known volume of
water from a well and recording the rate at which the water level in the well or piezometer
Attachment B - Page l

fell or rose to equilibrium. A 5-foot long, 1-inch diameter slug was used to displace water in
the well. The rate of recovery in the well and other parameters of the well were analyzed to
calculate a value for the hydraulic conductivity of the aquifer in the vicinity of the tested
wells. Calculations of the hydraulic conductivities were performed using the Bower and Rice
method (1976, 1989) and the I-lvorslev method (1951). The averages of the falling head and
rising head hydraulic conductivity test results are 5.134 ft/day and 7.833 ft/day, respectively
(Rust, 1996).
Transmissivity is a measure of the rate at which water can move horizontally through an
aquifer and is a product of the hydraulic conductivity and, for unconfined aquifers, the
saturated thickness of the aquifer (Cherry/Freeze, 1979)_ The saturated thickness of the
aquifer, at monitoring wells MW-107, MW-120D, and MW-125 (the wells that were slug
tested) ranges from approximately 23 feet to 33.5 feet. Therefore, the surficial aquifer of the
site has an estimated transmissivity of 118 fClday to 262.5 ft2Iday.
Specific yield represents the volume of water that will drain from a material by gravity and is
calculated as the ratio of the volume of water drained to the total volume of material, Based
on the soil types encountered while drilling on the site, the specific yield of the surficial
aquifer at the site is estimated to be approximately 0.03 to 0.35 (Johnson, 1967).
4.0 Depth to Mean Seasonal High Water Table
The groundwater occurs at depths ranging from 28 feet bgs at monitoring well MW-1 16, on
the north side, to 77 feet bgs at recovery well RW-6, on the south side of the site. The
potentiometric surface map in Figure 3 (Attachment H) was generated from the water levels
collected during the September 2007 sampling event to depict groundwater elevations for the
shallow and deep groundwater units. Surfer 8 by Golden Software, Inc., was used to plot the
potentiometric surface map. This program mathematically calculates contours based upon
groundwater elevation measurements collected in the field.
The September 2007 potentiometric surface map indicates that the groundwater gradient is
generally soLrthward, but that the groundwater flow is being directly affected by pumping
conditions.
Attachment B — Page 2

ATTACHMENT C
INJECTION FLUID COMPOSITION

The additives that will be used are listed below:
■ Hydrogen peroxide; Bulk storage of 34% technical grade, used as oxidizing agent.
Diluted and injected into the aquifer with a maximum 11.3% concentration, with
resultant concentrations to groundwater of less than 1 %. This concentration is
expected to quickly fall to less than 25 ppm within several hours following injection
and typically is completely consumed within 3 to 5 days.
• Ferrous sulFare: Staged as solid powder of food -grade reagent, dissolved at typical
100-500 ppm aqueous solution, used as catalyst. The ferrous iron is oxidized in the
subsurface to ferric iron and precipitates as an iron oxide or iron hydroxide. Ferrous
sulfate may not be used if sufficient natural iron (typical greater than 25 mg/L) is
present in groundwater.
Phosphoric acid: Staged as 85% technical grade reagent, diluted prior to injection in
water to a pH of approximately 4 as part of the catalyst solution. This is used in the
catalyst solution to inhibit oxidation of ferrous iron to ferric iron in the catalyst
solution prior to injection, and to adjust pH of the groundwater to the optimal range
for Fenton's reagent (<6). Groundwater pH is expected to return to ambient
background conditions within a few days of injection. This reagent may not be
utilized depending upon site -specific conditions. Phosphoric acid may not be used if
either the groundwater pH is already acidic (<6) or if a more reactive catalyst
solution is desired (in which case sulfuric acid may be used).
Sufuric acid- MACTEC has submitted to the Underground injection Control (UIC)
and Occupational and Environmental Epidemiology Section (OEES) a request for
approval to use sulfuric acid in this injection. A copy of the "Information Needed to
Do Risk Assessments for Products Applied to Groundwater or Soil Containing No
Microorganisms" is included in this Attachment along with the Material Safety Data
Sheet for the sulfuric acid. If approved, the sulfuric acid will be staged as 98%
technical grade reagent, diluted prior to injection in water to a pH of approximately 4
as part of the catalyst solution. This is used in the catalyst solution to inhibit
oxidation of ferrous iron to ferric iron prior to injection, and to adjust pH of the
groundwater to the optimal range for Fenton's reagent (<6). Groundwater pH is
expected to return to ambient background conditions within a few days of injection.
This reagent may not be utilized depending upon site -specific conditions. Sulfuric
acid may not be used if either the groundwater pH is already acidic (<6) or if a more
stabilizing catalyst solution is desired.
A copy of the OEES of the Division of Public Health, Department of Health and Human
Services' list of approved intectants is included in this Attachment following the Material
Safety Data Sheets for the listed injectants.
Attachment C —Page 1

ATTACHMENT D
INJECTION RATIONALE

I.0 Goals of the Injection Project
The goal of this injection project is to conduct a pilot study of in -situ chemical oxidation
(1SCO), in the form of Fenton's Reagent. The goals of this pilot injection are to (1) evaluate
the effectiveness and efficiency of the oxidant in completely and non -selectively oxidizing
the contaminants of concern at the site, (2) reduce the overall contaminant mass, and (3)
assess the site -specific soil physical characteristics that may affect oxidant distribution and
injection procedures.
Fenton's Reagent was selected because it has, on many sites, effectively and completely
oxidized chlorinated ethenes and ethanes, such as those present at this site. MACTEC's
subcontractor has determined the most appropriate initial peroxide concentration from past
experience with similar contaminants and site conditions and from site -specific bench -scale
testing. The concentration of all reagents is modified to ensure proper chemistry (mildly
acidic pH and presence of elevated iron concentration), distribution of oxidant, and a safe and
controlled reaction based upon process monitoring.
2.0 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
Because Fenton's Reagent is able to destroy the parent products TCA and WE without
generating other breakdown chlorinated compounds, generation of daughter products is not
expected to occur_ A specific breakdown pathway has not been determined for 1,4-dioxane.
However, site -specific bench -scale testing resulted in a 99% reduction in 1,4-dioxane
concentrations. Some residual metals, acetone, and/or methyl -ethyl keytones may be
generated by the process however, it is anticipated that once the pH stabilizes to pre -injection
condition, the residual metals will precipitate and the acetone and methyl -ethyl keytones will
dissipate from the groundwater. Carbon dioxide and water are also expected to be generated
during oxidation; two vent wells (screened from 10 to 40 feet bgs) will be constructed to
allow the generated carbon dioxide gases to vent to controlled locations.
3.0 Summary results of modeling or testing performed to investigate the injectant's potential or
susceptibility to change (biological, chemical, or physical) in the subsurface
MACTEC's subcontractor, GeoCleanse, will conduct daily groundwater sampling within and
adjacent to the treatment area, to assess whether appropriate geochemical conditions are
established in the aquifer, reagents are distributed effectively, and an efficient oxidation
reaction is occurring. The parameters to be measured are groundwater pH, alkalinity,
dissolved iron. hydrogen peroxide, and temperature. From the results obtained it can be
assessed whether a conducive environment (e.g., low pH, sufficient iron, distribution of
peroxide, etc.) has been established to destroy the VOCs through oxidation utilizing Fenton's
Reagent.
Attachment D - Paae 1

ATTACHMENT E
INJECTION PROCEDURE AND EQUIPMENT

1.0 Construction plans and materials
Following NCDENR issuance of a permit to construct and use the subject injection wells, the
pilot test will begin with the installation of nine injection wells and two vent wells, as shown on
Figure 2A (Attachment H). Air rotary drilling will be used for the injection and vent well
installation. The injection wells will be constructed of 1/4-inch diameter Schedule 80 chlorinated
poly vinyl chloride (CPVC) pipe with a 0.010-slot screened interval of 5 feet. Three of the
wells will have a total depth of 65 feet bgs and the other 6 wells will have a total depth of 55
feet bgs (2 of which will be installed in the same boring as a 65' deep well). The 2 vent wells
will be constructed of 1/4-inch diameter Schedule 80 CPVC with a 0.020-slot screened interval
of 30 feet with a total well depth of 40 feet bgs. The filter sand will he size 20/30 or similar for
all injections wells, and will be overlain by a layer (2 feet thick) of barrier fine grain sand. The
grout collar will consist of 95% Portland cement and 5% bentonite powder.
2.0 Operation procedures
Upon completion of the well installation, MACTEC will submit to NCDENR a notice of
completion of construction and allow sufficient time (up to 10 days following receipt of
notice) for the Director to send notice of intent to inspect the installation or otherwise review
the injection wells. MACTEC will then commence injection of the materials described in
Attachment C.
3.0 A detailed diagram of the surface and subsurface portions of the system
The surface layout of the new wells is shown on Figure 2A (Attachment H). The subsurface
diagrams of the proposed wells are illustrated in the Well Construction Diagrams included in
this Attachment.
4.0 A planned injection schedule
Construction of the proposed wells will be scheduled following issuance of the injection
permit. We anticipate commencing drilling approximately 4 weeks following issuance of the
permit. Well construction will take place over the course of approximately 10 work days
after which MACTEC will submit a notice of completion to NCDENR.
Injection will commence once NCDENR has inspected or otherwise reviewed the wells and
found them to be in compliance with the permit conditions. In accordance with subsection
15A NCAC 02C .0211(h) of the North Carolina Administrative Code, Subchapter 2C - Well
Construction Standards, if MACTEC does not receive notice from the Director of intent to
inspect or otherwise review the injection well within 10 days after receiving the notice, the
injection will commence and will proceed over the course of approximately 9 work days.
Attachment E —Page 1

PROPOSED SHALLOW INJECTION WELL CNSTRUMON DETAILS
]OS NAME FORMER ABB FZAKT PRODUCTS
WELLS 6 EACH
TOTAL DEPTH 55.0
MACTEC ENGINEERING TBD
FIELD REPRESENTATIVE
JOB NUMBER 3031-05-2007
INSTALLATION DATE TBD
DRILLED BY TBD
RISER/SCREEN:
MATERIAL: SCHEDULE 80 CPVC
DIAMETER: ' 4 ry -
SLOT SIZE: 0. 010"
klWl W .DUALC;
1-1 i1riT_rwvujvl Dl CLL
CONCRETE PAD
?OUND SURFACE
PVC RISER
RTTLANDISENTONITE
UT
BOREHOLE WALL
FINE SAND SEAL
SAND FILTER PACK
PVC SCREEN
PVC END CAP
Wk. A,A .,�i1� iJ.I .IiN
FORMER FLAKT PRODUCTS SITE
IN -SITU CHEMICAL OXIDATION PILOT TEST
4tMACTEC WINSTON-SALEM, NORTH CAROLINA
MACPEC Engineering and Consulting, Inc, DRAFTING BY. \R_� PREPARED BY: { CHECKED BY: j'
1725 Louisville prlve l
KnoxWle, Tennemsee 37921-59D4 308 NUMBER: HATE: V SCALE:
865-588.8544 • Fax:[phone]
3031-08-2007-09 AUGUST 18, 2008 NOT TO SCALE

PROPOSED DEEP INJECTION WELL CONSTRUCTION DETAILS
+. NAME FORMER ,:: FLAKT PRODUCTS ,. NUMBER 00
3 EACH
INSTALLATIONWELLS DATE TBO
TOTALDEPTH ■
DRILLED BY T8D
MACTEC ENGINEERING ;i
FJELD REPRESENTATIVE
MATERIAL,, SCHEDULE:i CPVC
f
■
1 i
FLUSH -MOUNT
PSCIRUBBER EXPANDING
�r��❑uri r 3 �a��xGROUND SURFACE
PVC RISER
►' ��GROUTPORTLANDIBENTONfTE
56.0'�11r�!
n ►
i
1` '�.y ►� aCG..BOREHOLE WALL
FINE SAND SEAL
SAND FILTER PACK
►l ��1�► ,�tl'r.� 1�.�.�..�
PVC SCREEN
�Ian�Gt► 1 1��►`��n11a�.PVC END CAP
(NOT TO BOTTOM OF BOREHOLE
FORMERFLAKTPRODUCTS
ArMACTEC
IN -SITU CHEMICAL OXIDATION PILOT
WINSTON-SALEM, NORTH CAROLINA
Drive
■• .
■
,.
*:I
wig
0 11 i'
li:

I
PROPOSED DUAL INIECTION WELL CONSTRUCTION DETAILS
JOB NAME FORMER ABB ELAKT PRODUCTS
WELLS 2 EACH
TOTAL DEPTH 65, 0'
MACTEC ENGINEERING TBD
FIELD REPRESENTATIVE
PSC/RUBBER EXPANDING PLUG
46 0'
40
JOB NUMBER 3031-05-2007
INSTALLATION DATE TBD
DRILLED BY T8p
RISER/SCREEN:
MATERIAL: SCHEDULE 80 CPVC
DIAMETER: 314 „
SLOT SIZE: 0.010"
(NOT TO SCALE)
FLUSH -MOUNT STEEL
2'x2' CONCRETE PAD
GROUND SURFACE
PVC RISER
PORTLANDISEN'TONITF
GROUT
FINE SAND SEAL
BOREHOLE WALL
SAND FILTER PACK
PVC SCREEN
PVC END CAP
FINE SAND SEAL
�- PVC MISER
SAND FILTER PACK
PVC SCREEN
�-- PVC END CAP
ROTTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
r� IN -SITU CHEMICAL OXIDATION PILOT TEST
',''MACTEC WINSTON-SALEM NORTH CAROLINA
MACTEC Englnocrtng and Comwtting, Inc. DRAFTING BY; ` PREPARED BY: y CHECKED BY: y! i
1725 Lowsvllle Drive
Knoxville, Tennessee 37921-5904 JOB NUMBER: DATE: 4 SCALE:
865-588-8544 0 Fax: 865-SB8-6926
3031-08-2007-09 AUGUST 18, 2008 NOT TO SCALE

PROPOSED
VENT
WELL
CONSTRUCTION
DETAILS
308 NAME FURMER A88 fLArfT PRCDLICTS 306 NUMBER 303 P—D5—Z007
WELLS
TOTAL DEPTH
MACTEC ENGINEERING
FIELD REPRESENTATIVE
2 EACH
40.0'
mp
INSTALLATION DATE
DRILLED BY
RISER/SCRFEN:
MATERIAL:
DIAMETER:
SLOT SIZE:
TBD
T8D
SCHEDULE 80 CPVC
j»
0.020 ,
, y_1 uufvT STEEL
CONCRETE PAD
�OUNO SURFACE
PVC RfSER
RTLAND/eENTONITE
OUT
BOREHOLE WALL
FINE SAND SEAL
SAND FrLTER PACK
PVC SCREEN
PVC END CAP
(NOT TO SCALE)­*_�� BOTTOM OF BOREHOLE
FORMER FLAKT PRODUCTS SITE
At
IN-SITU CHEMICAL ❑XIDATION PILOT TEST
MACTEC WINSTON-SALEM, NORTH CAROLINA
MACTEC Engineering and Consulting, Inc— DRAFTING BY: PREPARED BY. i CHECKED BY: -
1725 Louisville Drive 1
Knoxville, Tennessee 37921.5904 JOB NUMBER: DATE: SCALE:
665-566-8544 • Fax. [phone]
3031-08-2007-09 AUGUST 14, 2008 NOT TO SCALE

ATTACHMENT F
MONITORING PLAN

1.0 A list of existing and proposed monitoring wells to be used
Performance monitoring will be conducted from monitoring wells MW-I 12 and MW-129,
recovery well RW-10, along with one or more of the proposed injection well and at least one
of the proposed vent wells.
2.0 A list of monitoring parameters and analytical methods to be used
Parameter
Analytical Method
VOCs
8260 (EPA)
pH/DO/ORPrf'emp
Horiba field flow -through cell
1,4-Dioxane
8260 (EPA)
Ferrous iron
3500D (EPA)
Alkalinity
SM2320B
3.0 A schedule for sampling to monitor the proposed injection
Monitoring E-ent
Wrfi ID
(TJ pc of Moniwrink)
Selected
MW-I12
MW-I29
RW-10
injection Well
Vent Well
Rasciine (Performance)
List A
List A
Liss A
Lis[ A
---
During Injection (Process)
List. B
List B
-
List B
List C
7 Days After Injection (Performance)
List A
List A
List A
List A
30 Days After Injection (Performance)
List A
List A
List A
List A
---
The parameter listed refers to the lists below.
Method
Parameter List A — Groundwater
Vocs
8260 (EPA)
pH/DO/ORP/I'emp
Horiba field flow -through cell
1,4-Dioxane
8260 (EPA)
Ferrous iron
3500D (EPA)
Alkalinity
SM2320B
Parameter List B— Groundwater and/or Offgas
pH/Temp
Field kit
Total iron
Field kit
Peroxide
Field kit
VOCs
PID
Parameter List C — Offgas
Carbon dioxide
Meter
Oxygen
Meter
VOCs
PID
Notes: DO = dissolved oxygen
EPA = Environmental Protection Agency
Prepared by/Date: K1D 8/7/2008
ORP = oxygen reduction potential
PID = photoienization detector
Checked hy/Date: ALA/8/14/08
VOC = volatile organic compound
Attachment F -- Page 1

ATTACHMENT G
WELL DATA

Attachment G
Wetl Data
ABE Fla kr Pr odvcta Sit*
Winston-Salem, North Carelins
Screen interval
Survey Coordinates
Well Material
Cam Iebon
Well ID
pate
installed
Well
Pur CseiT a
polity of Weil
Boring
pe th
Well
Depth
Top
I
Bottom
Easting
Northing
I
Elevation
I
Riser/Screen
Plush-
mount
Vault
Stick-up
SP-6
12M9197
Monitor
water level gauging
40.0
40.0
30
40
1641423.15
854456.07
824.01
PVC
x
SIP-9
12/19/97
Monitor
water level gauging
50.0
510
40
50
1650847,60
854457.74
833.35
PVC
x
SP-10
12/20/97
Monitor
water level gauging
50.0
50.0
40
50
1641568.77
854477.59
834.05
PVC
x
SP-11
12/20/97
Monitor
water level gauging
50.0
50.0
40
50
164159&48
854482.25
833.67
PVC
x
SP-23
03/24/97
Monitor
water level gauging
64.0
64.0
49
E4
1E41401.59
B54512.16
035.61
PVC
x
RVV-2
0IM3198
Recovery
0 & M program
1UUA
100.0
80
100
184147C25
854470.33
826.75
PVCIStainless
x
RW-3
01/24/98
Recovery
❑ & M program
110.0
110.0
80
110
1641407.64
854458.30
821.9
PVC/Stainless
x
RW-6
01/25/98
Recovery
0 & M program
115,0
115.0
85
115
1641543,73
854473.80
832.99
PV01Stainiess
x
RW-7
01/14/98
Recovery
0 & M program
110.0
110.0
90
110
1641339.29
B54444.50
819.02
PVC/Stainless
x
RW-1U
01/26/98
Recovery
0 & M program
115.0
115.0
85
115
1641611.96
854485.32
833.54
PVC/Stainless
x
RW-13
12/17/97
Recovery
❑ & M program
77.0
77.0
57
77
1641236,39
854426,3E
816.9
PVC/Stainless
x
RW-14
12/20191
Recovery
0 & M program
100.0
100.0
E0
100
1641684.44
854499.19
534.16
PVCIStainless
x
MW-C
06/24/88
Monitor
Sample
45.0
45.0
34.6
44.6
1641297.85
854718.32
839.81
PVC
x
MW-E
06/23/88
Monitor
Sample -alt.
56.5
54.4
44
54
1642023,38
854621,83
835.79
PVC
x
MW-1
06/02/88
Monitor
Sample
38.5
35.9
25
35
1641434.0(3
854464,50
826.72
PVC
x
MW-102
1212018E
Monitor
water level gauging
43.9
43.3
37.9
42.9
1641225.45
054031.02
839.79
PVC
x
MW-104
121IW88
Monitor
Sample
68.0
68.0
57.6
67.6
164137424
854677.7E
839.69
PVC
x
MW-105
12/14/80
Monitor
water level gauging
50.0
40.6
44.2
49.2
1641279.20
854715.89
839.77
PVC
x
MW-106
12/20/88
Monitor
Sample
67.4
88.9
56.5
66.5
1841259.77
854492.02
635.47
PVC
x
MW-107
12/15/88
Monitor
Sample
69A
89.4
64.9
69A
1641442.37
854465.30
825.09
PVC
x
MW-110
03/22/89
Monitor
Sample
65.0
65.0
54.6
64.6
1641830.59
654539,23
835,34
PVC
x
MW-111
03123/89
Monitor
water level gauging
50.5
50.2
39.8
49.8
1641546.46
854747.89
839.79
PVC
x
MW-112
OW24/89
Monitor
Sample
55.2
55.2
44.E
54.E
1841633.29
854498.83
834.16
PVC
x
MW-113
OW27189
Monitor
water level gauging
52,9
51.9
41.5
51.5
1541288.78
85449533
835.56
PVC
x
MW-114
03129/89
Monitor
Sample - all.
40.5
39.8
29.4
39A
1841016.63
854457/4
834.59
PVC
x
MW-115
03/29/89
Monitor
water level gauging
35.5
35.5
25.1
35.1
1641546.03
854982.28
839.73
PVC
x
MW-11E
03/31/89
Monitor
Sample
38.0
37.5
27.1
37.1
1641214.23
854935,42
839.25
PVC
x
MVV-117
D4118189
Monitor
Sample
51.0
45.8
40.7
46.7
1641236.78
854579,05
839.89
PVC
x
MW-118
041119189
Monitor
water level gauging
51,0
50.8
40.4
50A
1641571,06
854624.68
839.64
PVC
x
MW-119D
11/10193
Monitor
Sample
59.0
59.0
49
59
1640877,57
854511.59
842.35
PVC
x
MW-119S
11/11/93
Monitor
Sample
39.0
39.0
24
39
1640885.40
854512.79
842.66
PVC
x
MW-120D
11/11/93
Monitor
Sample
131.0
121.0
116
121
1641405.89
654491.58
835.41
PVC
x
MW-121❑
IV13193
Monitor
Sample
84.0
84.0
79
84
1641320,53
854694.10
839.77
PVC
x
MW-122
11/22/94
Monitor
Not used
31.0
31.0 1
21
31
1640732.04
854515 17
841A7
PVC
x
MW-123
04/04/95
Monitor
Sample
56.5
56.5
41.5
56.5
1640466 80
054087.00
810A3
PVC
x
MW-124
04/03/95
Monitor
Sample
34.0
34.0
19
34
1640885.64
854256.20
819.61
PVC
x
MW-125
04/03/95
Monitor
Sample
39.0
39.0
24
39
1641279.62
854218.31
017.53
PVC
x
MW-126
04/04/95
Monitor
Sample
20.0
20.0
5
20.0
1640882.34
853909.89
783.52
PVC
x
MW-127
03/24/97
Monitor
Sample - alt.
99.5
99.5
39.5
99.5
1041898.29
854565.25
835.28
PVC
x
MW-128
03/24/97
Monitor
water level gauging
104.0
104.0 1
39
104
1641423.27
854489.95
834.85
PVC
x
MW-129
04/23104
Monitor
Sample
67.0
65.5
55
65
1841598,75
854494,55
834.13
PVC
x
Attachment G - Page 1

Attachment G
Well Data
ABB FIskt Produets Sloe
Winston-Salem. North Carolina
Screen Interval
$urvev Ceardinates
omicietion
Well iD
Date
In
Well
Pur ose1T
iltllity of Well
Boring
Depth
Well
Depth
Top
Bottom
Easting
Northing
Elevation
RlserlScreen
Flvsh
mount
Vault
Stick-up
MW-130
04127104
Monitor
Sample
57.0
55.5
45
55
1641455.29
854468 31
825.68
PVC
X
MW-131❑
04127/04
Monitor
Sample
84.0
81.5
76
81
1641396A6
954506.36
835.52
PVC
X
Proposed
TBD
Injection
Injection of Fenton's
65.0
65.0
60
65
TBD
TBD
TBD
CPVC
X
Proposed
TBD
Injection
Injection of Fenton's
65.0
65.0
50
55
TBD
TBD
TBD
CPVC
X
Proposed
TBD
Injection
Injection of Fenton's
05.0
65.0
60
65
TB❑
TBD
TBD
CPVC
X
Proposed
TBD
Injection
Injection of Fenton's
05.0
55.0
50
55
TBp
TBD
TBD
CPVC
X
Proposed
TBD
Injection
Injection of Fenton's
65.0
55.0
50
55
TBD
TBD
TBD
CPVC
X
Proposed
TBD
Injection
Injection of Fenton's
55.0
55.0
50
55
TBD
TBD
TBD
CPVC
X
Proposed
TBD
Injection
Injection of Fenton's
66.0
55.0
50
55
TBD
TBD
TBD
CPVC
X
Proposed
TBD
Injection
Injection of Fenton's
55.0
55.0
50
55
TBD
TBD
TBD
CPVC
X
Proposed
TBD
Injection
injection of Fenton's
55.0
55.0
50
55
TBD
TBD
TBD
CPVC
x
NOTE Oniy moniloring wells MW-112 and MW-129, recovery well RW-10, and the propsed injection and vent wells are expected to he impacted by this injection.
Attachment G - Page 2

REFERENCES

References
Cherry, J.A. and R.A. Freeze, 1979. Groundwater, Prentice -Hall, Inc., Englewood Cliffs. New
Jersey. Equation 2.61.
Johnson, A.I., 1967. Specific yield — compilation of spec fc yields for various materials.
U.S. Geological Survey Water Supply Paper 1662-D.
MACTEC Engineering and Consulting, Inc_, 2004. Scope of Work Well Installation and
Development (April).
MACTEC Engineering and Consulting, Inc., 2006. Groundwater Recovery Hydraulic Control
,System, Annual Report 2005 and Focused Soils Investigation (February).
Mundorff, M.J., 1949. Geology and Ground Water in the Greensboro Area, North Carolina.
North Carolina Department of Conservation and Development, Bulletin Number 55.
Roy F. Weston, Inc., 1991. Comprehensive Report of Site Investigations and Remediation
Activities, Flakt Products, Inc., Lowery Street Facility, Winston-Salem, North Carolina
(October).
Rust Environmental & Infrastructure, 1995. Groundwater Remedial Investigation Report, Flakt
Products Site, Winston-Salem, North Carolina (July).
Rust Environment & Infrastructure, 1996. Groundwater Remedial action Plan, Flakt Products
Site, Winston-Salem, North Carolina (February).
References — Page 1

Material Safety Qata Sheet (MSDS)
Hydrogen Peroxide 30-54°/6
ACROSI 1189
**** SECTION I - CHEMICAL PRODUCT AND COMPANY IDENTIFICATION ****
MSDS Name: Hydrogen Peroxide 30-50%
Catalog N um hers:
AC9470941. S74876, S74876-1, S748761. S7487% S74882, H323-500, H323500.
H 325 100, H325 4. H325 500. H325-I00. H325-4, H325-500, 1-1325100, H3254,
H325500, H325500001, H327 500, H327-500, H327500, 1-13275001-C, H341 500.
H341-500- H341500, S74876IMF, WESH325500_. ZZH3253015
Synonyms:
Carbamide peroxide; Hydrogen dioxide; Peroxide: Hydroperoxide; Urea
peroxide, Hydrogen peroxide 100 volumes;
Company Identification (Europe): Acros Organics N.V.
Janssen Pharmaceuticalaan 3a
2440 Gee], Belgium
Company Identification (USA): Acros Organics
One Reagent Lane
Fairlawn, NJ 07410
For information in Europe, call: 0032(0) 14575211
For information in North America, call: 800-ACROS-01
For emergencies in Europe, call: 0032(0) 14575299
For emergencies in the US, cal] CHEMTREC: 800-424-9300
**** SECTION 2 - COMPOSITION, INFORMATION ON INGREDIENT'S ****
CAS# Chemical Name j % I EINECS#
I 7722-84-1 )Hydrogen peroxide j 30-50 E 23I-7b5-0
I--------------- -1----------------- -- ----__-I
j 7732 18-5 )Water j Balance j 231-791-2 I
Hazard Svmbols: O C
Risk Phrases: 34 8
**** SECTION 3-HAZARDS IDENTIFICATION ****
EMERGENCY OVERVIEW
Appearance: clear. colorless.
Danger! Strong oxidizer. Contact with other material may cause a
fire. Corrosive. Light sensitive. Mutagen. May be harmful if
swallowed. May cause central nervous system effects. Eye contact may
result in permanent eye damage. May cause blood abnormalities. May
cause severe respiratory tract irritation with possible burns.
Causes eye and skin irritation and possible burns. May cause severe
digestive tract irritation with possible burns.
Target Organs: Blood, central nervous system.
Potential Health Effects
Eve:
Contact with liquid is corrosive to the eyes and causes severe
burns. Contact with the eyes may cause corneal damage.
Skin:

Causes severe skin irritation and possible burns. May cause
discoloration, erythema, swelling, and the formation of papules and
vesicles.
Ingestion:
Causes gastrointestinal irritation with nausea, vomiting and
diarrhea. Causes gastrointestinal tract burns. May cause vascular
collapse and damage. May cause damage to the red blood cells. May
cause difficulty in swallowing, stomach distension. possible cerebral
swelling and death. Ingestion may result in irritation of the
esophagus, bleeding of the stomach and ulcer formation.
Inhalation:
Causes chemical burns to the respiratory tract. May cause ulceration
of nasal tissue, insomnia, nervous tremors with numb extremities,
chemical pneumonia., unconsciousness, and death. At high
concentrations, respiratory effects may include acute lung damage and
delayed pulmonary edema.
Chronic:
Prolonged or repeated skin contact may cause dermatitis. Laboratory
experiments have resulted in mutagenic effects. Repeated contact may
cause corneal damage.
**** SECTION 4 - FIRST AID MEASURES ****
Eyes:
Get medical aid immediately. Do NOT allow victim to rub or keep eyes
closed. Extensive irrigation is required (at least 30 minutes).
Skin:
Get medical aid immediately. Immediately flush skin with plenty of
soap and water for at least 15 minutes while removing contaminated
clothing and shoes. Wash clothing before reuse. Destroy contaminated
shoes.
ingestion:
Do NOT induce vomiting. If victim is conscious and alert. give 2-4
cupfuls of milk or water. Never give anything by mouth to an
unconscious person. Get medical aid immediately. Wash mouth out with
water. Vomiting may occur spontaneously. If vomiting occurs and the
victim is conscious, give water to further dilute the chcm ical-
Inhalation:
Get medical aid immediately. Remove from exposure to fresh air
immediately. If breathing is difficult, give oxygen. DO NOT use
mouth-to-mouth respiration. If breathing has ceased apply artificial
respiration using, oxygen and a suitable mechanical device such as a
bag and a mask.
Notes to Physician:
Treat symptomatically and supportively. Attempts at evacuating the
stomach via emesis induction or gastric lavage should be avoided. In
the event of severe distension of the stomach or esophagus due to gas
formation. insertion of a gastric tube may be required, To treat
corneal damage, careful ophthalmologic evaluation is recommended and
the possibility of local corticosteroid therapy should be considered.
**** SECTION 5 - F1RE FIGHTING MEASURES ****
General Information:
As in any Fire, wear a self-contained breathing apparatus in
pressure -demand. MSHAINIOSH (approved or equivalent), and full

protective gear. Water runoff can cause environmental damage. Dike
and collect water used to fight fire. Strong oxidizer. Contact with
combustible materials may cause a #ire. During a fire, irritating and
highly toxic gases may be generated by thermal decomposition or
combustion. Use water spray to kcep fre-exposed containers coo3_
Substance is noncombustible. Use water with caution and in flooding
amounts. Vapors may be heavier than air. They can spread along the
ground and collect in low or confined areas. Some oxidizers may react
explosively with hydrocarbons(fuel). May decompose explosively when
heated or involved in a fire. May accelerate burning if involved in a
fire.
Extinguishing Media:
Use water only! Do NOT use carbon dioxide. Do NOT use dry chemical.
Do NOT get water inside containers. Contact professional
fire-fighters immediately. Cool containers with flooding quantities
of water until well after fire is out. For large fires, flood fire
area with large quantities of water, while knocking down vapors with
water fog.
**** SECTION 5 - ACCIDENTAL RELEASE MEASURES ***•
General Information: Use proper personal protective equipment as indicated
in Section 8.
Spi I ls/Leaks:
Avoid runoff" into storm sewers and ditches which lead to waterways.
Clean up spills immediately, observing precautions in the Protective
Equipment section. Use water spray to disperse the gas/vapor. Remove
all SDurceS of ignition. Absorb spill using an absorbent,
non-combustible material such as earth, sand, orvermiculiLe. Flush
spill area with water. Provide ventilation. Do not get water inside
containers. Keep combustibles (wood. paper, oil, etc.,) away from
spilled material.
**** SECTION 7 - HANDLING and STORAGE ****
handling:
Wash thoroughly after handling. Remove contaminated clothing and
wash before reuse. Use only in a well ventilated area. Contents may
develop pressure upon prolonged storage. Do not get in eyes, on skin,
or on clothing. keep container tightly closed. Avoid contact with
clothing and other combustible materials. Do not ingest or inhale.
Store protected from light. Discard contaminated shoes. Unused
chemicals should not be returned to the container. Rinse empty drums
and containers thoroughly with water before discarding.
Storage:
Keep away from heat, sparks, and flame. Do not store near
combustible materials. keep container closed when not in use. Store
in a cool. dry, well -ventilated area away from incompatible
substances. Store protected from light. Keep away form alkalies,
oxidizable materials, finely divided metals, alcohols. and
permanganates. Store below 35'C. Store only in light -resistant
containers fitted with a safety vent.
**** SECTION 8 - EXPOSURE CONTROLS, PERSONAL PROTECTION ****
Engineering Controls:

Use explosion -proof ventilation equipment. Facilities storing or
utilizing this material should be equipped with an eyewash facility
and a safety shower. Use adequate general or local exhaust
ventilation to keep airborne wric-entrations below the permissible
exposure limits.
Exposure Limits
j Chemical Name i ACGIH NIOSH JOSHA -Final PELsj
j Hydrogen peroxide 11 ppm ; 1.4 mglm3 11 ppm TWA: 1.4 11 ppm TWA; 1.4
mglm3 TWA 75 {mglm3 TWA j
{ { ppm IDLH j j
------------------- -j-----------------a------------------------------ {
I Water jnone listed Inane listed jnone listed I
OSHA Vacated PELs:
Hydrogen peroxide:
1 ppm TWA; 1.4 mglm3 TWA
Water:
No OSHA Vacated PELs are listed for this chemical.
Personal Protective Equipment
Eves:
. Wear appropriate protective eyeglasses or chemical
safety goggles as described by OSHA's eye and face
protection regulations in 29 CFR 1910.133 or European
Standard EN 166.
Skin:
Wear appropriate protective gloves to prevent skin
exposure.
Clothing:
Wear appropriate protective clothing to prevent skin
exposure.
Respirators:
A respiratory protection program that meets OSHA's 29
CFR § 1910.134 and ANSI Z88.2 requirements or European
Standard EN 149 must be followed whenever workplace
conditions warrant a respirator's use.
**** SECTION 9 - PHYSICAL AND CHEMICAL PROPERTIES ****
Physical State: Liquid
Appearance:
clear, colorless
Odor:
slight acid odor
pH:
3.3 (30% solution)
Vapor Pressure:
23 mm Hg kir 30C
Vapor Density:
1.10
Evaporation Rate:
>1.0 (Butyl acetate=1)
Viscosity:
1.25 cP
Boiling Point:
108 deg C c.@ 760 mmHg
Freezing/Melting Point: -3. deg C
Autoignition Temperature: Noncombustible
Flash Point:
Noncombustible

NFPA Rating: Not published.
Explosion Limits. Lower: 40 vol %
Upper: 100 vol %
Decomposition Temperature: Not available.
Solubility: Miscible in water.
Specific Gravity/Density: 1.1-1.2 (30-50%)
Molecular Formula: H2O2
Molecular Weight: 34.0128
* * * * SECTION 10 - STABILITY AND REACTI VITY ****
Chemical Stability:
Decomposes slowly to release oxygen. Unstable when heated or
contaminated with heavy metals, reducing agents, rust, dirt or
organic materials. Stability is reduced when pH is above 4.0,
Conditions to Avoid:
Mechanical shock, incompatible materials, light, ignition sources.
dust generation, excess heat, combustible materials, reducing
agents, alkaline materials, strong oxidants. rust, dust, pH > 4.0.
Incompatibilities with Other Materials:
Strong oxidizing agents, strong reducing agents, acetic acid. acetic
anhydride. alcohols, brass, copper, copper alloys, finely powdered
metals, galvanized iron, hydrazine, iron, magnesium, nitric acid,
sodium carbonate, potassium permanganate, cyanides (e.g. potassium
cyanide, sodium cyanide), ethers (e.g. dioxane, furfuran,
tetrahydrofuran (THF)), urea, chlorosuifonic acid. alkalies, lead.
nitrogen compounds, trieth y I am i n e, silver, nickel, palladium, organic
matter, charcoal, sodium borate, aniline, platinum, formic acid,
cvcIopentadiene, activated carbon, tert-butyl alcohol, hvdrogen
selenide, manganese dioxide, mercurous chloride, rust. ketones,
carboxylic acids, glycerine, sodium fluoride, sodium pyrophosphate,
soluble fuels (acetone, ethanol, glycerol), wood, wood, asbestos,
hexavalent chromium compounds, salts or iron, copper, chromium,
vanadium, tungsten. molyhdeum, and platinum.
Hazardous Decomposition Products:
Oxygen. hydrogen gas, water, heat, steam.
Hazardous Polymerization: Will not occur.
**** SECTION 1 I - TOXICOLOGICAL INFORMATION ****
RTECS#:
CAS# 7722-84-1: MX0899000 MX0900000
CAS# 7732-18-5: ZCOI 10000
LD50/LC50:
CAS# 7722-84-1: Inhalation, rat: LC50 =2 gmIm3/4H: Oral, mouse: LD50
= 2 gmlkg; Skin, rat: LD50 = 4060 mgfkg.
CAS# 7732 18-5: Oral, rat: LD50 = >90 mLlkg.
Carcinogenicity:
Hydrogen peroxide -
ACGIH: A3 - Animal Carcinogen
IARC: Group 3 carcinogen
Water -
Not fisted by ACGIH, IARC. NIOSH, NTP, or OSHA.
Epidemiology:
No information available.
Teratogenicity:

No information available.
Reproductive Effects:
No information available.
Neurotoxicity:
No information available.
Mutagenicity:
CAS#: 7722-84-1 Mutation in Microorganisms: Salmonella typhimurium =
100 uglplate.; Hyman, embryo = 50 umol/L.; Cytogenetic Analysis:
Human, embryo = 20 umollL. Mutation in Mammalian Somatic Cells:
Hamster, I ung = 1 mmollL.
Other Studies:
No data available.
**** SECTION 12 -ECOLOGICAL INFORMATION ****
Ecotoxicity:
Not available.
Fish: Fathead Minnow: 16.4 mglL; 96 Hr; LC50 (Fresh water)
Fish: Fathead Minnow: 5 mg/L; 96 Hr; NOEC (fresh water)
Mollusk Daphnia: 2.4 mg1L: 48 Hr, EC50 (fresh water)
Fish: Channel catfish: 37.4 mg/L; 96 Hr; LC30 (fresh water)
Environmental Fate:
Rain washout is expected due to condensation of hydrogen peroxide on
contact with water droplets. in the atmosphere. indirect
photooxidation is perdicted with a half -fife of 10 to 20 hours.
Non -significant evaporation and adsorption from water surfaces and
soil/sediments is expected. Rapid and cosiderable aerobic
biodegradation was determined with a half-life < 1 minute
(biological treatment sludge) and 0.3 to 2 days (fresh water).
Hydrogen peroxide is non-bioaccumulable.
Physical/Chemical:
Not available.
Other;
Not available.
**** SECTION 13 - DISPOSAL CONSIDERATIONS ****
Dispose of in a manner consistent with federal, state, and local regulations.
RCRA P-Series: None listed.
RCRA U-Series: None listed.
* * * * SECTION 14 -TRANSPORT INFORMATION * * * *
US DOT
Shipping Name: HYDROGEN PEROXJDE, AQUEOUS SOLUTIONS 30%
Hazard Class: 5.1
UN Number: UN2014
Packing Group: II
IMO
Shipping Name: HYDROGEN PEROXIDE, AQUEOUS SOLUTION
Hazard Class: 5.1
UN Number: 2014
Packing Group: I1
IATA
Shipping Name: IIYDROGEN PEROXIDE. AQUEOUS SOLUTION
Hazard Class: 5.1

UN Number: 2014
Packing Group: II
RIDIADR
Shipping Name: HYDROGEN PEROXIDE, AQUEOUS SOLUTION
Dangerous Goads Code: 5.1(62B)
UN Number: 2014
Canadian TDG
Shipping Name: HYDROGEN PEROXIDE
Hazard Class: 5.1(8)
UN Number: UN2014
**** SECTION 15-R.EGULATORY INFORMATION ****
US FEDERAL
TSCA
CAS# 7722-84-1 is listed on the 'TSCA inventory.
CAS# 7732-18-5 is listed on the TSCA inventory.
Health & Safety Reporting List
None of the chemicals are on the Health & Safety Reporting List.
Chemical Test Rules
None of the chemicals in this product are under a Chemical 'Pest Rule,
Section 12b
None of the chemicals are fisted under TSCA Section 12b.
TSCA Significant New Use Rule
None of the chemicals in this material have a SNUR under TSCA.
SARA
Section 302 (RQ)
None of the chemicals in this material have an RQ.
Section 302 (TPQ)
CAS# 7722-84.1: concentration > 52%: TPQ = 1000 pounds; RQ = 1000
pounds
SARA Codes
CAS # 7722-84-1: acute, flammable.
Section 313
No chemicals are reportable under Section 313.
Clean Air Act:
This material does not contain any hazardous air pollutants.
This material does not contain any Class 1 Ozone depletors.
This material does not contain any Class 2 Ozone depletors.
Clean Water Act:
None of the chemicals in this product are listed as Hazardous
Substances under the CWA.
None of the chemicals in this product are Iisted as Priority
Pollutants under the CWA.
None of the chemicals in this product are Iisted as Toxic Pollutants
under the CWA.
OSHA:
CAS# 77'2-94-1 is considered highly hazardous by OSHA.
STATE
Hydrogen peroxide can be found on the following state right to know
lists: California, New Jersey. Florida. Pennsylvania. Minnesota,
Massachusetts.
Water is not present on state lists from CA, PA, MN, MA. FL. or NJ.
California No Significant Risk Level:
None of the chemicals in this product are listed.
European/international Regulations

European Labeling in Accordance with EC Directives
Hazard Symbols: ❑ C
Risk Phrases:
R 34 Causes burns.
R 8 Contact with combustible material may cause
fi re.
Safety Phrases:
S 28 After contact with skin, wash immediately with
plenty of... (to be specified by the manufacturer).
S 3 Keep in a cool place.
S 36139 Wear suitable protective clothing and
eye/face protection.
S 45 In case of accident or if you feel unwell, seek
medical advice immediately (show the label where
possible).
WGK (Water Danger/Protection)
CAS# 7722-84-1: U
CAS# 7732-18-5: No information available_
Canada
CAS# 7722 84-1 is listed on Canada's ❑SL(NDSL List.
CAS# 7732-18-5 is listed on Canada's DSLINDSL List.
This product has a WHMIS classification of C. E. F. D2A.
CAS# 7722-84-1 is not listed an Canada's Ingredient Disclosure List.
CAS# 7732-18-5 is not listed on Canada's Ingredient Disclosure List.
Exposure Limits
CAS# 7722-84-1. OEL.AUSTRALIA-TWA 1 ppm (.1.5 mglm3)
DEL-BELGIUM:TWA 1 ppm (1.4 mglm3)
OEL-DENMARK:TWA 1 ppm (1.4 mglm3)
OEL-FINLAND:TWA 1 ppm (1.4 mglm3);STEL 3 ppm (4.2 mglm3)
OEL-FRANCE:TWA I ppm (1.5 mg/m3)
OEL-GERMANY:TWA I ppm (1.4 mg/m3)
❑EL -THE NETHERLANDS:TWA 1 ppm (1.4 mglm3 )
DEL THE PHILIPPINES:TW A I ppm (1.4 mglm3)
DEL-SWITZERLAND:TWA 1 ppm (1.4 mglm3);STEL 2 ppm (2.8 mglm3)
OEL-TURKEY:TWA 1 ppm (1.4 mgfm3)
OEL-UNITED KINGDOM:TWA 1 ppm (1.5 mglm3);STEL 2 ppm (3 mglm3)
"MI 0141M161211111IMMA6]r]1lYMM21M121MOOirlL•i 1IM
MSDS Creation Date: 1/12/1995 Revision 426 Date: 4/21/1999
The information above is believed to be accurate and represents the best
information currently available to us. However, we make no warranty of
merchantability or any other warranty_ express or implied, with respect to
such information, and we assume no liability resulting from its use. Users
should make their own investigations to determine the suitability of the
information for their particular purposes. In no way shall the company be
liable for any claims, losses. or damages of any third party or for lost
profits or any special, indirect, incidental, consequential or exemplary
damages, howsoever arising, even if the company has been advised of
the possibility of such damages.

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24 dour Emergency Telephone: 9D&459-2151
CHEMTREC. 1-500-42"300
i fl SDS Material Safety Data Sheet CILNUTECoSpons In Carwida
dulslda U-S. and Canada
GF16RIr+eC: 202-48S-T815
From: Maillinckrodt Baker, Inc.
222 Rod SOW Lr1nQ ALLINCICRODT J.T
NOTE: CKELITREC. CANUTEC and Na 4pnzl
Rl -. W st Ceazor emor9oncy rw"'0 s to be
Phillipsburg, NJ OB865 used ony iD the sect o1 cheemat anwn"fon
invoMn6 a sp3f. lcaL Irre, mpocuto or ecodont
twol ing a wrriurs,
AI non -antgercy c smons should be dtrectsd to Cuganoer Semce (1.800-S82-2537) for assistance.
FERROUS SULFATE
MSDS Number: F1802 --- Effedive Date: 03101100
I. Product Identification
Synonyms: iron (Ii) sulfate [ 1:1 ], heptahydrate; sulfuric acid, iron (2+) salt (1:1 ), heptahydrate
CAS No.: 7720-78-7
Molecular Weight. 278
Chemical Formula: FcSO4 7H2O
Product Codes:
J.T. Baker: 2070, 2074, 2075, 5830
Mallincicrodt: 5055. 5056, 5401, 5572
2. Composition/Information on Ingredients
Ingredient CAS No Percent Hazardous
Ferrous Sulfate 7720-78-7 99 - 100% Yes
3. Hazards Identification
Emergency Overview
WARNING'. HARMFUL IF SWALLOWED OR INHALED. CAUSES IRRITATION TO
SKIN, EYES AND RESPIRATORY TRACT. AFFECTS THE LIVER.
J.T. Baker SAJZLT-DATA("Ratings (Provided here for your convenience)
Health Rating: I - Slight
Flammability Rating: 0 - None
Reactivity Rating: 0 -None
Contact Rating: 0 - None
Lab Protective Equip: GOGGLES. LAB COAT

Storage Color Code: Orange [General Storage]
Potential Health Effects
Inhalation:
Causes irritation to the respiratory tract. Symptoms may include coughing, shortness of breath.
Ingestion:
Low toxicity in small quantities but larger dosages may cause nausea, vomiting, diarrhea, and
Mack stool. Pink urine discoloration is a strong indicator of iron poisoning. Liver damage, coma.
and death from iron poisoning has been recorded. Smaller doses are much more toxic to children.
Skin Contact:
Causes irritation to skin. Symptoms include redness, itching, and pain.
Eye Contact:.
Causes irritation. redness, and pain.
Chronic Exposure:
Severe or chronic ferrous sulfate poisonings may damage blood vessels. Large chronic doses cause
riekets in infants. Chronic exposure may cause liver effects. Prolonged exposure of the eyes may
cause discoloration.
Aggravation of Pre-existing Conditions:
Persons with pre-existing skin disorders or eye problems, or impaired liver, kidney or respiratory
function may be more susceptible to the effects of the substance.
4. First Aid Measures
Inhalation:
Remove to fresh air. Ifnot breathing, give artificial respiration. If breathing is difficult, give
oxygen. Get medical attention.
Ingestion:
Induce vomiting immediately as directed by medical personnel. Never give anything by mouth to
an unconscious person. Get medical attention.
Skin Contact:
Immediately flush skin with plenty of soap and water for at least 15 minutes. Remove
contaminated clothing and shoes. Get medical attention. Wash clothing before reuse. Thoroughly
clean shoes before reuse.
Eye Contact:
Immediately flush eyes with plenty of water for at least IS minutes, lifting lower and upper eyelids
occasionally. Get medical attention immediately.
5. Fire Fighting Measures
Fire:
Not considered to be a fire hazard.
Explosion:
Not considered to he an explosion hazard.
Fire Extinguishing Media:
Use any means suitable for extinguishing surrounding fire.
Special Information:
Use protective clothing and breathing equipment appropriate for the surrounding lire.

6. Accidental Release Measures
Ventilate area of leak or spill. Wear appropriate personal protective equipment as specified in
Section 8. Spills: Pick up and place in a suitable container for reclamation or disposal, using a
method that does not generate dust. US Regulations (CERCLA) require reporting spills and
releases to soil, water and air in excess of reportable quantities. The toll free number for the US
Coast Guard National Response Center is [phone].
7. Handling and Storage
Keep in a tightly closed container, stored in a cool, dry. ventilated area. Protect against physical
damage. Maintain a constant temperature not to exceed 24 degrees centigrade (75 degrees
fah renheit). Fluctuating temperatures causes pro ductoxidation. Oo not use this product if coated
with brownish -yellow basic ferric sulfate. Isolate from incompatible substances. Containers of this
material may be hazardous when empty since they retain product residues {dust, solids); observe
all warnings and precautions listed for the product.
S. Exposure Controls/Personal Protection
Airborne Exposure limits:
-ACGIH Threshold Limit Value (TLV):
I mg/m3 (TWA) soluble iron salt as Fe
Ventilation System:
A system of local and/or general exhaust is recommended to keep employee exposures below the
Airborne Exposure Limits. Loral exhaust ventilation is generally preferred because it can control
the emissions of the contaminant at its source, preventing dispersion of it into the general work
area. Please refer to the ACGIH document. Industrial 1'entiladlon, A Manual of Recommended
Practices, most recent edition, for details.
Personal Respirators (NIOSH Approved):
If the exposure limit is exceeded, a half -face dust/mist respirator may be warn for up to ten times
the exposure limit or the maximum use concentration specified by the appropriate regulatory
agency or respirator supplier, whichever is lowest. A full -face piece dust/mist respirator may be
worn up to 50 times the exposure limit, or the maximum use concentration specified by the
appropriate regulatory agency, or respirator supplier, whichever is lowest. For emergencies or
instances where the exposure levels are not known, use a full-facepiece positive -pressure, air -
supplied respirator. WARNING: Air -purifying respirators do not protect workers in oxygen -
deficient atmospheres.
Skin Protection:
Wear impervious protective clothing. including boots, gloves. lab coat_ apron or coveralls, as
appropriate. to prevent skin contact.
Eye Protection:
Use chemical safety goggles and/or full face shield where dusting or splashing of solutions is
possible. Maintain eye wash fountain and quick drench facilities in work area.
9. PhysicaI and Chemical Properties
Appearance:
Blue green crystals.
Odor:
Odorless.

Solubility:
48.5 g/IW g water @ W (122F)
Density:
1.90
PH:
No information found.
% Volatiles by volume @ 21C (70F):
0
Boiling Point:
> 300C (> 572F) Recomposes.
Melting Point:
57C (135F) Loses water
Vapor Density (Air --I):
No information found.
Vapor Pressure (mm Hg):
No information found.
Evaporation Rate (BuAc=1):
No information found.
10. Stability and Reactivity
Stability:
Stable under ordinary conditions of use and storage. Looses water in dry air and oxidizes upon
exposure to moisture, forming a brown coating of extremely corrosive basic ferric sulfate.
Hazardous Decomposition Products:
Burning may produce sulfur oxides.
Hazardous Polymerization:
This substance does not polymerize.
Incompatibilities:
Alkalis, soluble carbonates, and oxidizing materials. Reacts in moist airto form ferric sulfate.
Conditions to Avoid:
Moisture.
11. Toxicological Information
Oral rat LD50: 3I9 mg/kg. Investigated as a tumorigen and mutagen.
--------\Cancer Lists\------------------------------------------------------
--- NTP Carcinogen___
Ingredient Known Anticipated IARC Category
Ferrous Sulfate t7720-7@-7y No No None
12. Ecological Information
Environmental Fate:
No information found.
Environmental Toxicity:
No information found.

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 of container and unused contents in accordance with federal, state and local
requirements.
14. Transport Information
Not regulated.
15. Regulatory Information
--------\Chemical Inventory Status - Part 1\ --------------------------------
Ingredient TSCA EC Japan Australia
Ferrous Sulfate (7720-78-7) Yes Yes Yes Yes
\Chemical Inventory Status - Part 2\--------------------------------
--Canada--
Ingredient Korea DSL NDSL Phil.
----------------------------------------------- ----- --- ---- -----
Ferrous Sulfate (7720-78-7) Yes Yes No Yes
--------\Federal, State & International Regulations - Part 1\ ---------------
-SARA 302-------SARA 313-----
Ingredient RQ TPQ List Chemical
Catg.
----------------------------------------- --- ----- ---- -------------
Ferrous Sulfate (7720-78-7) No No No No
--------\Federal, State & International Regulations - Part 2\---------------
-RCRA- -TSCA-
Ingredient CERCLA 261.33 8(d)
----------------------------------------- ------ ------ ------
Ferrous Sulfate (7720-78-7) 1000 No No
Chemical Weapons Convention: No TSCA 12(h): No CDTA: No
SARA 311./312: Acute: Yes Chronic: Yes Fire: No Pressure: No
Reactivity: No (Mixture 1 Solid)
Australian Haxchem Code: No information found.
Poison Schedule: No information found.
WHM1S:

This MSDS has been prepared according to the hazard criteria of the Controlled Products
Regulations (CPR) and the MSDS contains all of the information required by the CPR.
16. Other Information
NFPA Ratings: Heaith:I Flammability: U Reactivity: U
Label Hazard Warning:
WARNING! HARMFUL IF SWALLOWED OR INHALED. CAUSES IRRITATION TO SKIN.
EYES AND RESPIRATORY TRACT. AFFECTS THE LIVER.
Label Precautions:
Avoid contact with eyes, skin and clothing.
Wash thoroughly after handling.
Avoid breathing dust
Keep container closed.
Use only with adequate ventilation.
Label First Aid:
If swallowed, induce vomiting immediately as directed by medical personnel. Never give anything
by mouth to an unconscious person. If inhaled, remove to fresh air. If not breathing, give artificial
respiration. If breathing is difficult, give oxygen. In case of contact, immediately flush eyes or skin
with plenty of water for at least 15 minutes. Remove contaminated clothing and shoes. Wash
clothing before reuse. In all cases, get medical attention.
Product Use:
Laboratory Reagent. Bulk pharmaceutical chemical.
Revision Information:
No changes.
Disclaimer:
##############k#### k k##9+F kkY k�k e*k k k�k k#k�■#Mk k %yk C#k +%k k ■ ## NMk�k * � �k� �*ek +k**k k k �
Mallinckrodt Baker, Inc. provides the information contained herein in good faith but makes
no representation as to its comprehensiveness or accuracy. This document is intended only
as a guide to the appropriate precautionary handling of the material by a properly trained
person using this product. Individuals receiving the information must exercise their
independent judgment in determining its appropriateness for a particular purpose.
MALLINCKRODT BAKER, INC. MAKES NO REPRESENTATIONS OR
WARRANTIES, EITHER EXPRESS OR IMPLIED, INCLUDING WITHOUT
LIMITATION ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A
PARTICULAR PURPOSE WITH RESPECT TO THE INFORMATION SET FORTH
HEREIN OR THE PRODUCT TO WHICH THE INFORMATION REFERS.
ACCORDINGLY, MALLINCKRODT BAKER, INC. WILL NOT BE RESPONSIBLE
FOR DAMAGES RESULTING FROM USE OF OR RELIANCE UPON THIS
INFORMATION.
Prepared by: Strategic Services Division
Phone Number: [phone] (U.S.A.)

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24 Hour Emergency Telephone: 965-a59-2151
CAEMTREC- 1.800-424-WDO
Naloonnl ,AlSD Material Safety Data Sheet CANUTECo6io iCn 66
Outside 11G_ and Canada
Chemtrec: 2024M-76%
From: Maliinckroch Baker, ina.
222 Red School Lang ALU'tiiCI{RODT JTl3aker NOTE o Ctri'arc rgorcy nuANLFTEC rand r, to e
Phllli sGur NJ 0$865 Rc'+Para.a Ccn'nr amorgercy numhan: =a be
P 9• used only In the cwenl o1 cllcrncsL arwrgenoles
vrralving a sp k 1"k irre, oxp5srsra or ac[Ir3enl
rnw1ong clx+mcaN
All non •enwrgency questions should he directed 10 Customer Service (1.800-682-2537) For assimance,
PHOSPHORIC ACID
MSDS Number: P3973 --- Effective Date: 06130 98
1. Product Identification
Synonyms: Ortho-phosphoric acid; white phosphoric acid
CAS No.: 7664-38-2
Molecular Weight: 98.00
Chemical Formula: H3PO4 in H2O
Product Codes:
J.T. Baker: 0259, 0260, 0262. 0263, 0264, 0268, 0273, 0274, 5372, 5592, 5804, 594L 6908
Mal linckrodt: 2779, 2788, 2796, 3563, H 106
2. Composition/Information on Ingredients
Ingredient
---------------------------------------
Phosphoric Acid
Water
3. Hazards Identification
CAS No Percent Hazardous
7664-36-2 74 - 95% Yes
7732-18-5 5 - 26% No
Emergency Overview
DANGER! CORROSIVE. CAUSES SEVERE IRRITATION AND BURNS TO EVERY
AREA OF CONTACT. HARMFUL IF SWALLOWED OR INHALED.
J.T. Baker SART-DATA("' Ratings (Provided here for your convenience)
Health Rating: 2 - Moderate
Flammability Rating: 0 -]None
Reactivity Rating: 2- Moderate
Contact Rating: 3 - Severe (Corrosive)

Lab Protective Equip: GOGGLES & SHIELD; LAB COAT & APRON; VENT HOOD; PROPER
GLOVES
Storage Color Code. White (Corrosive)
Potential Health Effects
Inhalation:
Inhalation is not an expected hazard unless misted or heated to high temperatures. Mist or vapor
inhalation can cause irritation to the nose, throat, and upper respiratory tract. Severe exposures can
lead to a chemical pneumonitis.
Ingestion:
Corrosive. May cause sore throat, abdominal pain, nausea, and severe bums of the mouth, throat.
and stomach. Severe exposures can lead to shock, circulatory collapse, and death.
Skin Contact:
Corrosive. May cause redness, pain. and severe skin burns.
Eye Contact:
Corrosive. May cause redness, pain. blurred vision, eye bums. and permanent eye damage.
Chronic Exposure:
No information found.
Aggravation of Pre-existing Conditions:
Persons with pre-existing skin disorders or eye problems, or impaired respiratory function may he
more susceptible to the effects of the substance.
4. First Aid Measures
inhalation:
Remove to fresh air. If not breathing, give artificial respiration. if breathing is difficult, give
oxygen. Call a physician immediately.
Ingestion:
If swallowed, DO NOT INDUCE VOMITING. Give large quantities of water. Never give
anything by mouth to an unconscious person. Get medical attention immediately.
Skin Contact:
Immediately flush skin with plenty of water for at least 15 minutes while removing contaminated
clothing and shoes. Call a physician. immediately. Wash clothing before reuse.
Eye Contact:
Immediately flush eyes with gentle but large stream of water for at least 15 minutes, lifting lower
and upper eyelids occasionally. Call a physician immediately_
5. Fire Fighting Measures
Fire:
Not considered to be a fire hazard. Contact with most metals causes formation of flammable and
explosive hydrogen gas.
Explosion:
Not considered to be an explosion hazard.
Fire Extinguishing Media:
Use any means suitable for extinguishing surrounding fire. Water spray may be used to keep fire
exposed containers cool. If water is used, use in abundance to control heat and acid build-up.
Special Information:
In the event or fire, wear full protective clothing and N I OS H -approved self-contained breathing
apparatus with full facepiece operated in the pressure demand or other positive pressure mode.

6. Accidental Release Measures
Ventilate area of leak or spill. Wear appropriate personal protective equipment as specified in
Section 8. Isolate hazard area. Keep unnecessary and unprotected personnel from entering.
Contain and recover liquid when possible. Neutralize with alkaline material (soda ash, lime), then
absorb with an inert material (e. g., vermiculite, dry sand, earth), and place in a chemical waste
container. Do not use combustible materials. such as saw dust. Do not flush to sewer! US
Regulations (CERCLA) require reporting spills and releases to soil, water and air in excess of
reportable quantities. The toll free number for the US Coast Guard National Response Center is
[phone].
J. T. Baker NEUTRASORB(R) or TEAM(R)'Low Na+' acid neutralizers are recommended for
spills of this product.
7. Handling and Storage
Keep in a tightly closed container. Protect from physical damage. Store in a coo1, dry, ventilated
area away from sources of heat, moisture, incompatibilities. and direct sunlight. Corrosive to mild
steel. Store in rubber lined or 316 stainless steel designed for phosphoric acid. Do not wash out
container and use it for other purposes. When diluting, the acid should a]ways be added slowly to
water and in small amounts. Never use hot water and never add water to the acid. Water added to
acid can cause uncontrolled boiling and splashing. Protect from freezing. Containers of this
material may be hazardous when empty since they retain product residues (vapors, liquid); observe
all warnings and precautions listed for the product,
S. Exposure Controls/Personal Protection
Airborne Exposure Limits:
-OSHA Permissible Exposure Limit (PEL):
1 mglm3 (TWA)
-ACGIH Threshold limit Value (TLV):
] mglm3 (TWA), 3 mglm3 (STEL)
Ventilation System:
A system of local and/or general exhaust is recommended to keep emplovee exposures below the
Airborne Exposure Limits. Local exhaust ventilation is generally preferred because it can control
the emissions of the contaminant at its source, preventing dispersion of it into the general work
area. Please referto the ACGIH document. Industrial I'emilation, A Alanual of Recommended
Practices, most recent edition, for details.
Personal Respirators (NIOSH Approved):
Ifthe exposure limit is exceeded, a full facepiece respirator with high efficiency dust/mist filter
may be worn up to 50 times the exposure Iimil or the maximum use concentration specified by the
appropriate regulatory agency or respirator supplier, whichever is lowest. For emergencies or
instances where the exposure levels are not known, use a Full-facepiece positive -pressure, air -
supplied respirator. WARNING: Air purifying respirators do not protect workers in oxygen -
deficient atmospheres.
Skin Protection:
Wear impervious protective clothing, including boots, gloves, lab coat, apron or coveralls. as
appropriate, to prevent skin contact.
Eye Protection:

Use chemical safety goggles and/or a full face shield where splashing is possible. Maintain eye
wash fountain and quick -drench facilities in work area.
9. Physical and Chemical Properties
Appearance:
Clear, colorless syrupy Iiquid.
Odor:
Odorless.
Solubility:
Miscible in all proportions in water.
Specific Gravity:
1.69 !.3 25C
pH:
1.5 (0.1 N aqueous solution)
% Volatiles by volume a. 21C (70F):
100
Boiling Point:
158C(315F)
Melting Point:
21C [70F]
Vapor Density (Air --I):
3.4
Vapor Pressure (mm Hg):
0.03 e 20C (68F)
Evaporation Rate (SuAc=l ):
No information found.
10. Stability and Reactivity
Stability:
Stable under ordinary conditions of use and storage. Substance can supercool without
crystallizing.
Hazardous Decomposition Products:
Phosphorus oxides may form when heated to decomposition.
Hazardous Polymerization:
W i l l not occur.
Incompatibilities:
Liberates explosive hydrogen gas when reacting with chlorides and stainless steel. Can react
violently with sodium tetrahy dro borate. Exothermic reactions with aldehydes, amines. amides,
alcohols and glycols, azo-compounds, carbamates. esters, caustics, phenols and cresols. ketones,
organophosphate& epoxides, explosives, combustible materials, unsaturated halides, and organic
peroxides. phosphoric acid forms flammable gases with sulfides, mercaptarns. cyanides and
aldehydes. It also forms toxic fumes with cyanides, sulfide, fluorides, organic peroxides, and
halogenated organics. Mixtures with niitromethane are explosive.
Conditions to Avoid:
Incompatibles.
11. Toxicological Information

Oral rat LD50: 1530 mg/kg, investigated as a mutagen.
--------\Cancer Lists\------------------------------------------------------
--- NTP Carcinogen ---
Ingredient Known Anticipated 1ARC Category
Phosphoric Acid (7664-38-2) No No None
Water (7?32-18-5) No No None
12. Ecological information
Environmental Fate:
When released into the soil, this material may leach into groundwater. When released to water,
acidity may be readily reduced by natural water hardness minerals. The phosphate, however. may
persist indefinitely.
Environmental Toxicity:
No information found.
13. Disposal Considerations
Whatever cannot be saved for recovery or recycling should be handfed as hazardous waste and
sent to a RCRA approved incinerator or disposed in a RCRA approved waste 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 of container and unused
contents in accordance with federal, state and local requirements.
14. Transport Information
Domestic (Land, D.O.T.)
Proper Shipping Nam e:PHOSPHORIC ACID
Hazard Class: 8
UN/NA: UN 1805
Packing Group: 11]
Information reported for product/size: 3 55LB
International (Water. I.M.O.)
Proper Shipping Naine.PHOSPHORIC ACID, LIQUID
Hazard Class: 8
UN/NA: UN1805
Packing Group: III
Information reported for prod uctlsize:355LB
15. Regulatory information
--------\Chemical Inventory Status - Part 1\
Ingredient TSCA EC Japan Australia

Phosphoric Acid (7664-38-2) Yes Yes Yes Yes
Water (7732-18-5) Yes Yes Yes Yes
--------\Chemical Inventory Status - Part 2\ --------------------------------
--Canada--
Ingredient Korea DSL NDSL Phil.
----------------------------------------------- _____ --- ---- -----
Phosphoric Acid (7664-38-2) Yes Yes No Yes
Water (7732-18-5) Yes Yes No Yes
--------\Federal, State & International Regulations - Part 1\ ---------------
-SARA 302- -------SARA 313-----
Ingredient RQ TPQ List Chemical
Catg.
----------------------------------------- --- ----- ---- -------------
Phosphoric Acid (7664-38-2) No No Yes No
Water (7732-18-5) No No No No
--------\Federal, State & International Regulations - Part 2\ ---------------
-RCRA- -TSCA-
Ingredient CERCLA 261.33 8(d)
Phosphoric Acid (7664-38-2) 5000 No No
Water (7732-18-5) No No No
Chemical Weapons Convention: No TSCA 12(b): No CDTA: No
SARA 311/312: Acute: Yes Chronic: No Fire: No Pressure: No
Reactivity: No (Pure 1 Liquid)
Australian Hazehem Code:211
Poison Schedule: S5
W H MIS:
This M S D S has been prepared according to the hazard criteria of the Controlled Products
Regulations (CPR) and the MSDS rtmtains all of the information required by the CPR_
16. Other Information
NFPA Ratings: Hcalth:3 Flammability: if Reactivity:0
Label Hazard Warning:
DANGER! CORROSIVE. CAUSES SEVERE IRRITATION AND BURNS TO EVERY AREA
OF CONTACT. HARMFUL IF SWALLOWED OR INHALED.
Label Precautions:
Do not get in eyes, on skin, or on clothing.
Keep container closed.
Use only with adequate ventilation.
Do not breathe vapor or mist.
Wash thoroughly after handling.

Label First Aid:
In case of contact, immediately flush eyes or skin with plenty of water for at least 15 minutes.
Remove contaminated clothing and shoes. Wash clothing before reuse. if swallowed_ DO NOT
INDUCE VOMITING. Give large quantities of water. Never give anything by mouth to an
unconscious person. If inhaled, remove to fresh air. if not breathing, give artificial respiration. If
breathing is difficult, give oxygen. In all cases call a physician immediately.
Product Use:
Laboratory Reagent.
Revision Information:
MSDS Section(s) changed since last revision of document include: 1. 2.
Disclaimer:
*****•****s***.ra*t�*:r■*���*�**«.*****.*******�.*.*ass*r*+*r*r��*+****+****a�*r
Mallinckrodt Baker, Inc. provides the information contained herein in good faith but makes
no representation as to its comprehensiveness or accuracy. This document is intended only
as a guide to the appropriate precautionary handling of the material by a properly trained
person using this product. Individuals receiving the information must exercise their
independent judgment in determining its appropriateness for a particular purpose.
MALLINCKRODT BAILER, INC. MAKES NO REPRESENTATIONS OR
WARRANTIES, EITHER EXPRESS OR IMPLIED, INCLUDING WITHOUT
LIMITATION ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A
PARTICULAR PURPOSE WITH RESPECT TO THE INFORMATION SET FORTH
HEREIN OR THE PRODUCT TO WHICH THE INFORMATION REFERS.
ACCORDINGLY, MALLINCKRODT BAKER, INC. WILL NOT BE RESPONSIBLE
FOR DAMAGES RESULTING FROM USE OF OR RELIANCE UPON THIS
INFORMATION.
Prepared by: Strategic Services Division
Phone Number: (314) 539t 1600 (U.S.A.)

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24 Hour Emergency Telephone. 906-Mg-2151
CHErdTREC: t-Bap-42443c0
,DMS Material Safety Data SheetHet`onalRosporrsoinCanada
CANUTFC!613AVA-66ft
Cuialdo U.S. and Canada
Chemtrec; M4034616
From: Mailinckrodt Baker, lnc.
2z2 Rod School Lana ALLINC>f�R T J.T.Baker NOTF- CHc'1A1TFlEC. CANVTEC mid Nptwial
222 d S N,1 U8B65 R'*Wnso C*Tft arwrwc7 nWrrsars to tw
P g, used o* 1n me c+veat 01 thental a"rgencK s
�' mvotving a :p31. !cart. Inc, expxure or amdent
amohnna owm--CaK
All non -emergency aueaticns "uld be difwed to Custamer Service (1-800-582-2537t for assistance.
SULFURIC ACID, 52 -1 00 %
MSDS Number: S8234 --- Effective Date: 07113100
I. Product Identification
Synonyms: Oil of vitriol: Babcock acid: sulphur4: acid
CAS No.: 7664-93-9
Molecular Weight: 98.08
Chemical Formula: H2SO4 in H2O
Product Codes:
J.T. Baker: 5030, 5137, 5374, 5802, 5815, 5889, 5960, 5961, 5971, 6902, 9673, 9674, 9675, 9676,
9679, 9680, 9681, 9682, 9684, 9687. 9691. 9693, 9694
Mal I inckrodt: 2468, 2876, 2878, 2900, 29GC 3780, 4222, 5524, 5557, H644, H976, H996, V344
2. Composition/Information on Ingredients
Ingredient CAS No Percent Hazardous
Sulfuric Acid
Water
3. Hazards Identification
Emergency Overview
7664-93-9 52 - 100% Yes
7732-18-5 0 - 48% No
POISON! DANGER! CORROSIVE. LIQUID AND MIST CAUSE SEVERE BURNS TO
ALL BODY TISSUE. MAY BE FATAL IF SWALLOWED OR CONTACTED WITH
SKIN. HARMFUL IF INHALED. AFFECTS TEETH. WATER REACTIVE. CANCER
HAZARD. STRONG INORGANIC ACID MISTS CONTAINING SULFURIC ACID CAN
CAUSE CANCER- Risk of cancer depends on duration and level of exposure.
J.T. Baker SAIRT-DATA"'i Ratings {Provided here for your convenience}

Health Rating: 3 - Severe (Poison)
Flammability Rating: 0- None
Reactivity Rating: 3 - Severe ( Water Reactive)
Contact Rating: 4 - Extreme (Corrosive)
Lab Protective Equip: GOGGLES & SHIELD; LAB COAT & APRON: VENT HOOD; PROPER
GLOVES
Storage Color Code: White (Corrosive)
Potential Health Effects
Inhalation:
Inhalation produces damaging effects on the mucous membranes and upper respiratory tract.
Symptoms may include irritation of the nose and throat. and labored breathing. May cause lung
edema, a medical emergency.
1 ngestion:
Corrosive. Swallowing can cause severe burns of the mouth, throat, and stomach, leading to death.
Can cause sore throat_ vomiting, diarrhea. Circulatory collapse with clammy skin, weak and rapid
pulse, shallow respirations, and scanty urine may follow ingestion or skin contact. Circulatory
shock is often the immediate cause of death.
Skin Contact:
Corrosive. Symptoms of redness, pain, and severe burn can occur. Circulatory collapse with
clammy skin, weak and rapid pulse, shallow respirations, and scanty urine may follow skin contact
or ingestion. Circulatory shock is often the immediate cause of death.
Eye Contact:
Corrosive. Contact can cause blurred vision. redness. pain and severe tissue bums. Can cause
blindness.
Chronic Exposure:
Long-term exposure to mist or vapors may cause damage to teeth. Chronic exposure to mists
containing sulfuric acid is a cancer hazard.
Aggravation of Pre-existing Conditions:
Persons with pre-existing skin disorders or eye problems or impaired respirator} function mad be
more susceptible to the effects of the substancc.
4. First Aid Measures
Inhalation:
Remove to fresh air. If not breathing, give artificial respiration. ll'breathing is difficult. give
oxygen. Call a physician immediately.
Ingestion:
DO NOT INDUCE VOMITING. Give large quantities of water. Never give anything by mouth to
an unconscious person. Call a physician immediately.
Skin Contact:
In case of contact. immediately flush skin with plenty of water for at least 15 minutes while
removing contaminated clothing and shoes. Wash clothing before reuse. Excess acid on skin can
be neutralized with a 2% solution of bicarbonate of soda. Cal a physician immediately.
Eye Contact:
Immediately flush eyes with gentle but large stream of water for at least 15 minutes, lifting lower
and upper eyelids occasionally. Call a physician immediately.
5. Fire Fighting Measures

Fire:
Concentrated material is a strong dehydrating agent. Reacts with organic materials and may cause
ignition of finely divided materials on contact.
Explosion:
Contact with most metals causes formation of flammable and explosive hydrogen gas.
Fire Extinguishing Media:
Dry chemical, foam or carbon dioxide. Do not use water on material. However, water spray may
be used to keep fire exposed containers cool.
Special Information:
In the event of a fire, wear full protective clothing and: NIOSH -approved self-contained breathing
apparatus with full facepiece operated in the pressure demand or other positive pressure mode.
Structural firefightces protective clothing is ineffective for fires involving this material. Stay away
from sealed containers.
6. Accidental Release Measures
Ventilate area of leak or spit I. Wear appropriate personal protective equipment as specified in
Section 8. lsalate hazard area. Keep unnecessary and unprotected personnel from entering.
Contain and recover liquid when possible. Neutralize with alkaline material (.soda ash, lime), then
absorb with an inert material (e. g., vermiculite, dry sand, earth), and place in a chemical waste
container. Do not use combustible materials, such as saw dust. Do not flush to sewer! US
Regulations (CERCLA) require reporting spills and releases to soil, water and air in excess of
reportable quantities. The toll free number for the US Coast Guard National Response Center is
[phone].
3_ T_ Baker NEUTRASDRB(R) or TEAM(R)'Low Nla+' acid neutralizers are recommended for
spills of this product.
7. Handling and Storage
Store in a cool, dry, ventilated storage area with acid resistant floors and good drainage. Protect
from physical damage_ Deep out of direct sunlight and away from heat, water, and incompatible
materials. Do not wash out container and use it for other purposes. When diluting, always add the
acid to water; never add water to the acid. When opening metal containers, use non -sparking tools
because of the possibility of hydrogen gas being present. Containers of this material may be
hazardous when empty since they retain product residues (vapors. liquid); observe all warnings
and precautions listed for the product.
S. Exposure Controls/Personal Protection
Airborne Exposure Limits:
For Sulfuric Acid:
-OSHA Permissible Exposure Limit (PEL):
1 mg/m3 (TWA).
-ACGIH Threshold Limit Value (TLV):
l mg/m3 (TWA). 3 mg/m3 (STEL)
Ventilation System:
A system of local and/or general exhaust is recommended to keep employee exposures below the
Airborne Exposure Limits. Local exhaust ventilation is generally preferred because it can control
the emissions of the contaminant at its source. preventing dispersion of it into the general work
area. Please refer to the ACGIH document, Induslrlal 1 entilarion, A Manual of Recommended

Practices, most recent edition, for details.
Personal Respirators (NIOSH Approved):
1 f the exposure I imit is exceeded, a full facepiece respirator with an acid gas cartridge and
dust/mist filter may be worn up to 50 times the exposure limit. or the maximum use concentration
specified by the appropriate regulatory agency or respirator supplier, whichever is lowest. Far
emergencies or instances where the exposure levels are not known, use a full- face piece positive -
pressure, air -supplied respirator. WARNING: Air purifying respirators do not protect workers in
oxygen -deficient atmospheres.
Skin Protection;
Wear impervious protective clothing, including boots. gloves, lab coat, apron or coveralls, as
appropriate, to prevent skin contact.
Eye Protection:
Use chemical safety goggles and/ora full face shield where splashing is possible. Maintain eye
wash fountain and quick -drench facilities in work area.
9. Physical and Chemical Properties
Appearance:
Clear oily liquid.
Odor:
Odorless.
Solubility:
Miscible with water, liberates much heat.
Specific Gravity:
1.84 (98%), 1.40 (50%), 1.07 (10%)
pH:
1 N solution (ca. 5% wlw) = 0.3; 0.1 N solution (ca. 0.5% wlw) = 1 2; 0.01 N solution (ca. 0.05%
wlw) = 2.1.
% Volatiles by volume aQ 21C (70F):
No information found.
Boiling Point:
ca. 290C (ca. 554F) (decomposes at 340C)
Melting Point:
3C (100%), -32C (93%),-38C (78%), -64C (65%),
Vapor Density (Air --I):
3.4
Vapor Pressure (mm Hg):
1 n 145.8C (295F)
Evaporation Rate (RuAc=1):
No information Found.
10. Stability and Reactivity
Stability:
Stable under ordinary conditions of use and storage. Concentrated solutions react violently with
water, spattering and liberating heat.
Hazardous Decomposition Products:
Toxic fumes of oxides of sulfur when heated to decomposition. Will react with water or steam to
produce toxic and corrosive fumes. Reacts with carbonates to generate carbon dioxide gas, and
with cyanides and sulfides to form poisonous hydrogen cyanide and hydrogen sulfide respectively_
Hazardous Polymerization:
will not occur.
Incompatibilities:

Water, potassium chlorate, potassium perchlorate, potassium permanganate, sodium, lithium,
bases, organic material, halogens, metal acetyIides, oxides and hydrides, metals (yields hydrogen
gas), strong oxidizing and reducing agents and many other reactive substances.
Conditions to Avoid:
Heat, moisture, incompatibles.
11. Toxicological Information
Toxicological Data:
Oral rat LD50: 2140 mg/kg; inhalation rat LC50: 510 mg/m3121-1; standard Draixe, eye rabbit, 250
ug (severe); investigated as a tumorigen, mutagen. reproductive effector.
Carcinogenicity:
Cancer Status: The International Agency for Research on Cancer (\ARC) has classified "strong
inorganic acid mists containing sulfuric acid" as a known human carcinogen, (]ARC category 1).
This classi lication appl ies only to mists containing sulfuric acid and not to sulfuric acid or sulfuric
acid solutions.
--------\Cancer Lists\
Ingredient
----------------------
Sulfuric Acid (7664-93-9)
Wager (7732-28-5)
12. Ecological Information
Environmental Fate:
---NT2 Carcinogen ---
Known Anticipated
No No
No No
IARC Category
-------------
None
None
When released into the soil, this material may leach into groundwater. When released into the air,
this material may be removed from the atmosphere to a moderate extent by wet deposition, When
released into the air, this material may be removed from the atmosphere to a moderate extent by
dry deposition.
Environmental Toxicity:
LC50 Flounder 100 to 330 mg/l/48 hr aerated water/Conditions of bioassay not specified; LC50
Shrimp 80 to 90 mg/l/48 hr aerated water /Conditions of bioassay not specified; LC50 Prawn 42.5
ppm/48 hr salt water /Conditions of bioassay not specified.
This material may be toxic to aquatic life.
13. Disposal Considerations
Whatever cannot be saved for recovery or recycling should be handled as hazardous waste and
sent to a RCRA approved incinerator or disposed in a RCRA approved waste 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 of container and unused
contents in accordance with federal. state and local requirements.
14. Transport Information
Domestic (Land, A.U.T.)
Proper Shipping Name: SULFURIC ACID [WITH MORE THAN 5 1 % ACID)
Hazard Class: 8

UN/NA: UN1830
Packing Group: 11
Information reported for product/size: 440M
International (Water, I.M.O.)
Proper Shipping Name: SULPHURIC ACID ( WITH MORE THAN 51% ACID)
Hazard Class:8
UNINA: UN1930
Packing Group: 11
Information reported for productlsize:440LB
15. Regulatory Information
--------\Chemical Inventory Status - Part 1\ --------------------------------
Ingredient
-----------------------------------------------
TSCA
----
EC .japan Australia
--- ----- ---------
Sulfuric Acid (7664-93-9)
Yes
Yes Yes Yes
Water (7732-18-5)
Yes
Yes Yes Yes
--------\Chemical Inventory Status - Part 2\--------------------------------
--Canada--
Ingredient
Korea
DSL NDSL Phil.
Sulfuric Acid (7664-93-9)
Yes
Yes No Yes
Water (7732-18-5)
Yes
Yes No Yes
--------\Federal, State & International
Regulations -
Part 1\---------------
-SARA 302-
------SARA 333-----
Ingredient
RQ TPQ
List Chemical
Catg.
-----------------------------------------
--- -----
---- -------------
Sulfuric Acid (7664-93--9)
1000 1000
Yes No
Water (7732-18-5)
No No
No Na
--------\Federal, State & International
Regulations -
Part 2\ ---------------
-RCRA- -TSCA-
ingredient
-----------------------------------------
CERCLA
------
261,33 8(d)
------ ------
sulfuric Acid (7664-93-9)
1000
No No
Water (7732-18-5)
No
No No
Chemical Weapons Convention: No TSCA
12(b): No
CDTA: Yes
SARA 311/312: Acute: Yes Chronic: Yes Fire: No Pressure: No
Reactivity: Yes (Pure 1 Liquid)

Australian Hazehem Code:2P
Poison Schedule: No information found.
WHMIS:
This MSDS has been prepared according to the hazard criteria of the Controlled Products
Regulations (CPR) and the MSDS contains all of the information required by the CPR.
16. Other Information
NFPA Ratings: Health.3 Flammability:0 Reactivity: 2 Other: Water reactive
Label Hazard Warning:
POISON! DANGER! CORROSIVE. LIQUID AND MIST CAUSE SEVERE BURNS TO ALL
BODY TISSUE. MAY BE FATAL IF SWALLOWED OR CONTACTED WITH SKIN.
HARMFUL IF INHALED. AFFECTS TEETH. WATER REACTIVE. CANCER HAZARD.
STRONG INORGANIC ACID MISTS CONTAINING SULFURIC ACID CAN CAUSE
CANCER. Risk of cancer depends on duration and level of exposure.
Label Precautions:
Do not get in eyes, on skin, or on clothing.
Do not breathe mist.
Keep container closed.
Use only with adequate ventilation.
Wash thoroughly after handling.
Do not contact with water.
Label First Aid:
In all cases call a physician immediately. In case of contact, immediately flush eves or skin with
plenty of water for at least 15 minutes while removing contaminated clothing and shoes. Wash
clothing before re -use. Excess acid on skin can be neutralized with a 2% bicarbonate of soda
solution. If Swallowed, DO NOT INDUCE VOMITING. Give large quantities of water. Never
give anything by mouth to an unconscious person. If inhaled, remove to fresh air. If not breathing.
give artificial respiration. If breathing is difficult. give oxygen.
Product Use:
Laboratory Reagent.
Revision Information:
MSDS Section(s) changed since last revision of document include: 1.
Disclaimer:
Mailinekrodt Baker, Inc. provides the information contained herein in good faith but makes
no representation as to its comprehensiveness or accuracy. This document is intended only
as a guide to the appropriate precautionary handling of the material by a properly trained
person using this product. Individuals receiving the information must exercise their
independent judgment in determining its appropriateness for a particular purpose.
MALLINCKRODT BAKER, INC. MAKES NO REPRESENTATIONS OR
WARRANTIES, EITHER EXPRESS OR IMPLIED, INCLUDING WITHOUT
LIMITATION ANY WARRANTIES OF MERCHANTABILITY, FITNESS FOR A
PARTICULAR PURPOSE WITH RESPECT TO THE INrFORM ATION SET FORTH
HEREIN OR THE PRODUCT TO WHICH THE INFORMATION REFERS.
ACCORDINGLY, MALLINCKRODT BAKER, INC. WILL NOT BE RESPONSIBLE
FOR DAMAGES RESULTING FROM USE OF OR RELIANCE UPON THIS
INFORMATION.
Prepared by: Strategic Services Division
Phone Number: (314) 53%1600 (U.S.A.)

NC OWD - UIC Program
Tracers and Remediation Injectants with Completed OEES Risk Assessments
Last Updated December 19, 2007
Purpose
Additive Name
Manufacturer
Chemical Oxidation
Fenton's Reagent (FeSO4 & H202)
n/a
Chemical Oxidation
GeoCleanse
Chemical Oxidation
Hydrogen Peroxide
n/a
Chemical Oxidation
ISOTEC Fenton's Reagent
TMC Chemicals
Chemical Oxidation
"On -Contact" Fenton's Process
n/a
Chemical Oxidation
Ozone
n/a
Chemical Oxidation
Potassium Permanganate
Carus Chemical
Chemical Oxidation
Sodium Permanganate
Carus Chemical
Chemical Oxidation
Sodium Persulfate
n/a
Chemical Oxidation
Soil Savers
Soil Savers
Chemical Reduction
Calcium polysulfide
n/a
Chemicat Reduction
EHC
Adventus
Chemical Reduction
EHC-A
Adventus
Chemical Reduction
EHC-M
Adventus
Chemical Reduction
Emulsified Zero-Valent Iron
n/a
Chemical Reduction
Palladized iron
n/a
Chemical Reduction
Sodium Bisuifite
n/a
Chemical Reduction
Sodium Dithionite
n/a
Chemical Reduction
Sodium Metabisulfite
n/a
Chemical Reduction
Zero-valent Iron
IRedoxTech
n/a
Chemical Reduction
ZVi & Molasses Slurry
n/a
Enhanced Bioremediation
ABC
Enhanced Bioremediation
Ammonium Nitrate
n/a
Enhanced Bioremediation
Ammonium Phosphate
n/a
Enhanced Bioremediation
Bio-Dechlor INOCULLIM
n/a
Enhanced Bioremediation
Bio-Integration
ERC
Enhanced Bioremediation
Black Biomass
VEETech
Enhanced Bioremediation
Blackstrap Molasses
nla
Enhanced Bioremediation
BOS 100
RPI
Enhanced Bioremediation
BOS 200
RPI
Enhanced Bioremediation
Butyric acid
n/a
Enhanced Bioremediation
Calcium Hydroxide
n/a
Enhanced Bioremediation
CL-Out
Osprey Biotechnics
Enhanced Bioremediation
EHC-O
Adventus
Enhanced Bioremediation
EOS 400
EOS Remediation
Enhanced Bioremediation
EOS 450
EOS Remediation
Enhanced Bioremediation
EOS 598
EOS Remediation
Enhanced Bioremediation
EOS 598B42 former) EOS
EOS Remediation
Enhanced Bioremediation
EOS 600
EOS Remediation
Enhanced Bioremediation
EOS 600EX
EOS Remediation
Enhanced Bioremediation
Epsom Salt
n/a
Enhanced Bioremediation
Ethyl Lactate
nla
Enhanced Bioremediation
HRC
Regenesis
Enhanced Bioremediation
HRC-Advanced
Regenesis
Enhanced Bioremediation
HRC-X
Re enesis
Enhanced Bioremediation
Hydrogen
n/a
Enhanced Bioremediation
KS-1
SiREM Laboratories
Enhanced Bioremediation
Lactic acid
n/a
Enhanced Bioremediation
Micro-Bac
Micro-Bac
Enhanced Bioremediation
Molasses
nla
Enhanced Bioremediation
Munox
10sprey Biotechnics
NOTE: This list does not constitute an endorsement of any product nor an assessment of its effectiveness. Not all
of the injectants listed have been permitted or used in North Carolina.

NC DWQ - UIC Program
Tracers and Remediation Injectants with Completed OEES Risk Assessments
Last Updated ❑ecember 19, 2007
Enhanced Bioremediation
Newman Zone
RNAS
Enhanced Bioremediation
ORC
Regenesis
Enhanced Bioremediation
ORC-Advanced
Regenesis
Enhanced Bioremediation
O-SOX
Adventus
Enhanced Bioremediation
Oxygen
n/a
Enhanced Bioremediation
PermeOx Pius
FMC
Enhanced Bioremediation
Sodium Bicarbonate
n/a
Enhanced Bioremediation
Sodium Lactate
n/a
Enhanced Bioremediation
Sodium Pioymetaphosphate
nla
Enhanced Bioremediation
Soybean Oil
n/a
Enhanced Bioremediation
SRC
Geovations
Enhanced Bioremediation
SRC-7
Geovations
Enhanced Bioremediation
SRC -ER
Geovations
Enhanced Bioremediation
SRS Substrate
Terra Systems
Enhanced Bioremediation
Sucrose
nla
Enhanced Bioremediation
WMI-2000
WMI International
Enhanced Bioremediation
Yeast extract
n/a
Enhanced Extraction
Biosolve
Westford Chemical
Enhanced Extraction
EnvlroClean 165
Enviro Clean Products & Services
pH Adjustment
Calcium Carbonate
n/a
pH Adjustment
Magnesium Hydroxide
n/a
Tracer
Eosin Dye
nla
Tracer
Fluorescein ❑ye
n/a
Tracer
Halon 1211
n/a
Tracer
Helium
n/a
Tracer
Potassium Bromide
n/a
Tracer
Rhodamine ❑ e
n/a
Tracer
Sodium Bromide
n1a
Tracer
Sulfur Hexafluonde
n/a
Tracer
Tinopal Dye
n/a
Tracer
Uramine aye
I n/a
Tracer
Xanthene Dye
I n/a
NOTE: This list does not constitute an endorsement of any product nor an assessment of its effectiveness. Not all
of the injectants listed have been permitted or used in North Carolina.

INFORMATION NEEDED TO DO RISK ASSESSMENTS FOR PRODUCTS APPLIED
TO GROUNDWATER OR SOIL
CONTAINING NO MICROORGANISMS
Page I of 4
SEND TWO COPIES TO: [TIC PROGRAM
AQUIFER PROTECTION SECTION
NORTH CAROLINA DENR-DWQ
1636 MAIL SERVICE CENTER
RALEIGH, NC 27699-1636
TELEPHONE [phone]
Note: Please provide direct responses to each of the following items, rather than "see
attachment", etc.
Required General Information
l . Department of Environment and Natural Resources Aquifer Protection Section contact
person and phone number.
Qu Qi [phone]
2. Current or future use of site with site contact person, address, and phone number.
The site consists of a 570,000 square foot former manufacturing plant on a 52-acre
property in an area of industrial and residential development near Interstate 40 Business
in Winston-Salem. Manufacturing operations ceased in 1986. Presently the northeast
corner of the building is leased to a cardboard recycling company; the rest of the facility
remains vacant.
Future use of the site is anticipated to be non-residential.
Site Contact Person:
Rick Ryan
MACTEC Engineering and Consulting, Inc.
1725 Louisville Drive After 1011108: 9725 Cogdill Road
Knoxville, TN 37931 Knoxville, TN 37932
[phone]
Contractor applying product, contact person. address, and phone number.
Will Moody
GeoCleanse International, Inc.
400 State Route 34
Matawan, NJ 07747
[phone]
Revised 7/06 GWMIC-3

INFORMATION NEEDED TO DO RISK ASSESSMENTS FOR PRODUCTS APPLIED
TO GROUNDWATER OR SOIL
CONTAINING NO MICROORGANISMS
Page 2 of 4
4. Distance and likelihood of impact to public or private wells used for drinking, industrial
processes, cooling, agriculture, etc. Is area served by public water supply? Verification
must be provided by the appropriate Regional Office of the Public Water Supply Section.
No impact to public or private wells used for drinking, industrial processes, cooling,
agriculture, etc., is expected. The NC DENR Winston-Salem Regional Office, Division
of Environmental Health Services, Public Water Supply Section confirmed in an email
dated August 29, 2008 that, to the best of their knowledge, "there have been no public
water systems served by wells in that area. The area is currently being served by the City
of Winston-Salem's Water System." This email is attached for verification.
5. General description of the contaminants if present in the soil and/or groundwater at the
site.
Primarily, the contaminants of concern present in the site groundwater include
chlorinated ethanes, chlorinated ethanes, 1,4-dioxane, and other volatile organic
compounds.
b. Name, approximate distance, and likelihood of impact to the nearest body of surface
water to the site.
The nearest body of surface water to the site is Brushy Fork Creek, located approximately
2,000 feet from the injection area. Treated groundwater is currently discharged to the
creek under an approved NPDES permit (NC0085871).
7. Approximate distance to nearest residence(s) and workplace.
The nearest workplace is located inside the facility on site, which is hydraulically
upgradient of the injection area. The actual distance to the nearest residence is unknown
but is at least 2,500 feet.
Required Product/Process-Specific Information
1, Product manufacturer name, address, phone number, and contact person.
Univar USA
300 Columbus Cir Ste E
Edison, NJ 08837
[phone]
Primary Contact: Jim Delaney
Revised 7/06 GW/UIC 3

INFORMATION NEEDED TO DO RISK ASSESSMENTS FOR PRODUCTS APPLIED
TO GROUNDWATER OR SOIL
CONTAINING NO MICROORGANISMS
Page 3 of 4
2. Identity of specific ingredients (including CAS#) and concentrations of ingredients
contained in the product and purpose of each.*
Staged On site:
Ingredient CAS No._ Percent Purpose
Sulfuric Acid 7664-93-9 52 - 100% Lower pH of groundwater (if needed)
as a part of the catalyst
Water 7732-18-5 0 - 48% Dilute acid to desired concentration
Contained in the Product:
The concentration of the sulfuric acid will be approximately 0.002 M prior to injection,
which should be sufficient to achieve a catalyst solution pH less than 4.
Approximate concentration of each ingredient following release into groundwater or soil.
The concentration will be sufficient to achieve a pH less than 4, or approximately 0.002
M concentration as H2SO4.
4. Approximate distance and direction of travel for product in groundwater, the groundwater
concentration of each ingredient at this distance, and distance from this point to the
nearest drinking water source (that is currently used for drinking purposes). These should
be reasonably accurate estimates based on the best available information and calculations
(modeling, if necessary) regarding aquifer characteristics and flowpaths at the site; where
uncertainty exists in critical aquifer parameters (e.g. effective porosity), conservative
assumptions should be made in estimating these values so that worst -case predictions of
travel distances are made.
The sulfuric acid will travel approximately 20 feet from the injection wells. The direction
will be based upon the permeability and hydraulic conductivity of the site specific soils.
Based on water level readings taken during sampling events, groundwater flow direction
at the site is generally to the southwest. The area is served by a municipal water supply:
likely the R.A. Thomas Plant located near downtown Winston-Salem. The plant draws
water from the river and Salem Lake, located at least 1.5 miles eastward of the site.
Approximate groundwater concentration of each ingredient after pumping or recovery (if
applicable).
Not applicable: no pumping or recovery will be performed. However, after injection, the
approximate groundwater concentration will be less than 0.002 M (and will decrease
further beginning immediately due to the natural buffering capacity of aquifer solids).
Revised 7/06 GWIUIC-;

INFORMATION NEEDED TO DO RISK ASSESSMENTS FOR PRODUCTS APPLIED
TO GROUNDWATER OR SOIL
CONTAINING NO MICROORGANISMS
Page 4 of 4
6. if the product is expected to discharge to a nearby surface water, approximate
concentrations of product in the water.
The product is not expected to discharge to surface water.
7_ Documentation from authoritative technical references of specific degradation products
expected. (Provide a brief summary of the referenced material as well as a copy of the
referenced material.)
As described in the referenced general chemistry text book, sulfuric acid will break down
to H+ and sulfate in groundwater (R.S Becker and W.E. Wentworth from the University
of Houston, General Chemistry, Second Edition, Houghton Mifflin Company, Boston,
1980, page 386). A copy of the reference page is attached to this document.
Documentation from authoritative technical references of expected migratory potential of
specific ingredients and degradation products in soil and groundwater. (Provide a brief
summary of the referenced material as well as a copy of the referenced material.)
eXtensionC, an educational partnership of 74 universities in the United States, defines a
soil's buffering capacity as its ability to resist changes such as pH modification. In a
bench test performed for the site by subcontractor, Geo-Cleanse, soil buffering tests
were conducted to assess the amount of acid necessary to achieve a pH less than 4. Three
tests were performed on prepared slurries with different amounts of acid. The baseline
slurry pH (before acid addition) in the three slurries ranged from 5.99 to 6.14, indicating
that the aquifer materials are already mildly acidic. The results of these three tests
indicated that the buffering capacity of the site soils is very low. In the sample prepared
with the lowest concentration of acid (0.3 mL of 10% sulfuric acid) the pH was initially
lowered to 2.22 and increased to 2.64 over a 60-minute period, demonstrating the soil's
natural capacity to stabilize to pre -injection conditions thereby inhibiting the migratory
potential of sulfuric acid or the degradation products.
Complete description of the use of the product at the site.
Sulfuric acid will be utilized to lower the groundwater pH to approximately 4.
* if the composition of the proposed injected fluid is considered a trade secret and needs to be treated as
confidential. please submit the confidential information clearly labeled as confidential. In addition,
include a letter identifying the confidential information and stating why the information should be
processed as confidential. All information warranting protection as a trade secret will be kept from
public disclosure in accordance with G.S. 132-1 2. and 15A NCAC 2C .0211(f).
The risk assessment will be forwarded to the designated contact person for the site. consultant
applying the product, and Aquifer Protection Section contact person.
Revised 7106 GWAJJC-3

NC DENR Form GWMC-3
Attachments

Letter from County of Forsyth
Page I of I
Stone, Jennifer
From: Tammy Taylor [[e-mail]]
Sent: Friday, August 29, 2008 4:32 PM
To: Stone, Jennifer; turnerbh@forsyth_cc
Subject: Re: Letter from County of Forsyth
Attachments: Tammy Taylor.vcf
Dear Jennifer,
This is in response to your request by telephone for information concerning the property located at 2000
Lowery Street in Winston-Salem, NC. I visited the site on August 28, 2008 and to the best of my knowledge,
there have been no public water systems served by wells in that area. The area is currently being served by the
City of Winston-Salem's Water System_ If you should have any questions, please contact me. Thanks!
Tammy Taylor
Tammy Taylor
NC DENR Winston-Salem Regional Office
Div Environmental Health Services, Public Water Supply Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
On 8/26/2008 5:18 PM, Stone, Jennifer wrote:
«s2d 19779EE8AB5591 C319998FE5FC 1 C D6DD_1. pdfh>
Thanks so much for your help!
Jennifer Stone, P.E.
MACTEC Engineering and Consulting, Inc,
1725 Louisville Drive
Knoxville, TN 37921
[phone] extension 1154
Fax. [phone]
9/4/2008

NONMETALS of GhuuPS TVA-rTJI ]
molecules can become tighter relative to the solid, causing the density to increase
upon melting. It also appears that clusters of water molecules still exist that are tetra-
hedrally hound, as in ice. In any event, upon melting there is both an overall decrease in
„[ the degree of hydrogep bonding and an overall collapse of the open structure present in
ice. Somewhere in the vicinity of 45% of the hydrogen bonds present in ice are
broken in the change of state to liquid HSO. The energy required to break a mole
of hydrogen bonds in Hr,O is 3.7 to 4.5 keal.
The following discussion refers primarily to sulfur, selenium, and tellurium, polo-
Iteru itians nium is excluded, None of these elements (including oxygen) reacts with water. Sulfur
appears to be the only element in the group (including oxygen) that reacts with strong
+^ bases. However, all except oxygen react with concentrated HNOa and with 0$ to
t produce the corresponding dioxide; SO$ is the only gaseous dioxide of the group. The
dioxides react with water to produce hydroxides that are oxyacids--sulfurous acid,
for example:
SO,(,, + H¢O(o SO(OH), or HsSO3t,w�
Pure H$S03 and pure H$TeO. have not been made. Each of the acids is moderately
strong and can dissociate two protons. Dissociation is not complete, however, and the
second H* ion comes off with considerably greater difficulty than the first. The dioxides
and hydroxides are all acidic and show the typical reactions (Section 9-C). Sulfur
trioxide, SO., is an acidic oxide that can react with water to produce the oxyacid
sulfuric acid, H,SO4. In HpSO4, which is
:Q:
I
S:1[fisric HD—S—OH
avid I
:0:
two protons can dissociate in H2O. It is considered a strong acid. Although removal
of the second proton is not complete, it is nonetheless highly dissociated;
HESO"M _ 1[x)%i H+ + HSO, 2H+ + SOa-
Obviously, both SO,, and H,SO4 react with bases or basic oxides. Peroxysulfuric acids
exist, the most important of which is peroxydisulfuric acid (or persulfuric):
:0: :0:
I I
HO-S-0-0---S-oH
.. I .. .. I ..
:O: :0:
1 3fu; ]
.S Becker and W.E. Wentworth frmn the University cif
ouston, Generul C'hemi.rtr)-. 5E et.)nd Edilion, Houghton
lifflin Company'. Bc ston. 1980. page 386

Raising Soil PH and Soil Acidification - eXtension
Page 1 of 4
e tension
mare mind reaCh
Raising Soil pH and Soil Acidification
Last Updated: August o6, 2008 1 Related resource areas: Gardens, Lawns &_Landseapes
Table of Contents Show
Adapted from Carl J. Rosen, Peter M. Bierman, and Roger D. Eliason. Department of Soil, Water, and Climate. University
of Minnesota.[']
Ground limestone is the most common material used to raise soil pH. Limestone consists either of calcium carbonate
(calcitic limestone) or calcium/magnesium carbonate (dolomitic limestone). On soils low in magnesium, dolomitic
limestone is the preferred form.
Apply Imestone only if a need is indicated by the results of soil testing and the requirements of the
plants being grown. Overliming can reduce nutrient availability, especially of nucronutrients such as iron, manganese,
and zinc. iron deficiency (chlorosis) of pin oak, for example, is common when soil pH is greater than 7.0.
Mineral Soils
Limestone recommendations for mineral soils are based on two factors:
i. Soil pH measurement
z. Determination of a buffer pH or buffer index value
The soil's buffering capacity represents its ability to resist changes such as pH modification. The amount of clay and/or
organic matter in a soil will determine its buffering capacity. The more clay and/or organic matter a soil has, the greater
its buffering capacity and the more limestone or sulfur will be needed to effect a pH change. There are several commonly
used methods of measuring a soil's buffering capacity. Some commonly used methods include the Mehlich buffer test,
SMP buffer test, and Woodruff buffer test. While the techniques of these test are different, they are used to interpret a
soil's buffering capacity in similar ways.
The soil pH value reported in a soil test indicates whether limestone is needed, but it cannot be used to determine how
much lime is needed. The amount of limestone to apply depends upon reserve soil acidity, which is measured by a buffer
pH test. The lower the buffer pH or buffer index., the larger is the quantity of limestone required to raise soil pH to the
desired level. Find a local laboratory, using the following hyperlink, to provide a calibrated buffer index that is suitable for
http://www.exien,,ion.org/pages/Raising_Soi1�H_and_Sail_Acidification 8/26/2008

Raising Soil pH and Soil Acidification - eXtension Page 2 of
determining liming rates for your local soils.
Soil Testing Laboratories
Most liming materials take several months to react with the soil, so for best results they should be applied and
incorporated to a depth of 6 inches well before planting time. For established lawns or turfgrass areas, perennial
vegetables and flowers, small fruits, fruit trees, and ornamental trees and shrubs, topdress applications of limestone are
used. These surface applications may take longer to change the soil pH than direct soil incorporation prior to planting.
Also, when large quantities of limestone need to he applied to established planting sites, they are made at rates of g to 7
pounds of ground limestone per xo❑ square feet spaced at least at one -month intervals. The best time to apply limestone
to established turf is following core aeration for thatch control or compaction. Spread the limestone uniformly around
other types of established plants. If possible, work it lightly into the soil, while avoiding the disturbance of plant roots.
Soil Acidification
Neutral to Slightly Acid Soils
For most plants, soil acidification is unnecessary, but lowering soil pH is frequently required to grow blueberries, azaleas,
and rhododendrons successfully. These plants require an acid soil with a pH between 4.5 and 5.2. If soil pH is above this
range, it is usually desirable to lower soil pH to 4.5 prior to planting. Over time the soil pH will migrate towards values
typical of native soils. In some areas of the country it will tend to increase, especially if the water supply used for
irrigation is alkaline, as is the case in municipal water supplies in some parts of the country. In other areas, such as the
northeast, many sails are naturally acidic and would seldom require sulfur additions.
Table S- Elemental sulfur application rates to lower soil pH by one unit
Soil texture
Amount of elemental sulfur (S) to apply*
Area basis Volume basis
l b.l100 IbJ1000
lb. /cubic
scl. ft so. ft.
yard
sand, loamy sand.
O.B B-0
1-0
sandy loam
Iparn. silt loam
2.4 24.0
3.0
'Multiply by 44 to convert the rates in Ib.l1000 sq. ft. to Ib.Iacre.
Table x. Image courtesy of University of Minnesota Extension.
Table 2 Elememal sulfur application rates to lover soil pH to 4.5
Initial pal Soil texture
sand, loamy sand, loam, silt loarn
sandy loam
Amount of elemental sulfur (S) to apply
lb.I100 sq.ft.
Elemental sulfur is one amendment that
can be used to lower soil pH. The soil
texture, amount of soil organic matter,
present pH, and the desired pH are all used
to determine the amount of elemental
7-0 1.9 5-8 sulfur needed. Table i provides guidelines
G5 1.5 4-6
httP://www.extension.org/pages/Raising_Soil_pH_and_Soil_Acidification 8/26/2008

Raising Soil pH and Soil Acidification - eXtension Page 3 of 4
to lower the pH of a soil with elemental
sulfur by one unit on an area basis and volume basis. Table 2 provides guidelines for elemental sulfur use to lower soil pH
to 4,5. Because it reacts slowly with the soil, elemental sulfur should be applied and incorporated to a depth of 6 inches
the year before planting for best results. Test soil pH again 6 to g months after the initial application. If soil pH is not in
the desired range, reapply according to the recommendations in Tables 1 or 2. Most homeowners prefer to use granulated
elemental sulfur.
Aluminum sulfate or iron sulfate can also be used to acidify soils. These materials react much faster than elemental
sulfur, usually within three to four weeks following application. Multiply the rate of elemental sulfur recommended in
Table 1 by 6 to determine the rate of iron sulfate or aluminum sulfate required for an equivalent pH reduction. Do not
apply more than g lb/ioo sq. ft. of iron sulfate or aluminum sulfate in a single application. If higher rates are required,
split applications are recommended to avoid excessive levels of soluble salts. Use iron sulfate or aluminum sulfate
cautiously because of the potential for iron or aluminum toxicity to plant roots and soil organisms.
Acid sphagnum peat incorporated into the soil prior to planting will provide a more favorable root environment for the
establishment of acid -loving plants in high -pH soils. Incorporate acid sphagnum peat moss at the rate of 2 to 2 cubic feet
per plant, or when possible incorporate an inch or two of acid sphagnum peat moss into the top 6 inches of soil before
planting. According to one source an application of 2 inches of sphagnum peat moss incorporated into the top 6 inches
of soil will lower the soil pH by one unit or more within a growing season. The positive effects of sphagnum peat can last
two or more years, but unless other measures are used the pH of the soil will eventually increase.
Ammonium sulfate or urea used as nitrogen fertilizer sources will also help maintain low soil pH_ However, do not use
them at rates greater than those required to meet the nitrogen needs of the plants. Fertilizers that contain nitrogen only
in the nitrate form will increase soil pH and should not be used for acid loving plants.
Alkaline Soils
Fine -textured clay and clay loam soils and high lime soils with a pH greater than about 7.3 require higher rates of
acidifying amendments than given in Table i. These soils are not recommended for growing acid -loving plants because
the amendment rates required to lower soil pH initially result in excessive levels of soluble salts and the soil pH will
eventually increase. The best strategy on these soils is to select plants that are adapted to high pH conditions.
Credits and Literature Cited
I. T Rosen, C. et al. 2004. Soil pH Modification. Soil Test Interpretations and Fertilizer Management for Lawns, Turf,
hardens, and Landscape Plants. http://www.extension.umn.edu/distribution/horticulture/components/1731-03.html
(accessed January 15, 2oo8). University of Minnesota.
a. 1 Rose, M. and H. Wang.1996. Composts in the Landscape: Effects on Soil pH and Plant Growth.
http://ohioline.osu.edu/sc157/sc'57_14.hbml (accessed February 15, 20o8). The Ohio State University, Ohio
Agricultural Reseamh and Development Center. Special Circular 152.Ornamental Plants: Annual Reports and
Research Summaries. pp. 7-11.
ltttp:Ilwww.extension.orglpageslRaising_5ai1_pH_and_Soil_Acidifcation 8/26/2008

Raising Soil pH and Soil Acidification - extension
Page 4 of 4
More information:
soil fertility. soil management, soils and composting
Comments
to whom is their on 03.oi.o8 at 07:51 PM
I have read that you could use sawdust ,sand and pine needles with a 112 cup ammonium sulfate put this around each plant when
you go to plant them. And you can put chicken wire under about four feet with a little brick in middle of roots with some peat or
saw dust.This book also said that sawdust was better than peat mooss to lower ph whereph is high. This is a very old book. I am
going to try to grow blueberries this spring I got plant coming but didn't relise about ph levels until i got studing about them. The
ph level is 6.o 5o I am really worried about setting this out. Thank you
Nick Broady on o3.o6.o8 at 01:48 PM
Thank you for your interest in the website, but in order for your question to be routed to the appropriate experts, you need to
use the "Ask the Expert" function. This is located immediately above the "Suggestions/Comments" area on the website
alice on 03.16.o8 at 04:22 AM
In our patch of Pacific NW woods, we have allowed native plants to be most of our beautiful "garden." However, our 4.5-5.0 ph
means I need to lime individual non -natives I might want to grow. How do I determine amounts per plant/shrub. By cup, pint,
quart, etc???
Nick Broady on 03.21.o8 at 04:07 PM
Thank you for your interest in the website, but in order for your question to be routed to the appropriate experts, you need to
use the "Ask the Expert" function. This is located immediately above the "Suggestions/Comments" area on the website. —
extension Staff
This resource area was created by the:
Consumer Horticulture
Community
eXtension provides objective and research -based information and learning opportunities that help people improve their lives. eXtension is an
educational partnership of 74 universities in the United States.
Q 2oo8 extension. All rights reserved.
http://www.extension.orglpages[Raising_Soil_pH_and_Soil—Acidification 8/26/2008

ATTACHMENT H
MAPS (Listed by Figure Number)
1.0 Area Map based on USG 7.5' Topographic Map (scale of 1:24,000) with Injection Site Labeled
2.0 Site Map Including
2.1 All property boundaries
2.2 All buildings within the property boundary
2.3 Existing and proposed injection wells or well field
2.4 Any existing sources of potential or known groundwater contamination, including waste
storage, treatment or disposal systems within '/a mile of the injection well or well system
2.5 All surface water bodies within '/d mile of the injection well or well system
2.6 All existing or abandoned wells within'/< mile of the injection wells which penetrate the
proposed injection zone, including, but not limited to, monitoring wells proposed for use as
injection wells
3.0 Potentiometric Surface Map(s) including
3.1 Direction of groundwater movement
3.2 Existing and proposed monitoring wells
3.3 Existing and proposed injection wells
4.0 Contaminant Plume Map(s) including
4.1 The horizontal extent of the contaminant plume, including isconcentric lines
4.2 Existing and proposed monitoring wells
4.3 Existing and proposed injection wells
5.0 Crass -Sections) to the known or projected depth of contamination, including
5.1 Horizontal and vertical extent of the contaminant plume, including isoconcentric lines
5.2 Major changes in lithology
5.3 Existing and Proposed monitoring wells
5.4 Existing and proposed injection wells
Revised 6109 UIC-51/5T Page 47 of 56

L
cREEK
bUALL:
0 0
LOWERY -STREET
li
SEE FIGURE 2A FOR
INJECTION WELL LAYOUT
MIT
F,
Ql qpw-c
ww-111
PAW-104
FCfWER
ABOVE GROUND TANK
ww-l's
41133
DLW-1
VW-3 Vw-2
MV&S
413 mvd-13$D SPA)Pn z1w-1 SIW-3
11will
M*134 127
1w-7 RW-3
RAI-14
SM-4
m" OpLe WOO
ouv" 136
RY&II) S..,, F01IIIIIIIIIIIIIIIIIIIItUgrAFMA
SIW-2
ePs
RECOVERY WELL LOCATION
-� MOWOH WELL LOCATION
FORMER AST CONVEYANCE PIPING
FIGURE
TE C SITE MAP
ABB FLAKT PRODUCTS 2
U14� %,VIJUILL MUAIJ WINS I ON-SAI-Em, Nu
KNOXVILLE. TN 37932
PHONE: [phone] DRAWN JOB Ntjm9FR APPROVED DATE REVISED DATE
FAX: [phone] `R,')� 3031 -05-2007-12 03/20/01 09 /28/10

MW-130
x
x x x x x x x x X— FENCyLINE x x
SCALE-
0 2 D'
PROPOSED WELLS
• 1 PROPOSED INJECTION WELL(70'-80' TREATMENT INTERVAL)
- 2 PROPOSED INJECTION WELLS (50'-60' AND 70'-K TREATMENT INTERVALS)
J) - 2 PROPOSED INJECTION WELLS (60'-80' TREATMENT INTERVAL)
- 2 PROPOSED INJECTION WELLS (50'-70' TREATMENT INTERVAL)
- 3 PROPOSED INJECTION WELLS (50'-80' TREATMENT INTERVAL)
D PROPOSED VENT WELL (screened from 3-60 ft bls)
MW-133
EXISTING WELLS
- MONITORING WELL
SHALLOW INJECTOR (screened from 55-60 ft bls)
DEEP INJECTOR (screened from 65-70 ft bls)
VENT WELL (screened from 3-65 ft bls)
DUAL INJECTOR (shallow and deep injectors set in same hale)
bls BELOW LAND SURFACE
�- ESTIMATED PILOT CHEMOX TREATMENT AREA
®- PROPOSED EXPANDED CHEMOX TREATMENT AREA
NORTH
RW-14
x —x —x —x — x x - x - x x - x - x - x - x -I
PREPARED BY DATE: 1"1.10 CHECKED BY', 3D DATE: 10-01-10
MA TE FIGUREMONITORING WELL LOCATIONS
AND PROPOSED EXPANDED CHEMOX TREATMENT
ABB FLAKT PRODUCTS
9725 Cogdill Road WINSTON-SALEM, NORTH CAROLINA
Knoxville, TN 37932
Phone: [phone] Fax: [phone] PROJECT NO. 3031-05-2007-12

1 /
LOWERY STREET r
l l • r l
.` .` y � rrrr ♦ .
l '
MW-116 rr _
I'
I`
.ti
I'
I'
GROUNDWATER
TREATMENT
r �f. SYSTEM �.
BUILDING
-��
- - lNYII--119A •� .•
MW-114
\4
MrM-W-107 MW t30 ° $ PR_ 46—PRW-14
-124 2" HDP WATER LINE AND
" HAIR LINE
ESTIMATED
LOCATION OF
- DRAINAGE CULVERT : -
MW-123 - '-------_
PRW-13
-­--------- ----- ----- -- --------- ,... ..
_-_ r
.r -
MW-1D2 r-
-___---____----F- ER
NO PIT ---------------------
MW-105 M -C Mw-111
1:01rr +
0 -_ - -- ----- -
MW-121D r'
moo_
FORMER
_.�
PAW-1 17 - ABOVE GROUND TANK FORMER UST AREA
rr FORMER - , f MW-E
rr SOUTH PI1.nMW-113 MW-131D MW-120D MW-124,
---
--IFllfhl-lD6-,9 MW-1i2 Mw-127 •� _ - -
.�
� i .♦ ® ! PRW-13n
PRW-7 PRW-3-3 P -
LEGEND
MONITORING WELL LOCATION ------ CONTOUR LINE
RECOVERY WELL LOCATION
•r
MW-125
�7eU_
NOTE: PtEZOMETERS NOT SHOWN
=> GROUNDWATER FLOW DIRECTION
SCALE:
0 140'
Well ID I Elevation
MWA
DRY
MW-102
808,81
MW-104
788.23
MW-105
794.95
MW-106
782.75
MW-107
778.42
MW-110
786.35
M W-111
790.39
MW-112
785.07
MWA13
DRY
MWA14
DRY
MWA 15
804.94
MW-116
810.81
MWA 17
DRY
MW-118
839.64
MWA 19D
798.41
MW-119S
DRY
M W-120D
780.2
M W-121 ❑
795.49
MW-123
770.61
MW-124
786.67
MW-125
778.84
MWA 26
769.41
MW-127
786.23
MWA 28
778
M W -129
783.87
M W -130
777.33
M W-131 D
780.25
MW-C
DRY
MW-E
785.79
PRW-21
778,64
PRW-3'
779.9
PRW-6'
781.08
PRW-71
780.3
PRW-101
784.84
PRW-131
784.44
PRW-141 I 785.05
Footnote 1 = Water levels measured from Piezometer located
inside the extraction well vault. -
Nate :
Off.
GROUNDWATER POTENTIOMETRIC SURFACE MAP FIGURE
ArMACTE SEPTEMBER 2009 SAMPLING EVENT
ABB FLAKT PRODUCTS 3
KNO ILL,,COGTN 3793ROAD WINSTON-SALEM, NC
ICNOICVILLi:, TN 37g32
PHONE: [phone] DRAWN J NUIJ APPROVED DATE REVISED DATE
Fax: [phone] _3 3031
-05 - 2007-14 1 1 17 08 09 28 10

I�MW-123
i
f
I
f
3' HDPE DISCHARGE PIPE
_ MIN-122 MW•1195
_ ;1! MW-119D
—
117
~ R ti
s _
1 {
LEGENp
NOT SAMPLED
,t RECOVERY WELL LOCATION
O MONITGR WELL LOCATKDN
SURVEY F'OINTBM LOCATION
Q vEw vieLL
■ DRAINAGE INLET
FORMER AST CONVEYAWE PIPING
pWL MICROGRAMS PER LITER
TCA TRICHLOROETHANE
TCE TRIC4LORCETHENE
DCE DICHLOROETHENE
DCA DK:HLOROETHANE
0
MW-126
GROUNDWATER
TREATMENT
SYSTEM
6UILDING
1.'..
MW-1C2
Rio r %IT
11
1v1W-Ta BMW-C IDRY1
BMW-121D is MW-1II
V'MW-104
2" HDPE WATER LINE AND
1" HDPE AIR LINE
117
FORMER
SOUTH PIT n MW-113 1AW-131
® MW-106 p
MW-11&
FORMER s,�!
ABOVE GROUND TANK
MW-132
MW-107 MW-130
— — — — — — MW-1
— MW-1
MW-125
ESTIMATED
LOCATION OF
DRAINAGE CULVERT
SCALE:
0 100'
NOTE:
CONTAINMENT PLUME CONTAINED ON SITE BY
GROUNDWATER EXTRACTION SYSTEM.
SEE FIGURE 2A FOR
INJECTION WELL LAYOUT
MW-133 FORMER UST AREA MW-E
MW-1f ` BMW-127
- - W-14 -
RW-10
LEGEND
- - - - Approximate 200 pgA-1,1, 1 - TCA plume bourxlary
- - Approximate 3.0 pWL TCE plume boundary
- - - - Approximate 7.0 pg/L 1, 1 - DCE plume boundary
- - - - Approximate 6.0 pg/L 1, 1 - DCA plume boundary
- - - Approximate 0.4 pg/L 1, 2 - DCA plume bourxtary
- - - - Approximate 3.0 NgIL 1,4 - DIOXANE plume boundary
Notes:
1.The above values reftect NCAC 2L Standards except 1,2 DCA
which reflects the laboratory reportlng limlL
2. MW-129, NMI-112, RWA0, VW-2 were sampled in November
2009 and all other bolded wells were sampled in September 2009.
CONTAMINANT PLUME MAP FIGUREOMACTEC
ABB FLAKT PRODUCTS 4
9725 Cogdill Road WINSTON-SALEM, NC
KNO7MLLE. TN 37932
PHONE- [phone] DRAWN JOl NUMBER APPROVED REVISED GATE
FAX (a65) 588-8026 �3031-05-2007-12 `r 03/20/01�1%1/1005-2007-12 `r 03/20/01 10/01 / 1 U

RWMib1;"mlylKa?;rT:W:yiflii:4
0
MW-1195
- MW-119D
MW-122` -
r`
e�
s
GROUNDWATER
TREATMENT
SYSTEM
BUILDING
e W-11 B
im
FORMER
NORTH PIT
MW-105 eW-C
leW-121 D
*MW-104
2" HOPE WATER LINE AND
1" HOPE AIR LINE
4MW-117
FORMER
SOUTH PIT[]_ MW-1311
�\MW 114
_ _ •- , o o MW-113
` - ' • ® MW-10B MW-12
DP-4RW_7
RW-13 MW-1
FR7-Y _ _ _ MW-1�r
��--- -
1
125
MW-115
�B
SEE FIGURE 2A FOR
MW-1II INJECTION WELL LAYOUT
'
FORMER
ABOVE GROUND TANK
MW-118
FORMER U
AREA
MW-132
W-133
SP-23 MW-129
MW 112
A
MW-134
*�
MW-127
MW-12 Q
_
�
W-110 -
W-2
SPID
RW-6
SP-11
RW-14
SP-fi _ SPMO �
RW-10
MW-130
LEGEND
RW-13
RECOVERY WELL LOCATION
MONITOR WELL LOCATION
SURVEY POINTIBM LOCATION
- - - FORMER AST CONVEYANCE PIPING
° FIGURE
B' OMACTEC CROSS SECTION OVERVIEW MAP
ABB FLAKT PRODUCTS 5
SCALE: 9725 Co9dilI Road WINSTON-SALEM, NC
1 �� KNOXVILLE. TN 37932
PHONE: [phone]++ DRAWN JOB NUMBER APPROVED DATE REVISED DATE
Fax: (8�s) 550-8026 3031--05-2UQ7-12 _,t, 03 20 41 1 Q C 1 1 o

840
820
800
C
C
780
W
760
740
720
700
A
z
�z
C
Silty Sand with Clay Lenses
Saprolite
(Weathered)
ti
N
y
aaprolke
As
B
840
820
780
760 7
Be
W
740
LEGEND
- PROPOSED IW'S
- - 0 160'
- E}(ISTING IW'S HORIZONTAL SCALE
0 'OVA MAC FIGURE
/ CROSS SECTION A -A' ANC B-6'
ABB FLAKT PRODUCTS 5A
KNO�IVItLE, 9725 CQWINSTON-SALEM, NC
TTN N 37932 793
PHONE: (m) sm-85" DRAWN 408 NUM8ER APPROVED DATE REVISED DATE
FAx: (sss) sss—saes 3031-05-2007-12) 08 15 08 09 29 10

�`Il 1114.
gcST4 % A*7
1 0;7-!M� -W-71atol
5
T
�vv

FORK —CR
I`r #
Z3
t r�
i
SCALE:
Q 250'
•m up *mA*
•
M
11
A1W ,[N�L
�Wl , N
LOWMy 57RMT
• My-, u 0
*ter $c%" AMA
-- I
f A
iMACTEC
1725 LOUISVILLE DRIVE
KNOXVILLE, TN 37921
PHONE: [phone]
FAX: (M) 588-OD26
ow lIPY@lf rr1.L W[J�l'R]II
# bKMffM WELL LOCATM
- FOFAM Asr CO *WAKE FFM
RGURE
SITE MAP
ABB FLAKT PRODUCTS 2
WINSTON-SALEM, NC
DRAWN JDB NUMBER APPR D Y REVISED DATE
303 1 -o - aa7- os � 03L20Za i 08f 2s/Os

:SHED]
EXTRACTION WELL LINE
FENCE LINE
0 0
0
MW-129
FOMER UST AREA
,�,RW -1 0
MW--112
SCALE: • -SHALLOW INJECTOR (screened from SD-56 it b1s)
�� • -DEEP INJECTOR (screened from 60-65 ft 61s)
• -VENT WELL (screened from 10-40 ft b1s)
DUAL INJECTOR (shallow and deep injectors set in same hole)
PREPARED BY _DATE. 8-MG8 CHECKED BYa` �1' DATE: 8-20-98 bis BELOW LAND SURFACE
MATTE PROPOSED INJECTION WELL LAYOUT
;ArABB FLAKT PRODUCTS
1725 Laus+ville Orvie WINSTON-SALEM, NORTH CAROLINA
Knoxville, TN 37921
Phone: [phone] Fax: 865-58&8026 PROJECT NO. 3039-05-2007-09 FIGURE 2A

3' HDPE MaiARGE PIPE �-
MW-1195
- _ MW-122 GROUNDWATER
- - _ � MW-119D TREATMENT
- _- SYSTEM
BUILDING
14
1 � ~■ter \
o .fir
1
MW-116 MW-115
MW-102
FORMER
NORTH PIT
MW-105 '- - W1_C
`� ►
MW-121 D * MW-111
*MW-104
2" HDPE WATER LINE AND
1" HDPE AIR LINE
MW-117
FORMER
SOUTH PITS,, MW_131D
MW-118
FORMER
ABOVE GROUND TA K
MW-106 MW-128 - - W- ■
. ' tiR
- --j- _ &W-3 = •
- MW-1 SP-6 MW-130 r
MW-197
RW-10
MW-125
SEE FIGURE 2A F)R
INJECTION WELL LAYOUT
FORMER US AREA
MW-E
27-
MW-110 •� _ - �_
RW-14 - _
NOTE:
CONTAINMENT PLUME CONTAINED ON SITE BY
GROUNDWATER EXTRACTION SYSTEM.
LEGEND
Approximate 200 pgI1 I 1, 1 - TCA plume boundary
�- - Approximate 0.7 Ng/L PCE plume boundary
- - - - Approximate 2.8 p9k TCE plume boundary
Approximate 7.0 µg/L 1, 1 - DC plume boundary
- - - - Approximate 700 pgtL 1, 1 - DCA plume boundary
- Approximate 0.38 UgIL 1, 2 - DCA plume boundary
-- - - - Approximate 7.0 4L 1,4 - ❑IOXANE plume boundary
Note: The above values reflect NCAC 2L Standards.
ESTIMATED
LOCATION OF
DRAINAGE CULVERT 4rMACTEC CONTAMINANT PLUME MAP FIGURE
LtISVILLE DRIVE ABB FLAKT PRODUCTS 4
SCALE: 1725 LO
0 100' KNOXVILLE. TN 37921 WINSTON-SALEM, NC
PHONE: [phone] DRAWN jog—NjjQMBER APPROVED DATE REVISED DATE
FAX: (565) see -eats 3031-Q5-2007-g9 03 2D 01 09 05 08

A
no -
Silty Sand with Clay Lenses
800 -- - -
rr
C —
#y
780-
a)
W
' 760
740
720
700
Ar B Be
m 1
a 5? 840 a - -
sinv Clay
� h
m m silty C SY
820
a �
a c
Lu
3 J
-
C w Silty sand wt h =" L.eemes
d 800 X.
o a
Saprollte 11d
(Weathered)
a a -
- C, Saprolite
(Weathered)
- 780
(weeti�.:rd1
760
a 160'
HORIZONTAL SCALE
CROSS SECTION A-A'AN❑ B-B' FIGUREcuaEOMACTEC
ABB FLAKT PRODUCTS 5l'1
1725 LOU15MLLE DRIVE WINSTON-SALEM, NC
KNOXVILLE, TN 37921
PHONE: (m) 5H8-8544 DRAWN J B MIMER APPROVED REVI ED DATE
FAX: (865) SM-80213 3031-05-2007-09 � : 08 15 08 Dg D5 0$

1Nurer R esourres
ENVIRONMENTAL ❑W1 L17y
January 11, 2016
R. Keith Knauerhase
ABB, Inc.
5 Waterside Crossing
Windsor, CT 06095
Re: Issuance of Injection Permit W10400098
ABB, Inc.
Forsyth County. NC
Dear Mr. Knauerhase:
PAT MCCRnRY
❑ONALD R. VAN DER VAART in
'1,', r•. t,V,,
S. JAY ZIMMERMAN
In accordance with the application and name change request received on October 5, 2015, and
additional information received October 6, 2015, and December 28, 2015, we are forwarding permit
number W10400098. This permit is to inject hydrogen peroxide, ferrous sulfate, and phosphoric
and sulfuric acid to remediate groundwater contaminated with VOCs at the Former FIakt Products
Site, 2000 Lowery Street, Winston-Salem, Forsyth County, NC 27101. This permit shall be
effective from April 1. 2016 (i.e., the day after the expiration date of the existing permit), which
may differ from the date of this letter. This permit shall be effective from April 1. 2016, until
March 3I, 2021, and shall be subject to the conditions and limitations stated therein, including the
requirement to submit a Final Project Evaluation (FPE) as stated in PART VII — MONITORING
AND REPORTING REQUIREMENTS. Please read the entire permit to ensure that you are aware
of all compliance requirements of the permit.
Please note the following:
Per permit condition Part VI.5, prior to closing this permit, the Permittee must meet
groundwater quality standards or pre -injection levels, whichever concentration is higher, for
all of the injection constituents; otherwise, continued monitoring as approved in the
monitoring plan will be required until such levels can be established;
Per permit conditions Part VI.3 &4, and IX.2(G), within 30 days after each injection event,
please provide the well construction (if not previously submitted) and injection information
on the applicable forms listed below. Note: if well construction/abandonment information
is essentially the same (e.g., direct push points or geo-probes), then only one GW-1 or GW-
30 form is needed. lust indicate in the comments section on the form the total number of
well points. These forms are available on the Division of Water Resources' website at
http://portal .nedenr-nrg/web/wg/aps/gwpro/reporting-forms
State of Nonh Carolina I £nvima+mensal Qt alio I Water RewLvices
i 611 N1aii sen•irr C enter i Raleigh, North Caroliti4 ? 7699- I G 1 I
a19 707 9000

❑ Injection Event Record
❑ Well Construction Record (GW-1)
❑ Well Abandonment Record (GW-30)
In order to continue uninterrupted legal use of this well for the stated purpose, you should submit an
application to renew the permit 120 days prior to its expiration date. As indicated in the permit, this
permit is not transferable to any person without prior notice to, and approval by, the Director of the
Division of Water Resources. If you have any questions regarding your permit or the Underground
Injection Control Program please call me at [phone].
Best Regards,
Ps�
Michael Rogers. P.G. (NC & FL)
Underground Injection Control (UIC) Program Manager - Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
cc: Sherri Knight, WQROS — Winston-Salem Regional Office
Central Office File, WI0400098
Joe Deatherage, Amec Foster Wheeler, 2030 Falling Waters Road, Suite 300, Knoxville, TN

Rogers, Michael
From: Rogers, Michael
Sent: Friday, December 18. 2015 3:48 PM
To: 'Deatherage. Joe'
Subject: RE: W10400098 Add Info request - Please Send Injection Permit Renewal Form
I talked it over with my supervisor and she was satisfied as I provided current property ownership via Forsyth County
GIS. As we discussed, we will work on the renewal permit after the holidays. Thanks and have a great time.
From: Deatherage, Joe[mailto:[e-mail]]
Sent: Friday, December 18, 2015 2:23 PM
To: Rogers, Michael <[e-mail]7
Subject: RE: W10400098 Add Info request - Please Send Injection Permit Renewal Form
Michael, as I understand it there has just been a name change, not an ownership change. Do we still need to complete
the form you sent? if so, who signs it?
The wells proposed to be included in the next injection are listed below. Each is projected to receive approximately
1,650 gallons. Note that both the number location of injection wells and volume is subject to change based on baseline
sampling data.
• SIW-1 lc, �p
■ SIW-3 U
• SIW-4 l4So
■ DLIW-23S r�o
* DUW-24S j
+ DLIW-34S
.Joe Deatherage, P.E.
Senior Environmental Engineer
Amec Foster Wheeler
2030 Falling Waters Roao STE 300
Knoxville, TN 37922
Tel [phone]
Direct [phone]
ioe . death e raaeea mecfw. com
amarfw rnm
From: Rogers, Michael Imaiito:michael.ro err ncdenr. ov]
Sent: Tuesday, December 15, 2015 2:20 PM
To: Deatherage, Joe <Joe.Deatherape amec.com>
Subject: RE: W10400098 Add Info request - Please Send Injection Permit Renewal Form
Joe -
My supervisor reviewed it last week. She has the following questions/comments that need follow up.
Has there been a change in ownership of the company since the permit was last issued. or just a change of the
company name? If there has been an ownership change, please provide documentation showing the
transfer. Attached is an ownership change form to complete.

Which six well are proposed to be used for injection and how much injectant will be injected per well in gallons?
Thanks.
From: Deatherage, Joefmailto:[e-mail]
Sent: Monday, December 14, 2015 4:17 PM
To: Rogers, Michael [e-mail]
Subject: RE: Please Send Injection Permit Renewal Form
Michael, attached is DEQ's Oct. 6 acknowledgement of receipt of our injection renewal w/o modification. Can you give
me an update on the approval status? The letter mentions taking as long as 60-90 days and it has been 69 days since
receipt, so I thought I would check on it.
Thanks,
Joe Deatherage, P.E.
Senior Environmental Engineer
Amec Faster Wheeler
2030 Falling Waters Road. STE 300
Knoxville, TN 37922
Tel [phone]
Direct [phone]
ice deatheragePamecfw.com_
a mecfw. com
From: Rogers, Michael [inailto:[e-mail]]
Sent: Thursday, July 09, 2015 3:04 PM
To: Deatherage, Joe <[e-mail]?
Subject: RE: Please Send Injection Permit Renewal Form
This is link to all of our forms.
http:l/portal. ncdenr.orgtweblwq/aps/gwprojeermit-applicat o_n_s
From: Deatherage, Joe[mailtoJoe.deatherape(aamecfw.com]
Sent: Thursday, July 09, 2015 2:58 PM
To: Rogers, Michael
Subject: Please Send Injection Permit Renewal Form
Michael, as we discussed, please send me either a copy of the injection renewal form or a link to the most current
version.
Thanks for your help on the phone.
,Joe Deatherage, R.E.
Senior Environmental Engineer
AMEC Foster Wheeler

9725 Cogdill Road, Knoxville. TN 37S--
Tel [phone]
Direct [phone]
jce.deathera-qeO.@rnecfw eem
a mecfw. co m
amec
foster
Wheeler
This message is the property of Amec Foster Wheeler pie and/or its subsidiaries and/or affiliates and is intended only for the named
recipient(s). Its contents (including any attachments) may be confidential, legally privileged or otherwise protected from disclosure by
law. Unauthorised use, copying, distribution or disclosure of any of it may be unlawful and is strictly prohibited. We assume no
responsibility to persons other than the intended named recipient(s) and do not accept liability for any errors or omissions which are a
result of email transmission. If you have received this message in error, please notify us immediately by reply email to the sender and
confirm that the original message and any attachments and copies have been destroyed and deleted from your system. This disclaimer
applies to any and all messages originating from us and set out above. For Canada and the United Slates: If you believe this is an
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France..

Rogers, Michael
From: Deatherage, Joe <joe.deatherage@amecfw,com>
Sent: Friday, December 18, 2015 2:23 PM
To: Rogers, Michael
Subject: RE, W10400098 Add Info request - Please Send Injection Permit Renewal Form
Michael, as I understand it there has just been a name change, not an ownership change. Do we still need to complete
the form you sent? If so, who signs it?
The wells proposed to be included in the next injection are listed below. Each is projected to receive approximately
1,650 gallons. Note that both the number/location of injection wells and volume is subject to change based on baseline
sampling data.
• SIW-1
■ SIW-3
+ SIW-4
+ DLIW-23S
■ DLIW-24S
• DLIW-34S
Joe ❑eatherage, P.E.
Senior Environmental Engineer
Amec Foster Wheeler
2030 Falling Waters Road. STE 300
Knoxville, TN 37922
Tel [phone]
Direct [phone]
toe deatheraoe0amecfw com
amecfw corn
From: Rogers, Michael[mailto:[e-mail]]
Sent: Tuesday, December 15, 2015 2:20 PM
To: Deatherage, Joe <[e-mail]>
Subject: RE: W10400098 Add Info request - Please Send Infection Permit Renewal Form
Joe
My supervisor reviewed it last week. She has the following questions comments that need follow up:
Has there been a change in ownership of the company since the permit was last issued, or just a change of the
company name? If there has been an ownership change, please provide documentation showing the
transfer. Attached is an ownership change foray to complete,
• Which six well are proposed to be used for injection and how much injectant will be injected per well in gallons?
Thanks
From: Deatherage, Joe mailto: oe.deathera a amecfw,com]
Sent: Monday, December 14, 2015 4:17 PM

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Rogers, Michael
From: Rogers, Michael
Sent: Tuesday, December 15, 2015 2:20 PM
To: 'Deatherage, Joe'
Subject: RE: W10400098 Add Info request - Please Send Injection Permit Renewal Form
Attachments: PermitNameOwnershipChangeForm Rev 12-15-2015.docx
Joe -
My supervisor reviewed it last week. She has the following questions/comments that need follow up,
Has there been a change in ownership of the company since the permit was last issued, or just a change of the
company name? If there has been an ownership change, please provide documentation showing the
transfer. Attached is an ownership change form to complete.
Which six well are proposed to be used for injection and how much injectant will be injected per well in gallons?
Thanks
From: Deatherage, Joejmailto:[e-mail]]
Sent: Monday, December 14, 2015 4:17 PM
To: Rogers, Michael <[e-mail]>
Subject: RE: Please Send Injection Permit Renewal Form
Michael, attached is DEQ's Oct_ 6 acknowledgement of receipt of our injection renewal w/o modification, Can you give
me an update on the approval status? The letter mentions taking as long as 60-90 days and it has been 69 days since
receipt, so I thought I would check on it.
Thanks
Joe Deatherage, P.E.
Senior Environmental Engineer
Amec Foster Wheeler
2030 Falling Waters Road. STE 300
Knoxville. TN 37922
Tel [phone]
Direct [phone]
ioe deatheraaeearn ecfw,com
amecfw.com
From: Rogers, Michael [mai_l_to m_ichae],ro eg [e-mail])
Sent: Thursday, July 09, 201.5 3:04 PM
To: Deatherage, Joe <Joe.Deal [e-mail]>
Subject: RE: Please Send Injection Permit Renewal Form
This is link to all of our forms.
htlp.Jlportal_.n_cdenr.orpJwebf wqi apsJgwpro/permit-applications

From: Deatherage, Joe[mailto:joe.deatherag_eCamecfw.com]
Sent: Thursday, July 09, 2015 2:58 PM
To: Rogers, Michael
Subject: Please Send Injection Permit Renewal Form
Michael, as we discussed, please send me either a copy of the injection renewal form or a link to the most current
version.
Thanks for your help on the phone.
Joe Deatherage, P.E.
Senior Environmental Engineer
AMEC Foster Wheeler
9725 Cogdill Road, Knoxville, TN 37932
Tel [phone]
Direct [phone]
ioe-deather@qe(ZDarnecfw.com
am ecfw. co m
IT.
amec
foster
wheeler
This message is the property of Amec Foster Wheeler plc and/or its subsidiaries and/or affiliates and is intended only for the named
recipient(s). Its contents (including any attachments) may be confidential. legally privileged or otherwise protected from disclosure by
law. Unauthorised use, copying, distribution or disclosure of any of it may be unlawful and is strictly prohibited_ We assume no
responsibility to persons other than the intended named recipient(s) and do not accept liability for any errors or omissions which are a
result of email transmission. If you have received this message in error, please notify us immediately by reply email to the sender and
confirm that the original message and any attachments and copies have been destroyed and deleted from your system. This disclaimer
applies to any and all messages originating from us and set out above. For Canada and the United States: If you believe this is an
unsolicited email and do not wish to receive future commercial electronic messages from us, please click unsubscribefc;�.amecfw.com
and include "Unsubscribe r in the subject line.
Please click http:Pamecfw corn/email-disclairner for notices and company information in relation to emails originating in the UK, Italy or
France_

Rogers, Michael
i w
From: Deatherage, Joe <joe.death [e-mail] >
Sent: Tuesday, October 06, 2015 2:24 PM
To: Rogers, Michael
Subject: RE: Address W10400098
Flakt Products underwent a name change to ABB sorne time ago. They are the same company. Sorry For the confusion.
Jae Deatherage, P.E,
Senior Environmental Engineer
Amec Foster Wheeler
2030 Falling Waters Road. STE 300
Knoxville, TN 37922
Tel [phone]
Direct [phone]
ioe. deathera ae(a.a mecfw. co m
amecfw com
From: Rogers, Michael (mailto:[e-mail])
Sent: Tuesday, October 06, 2015 2:20 PM
To: Deatherage, Joe <Joe.Deatherage @amec.com>
Subject: RE: Address W10400098
The current permittee is Flakt Products.
From: Deatherage, Joe [mailto:[e-mail]]
Sent: Tuesday, October 06, 2015 2:18 PM
To: Rogers, Michael <michael.rogers@ncdenrfgov>
Subject: RE: Address W10400098
ABB is the Responsible Party who owns the wells. The property is owned by the City of Winston-Salem, who obtained
ownership I believe — 2011 from the previous owner, Fred Godley.
Joe Deatherage, P.E.
Senior Environmental Engineer
Amec Foster Wheeler
2030 Falling Waters Road, STE 300
Knoxville, TN 37922
Tel [phone]
Direct [phone]
ice.deatheraae(-?a amecfw.com
amecfw,com
From: Rogers, Michael [mailto:[e-mail]�j
Sent: Tuesday, October 06, 2015 2:14 PM
To: Deatherage, Joe <Joe.Death erage @amec.corn>
Subject: RE: Address W10400098
We rec'd the permit renewal app. The owner is ABB, Inc. Is this a change of ownership also?

From: Deatherage, Joe fmailto:ioe.deatheragePamecfw.com]
Sent: Tuesday, September 29, 2015 1:44 PM
To: Rogers, Michael <michael.ro ers ncdenr. ov>
Subject: RE: Address
Thanks, I'm glad you told me because # calfed DEN and asked for your mailing address since I will include a cover letter
addressed to you, and they told me 450 Hanes Mill Road, Suite 300. I'll use the one below.
Joe Deatherage, P.E.
Senior Environmental Engineer
Amec Foster Wheeler
2030 Falling Waters Road, STE 300
Knoxville, TN 37922
Tel [phone]
Direct [phone]
[e-mail]
am ecfw. com
From: Rogers, Michael[mailto:[e-mail]
Sent: Tuesday, September 29, 2015 11:40 AM
To: Deatherage, Joe <[e-mail]>
Subject: Address
The address is on the form, but it is also included below. Cheers.
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDEQ- DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http:/Iportal.ncdenr,org/web/wg/apsJ�w ro re og rting-forms
(VOTE: Per Executive Order No. 150, afl e-mails sent to and from this account are subject to the North Carolina Public
Records Low and may be disclosed to third parties.
r.
amec
faster
wheeler
This message is the property of Amec Foster Wheeler plc and/or its subsidiaries and/or affiliates and is intended only for the named
recipient(s). Its contents (including any attachments) may be confidential, legally privileged or otherwise protected from disclosure by
law. Unauthorised use, copying, distribution or disclosure of any of it may be unlawful and is strictly prohibited. We assume no
responsibility to persons other than the intended named recipient(s) and do not accept liability for any errors or omissions which are a
result of email transmission. 1f you have received this message in error, please notify us immediately by reply email to the sender and
confirm that the original message and any attachments and copies have been destroyed and deleted from your system. This disclaimer
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NCDENR
North Carolina [department of Environmental Quality
Rat McCrory
Governor
October 6, 2015
Mr. Keith Knauerhase, Chief Counsel
ABB, Inc.
5 Waterside Crossing
Windsor, CT 06095
RE: Acknowledgement of Application No. W10400098
ABB, Inc.
In Situ Groundwater Remediation Well System
Forsyth County
Dear Mr. Knauerhase:
❑onald R. van der Vaart
Secretary
The Water Quality Regional Operations Section (WQROS) acknowledges receipt of your
permit application and supporting documentation received on October 5, 2015. Your application
package has been assigned the number listed above, and the primary reviewer is Michael Rogers.
Central and Winston-Salem Regional Office staff will perform a detailed review of the
provided application, and may contact you with a request for additional information. To ensure
maximum efficiency in processing permit applications, the Water Quality Regional Operations
Section (WQROS) requests your assistance in providing a timely and complete response to any
additional information requests -
Please note that processing standard review permit applications may take as long as 60 to
90 days after receipt of a complete application. If you have any questions, please contact
Michael Rogers at [phone] or [e-mail].
Sincerely,
60,' Debra J. Watts, Supervisor
Animal Feeding Operations & Groundwater
Protection Branch
Division of Water Resources
cc: Winston-Salem Regional Office, WQROS
Joe Deatherage, AMEC Foster Wheeler, 2030 Falling Waters Road, Suite 300, Knoxville,
TN 37922
Permit File WI0400098
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Phone: [phone] Internet http:l1www.ncwater.org
An Equal OpporlunIty I AffirmaM Aclion Employer - Made in pad by recycled paper

r UVE01 }ENf)uwf {
OCT - ' 2015
October 1, 2015
Mr. Michael Rogers, P.G.
Hydrogeologist
NCDENR — OWR UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
It
amec
foster
wheeler
Subject: Renewal of Existing Injection Permit #W10400098 without Modification
Former Flakt Products Site
2000 Lowery Street
Winston-Salem, North Carolina
Amec Foster Wheeler Project Number 3031052007
Dear Mr. Rogers:
On behalf of ABB, Inc. (formerly Flakt Products, Inc.), Amec Foster Wheeler
Environment & Infrastructure, Inc. (Amec Foster Wheeler) is submitting two copies of the
enclosed Application for Permit to Construct andlor use a Wet1(s) for Injection for the
former Flakt Products site in Winston-Salem, North Carolina (Site). This permit renewal
without modification is to continue the injection program utilizing a limited number of the
existing injection wells at the Site (approximately six out of 101) after the referenced
permit expires on March 31, 2016. These wells will continue to be used to inject
components of catalyzed hydrogen peroxide (hydrogen peroxide, ferrous sulfate, and
phosphoric and/or sulfuric acid) into the Site groundwater to expedite the remediation of
chlorinated solvent compounds and 1,4-dioxane.
As discussed with you in an August 12, 2015.phone call, per the referenced injection
permit Amec Foster Wheeler will continue to submit Injection Event Reports following
any additional injection events and will submit a final project evaluation within nine
months of completion of all injection related activities.
Amec Foster Wheeler Environment & Infrastructure, Inc.
2030 Falling Waters Road, 5TE 300
Knoxville. TN 37922
Tel [phone]
Fax [phone]
www.amecfw.com

Mr. Michael Rogers
October 1, 2015
Page 2
Should you have any questions or require additional information, please contact Joe
Deatherage [phone] or joe.deatheraget�amecfw.com.
Sincerely,
Amec Foster Wheele nvironment & Infrastructure, Inc.
Ricky A. Ryan, P.E. K. Joe Deatherage
Senior Principal Project Manager Senior Environmental Engineer
Enclosure
c: Melody Christopher, A66 (with electronic and hard copy enclosure)
Nelson Walter, Amec Foster Wheeler (with electronic enclosure)
Ryan Newcomb, City of Winston-Salem (with electronic enclosure)
Robert Prestwood, City of Winston-Salem (with electronic enclosure)
Alan Griffith, Griffith Enterprises (with electronic enclosure)
Tod Dalehite, Pratt Industries (with electronic enclosure)

Slusser, Thomas
From:
Slusser. Thomas
Sent:
Friday, December 09, 2011 10.18 AM
To:
'Deatherage, Joe'
Cc:
Rogers, Michael
Subject:
RE: Addition of Wells for Permit W10400098
Attachments:
FW : Injection Permit W 110400098
Greetings Joe,
Thank you for notifying us about the additional wells for the subject permit. You are correct that the permit requires
prior notification of any planned modifications of the originally permitted activity. Please accept this email as written
approval of the proposed well additions_ As Mike advised, be sure to send us the well construction records when the
wells are complete. You can just send them all at once in order to make everything clear and easy to keep track of.
Please let us know if you need anything else,
Thomas.
mail carrosaarrdsrres to and frnn this a7dross ma{r Ps, satyrct to the Ncrta Carolina U11C records I aW 317C r7nav 6o &sclosad Al third gorges Unless tRe tartrsrrr
axempt h)+ statute yr ether regUlatim
From: Deatherage, Joe[mailto:[e-mail]3
Sent: Friday, December 09, 2011 9:32 AM
To: Slusser, Thomas
Subject: Addition of Wells for Permit W10400098
Thomas, the referenced permit is for 80 injection wells (IWs) and 12 vent wells (VWs). Based on sampling of certain IWs
during the initial installation process we feel we need to add 12 additional IWs and 2 additional VWs to the original
planned footprint. These wells will be added adjacent to the east end of the original footprint and will serve to expand
the footprint slightly to the east.
I received an October 20, 2011 email from Michael Rogers where he stated that adjusting the number wells slightly does
not merit notification. He said the number of wells in the application and depth and construction are proposed, and
that submittal of GW-1 forms in the Final Project Evaluation will show the actual number, construction, and location of
the Wells. Additionally, our cover letter in our permit application indicated that is we adjusted the number and/or
location of wells we would provide that information in the Injection Event Report. Although notification is not required I
still wanted to let you know what we are doing just so we have it on the record.
Please let me know if you have any questions. Thanks Thomas.
Joe Deatherage
Senior Engineer
AM EC
Environment & Infrastructure
9725 Cogbil Road, Knoxville. TIN 37932
Tel [phone] x1149
Direct (865 i 218.1049
toe. Deathe rage @ a mec. cam
amec.corn

The information contained in this a -mail is Intended only for the individual or entity to whom it is addressed
Its contents (including any attachments) may contain confidential andfor privileged rntormatidn.
If you are not an intended recipient you must not use. disclose. disseminate. copy or print its contents.
If you receive this a -mail in error. please notify the sender by repiy a -mail and delele and destroy the rnessage.

Slusser, Thomas
From: Deatherage, Joe [Joe. [e-mail]]
Sent: Thursday, July 26, 2012 3:09 PM
To: Slusser, Thomas
Subject: FW: Addition of Wells for Permit W10400098
Attachments: FW: Injection Permit WI10400098
From: Slusser, Thomas [mailto:thomas.slusser(c-pncden -.gov]
Sent: Friday, December 09, 2011 10:18 AM
To: Deatherage, Joe
Cc: Rogers, Michael
Subject: RE: Addition of Wells for Permit WI0400098
Greetings Joe,
Thank you for notifying us about the additional wells for the subject permit. You are correct that the permit requires
prior notification of any planned modifications of the originally permitted activity. Please accept this email as written
approval of the proposed well additions. As Mike advised, be sure to send us the well construction records when the
wells are complete. You can just send them all at once in order to make everything clear and easy to keep track of,
Please let us know if you need anything else,
Thomas.
f-marl correspondence to ar+d from rhis address map he subject to the North third parties unless the content's
exempt by statute ar ether regulation.
From: Deatherage, Joe fmailto:Joe.Deatherage0amec.com]
Sent: Friday, December 09, 2011 9:32 AM
To: Slusser, Thomas
Subject: Addition of Wells for Permit WJ0400098
Thomas, the referenced permit is for 80 injection wells (IWs) and 12 vent wells (VWs). Based on sampling of certain IWs
during the initial installation process we feel we need to add 12 additional IWs and 2 additional VWs to the original
planned footprint. These wells will be added adjacent to the east end of the Original footprint and will serve to expand
the footprint slightly to the east.
I received an October 20, 2011 email from Michael Rogers where he stated that adjusting the number wells slightly does
not merit notification. He said the number of wells in the application and depth and construction are proposed, and
that submittal of GW-1 forms in the Final Project Evaluation will show the actual number, construction, and location of
the Wells. Additionally, our cover letter in our permit application indicated that is we adjusted the number and/or
location of wells we would provide that information in the Injection Event Report. Although notification is not required i
still wanted to let you know what we are doing just so we have it on the record.
Please let me know if you have any questions. Thanks Thomas.
Joe Deatherage
Senior Engineer
AMEC

Environment & Infrastructure
9725 Cogdill Road, Knoxville, TN 37932
Tef [phone] x1149
Direct [phone]
t o e. D eath a rage foam ec.co m
amee.com
The Information contained in this e-mail is intended only For tha individual or entity to whom it is addressed.
Its contents !including any attachments; may contain confidential and/or privileged information.
If you are not an intended recipient you must not use, disclose, disseminate. copy or print its contents.
If you receive this e-mail in error. please notify the sender by reply e-mail and delete and destroy the message.
The information contained in this e-mail is intended only for the iridivOual or entity to whom it is addressed.
Its contents (including any attachments) may contain confidential and/or privileged information.
If you are not an intended recipient you must not use, disclose. disseminate. cagy or print its contents.
if you receive this a -mail in error, please notdy the sender by reply a -mail and delete and destroy the message.

Slusser, Thomas
From: Deatherage, Joe [Joe. Deatherage [e-mail]]
Sent: Friday, December 09. 2011 9:41 AM
To: Slusser, Thomas
Subject: FW: Injection Permit W110400098
From: Deatherage, Jae
Sent: Thursday, October 20, 2011 11:12 AM
To: Ryan, Ricky
Subject: FW: Injection Permit W110400098
From: Rogers, Michael[mailto:michael.rogers@nc_denr._gov]
Sent: Thursday, October 20, 2011 10:15 AM
To: Deatherage, Joe
Subject: RE: Injection Permit WI10400098
Just adjusting the number Wells, slightly does not merit any notification. The number of wells in the application and
depth and construction are proposed. Submittal of GW-1s in the Final Project Evaluation will show the actual number,
construction, and location of the Wells.
Michael Rogers, P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh, NC 27699-1636
Direct tine {919j 715-6166, Fax [phone] (put to my attn on cover letter)
htt :11 ❑rtal.ncdenr.or /web/w fa sf w rol ermit-a lications# eothermA s
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Deatherage, Joe [mailto:Joe.DeatherageCc amec.com]
Sent: Wednesday, October 19, 2011 3:44 PM
To: Rogers, Michael
Subject: Injection Permit WI10400098
Michael, Section V.2. of the referenced permit says the permittee must receive prior written approval from the Director
prior to making any additions to the injection. Can you elaborate on this s❑ I understand what is involved, how long it
takes, etc.? For example, if while installing our injection wells we feel we need to add more wells, is this something that
can be done with a call/email from me to the DWQ and the DWQ give email approval within a few hours/days, or is it
something more involved where we have to make a formal request and that request could take weeks for the DWQ to
respond? I just want to have an idea what is involved beforehand.
Thanks Michael,
Joe Deatherage
Senior Engineer
AIVIEC

Environment & Infrastructure
9725 Cogdill Road, Knoxville, TN 37932
Tel[phone] x1149
Direct [phone]
Joe. Death era Re Pam ec.com
amec.com
The information contained in this e-mail is intended only for the individual of entity to whom It is addressed.
Its contents (including any attachments) may contain confidential and/or privileged information.
It you are not an intended recipient you must not use, disclose, disseminate, copy or print its contents.
It you receive this e-mail in error. please notify the sender by reply e-mail and delete and destroy the message.
The infoanation contained in this a -mail is intended only for the individual of entity to whom It is addressed.
Its contents (Including any attachments) may contain confidential and/or privileged information.
If you are not an intended recipient you must not use, disclose, disseminate. copy or print its contents
If you receive this a -mail in error, please notify the sender by reply e-mail and delete and destroy the message.

Rogers, Michael
From: Rogers, Michael
Sent: Wednesday, October 12. 2011 5:16 PM
To: 'Deatherage, Joe'
Cc: Knight, Sherri
Subject: RE: Injection Permit W10400098
Joe -
Based upon the information provided on the construction of the injection wells, and the steps taken to secure and seal
the wells, I concur that this is a reasonable alternative to the permit condition requiring a locking cap.
Regards
Michael Rogers. P.G. (NC & FL)
Environmental Specialist
NC Div of Water Quality- Aquifer Protection Section (APS)
1636 Mail Service Center
Raleigh. NC 27699-1636
Direct Line [phone]; Fax [phone] (put to my attn on cover letter)
htti):llaortal. ncdenr.orcalweblwalaosfoworoloermit-aoolications#aeothermAoos
E-mail correspandence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties
From: Deatherage, Joe imailto:Joe.Deatherage5amec.coml
Sent: Wednesday, October 12, 2011 5:08 PM
To: Rogers, Michael
Subject: Injection Permit WI0400098
Mike, as we discussed a few minutes ago, our injection permit states that "Each injection well shall be reasonably
secured against unauthorized access and use ....... and the entrance to each well must be secured with a locking cap." The
injection wells are constructed of specialty pipe, 1.25" diameter Schedule 80 CPVC. Any locking caps would have to be
custom made, and the cost for 80 is almost $1,000. In my opinion, even without locking caps the wells will still be
reasonably secured for the following reasons:
■ All wells will be flush -mount with a baited manhole lid to prevent access to the casing
• The well casings will be capped to prevent rainwater from entering if the manhole takes on water
• The wells will be located at a site with a locked fence, and therefore no unauthorized people can access the site
Based on the above well security items, you indicated to me that we do not need locking caps for these wells.
Thanks,
Joe Deatherage
Senior Engineer
AMEC
Environment & Intrastructure
9725 Coadlll Roan, Knoxville, TN 37932
TeI 16651588-8544 x1149
U4 rc-cl i 8651 216.1049
[e-mail]
amec.com

The information contained in this a -mail is intended only for the individual or entity to whom it is addressed.
Iis contents (including any attachments) may contain confidential andlor privileged information.
If you are not an intended recipient you must not use, disclose. disseminate, copy or print its contents.
If you receive this a -mail in error. please notify the sender by reply e-mail and delete and destroy the message.

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water ouality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
August 22, 2011
Mr. John Conant
Flakt Products, Inc.
2000 Day Hill Road, CEP 880-1911
Windsor, CT 06095
Subject: Completion of 51 Injection Well Permit W100400099
Former Flakt Products Site
Forsyth County, NC
Dear Mr. Conant:
Dee Freeman
Secretary
On June 29, 2010, the Aquifer Protection Section received your Final Project Evaluation for injection activities conducted
under your permit referenced above. This report completes the monitoring and compliance reporting requirements of
your permit. Staff from the Winston-Salem Regional Office confirmed that there are no outstanding reporting,
compliance, or enforcement issues associated with your permit. Any other compliance monitoring or reporting
requirements of any other regulatory programs shall continue as needed.
If you wish to conduct future injection operations you must first apply for and receive a new injection well permit,
Operating an injection well without a valid permit could result in a civil penalty of up to $25,000 per day, Please contact
David Goodrich at [phone] or [e-mail] or Debra Watts at 919-715-6699 if you have any
questions.
Best Regards,
David Goodrich
Hydrogeologist
cc: Sherri Knight — Winston-Salem Regional Office
Ricky A. Ryan. PE, MACTEC Engineering and Consulting. Inc.. 9725 Cogdill Road. Knoxville, TN 37932
Kim Caulk. DWM Superfund Section, 1646 Mail Service Center, Raleigh, NC 27699-1645
W I0400098 Permit File
AQUIFER PROTECTION SECTION'
1636 Mail yen me Center. Raley n, Norm Carolina 27899-1636
Locavon 2728 Capital Boulevard. Raleigh. North Carolina 27604 One
Phone: [phone] ; FAX 1 919•71R588. FAX [phone]Q i Customer Service: 1-677-62M748 Forth Carolina
IrStemet: www_ngntemua*.orq
An E04im QDo0n par -A" auve Rcborr nmplaye- i4 `L

- Q=2 A��
NCDEN R
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coleen H. Sullins
Governor Director
April 26, 2011
Flakt Pyoduets, Inc.
c/o John -Conant, Dir., Nuclear Engr, & Compliance
5 Waterside Crossing
Windsor, CT 06095
Ref: Correction to Injection Permit W10400098 issued April 8, 2011
Farmer Flakt Products Site
Winston-Salem, Forsyth County, North Carolina.
Dear Mr. Conant:
Dee Freeman
Secretary
In accordance with a pF.7nZit correction request received April 25, 2011, we are Forwarding herewith the corrected Permit
No. Vv ]WO098, dated April 26, 2011. This permit is to inject catalyzed hydrogen peroxide (Fenton's Reagent)
(Geo-Clense) to remediate groundwater contaminated with cblorinated solvents at trc facility referenced above. Note
that the corrected expiration date is March 31, 2016,.and that samples from the additional wells RW-6 and RW-14
will be analyzed for VOC9 as established for the Baseline and Performance sampling, The permit shall be subject to
the conditions and limitations stated therein, including the requirement to submit a Final project evaluation as stated in
PART V11— MONITORING AND REPORTING REQUIREMENTS. The corrected pages are enclosed with this letter,
You will need to notify this office by telephone 48 hours prior to initiation of operation of the facility. In order to
continue uninterrupted legal use of the injection facility far the stated purpose, you must submit an application to renew
the permit 120 days prior to its expiration elate. Please contact me at [phone] or at john.ntcei-ay [e-mail] if you
have any questions about your permit.
Best Regards,
Joan R. Mccray
'Environmental Specialist
ec: Sherri Knight, Winston-Salem Regional Office
Mr. Ricky Ryan, MACTEC Engineering and Consulting
Kim Caulk, DWM — 5uperfund Section
WI0400098 Permit File
ACKAFEii PROTECTION UCTM
16M Mall 5ervke Center, itA0, North G=Ilno 27699.163G
Wcalim 7723 capital Owleraid, Ra4h. No& Card na 77604 Ile
Phone.919.7W221 l FAX 1: 9t9.715.0588; FAX 2:914.715�181 Custom Swine: l$77-623-$748 NoOiLl Cc`1ro n a
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4
NCDENR
North Caroilna Department of Environment and Natural Resources
L.lvision of Water Quality
Beverly E-aves Perdue Coleen H Gullins
%30vemor Director
April 8. 2011
Flakt Products. Inc. _
Go John Conant. Dir.. ]nuclear Eng. & Compliance
5 Waterside Crossing
Windsor, CT 06095
Ref: Renewal wl Modification of Injection Permit W10400098
Former Flakt Products Site
Winston-Salem, Forsyth County, North Carolina,
Dear Mx. Conant:
Gee rreelnan
5ecretan,
In accordance with the application received on October 21, 2010 and additional information received January 31, 2011.
we are forwarding permit number W10400098. This permit is to inject catalyzed hvdrogen peroxide (Fenton's
Reagent) (Geo-Clense) to remediate groundwater contaminated with chlorinated solvents at the facility referenced
above, This permit shall be effective from the date of issuance until March 31, 2013. and shall be subject to the
conditions and limitations stated therein, including the requirement to submit a final project evaluation as stated in PART
VII — MONITORING AND REPORTING REQUIREMENTS. Please read the entire permit to ensure that you are aware
of all compliance requirements of the permit.
You will need to notify this office by telephone 48 hours prior to initiation of operation of the facility. In order to
continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application to renew
the permit 120 days prior to its expiration date. Please contact me at [phone] or at john.mccrayCancdenr.gov if you
have any Questions about your permit.
Best Regards,
John R. McCray
Environmental Specialist
cc: Sherri Knight, Winston-Salem Regional Office
Mr. Ricky Ryan. MACTEC Engineering and Consulting
Kim Caulk. DWM — Superfund Section
W10400099 Permit File
k.JUI FR 1_7IrON SF71M.
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Mccray, John
Front: Deatherage, Joe [[e-mail]]
Sent: Tuesday. April 05, 2011 3:06 PM
To: Mccray. John
Subject: RE: Former Flakt Products Site
John, just to reiterate from our discussion earlier, we do not fee) the "SP" prefix wells are suitable wells for sampling
wells. These were put it years ago by our predecessor, and historically have been used for water level gauging only, not
for sampling,
Joe Deatherage- z.E
Senior Engineer
MACTEC Engineering and Consulting, Inc.
[phone]
From: Mccray, John mai{to: ohn.mccra taancdenr. ov
Sent: Tuesday, April 05, 2011 1,40 PM
To: Deatherage, Joe
Subject: Former Flakt Products Site
Mr, Deatherage,
I am finishing permit W10400098 for the renewal wl modification application for the former Flakt Products Site and need
to know if the Recovery Wells will be in operation during the injection events?
Best Regard,
John McCray

AMACTEC-1
engineering and constructing a better tomorrow
January 25, 2011
Mr. John McCray, Environmental Specialist
Aquifer Protection Section
DENR - Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Subicet: DENR Additional Information Request
- Application for Renewal of Injection Well Permit No. W10400098
with Modification
Former Flakt Products Site
2000 Lowery Street
Winston-Salem, North Carolina
MACTEC Project No. 303052007-17
Dear Mr. MGCray:
an behalf of Flakt Products, Inc., MACTEC Engineering and Consulting, Inc. (MACTEC) is
submitting this letter to provide the additional information requested in your January 18, 2011 letter
to Mr. Ricky A. Ryan with MACTEC regarding the above -referenced injection application.
The Site has a groundwater extraction and treatment system (System) that includes a row of seven
recovery wells located near the southern property boundary of the Site, including near the
downgradient edge of the proposed injection area. Four of the seven recovery wells are shown on
Figure 2A of the subject permit application (i.e., RW-2, RW-6, RW-10, and RW-14). The
recovery wells reduce contaminant mass in groundwater by extraction, as well as, serve to contain
the groundwater contaminant plume on the Site. Prior to operation of the System, contaminants
were observed in four downgradient monitoring wells on an adjacent railroad property to the south;
however, since operation of the System the level of contamination in these wells has naturally
attenuated, and are now at non -detectable levels. This demonstrates that the contaminant plume
has been contained by the recovery wells. The off -site monitoring wells will continue to be
monitored as part of the site -wide annual groundwater monitoring program.
As shown in Figure 2A, the proposed injection well layout is designed to treat the groundwater in
the vicinity of RW-14 and RW-10. Therefore we anticipate that the leading downgradient edge of
the groundwater plume will receive treatment. Additionally, to minimize the potential for
contaminants to migrate further downgradient during the injection, the injection will start in the
southern -mast injection wells to create an oxidative environment along the downgradient plume
edge. After the downgradient edge is initially treated, the injection will proceed upgradient to other
areas in the treatment zone. The downgradient edge will receive several additional treatments
during the entire injection process.
As shown in the table in Section 4.0 of Appendix F of the injection application, seven monitoring
wells within the proposed injection area (MW-112, MW-129, MW-132S, MW-132D, MW-I34S,
�-. r.
MACTEC Engineering and Consulting, Inc, L -- , •.;
9725 Cogdil4 Pood. Knoxville. IN 37932 ■ Phone: 865.588,8544 • Fox. 865.588.8026 - n
JAN � ���`""' mactec.com
flo­P..hn n

Mr. John McCray
January 25, 2011
Page 2
MW-134D, and MW-135) plus two additional monitoring wells located near the projected northern
treatment boundary (MW-133S and MW-133D) will be monitored during the injection.
Additionally, select injection and vent wells will also be used to monitor groundwater and/or off -
gases during the injection process. This monitoring will be used to optimize the injection process
to ensure effective treatment. Please note one editorial change to the table in Appendix F, as select
injection wells will be monitored during the injection process for the List B parameters shown in
the table.
Should you have any additional questions please let me know.
Sincerely,
MACTEC Engineering and Consulting. Inc. , 1.I
eAi�
K. ioe ❑eatherage
Senior Environmental Engineer
(IU361
Melody Christopher, ABB (electronic)
Nelson Walter, MACTEC (electronic)
r
Ricky A. Ryan, P.E.
Senior Principal Project Manager
RCEIVED I DENR I UAU
Aauifr- r'-1--+'--,f', crrtiun
JAN 1 2011

;-a
NCDENR
North Carolina Department of Environment and
Division of Wafer Quality
Beveriy Eaves Perdue Coleen H Sullins
Governor D: mctcr
J anuary 18.2a 11
ltick\ ,,, f;�a+t. t, f'rrnttpal f'r.�itc* �iastager
V AC 7 F-.s 1-Irt inr r Irr:� at�rt l_ eus,ult:+I
4 7 _'I Ct7i_-dIIl 11,[1a<< -
kno%%,i lz. TN 374.12
Ref: Additional Information Request
Injection Well Permit Application No. WI0400098
Flats PTCr Ju_Iti. 14)L
Forsyth County
Dear Mr. Ryan:
Natural Resources
Dee Freeman
Secretan,
The Aquifer Protection Section is currently reviewing the above referenced Permit Application received
t )c.wbct " 1. -'o I (I and has determined that further information is required before we can complete the
review of the permit renewal with modification. We have determined that no down -gradient monitoring
is planned for the proposed injection.
A lack of down -gradient monitoring wells in the vicinity of the proposed injection appears to prevent
detection and prevention of contamination migration. Provide information regarding anticipated down -
gradient migration of contaminants as a result of the proposed injection and how any possible migration
will be detected within the course of the permit. Submit the requested information no later than February
18, 2011 to:
NCDENR Division of Water Quality
Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
If you have any questions regarding this request, please contact me at [phone] or email me at
ioltn.mccrayLamctnail.net. Thank you in advance for your cooperation and timely response.
Sincerely.
John Mc ay
Environmental Specialist
Cc_ K. Joe Deatherage. MACTEC Engineering and Consulting,
John Conant. Dir.. Nuclear Engineering and Compliance. Flakt Products. Inc.
Shuying Wang. Winston-Salem Regional office
Permit File W10400099
AOUIFLR PRXECTION SECTiON
1635 M0 Selme Lerner, Raleq+r Norm uafolirla ;7fl� r•iE 1
Location. 2728 Caoital Bouleuar:. kaleryt+. Norih Cardina 278N ❑liv
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NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves, Perdue Coleen H Sulims
Goverw Director
October 28. 2010
Mr. John Conant
Director. Nuclear Engineering & Compliance
Flakt Products, Inc.
5 Waterside Crossing
Windsor, CT 06095
Subject: .Acknowledgement of Application No. W 1040009N
Former Haka Products Site
Injection in situ Groundwater Remediatinn Well 1511
Forsyth
Dear M r_ Conant:
Dee Freeman
Secretare
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit application and supporting materials
on October 21. 2010, This application package has been assigned the number listed above and will be reviewed by John McCray.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary. To ensure the maximum
efftcieney in processing permit applications, the Division requests your assistance in providing a timely and complete response to any additional
information requests.
Please be aware that the Di6sion-s Regional Office, copied below. must prrwidc recommen dation• prior to final action by the Division. Please also
note at this time, processing permit applications can take as ]ong as 60 - 90 days after receipt of a complete application.
If you have any questions, pierce contact John McC.rav at 919-715-6168, or via e-mail at john.mccray-ivnedenngov. If the reviewer is unavailable.
you may leave a message, and they will respond promptly, Also note that the Division has reorganized. To review our new organizational than, go to
httn:/ih2o.enr.state.nc.us/documenm'dwu orechart.ndf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS PROJECT.
Sincd;teiy_ � �
for Debra k : �ts
Supervisor
cc: Winston-Salem Regional Office_ Aquifer Protection Section
Kc Joe Deatherage, Senior Environmental Engineer (MACTEC Engineering & Consulting, inc- 9725 Cogdill Rd.. Knoxville, TN 37932)
Mr. Fred Godley (P.O. Box 1140. Cornelius. NC 28031)
Permit Application File W10400098
AQUIFER. PROTEZ7[ON &EC} ON
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L"virr 2728 "oiial Boulsvaro. Palargh North Ca ralina 276D4
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0MACTLU'
engineering and constructing a better tomorrow
October 18, 2010
Mr. Thomas Slusser
NC DENR
Division of Water Quality
Underground Injection Control Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Subject: Renewal of Existing Injection Permit 4WI0400098 with Modification
Former Flakt Products Site
2000 Lowery Street
Winston-Salem, North Carolina
MACTEC Project No. 3031052007-12
Dear Mr. Slusser;
On behalf of Maki Products, Inc., MACTEC Engineering and Consulting, Inc. (MACTEC) is
subnutting two copies of the enclosed Appliealion for Permit to Construct andlor Use a Mell(s) for
L#ection for the former FIakt Product Site in Winston-Salem, North Carolina (Site). This permit
renewal with modification is to install 80 additional injection wells at the Site. These wells will be
used to inject components of catalyzed hydrogen peroxide (CHP) (hydrogen peroxide, ferrous sulfate,
and phosphoric and/or sulfuric acid) into the Site groundwater to expedite the remediation of
chlorinated solvent compounds and 1,4-dioxane.
MACTEC notes that the injection fluids detailed in this permit renewal with modification were
previously approved by the Occupational and Environmental Epidemiology Section of the Division
of Public Health, Department of Health and Human Services for the initial CHP application at the
Site in 2009 (injection permit #W10400098). MACTEC also notes that the number of injection wells
proposed in this application is based on current Site data, and that the actual number and location of
injection wells may be adjusted after collecting additional data during the injection well installations.
Any deviations to this application will be detailed in the injection event report.
Considering that this permit application proposes up to three separate injection events, MACTEC
respectfully requests that the permit be issued for a period of five years, which you previously
indicated to us is the maximum permit period allowed.
MACTEC Engineering and Consulting, Inc.
9725 Cogdill Raar axville, TN 37932 ■ Phone: 865,588.8544 . Fox 865.588.8026
www.muctec.com
lYrrru.! n�rh 1n�ai�nw� �rr.r/h h.•��auiM. /Yrx
l7rrr.. A, rn or

Mr. Thomas Slusser
October 18, 2010
Page 2
Should you have any questions or require additional information, please contact Joe Deatherage at 865-
218-1049.
Sincerely,
MACTEC Engineering and Consulting, Inc
K. J e Deatherage
Senior Environmental Engineer
141
Ricky A. Ryan, F.E.
Senior Principal Project Manager
lloa81
c: John Conant, ABB (w/enclosure { electronic and hard copy )
Nelson Walter, ABB (w/enclosure {electronic)}
Fred Godley, Site owner
Enclosure: Application for Permit to Construct and/or Use a Well(s) for Injection

aMACTEC
engineering and constructing a better tomorrow
June 11, 2010
Thomas Slusser
NCDENR Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27669
Subject: Change of Address for ASS, Inc.
Former Flakt Products Site, Injection Permit #WI0400098
MACTEC Project 3031052007
Dear Mr. Slusser:
This is to update you on our client's new address, ABB, Inc. has moved to the following address:
ABB, Inc.
5 Waterside Crossing
Windsor, CT 06095
Please update your information. If there are any questions/concerns, please contact the undersigned at
865-218-1983 or [e-mail].
mactec.com.
Sincerely,
MACTEC Engineer' and Consulting, Inc.
Ri/ky A. yan
Senior Principal Project Manager
RAR/nzly ;� ; I
MACTEC Engineering and consulting, Inc.
9725 Cogdill Rood, Knoxville, TN 37932 • Phone: 865.588,8544 • Fax: [phone]
RECEIVED 1 DENR I OM
Aquifer Protection Section
JUN 10 2010
www.mactec.com
7�L Ws� i+ax,.•�

0MACT__L_.0
engineering and constructing a better tomorrow
November I8, 2009
DENR - Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Attn: UIC Program
Subject: Injection Event Record for Injection Permit W10400098
Former Flakt Products Site
2000 Lowery Street
Winston-Salem, North Carolina
MACTEC Project No. 3031-05-2007-10
To Whom it May Concern:
On behalf of Flakt Products, Inc., MACTEC Engineering and Consulting, Inc. is submitting an
Injection Event Record for Injection Permit W10400098.
Should you have any questions or require additional information, please contact Joe Deatherage at
865-218-1049.
Sincerely,
MACTEC Engineering and Consulting, Inc.
0"
K. Joe Deatherage Lky A. Ryan
Senior Environmental Engineer Senior Principal Project Manager
[962)
c: Melody Christopher, ABB (wlenclosure [electronic])
Nelson Walter, MACTEC (wlenclosure [electronic])
Enclosure: Injection Event Record
RECEIVED I DENR 1 DVVQ
Aqulb7r Prn!emien Seaton
NOV 2 0 2009
MACTEC Engineering and Consulting, Inc,
9725 Cogdill Row 0 �,r,oxvdle TN 37932 ■ 'hone 865.588.8544 • Fax: 865,588.8026 www.mach-c.corn

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number W10400098
1. Permit Information
_Fiakt Products, Inc.
Penmittee
Former Flak# Products Site
Facility Name — -
2000 Lowery Street, Winston-Salem, NC
Facility Address
2. Injection Contractor Information
MACTEC Enaineerinn and Consultine. Inc.
Injection Contractor 1 Company Name
Street Address 9725 Cogdill Rd
Knoxville TN 37932
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 9
Well names_SIW-1. SIW-2 SIW-3, SIW-4, DIW-
113, DLIW-1S. DLIW-1D. DLIW-2S, DLIW-2D
Were any new wells installed during this injection
event?
® Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells_ 9
Type of Well Installed (Check applicable type):
❑ Bored ® Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other {specify}
Please include two copies of form GW-1 b, for each
well installed.
Were any wells abandoned during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
catalyzed hydrogen peroxide FentoWs Reagent)
Injectant Type
Concentration 8.6°fe averaee
If the Injectant is diluted please indicate the source
dilution fluid. Potable water from fire hydrant
Total Volume Injected 17 327 lions
Volume Injected per well SIW-1 (2,010 gal), SIW-
2 (2,189 gal). SIW-3 (1,852 gal). SIW-4 (2,142 gal),
DIW-I B (517 gal), DLIW-15 (1,986 gal), DLIW-1 D
(2,697 gal), DLIW-2S (2,050 gal), DLIW-2D_(1,884_ gal
5. Injection History
Injection date(s)—October 14-23, 2009
Injection number (e.g. 3 of5) I of I
Is this the last injection at this site?
® Yes ❑ No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STA?�)ARDS LSD OUT IN THE PERMIT.
Ooq
S]Gt4AfUkE OF INJECTION CONTRACTOR ' DATE
P
PRINT NAME OF PERSON PERFORMING TILE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection. Fv r�f�llC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-I636, Phone No. 919-733-3221 Aqut ` Rev. 07109
NOV 2 0 2M

lfih _
NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carohna Depanrnelii of Finvironmrnt wtd Natural fi(--se)unxs• Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3576
1. WELL CONTRACTOR:
Stefan Smith
WON Contractor (Indsvrdual) Name
SAEBACCO Inc
Wen Contractor Company Name
STREET ADDRESS 9689 Northfield Drive
Fo±-G Mill SC 29707
City or Torn State Pip Code
7U{ 4 ]. 622-G920
Area code- Phone number
2. WELL INFORMATION;
SITE WELL ID *0 applicaWej S Iw- 3
STATE WELL PERMff*(gappliertxel
DWQ or OTHER PERMIT #(if applfeable) W10400099
WELL USE (Check Applicable Bout) Monitoring ❑ MunnpaVPublic LI
MoustriaVCommerC4 0 Agricultural 1 Reco►ery I*ction ,[j
lrngalion❑ Other ❑ (Fist use)
DATE DRILLED 7-23-119
TIMECOMPLETED li: oo AM M PM ❑
3. WELL LOCATION:
CITY: WINSTON-SALEM COUNTY FC!LSYTH
2000 L.OWERY STREET
(Street Name. Numbers. Community, Subdivision, Lot Np., Parcel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
Slope a Valley KI Flel ❑Ridge ❑ Other
(Check owwriale box)
LATITUDE 36 .09176 May be in &EF=.
minoles, seuonds or
LONGITUDE 00. 21307 ill a decimal formal
Laliludellongitude source; mGPS DTopographic map
flotation o1 weft must be shown on a USGS topo map and
attached to This form if nor using GPS)
4. FACILITY. is she name of""eneis where the well is rotated
FACILITY ID *(if appkcatalej
NAME OF FACILITY F'OgmEg Pi,,jta_FRCI�yCTS
STREET ADDRESS 2000 LOWwRY STREET
WINSTON-SALEM NC.
City or Town Stale Zip Code
CONTACT PERSON MACTEC
MAIUNG ADDRESS 9725 Cegdill Road
Kt:OXVILLE TN. 3?932
City or Town State Zip Cade
{ 865 - 599-8544
Area node - Phone number
5_ WELL DETAILS:
a. TOTAL DEPTH: 60FT
lb. DOES WELL REPLACE EXISTING WELL? YES© NO XJ
c. WATER LEVEL Beiow Top of Casing: 50 FT.
(Use -*- it Above Top of Casing)
d. TOP OF CASING IS a FT. Above Land Surface'
'Top of casing Ter rmnated a /vr below tend sLulace may require
a vananoe m accordance with I SA NCAC 2C .D718.
n. YIELD (9pan): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To— From To
From To From To
From Tv From To
a, CASING: Tlhickra U
Depth Diameter Weight Material
From o To 55FT Ft. 314 IN Scs 90 PVC
From To Ft.
From To 0 Ft.
7. GROUT: Depth Material Method
From 0 To 52 F T Fl, POP7LAND TRIMI
From To Ft.
F rpm To Ft,
IL SCREEN: Depth Diameter Slut Size Material
From 55FT To Gt)FT Ft.3 4 An. oxn in. PVC
From To Ft. in. M.
From Tq Ft. in, in,
9. SANDIr3RAVEL PACK:
Depth Size Mawal
From 54r T To 60FT Ft TRIM 30165 SILICA
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 60FT TAN SILTY SAND
11. REMARKS:
i Do H£RE9Y CERTIFY THAT THIS WELL WAS CONSTRUCTED iN ACCORDANCE WrrH
1 SA NCAC 2C. WELL CONSTRUCTION STANDAR D5, AND THAT A COPY OF THIS
R ECOrWi HA 5 9F E N PROMDE 1) TD THE WELL OWNER
x+'C 7-27-09
IGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Stefan Smith
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Suhnllt the original to the Division of Water Quality within 30 days. Attn: Information Mgt- --NED J DENR Fnm, GW-1b
1617 Mail Service Center —Raleigh, NC 27699-1617 Phone No. [phone] ext 668. brAuift,f PirAp(Ilop ( Rev. Troy
NOV 10 2009

NONRESIDENTIAL WELL CONSTRUCTION RECORD
Numh Carolina Dgwtsfmmt of Fnvilrwn rk and Natastl'P xs- Division of Water Quality
11'ELL CONTRACTOR CER- THICATION # 2675
1. WELL CONTRACTOR:
Robert Miller
Wail ConVaclor (Indlvirtuaq Name
SAROACCO Ino
Well COnftctor Company Name
STREETADDRESS 9000 MARKSWOOD RD.
CF:AP-=rE NC. 28278
City or Town Slate Zip Code
�). [phone]
Arse Code- Phone rAoMer
2. WELL INFORMATION:
SrTE WELL ID *(if applicahie) S I W - 2
STATE WELL PERMITi(11"o a0le}
DWQ or OTHER PERM171".*(Rapplrsbke) w1040o09s
WELL USE (Check AppkXble W Monttarigg :7 MuniciaellPub1ic ❑
InduatrieilCorrl wc4al E) Agricultural G Recovery ❑ )*dji3n g]
InigationE) Other p (list use)
DATE DR11 LED 7- 2 3 0 9
TINfE COMPLETED. 3 ! oo
3. WELL LOCATIOW
CITY: WINSTON-SALEM
2000 LOWERY STREET
AM D PM O
COUNTY FORSYTH
[Strew Name, Number;, 0&nrinuMy, SubdwiWon, Lot N4-. Parrak, Zip Code)
TOPOGRAPHIC / LANE) SETTING`.
CIS" DVefty, g)Fkat L7Rldge o Older
(Cho* at wmpdalp b*.
LATMUDE 36. 09179 Mk. -be ink..
TIhIrNt�{.-i�
LONGITUDE a 0.212 95 iri a 3ii�insl'
lAtillsdeJlnngittlde source: wGP8 ❑Topographic Asap
(bontion of wh91 must b6 drown 4n a JJS 3S kllio into and
affmk~ W Mis brm it not using GPS)
4. FACILITY- i e, aw nerve * am bLwr a whsa hhe wii is wrawa.
FACILITY ID *(if appGrihie}
NAME OF FACILITY ynpeR FLAxT PRanacrS
STREET AOORESS 2000 LOWERY STREET
WINSTON-SALEN NC.
City or Town Stale T1p Code
CONTACT PERSON MACTEC
MAILING ADDRESS 9725 C ill Road
KNOXVILLE TN. 37g3:
CNy, or Town State Zip Code
[ 865- 580-B544
Area coda - Phons number
a. TOTAL DEPTH. E o FT
la. DOES WELL REPLACE EXISTING WELL? YES 0 NO Ej
c. WATER LEVEL fWow Top of Casing: 50 FT
(Else '+- X Above Top of Casing)
& TOP OF CASING iS o FT. Above Land Surfam*
"Top of casing terminated atlor below land surface may requhe
a variance in accordance with T SA NCAC 2C .011 S.
P. YIELD (gpm)-
METHOD OF TEST
f. DISINFECTION: Type
Amount
g. WATER ZONES (depth):
Fn)rn
To
F"NL— TO
From
To
From To
From
To
Frain Tc
S, CA!lJiil[i:
Thk;krmsl
Depth
nlam w wao* material
From 0
Tk S5ET
Ft 314 IN SCH 8o PVC
From
T4.
Ft
From
. T- a
. Ft
7. GROLIC:
DOW
matrxial methm
Froq 0
TDS2Lr
Ft PCRTLAM TRIMI
From
To
FL.
From
To
S. SCREEN.
0"
Dia(lwlw'., :5i0L -No IYLe61r4sI
From 5 5FT To u s^r KaU—jk. , Dio In, _M
Fr*
To
FV---jM il
From
Td
R ih. -in,
t SANDAMVEL PACK:
Depth
Size AAateriel
From 54F"-L
To- 60F;
Ft, TRIMI 30165 SILICA
From
To
Ft.
From
To
Ft.
10. DRILUNG LOG
From To Formation DeSCription
0 6fFT- -
11. REMARKS;
2FT OF 30/65 SILICA SAXM FROM 52FT T054FT
I DO.HEREOrCERnFYTmTTm WELLWAS ODWTRLICTEO iH hr-. DRCE WTnH
93A-NCa6 2C; WELLCOHBTRt1CTION S7V0M05. At O. THAT A COPY OF THIS
R,MK4,k8 SUN PROVIDED nD THE WELL OWNIM
7-22-e9
S*NATURE >=Ri1—FIE R Wf.1 L CONTRACT OR []ATE
ROBERT L. MILLER
PFtINTER NAME OF PERSON. CONSTRUCTING THE WELL
Submit the original to the Division of Water Duality within 30 days..-Attit: Information Mgt.,
1617 Mail Service Center- RaWgh, NC 27SWIS17 Phone Rio. [Mi T33-TOIG ext ift
REGENED +
Ati11ifA, ►Pmfr--ry. ir, lr�r,
Form GW-1b
Rev. 7105

NoN RESIDENTUL WELT, CONSTRUCTION P. ECO§tD
Nonh Carolina Deimunnt ofEnyknia nabs and Naitural ftnureds-lDiriiiiO of Wasa-Qumby
WELL CUNTRACMR CERY1FICAT[ON # 2675
I. WELL CONTRACTOR. -
Robert miller
Well Contractor (Indiv6dual) Name
SAEDACCO Inc.
Well COMWM Company Name
STREET ADDRESS 9000 MARKSWC>OD 8D.
C?-i' OTTE NC. 28278
City or Town SUN Zip Cade
[ )-[phone]
Arft 00d1~ Phone rum+ber
2. WELL INFORMATION:
SITE WELL ID Ot f applicable) SIN-3
STATE WELL PERMITM(11applimW-s)
DWQ cc OTHER PERMIT *(if aMcabie), W1 Q40009a
WELL USE (ChecK Applicebls Bea[) Morlltwing O MunicipaltPublic C
IndustnaVComrne dW ❑ Agricul ;rd 0 Recovery ❑ Injection ;7
Iniyatlon© father ❑ (list um)
DATE DRILLE13 7-22-09
TIME COMPLETED 4 :Do AM ❑ PM CLI
3. WELL LOCATION:
CITY; WINSTON-SALEM CQtJtlj'jY FDRSYTH
2000 LOWERY STREET
(Street N.ma, NUrneera. Carnmunety, SuWrAslurn, Lae No., Parcel, Zip Coda)
TOPOGRAPHIC 1 LAND SETTING:
❑ Siope ❑ Vsky V Fbt Q Ridge LI Other
Schack +pPop+ima ":
LATITUDE 16.09183
mitrtaes wDwds or.
LONGITUDE 80.21297 idrdatimpltarutai
I_.atitudt~Ilongkudesource wGP5 OToptigmOic map
(bCatw of walmuM be &Khvn on a USGS lopo mW and
attached to ttys Arm Ynot using GPS)
4. FACILITY. is the rants or ttr buslnm wNrra the waii 4I0cmee.
FACILITY IDf(idWk*ble)
NAME OF FACILITY
STREE'{ ADORES,, 2000 LOWERY STREET
WINSTON-SALEM NC.
City or Town state Tip Code
CONTACT PERSON MACTEC
MAILINGADDRESS 9725 Copdill Road
KNOXVILLE � TN. 37932
City or Town State Zip Coda
965-588-a544
Area code - Phone number
5. WELL MAILS:
a. TOTAL DEPTH: en: T
b. DOES WELL REPLACE EXISTING WELL? YES E3 NO El
C- WATER LEVEL Below Top of Casing: 50 FT.
(Llse't' if Above Top of Casft)
d. TOP OF CASING IS o FT. Above Land Surface'
'Top of cw g ti rftmded at'Or below land surface may require
a variance in ac=dance with 15A NCAC 2C .0118.
a. YIELD (ppm)
METHOD OF TEST
f. DISINFECTION: Type
Amount
9. WATER ZONES (depth):
From To
From
To
From Tp
From
To
From To
from
To
1I. t A$0*
ThickrieeV
Depth
018meW
Weight Material
Fmm 0 To 55FT Ft. 3/4 IN
SCH fl0 PVC
Fmm Tc Ft
FMM To a Ft.
FMM 0
To 52FI'
Ft. BORTLAND TRIMI
From
TA
Ft.'
:from
Te
. Ft;
$CR E*
Depth
❑imm*Ar Slot SEze Material
Fmm551?T Ta_Uj Ft3!a jn. .0_0 in. D�­
Fruit!
Ta
FL ln, in.
From
To
Ft_ in. in.
e. SANDIGRAYEL PACK:
❑eplh size Malarial
Frarj 54>:'T To fiOFT Ft_ TRLMI 30/65 SILICA
Frost Ta Ft.
From To Ft_
Ia. !]KILLING LOG
From To
0 60FT
Formation Desc►ption
;W SILTY R"n
Tf. REMARKS;
2FT OF 30/65 SILICA SAND FROM 52FT T05417T
1 DO.WREBY CERTIFY THAT.TF4S WELL WAS CONSTRUCTED IN.ACCORDANCE WIN
19ANLAG 2C, WELL COMMUCTCH STANDARDS, AND THATA 0017Y OF THFS
KAS BEEN PROVIDE 0 TO THE WELL' DW NM
7-22-09
S1GHA'TURE DF kfiTIFIED WELL CONTRACTOR DATE
ROIiERT L. MILLZR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Ann: Intofrnatlon Mgt-, Form GW-1b
1817 Mall Service Center — RaMgh, NC 21099-1$17 Phony No. (919j T33-7015 axt 5$8. Rm. 7A)5
_ VED) DENR ! L .
Aglllffxr mrrrrfirl cFr;ljcln

7Art
NONRESIDENTIAL WELL CONSTRUCTION RECORD
Nmh Carolina Depannlenl of Env ironmcnt and Natural Resoumes- Division of Waicr Qualit}
WELL CONTRACTOR CERTIFICATION # 2675
1. WELL CONTRACTOR:
Robert Miller
Wall Contractor (Individual) Name
SARDACCO Inc
Well Contractor Company Name
STREET ADDRESS 9000 MARKSWOOC RD-
CHARLOTTE Nc. 28279
City or Town State zip Code
{ } [phone]
Area Dodo- Phone nu►r1beF
2. WELL INFORMATION:
SITE WELL ID #{if apptFcaGle) S1W-4
STATE WELL PERMIT#(dappiicabie)
DWQ or OTHER PERMrr #(if swRcabie)Yi1o4 Da098
WELL USE (Check Applicable Oak) Mor4toMq 0 M:mir..ipallFutft:]
IndustrWCommercial D Agncultural ❑ Recovery L. Injection K!
IrrigatianE) ❑thdr [] (list use)
DATE DRILLED 7-21-09
TIME COMPLETED 5.00 AAA ❑ PM E
3. WELL LOCATION:
CITY: WINSTON-SALEM COUNTY FORSYTH
2GOD LOWaRY STREET
(Skew Name, Numbers, Community. Subdmskm, tot No. Psrcal. Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
[3SIope ❑valley glrket DRtdge [3 Olher
(check appropriate box)
LATITUDE 36 . 09176 May be in degree,
mimics. wwrid3 or
LONGITUDE 80.21268 in a dec i ma I I;Dr=l
Latiludeylongiludesource: mCPS GTopographicmap
(bcatw of wa# must be shown on a USGS topo map and
attached to rw form Or nor using GP8)
4. FACILITY• In the hams M ne Enn nm* where Iris wd[ is Iomled.
FACILITY ID #(tf applicable)
NAME OF FACILITY ROPME2 F AKT PRODUCTS
STREET ADDRESS 2000 LOWERY STREET
WINSTON-SALE'M NC.
City Or Town state Zip Code
CONTACT PERSON MACr3C
MAILING ADDRESS 9725 Cagdill Road
KNOXVILLE � TN. _.._ 37932
City or Tawm State Zip Cede
[ BfiS - 588-9544
Area code - Phone number
5. WELL DETAILS:
a. TOTAL XPTH: 6 n, r
b. DOES WELL REPLACE EXISTING WELL? YES EI NOg)
c. WATER LEVEL Below Top of easing: 50 FT.
(Use "+• if Above Top of Casing)
d. TOP OF CASING Is c
FT- Above Land Surface'
'Tap of casing terminated aVor betvw Land surface may require
a variance in accordance with 15A NC AC 2C .011a.
a. YIELD (gpm):
METHOD OF TEST
t. D5INFECTION: Typo
Amount
g. WATER ZONES (depth):
From To
From To
Earn To
From To
From To
From To
C CASING:
Thickness!
Depth
Diameter
W eOt Material
From 0
To 55FT
FL 3/4 IN
SCH B❑ PVC
From
To
Ft.
Frorn
TOO
Ft.
7. GROUT:
Depth
Material
Method
Frtm 0
T652FT
Ft. PORTL.AND
TRIMI
From
To
Ft.
From
To
Ft.
8, SCREEN:
Depth
Diameter
Scot Size Material
From 5sFT
Tb60eT
Ft.3 /4 Iin
- • plp_ in, Pvc
From
To
Ft- in,
in.
From
T❑
Ft. In.
in.
g. SANDIGRAVEL PACK:
Depth
Size
Material
From 54^r
To 60FT
Ft. TRIMI
30/65 SILICA
From
Ta
Ft.
From
To
FL
10. DRILLING LOG
From To
Formation DescriloWn
0 60P7
TAN SILTY
SARI]
11. REMIARKS-
2F'r OP 30/65 SILICA SAND FROM 52FT T054FT
I DO HEREBY CERTIFY THAT THEE WEU WA CONSTRUCTED IN ACCORDARCE WITH
13A NG4C 2C, WELL CONSTWY-TION STANDARDS, AND THAT A COPY OF THIS
RECORD HA5 eEEN PRW DEG TD THE W£LL OWNER
- 7-22-09
SIGNA rURE OF CL TIFIED WELL CONTRACTOR HATE
ROBERT L, MIL PR
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Oiv,ision of Water Quality within 30 days. Attu: lnformatJon Mgt,
1617 Mail Service Center— Raleigh, NC 276994617 Phone No. [phone] ext 668-
- -:iVED I DEER I M
Form GW-1b
Rev. 71D5

NONRESIDENTIAL ON RESIDENTIAL WELL CONSFRUCTION RECORD
Nurtli Carolina DcpertmL'nt of Envhwineru and Natural.ResouTms- Divisive of Water (duality
WELL. CONTRACTOR CERTIFICATION # 2675
1. WFLL COINTRACTOR:
Robert miller
Well Contactor (IndhAdual) Nerve
SAEDACCO Inc -
Well Corrtr'actor Company Name
STREETADDRESS 9000 MARHSWaOD RI).
CHARLOTTE NC, 28278
City or Town Slate Zip Code
[phone]
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID*(i(appliCatAe) DLIW-2D DLIW-2S
STATE WELL PERMITO(w aWic s)
DWO Of OTHER PERIN[T *(tf 9pp4cab4e) w1040009s
WELL USE (Check Applicable Bw) Monitoring L] Munici 11Public o
IndustriaXornmercial i7 Agricuiltutal �] Rae--y 0 Injection ID
IrrigeitkxiEl Other p (list use)
DATE DRILLED 7-23-09
TIME COMPLETED 1_ : 00 AAA Z) PM ❑
3. WELL LOCATION:
CITY: WINSTON-SALFM COUNTY FORSYTH
2000 LOWERY STREET
(Street Name, Numbers, Gorrrmunity, SubdMz;c 1, Lot No , Parcet, Ztp Code)
TOPOGRAPHIC 1 LAND SETTING:
O Slop'e O Valley ® Flat O Rklga M tither
(Check apprv0016 b04
LATITUDE 3 6 . C 9176 may 1x irr degrc�—,
minums. Soanvil'x
LONGITUDE 80.21304 in a dccift) ronmr
LatirudrAongitude source: mGPS 0TePmgraphir ramp
(kcadon of wed must be shmm an a USGS topo map and
attschad to Mrs form if not using GPS)
4. FACtLfTY- is ev name of me eurdnerl: wttaillrerrrl Is ktol d.
FACILITY ID *(if applicable}
NAME OF FACILITY=oamp-P.--
STREET ADDRESS 200D LOWERY STREET
WINSTON-SALEM NC.
City Or Town State Zip Cade
CONTACT PERSON MACTEC
MAILING ADDRESS 9725 Coqdill Road
.UJOXVILLE TN. 3'?932
City or Term State Zip Code
(,865 - 588-8544
Area code - Phan number
E. WELL DETAILS:
& TOTAL DEPTH: 7r=
b. DOES WELL REPLACE EXISTING WELL? YES L NO t'sl
c. WATER LEVEL Below Top of Casing: 5 0 FT.
(Use "+- if Above Top of Caskro
d. TOP OF CASING 13 o FT. Above Land Surface,
'Top of rasing terminated aVor below land surface "require
a variance in a=ordanoswith 1SA NCAC 2C -0118-
e. YIELD (gpm):
METHOD OF TEST
I. DISINFECTION- Typf
Amount
g. WATER ZONES (depth):
From To
From
To
Ram To
FrorT1
To
From To
From
To
6, CASING:
Thickness/
DOW
Diameter
Weight Material
From ❑ To 65FT Ft_
3/4 IN
SCE, 80 PVC
From 0 TO 55FT Ft
3/4 IN
SCY- 8o PVC
From T.o Ft,
—
I. GROUT: Depth Material Method
From 0
TO53FT
Ft. PORTLAND
TRIMI
From
To
Ft.
Frartl
To
Ft,
$ SCREEN:
Depth
Diarmw
Slat size Material
�Frome�EZ Toj2.E7
FULL 11n. „ . jjg_ ln. Pic
From 55FT
T06UFT
Ft,3/4 I*;
.010 )A, PVC
rani
To
FL in:
in.
S. SAND IGRAVEL PACK:
Depth
Sire
Material
From 64FT
To 7CFT
Ft. TRIMI
30/65 SILICA
FrOM 54FT
TD 61)F c
FL TRIMI
30/65
From
Ta
Ft.
10. DRILLING LOG
From To
7 5 5 F'T
65FT 70FT
•� e Fr
Formations f]mription
TAN_LLTY SAND
PWR
I I- REMARIt',s:
FROM 6GFT TO 64FT SEAL PACK 30/65 FROM 52FT TO 54
I DO HERERY CERTIFY THAT TrOS WELL WAS 0011 STRUCTEDyN ACCORDANCE WITH
SSA NCAC 2C. WELL CDNSTRLCnON STAHDAROS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
7-22-09
SIGNATLIRE OF E-R-M 1ED WELL CONTRACTOR DATE
ROBERT L_ MILLER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water quality within 30 days, Attn: Information Mgt, -IVELJ LE: r Fd1ii4GW-1b
1617 Mail Service Center- Raleigh, NC 27099.1017 Phone No. [phone] ext 565. .�r Pt .+:'.' PAP70
NOV 2 0 2009

NON RESIDENTIAL WELL CONSTRUCTION RECORD
15 . North Carolina Llcparimcni of Fnvininment and Natural Re,,xmnxs- Division of 4Vcuer Qualily
r WELL CONTRACTOR CERTIFICATION # 2E75
�y
1. WELL CONTRACTOR:
Robert Miller
Well Contractor (Indila&wi) !Varna
SAErjACCO I n c
Well Contractor Company Name
STREET ADDRESS 9000 MARKSWOOD RD.
CPARLOTTS NC, 28279
City or Town State Zip Code
(�y (704) 634-45a9
Area code- Phone number
2. WELL INFORMATION:
8rrE WELL ID *(ifappiiCsbley DL1W-In & ❑LSW-1S
STATE WELL PERMITS(Iappllcable)
DWf3 or OTHER PERMIT #(if appiicable) W10400090
WELL USE (Check Applicable Sox) Monitonng D Municipai/Pubtic G
lndustruWCom(nercfal ❑ Agricultural 0 Recovery 0 Injection V1
Irrigalionn Ottw ❑ tJist use)
DATE DRJLLED 7-22-09
TIME COMPLETED to . n0 AM g] PM G
3. WELL LOCAT*N:
CITY: wINSTOt-SAiEP4 COUNTY i;'ORSYTH
2000 LOWERY STREET
(Street Name. Numbers. Community, Subdm9ion, Lot No.. Parcei. Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
L Slope ❑Valley 10FIM EjRidge ❑ Other
(chow appropriate box)
LATITUDE 36.09211 May he in &&rem,
mimics, smows or
LONGITUDE 30.21310 in dmirml format
t2titudeflongitude source: CIGPS D')'opographic snap
(location of you f must be shown on a USG S tcpo map and
atfachad to this form d not using GPS)
4. FACILITY- is the rwno of ow buelneas where the wd1 is loagW.
FACILITY ID *(R applicable)
NAME OF FACILITYFogfqLR FLAIU pBDDuQ S_
STREET ADDRESS 2000 LOWERY STREET
WINSTON-SALFIM NC,
City or Town State Zip Code
CONTACT PERSON MACTEC
MAILING ADDRESS 9725 C22dill Road
KNOXVILLE TN. 37932
City or Town Stale Zip Code
[ 865 }- 588-8544
Area code - Phone number
6. WELL DETAILS:
a_ TOTAL DEPTH: ?OFT
b. DOES WELL REPLACE EXISTING WELL? YES e_7 NOV
c. WATER LEVEL Below Top of Casing: 50 FT.
(Use "+- I Above Top o1 Casing)
d. TOP OF CASING IS o
FT. A"A Lard Surface'
'Top of Casing tormnated odor below Tana surface may require
a valance in accordance wilh T5A NCAC 2C .0118.
e. YIELD (gpm):
METHOD OF TEST
f. DISINFECTION: Type
Amount
g. WATER ZONES (depth):
From To
From
To-
From- To
From
To
From To
From
To
E_ CASING:
Thickness/
Depth
Diameter
W algal Maternal
From 0 TO 65FT
Ft. 3/4 IN
SC14 a PVC
From 0 To 55F1'
Ft. 3/4 IN
SCH 90 PVC
From TD 0
Ft.
7. GROUT: Depth
Materiel
"nod
From 0 To 53 F"r
Ft. PORTLAND
TRIMI
From To_
Ft.
From To
Ft.
S. SCREED: Depth
Diameter
Slat Size Material
From 65-n
T470PT
FL 4 I3n.
. D10 in. PVC
From55FT
T060F"P
Ft.3/4 I*h.
0-0 Jn. PVC
From
To
Ft. in.
in.
9. SANDIGRAVEL PACK:
Depth
Size
mateeiai
From G4FT
To 7GFC
Ft TRIMI
30/65 SILZC4
From 54fT
To SOFT
Ft, TRIMI
30/65
From
TO
F1.
10. DRILLING LOG
From Ta Formation Description
0 65FT TAN SILTY SUM
65FT 7oFT PWR
7GFr
11. REMARKS:
FROM 64FT TO 64FT SEAL PACK 30/65FRDN 52PT TO 54
1 pO HEREBY CERTIFY THAT THIS WELL vuASCONSTRMTED W ACCORDANCE WrTH
1 SA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY Or THtS
RECORD KA5 SEEN PROV1DCD TO THE WELL OWNER.
7-22-09
SIGMA"ruRL OF CLkTIFiED WELL CONTRACTOR DATE
ROB"T L. MILLER
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Ouallty within 30 days. Attn: information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 588.
Fonn GW-1b
Rev. 7105
Nnj 2 0 20

1 ■ONiIESIDENTIAL WELL CONSTRUCTION RECORD
Nmh Carolina Departakent of Envirrxtrnent and Natural Resources- Diwisim of Water Qua by
WELL CONTRACTOR CERTIFICATION # 2675
1. VVELL CONTRACTOR:
Robert Miller
Wee Contractor (Individual) Name
SAEDACCO Inc
Well C,ontiactor CompaW Name
STREET ADDRESS 9000 KMMKOOD RD.
CiARLOTTH NC. 28278
City or Torn StIft zip Cade
��_ [phone]
Area Code— Phone number
2. WELL INFORMATION:
SITE WELL ID *pf wolcabre) DIvI-18
STATE WELL PERMITt(Kapplicable}
OM or OTHER PERMIT Slif appkabla)rTlo400❑sa
WELL USE (Check Applicable Box) Monitoring 0 MwkipaVPublic la
industrIN Commercial ❑ Agricultural ❑ Recovery Ci InIedion gl
In igationp Other Ej (list use)
DATEDRILLED 7-25--09
TIME COMPLETED 2 coo AM LQ PM m
3. WELL LOCATION.
CITY: WINSTON-SALSit COUNTY FORSYTH
2000 LOrrERY STREET
(SbW Nome. Numbom Community, Subdivision, Lot No., Patreal. Zip Cade)
TOPOGRAPHIC 1 LAND SETTING:
C Slope o Vaaey M F kd O Ridge p Other
(check appropriate box)
LATITUDE 36.09181 May be in dcgnokss,
Tn1TluW'% xwwsar
LONGITUDE 80.21307 in a dccimal fwnui
[Atitude/longitude source: EGPS ❑Topographic snap
(bcstiort of wa N nwst be shown our a USGS tpy map and
eltaelIed to this ►orm i not usM GPS)
4. FACILITY. Is ft erne ar ft Lusinns whare tm wall is %prated,
FACILITY ID e(# applicable)
NAME OF FACILITY
STREET ADDRESS 2000 LONERY STREET
NTNSTON-SALM4 NC.
City or Town stale ZIP Coda
CONTACT PERSON xACTEC
MAILING ADDRESS 9725 Coqdill Road
KNOXVILLE TN. 37932
City 0r Town State Zip Code
{865 )- 588-8544
Area Cede - Phone number
b. WELL DETAILS:
a. TOTAL DEPTH: 7❑FT
b. DOES WELL REPLACE EXISTING WELL? YES Q NOX)
c. WATER LEVEL Below Top d CmN -. 5 ❑ FT.
(Use "+' H Abova Top of Caaing)
d. TOP OF CASINO IS o FT. Abeue Ladd Surface'
'Top of cuing termMaled Wor below tend surface ffW require
a v riance in accordance w1h 1SA NCAC 2C .0118.
a. YIELD ippm): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From Tp From To
Frain To From To
From To From To
S. CASING: TlrCiwaW
Depth Diameter Weighl Material
Frorn O To 65FT Ft. 3/4 IN BCH 80 PVC
From To Ft.
From Too FL
T. GROUT:
Depth
MBlarie3 Method
From 0
To62PT
Ft_ PORTLAND TRIMI
From
Tp
Ft.
From
To
Ft
8. SCREEN:
DepM
EWerneter Slot Sirs Malarial
FrornAj To79EZ
Ft.3 a M. . gig In. PVC
From
To
Ft in. In.
from
To
Ft in. In.
e. SANDIGRAVEL PACK:
Depth
Sim Material
From 64FT
To 70PT
FI. TRIMI 10/65 SILICA
From
To
Ft.
From
TD
Ft.
16. DRILLING LOG
From TO
2 _ 65FT
65FT 70FT
?OFT
Formation Description
TAN SILTY SAKI]
M
41. REMARKS:
FROM 62FT TO 64FT FINE SEA
1 DO HEREBY CERTIFY THAT THIS WELL WAS COMSTRUCTEO IN ACCORI ONCE WITH
15A NCAC 2C, WELL CONSTRk1CTX)N STANDARDS. AND THAT A COPY OF THIS
RECORD F1AS BEEN PROVIDED TO THE WELL OWNER
7-27-09
SIGNXI'UREt FiTIFILD WELL CONTRACTOR DATE
ROBERT L. MILLER
PRINTED NAME OF PERSON CONSTRUCT{NG THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn. Information Mgt, Form GW-1b
1617 Wien Service Center— Raleigh, NC 27689-16iT Phone No. (919)733-701ti ext "S. F2ECEIVGU t UENR r D� TIDY
Apifer Prn!"ir,i "�gfIJDf)
NOV 2 0 2009

NCDENR
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Coieen H. Sullins
Governor Director
March 30. 2009
John Conant
Flakt Products, Inc.
2000 Day Hall Road. CEP 880-191 l
Windsor, CT 06095
Ref: Issuance of Injection Permit WI0400098
Former Flakt Products Site
Winston-Salem, North Carolina.
Dear Mr. Conant:
Dee Freeman
Secretary
In accordance with the application received on October 14, 2008, and the supporting data submitted March 2, 2009, we
are forwarding permit number W10400098. This permit is for a pilot study to inject catalyzed hydrogen peroxide
(Fenton's Reagent) to remediate groundwater contaminated with chlorinated solvents at the former Flakt Products site in
Winston-Salem, Forsyth County, North Carolina. This permit shall be effective from the date of issuance until February
28, 2011 , and shall be subject to the conditions and limitations stated therein, including the requirement to submit a final
project evaluation as stated in PART VII — MONITORING AND REPORTING REQUIREMENTS. Please note that
some of the monitoring requirements have changed from your application. Please read the entire permit to ensure that you
are aware of all compliance requirements of the permit.
You will need to notify this office by telephone 48 hours prior to initiation of operation of the facility. In order to
continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application to renew
the permit 120 days prior to its expiration date. Please contact me at 9 I9-715-fit 64 or thomas.slusser(L—pncmai Lnet if you
have any questions about your permit.
Best Regards,
L
Thomas Slusser, L.G.
Hydrogeologist
Groundwater Protection Unit
cc: Sherri Knight, Winston-Salem Regional Office
Jennifer Stone, MACTEC Engineering & Consulting
WI0400098 Permit File
AQUIFER PROTECTION SECTION
1636 Mall Service Center, Ralegh. North Carolina 276W-1636
Location. 2728 Caphal Boulevard, Raleigh. North Carolina 276D4 One
Phone: [phone] i FAX 1: 919-715-0588; FAX 2:919-715-60481 Customer Service; 1.877-023-6748 D Carolina
Inremel www.ncwalerqualitY.org ������� L■■�
An Equal opporwaily 4 AlbrmOve Action Employer

MACTEC's Permit Application No. W10400098, Former Flakt Prod_
Subject: MACTEC's Permit Application No. W10400098. Former Flakt Products Site in
Winston-Salem
From: "Stone, Jennifer" CIESTONEomactec.com>
Date: Wed. 25 Mar 2009 08:11:31 -0400
To: "Thomas Slusser" <Thornas.Slusseri ncmaiLnet>
CC: "Deatherage, Joe" <[e-mail]>, "Ryan, Ricky" <RARYAN tt mactec.com>
Good morning, Thomas.
We have been making preparations for the upcoming pilot injection of Fenton's Reagent and, after
further discussions with our subcontractors, have concluded that the two proposed vent wells
should extend deeper than shown in our permit application. This will extend the wells into the
water table and provide a means for any gases that may be trapped in the fine-grained formation to
escape. This will change the total depth of the vent wells to 50 feet below land surface (screened
10 to 50 feet, 10 feet deeper than indicated in our permit application). What is the best way for us
to make this change (email you revised sheets, etc,)?
Also, we have a meeting with Sherrie Knight on site this week so hopefully you will receive her
response to the permit early next week. Thanks again for putting me in touch with her.
Thanks so much, as always, for your help, Thomas.
Jennifer
Jennifer Stone, P.E,, CPESC
MACTEC Engineering and Consulting, Inc.
9725 Cogdill Road
Knoxville, TN 37932
[phone] main line
[phone] direct line
[phone] fax
'[e-mail]
www.mactec.com
i of 1 3/30/2009 10:12 AM

Good Morning, Thomas. This email is a follow up to our telephone conversation Monday afternoon regarding MACTEC's Permit Application No-
W10400098, Former Flakt Products Site in Winston-Salem.
The average pump rate from RW-10 in 2008 was 1-3 gpm; the average pump rate in January 2009 was 1,1 gpm.
Concentration data in MW-112 and MW-129, the wells around which the pilot test will be conducted, is provided in the tables below for 2007 and
2008. Baseline data is provided for MW-112 as an indication of the progress made since start up of the recovery system (baseline data is not
available for MW-129, as it was installed after the system began operation).
I discussed the location of the off -site I downgradient wells with the Project Manager, Rick Ryan, and Senior Environmental Engineer, Joe
Deatherage, this morning- The locations for the off -site wells were determined based on a groundwater remedial investigation conducted by Rust
Infrastructure (RI) in 1995. RI reported the findings from this investigation in their Groundwater Remedial Investigation Report, Rust Infrastructure,
.Idly 1995. which was approved by NCDENR- During the investigation (conducted in two sampling events: HP-1 through HP-8, then HP-9 through
HP-13), 13 HydroPunch (direct push) borings were advanced on the adjacent (South) property to screen the off -site groundwater and support
locations for permanent monitoring wells; the HydroPunch locations are shown on the attached figure- Groundwater samples were collected from
the borings and analyzed for VGCs. The analytical results indicated that VOCs were detected in the groundwater samples collected from HP-1
through HP-4- Except for TCE in the sample collected from HP-6 at a low-level estimated value, no VGCs were detected in groundwater samples
collected at the most easterly sampling locations, HP-5 through HP-8- This trend indicated a southwesterly direction of VOC migration from the Flakt
facility.
HP-9 and HP-10 were placed 200 feet and 400 feet west of HP-1-to assist in evaluating the westernmost component of VOC migration. Additionally,
HP-11, HP-12, and HIP- 13 were placed south of the initial HydroPunch locations to assist in evaluating the groundwater quality in that direction. The
analytical results from the groundwater samples collected during the second event indicated low concentrations of 1,1-DCE in samples from HP-9,
HP-11, HP-12, and HP-13. Based on the results of these analyses, locations for the four off -site permanent shallow monitoring wells (MW-123, MW-
124, MW-125, and MW-126) were selected to evaluate groundwater quality south of the Flakt facility. Three of these wells (MW-123, MW-125, and
MW126) were placed near the anticipated downgradient extent of VOC migration, and one well (MW-124) was placed to evaluate the groundwater
quality in the interior of the off -site VOC plume. The locations of these wells was approved by NCDENR.
To better illustrate and confirm RI's findings, concentration data for the off -site wells (baseline, 2007, and 2008) is provided below. The marked
decreases in 1,1,1-TCA and 1,1-DCE in MW-124 since baseline confirm that the treatment system is effectively preventing off -site migration of the
contaminant plume -
Rust Infrastructure further state in the 1995 report that, based on groundwater elevation data collected during their investigation, from on -site wells,
the direction of groundwater flow is interpreted to be generally in a southeasterly direction (as shown on the figure we included in the permit).
Topographic maps, boring log data, and observation of surface features at the site indicate that an historic drainage feature predating the
construction of the railroad yard probably existed between the area of on -site monitoring well MW120D and the southwest limit of the railroad yard -
A buried drainage culvert (shown on the attached figure) was likely constructed in the approximate location of the former drainage feature to convey
surface runoff from the north side of the yard to the south side. Groundwater level data indicate southwesterly groundwater now roughly coincident
with the trace of the culvert, indicating that the drainage feature has an influence on the local direction of shallow groundwater flow- Groundwater
chemistry data also indicate that the VOC migration appeared to be southwesterly, approximating the trace of the drainage culvert -
Thomas, I Dope this information adequately addresses the questions you relayed during our phone conversation Monday. Should you have any
further questions, please do not hesitate to contact us.
Thanks again.
Jennifer Stone, P. IF-, CFIE SC
MACTEC Engineering and Consulting, Inc.
9725 Cogdill Road
Knoxville, TN 37932
[phone] main line
[phone] direct line
[phone] fax
jestone@mactec-com
www.mactec.com
ri
'eAnzAi ll is \V�0010 �d

MONITORING WELL DATA Ft 'HE FORMER FLAKT PRODUCTS SITE, vvirJSTOWSALEM, NC
10
o..
MW-112 screened: 44.8 - 54.8 feet bls
CONSTITUENT
CONCENTRATION
UNITS
98-Au 07-Sep 08-Oct
1,1,1-TCA
104200
10900
6290
pIL
PCE
28.2
20 U
10 U
pIL
TCE
14430
2360
1580
pIL
1,1-DCE
76160
16500
7480
pIL
1.1-DCA
4119
834
639
pIL
cis-1.2-DCE
70.4
20 U
22.1
Pq1L
trans-1,2-DCE
15.6
20 U
10 U
IL
1,2-DCA
1564
716
462
p 1L
Vinyl Chloride
17.9
20 U
10 U
pIL
Chloraethane 1
3.8
1 20 U
1 10 U
p IL
1. -Dioxane I
NS 1673001
62000
pglL
MW-123 screened: 41-5- -56.5 feet bls
CONSTITUENT
I CONCENTRATION
I UNITS
98-Au 07-Sep 08-Oct
1,1,1-TCA
2 U
1 U
1 U
pIL
PCE
2 U
1 U
1 U
IL
TCE
2U
I
1U
pIL
1,1-DCE
2 U
1 U
1 U
&L
1,1-DCA
2 U
1 U
1 U
pIL
cis-1,2-DCE
2 U
1 U
1 U
IL
trans-1 ,2-DCE
2 U
1 U
1 U
p IL
1,2-DCA
2 U
1 U
1 U
pIL
Vinyl Chloride
2 U
1 U
IL
Chloraethane
2 U
1 UpIL
LNN
1,4-Dioxane
NS
NSpg/L
MW-125 screened: 24 - 39 feet bls
CONSTITUENT
CONCENTRATION
UNITS
98-Au 07-Sep 08-Oct
1,1,1-TCA
2 U
1 U
DRY
IL
PCE
2 U
1 U
DRY
pIL
TCE
2 U
1 U
DRY
pIL
1-1-DCE
2 U
1 U
DRY
p IL
1.1-DCA
2 U
1 U
DRY
pIL
cis-1,2-DCE
2 U
1 U
DRY
p IL
trans-1,2-DCE
2 U
1 U
DRY
p IL
1.2-DCA
2 U
1 U
DRY
p IL
Vinyl Chloride
2 U
1 U
DRY
p IL
Chloroethane
2 U
1 U
DRY
IL
1-4-Dioxane
NS
NS
DRY
pglL
MW-129 screened: 55 - 65 feet bls
CONSTITUENT
CONCENTRATION
UNITS
07-Sep 08-Oct
1,1,1-TCA
20400
21100
pIL
PCE
40 U
50 U
pIL
TCE
4140
5120
pIL
1,1-DCE
40700
42900
IL
1,1-DCA
1290
1500
IL
cis-1,2-DCE
40 U
50 U
IL
trans-1,2-DCE
40 U
50 U
IL
1,2-DCA
533
667
pIL
Vinyl Chloride
40 U
50 U
11.
Chloraethane
40 U
50 U
pIL
1,4-Dioxane
49500
96300
pg11-
a
a
c
ti
nm
�a ter'-.
rrm
a
r�
rn
NO
M
�A
Ln
MW-124 screened: 19 - 34 feet bls
CONSTITUENT
CONCENTRATION
UNITS
98-Au 07-Sep 08-Oct
1,1,1-TCA
114.6
1.49
1 U
pIL
PCE
2 U
1 U
1 U
IL
TCE
2U
I
1U
IL
1,1-DCE
118.2
6.52
4.55
It
1,1-DCA
2 U
1 U
1 U
IL
cis-1,2-DCE
2 U
1 U
1 U
IL
trans-1,2-DCE
2 U
1 U
1 U
IL
1,2-DCA
2 U
1 U
1 U
IL
Vinyl Chloride
2 U
1 U
1 U
IL
Chloraethane
2 U
1 U
1 U
a IL
I A-Dioxane
NS
NS
NS
pglL
MW-126 screened 5 - 20 feet bls
CONSTITUENT
CONCENTRATION
UNITS
98-Au 07-Se 08-Oct
1,1,1-TCA
2 U
1 U
1 U
pIL
PCE
2 U
1 U
1 U
IL
TCE
2 U
1 U
1 U
IL
1,1-DCE
2 U
1 U
1 U
pIL
1,1-DCA
2 U
1 U
1 U
IL
cis-1,2-DCE
2 U
1 U
1 U
pgJL
trans-1,2-DCE
2 U
1 U
1 U
IL
1,2-DCA
2 U
1 U
1 U
IL
Vinyl Chloride
2 U
1 U
1 U
IL
Chloroetharie
2 U
1 U
1 U
pIL
1,4-Dioxane
NS
NS
NS
pglL
NS = Not Sampled for that parameter DRY = well was dry at time of sampling
Bold numbers = detected above 2L Standards Italic numbers = detected below 2L Standards
# U = not detected; number reported is Laboratory Quantitation Limit

36rC7`� f
LEGEND
4b MONITORING WELL LOCATION
b HYDROPUNCH LOCATION
v
HP-
W126 0
ESTI,MATEa
LOCATION OF
DRAINAGE CULVERT
OF R.R. TRACKS 4y
DIRT ROAD
(APPROX. LOCATION)
GRAPHIC SCALE FIGURE 3
ENVIRONMENT & LOCATIONS OF HYDROPUNCH SAMPLING POENTS
zo° 400MMINFRASTRUCTM FLAT PRODUCTS
WINSTON-SALEAA, N.C.
PROJECT N0= 83979.000
W Mffhmx4F

OMACTL C-4
engineering and constructing a better tomorrow
October 10, 2008
Mr. Qu Qi
NC DEN R
Division of Water Quality
Underground Injection Control Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Subject: Application for Permit to Construct and/or Use a Well(s) for Injection
Former Flakt Products Site
2000 Lowery Street
Winston-Salem, North Carolina
MACTEC Project No. 3031-05-2407-09
Dear Mr. Qi:
On behalf of Flakt Products, Inc., MACTEC Engineering and Consulting, Inc.
(MACTEC) is submitting two copies of the enclosed Application for Permit to Construct
and/or Use a Well(s) for Injection for the former Flakt Product Site in Winston-Salem,
North Carolina (Site). This permit application is to install nine injection wells at the Site.
These wells will be used to inject components of Fenton's Reagent (hydrogen peroxide,
ferrous sulfate, and phosphoric and/or Sulfuric acid) into the Site groundwater to expedite
the remediation of chlorinated solvent compounds.
We note that as part of the enclosed permit application, MACTEC submitted to you on
September 4, 2008 Form GW/UIC-3 "INFORMATION NEEDED TO DO RISK
ASSESSMENTS FOR PRODUCTS APPLIED TO GROUNDWATER OR SOIL
CONTAINING NO MICROORGANISMS" requesting approval to inject sulfuric acid
into the groundwater at the Site. We understand you have forwarded that submittal to the
Occupational and Environmental Epidemiology Section.
RECEIVED I DENR r DWQ
Ao UIFFR PRnTP('T1nNl SFCTION
OCT 14 2008
MACTEC Engineering and Consulting, Inc.
9725 Cogdill Road + Knoxville, TN 37932 ■ Phone. 865.588.B544 • Fax: [phone]
www.mactec.com

Mr. Qu Qi
October 10, 2008
Page 2
Should you have any questions or require additional information, please contact Joe
Deatherage at 865-218-1049.
Sincerely,
MACTEC Engineering and Consulting, Inc.
K. Joe Deatherage, P.E. x,, --L—iW percussion
Senior Environmental Engineer
18841
6� 1 ILI
Ricky �A.y'
an
Senior Principal Project Manager
c: John Conant, ABB (wlenclosure [electronic])
Keith Knauerhase, ABB (wlenclosure [electronic])
Donall Jackson, ABB (wlenclosure [electronic])
Melody Christopher, ABB (wlenclosure [electronic])
Nelson Walter, MACTEC (wlenclosure [electronic])
Enclosure: Application for Permit to Construct and/or Use a Well(s) for Injection
RECEiVEI) ! DENR 1 UWQ
AQUIFPP, PW)TFrTlt1N SPCTION
OCT 14 2008

O OF W R T�9 Michael F. Easley, Governor
William G. Ross Jr., Secretary
U3 r North Carolina Department of Environment and Natural Resources
p - Coleen H. Sullins Director
Division of Water Quality
October 15, 2008
Mr. John Conant
Flaki Products. Inc.
2000 Day Hill Road, CEP 880-1911
Windsor, CT 06095
Subject: Acknowledgement of Application No, W10400098
Former Flakt Products Site
Injection In situ Groundwater Remediation Well (51)
Forsyth
Dear Mr. Conant:
The Aquifer Protection Section of the Division of Water Quality (Division) acknowledges receipt of your permit
application and supporting materials on October 14, 2008, This application package has been assigned the number
listed above and will be reviewed by Thomas Slusser.
The reviewer will perform a detailed review and contact you with a request for additional information if necessary.
To ensure the maximum efficiency in processing permit applications, the Division requests your assistance in
providing a timely and complete response to any additional information requests,
Please be aware that the Division's Regional Office, copied below, must provide recommendations prior to final
action by the Division. Please also note at this time, processing permit applications can take as long as 60 - 90 days
after receipt of a complete application.
If you have any questions, please contact Thomas Slusser at 919-715-6164, or via e-mail at
thomas,[e-mail]. If the reviewer is unavailable, you may leave a message, and they will respond
promptly. Also note that the Division has reorganized. To review our new organizational chart, go to
http:llli?o.enr.state,nc.usldocumentsldM orachart.pdf.
PLEASE REFER TO THE ABOVE APPLICATION NUMBER WHEN MAKING INQUIRIES ON THIS
PROJECT.
Sinc ely,
for Debra atts
Supervisor
cc: Winston-Salem Regional Office, Aquifer Protection Section
Mr. Fred Godley (P.O. Box 1140, Cornelius, NC 2803I)
MACTEC Engineering & Consulting (Ricky A. Ryan, 9725 Cogdill Road, Knoxville, TN 37932)
Permit Application File W10400098
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone:
Internet: www.ncwaterouaIitv.orn Location! 2728 Capital Boulevard Raleigh, NC 27604 Fax 1:
Fax 2:
An Equal OpportunitylAifirmatiue Acton Employer- 50%Recy6edl10% Post Consumer Paper Customer Service
N'o"�`r►Carolina
Nalkallif
[phone]
[phone]
[phone]
(877y 623-6746

J
WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
Permit No. W10400098
Date: 10/29/2015 County: ForsyLh
To: Michael Rogers Permittee/Applicant: ABB Inc.
Central Office Reviewer Facility Name: Farmer Flakt Products
L GENERAL INFORMATION
1. This application is (check all that apply: ElNew ® Renewal �ECEIVEC7Il7tI��I�IN�
❑ Minor Modification ❑Major Modification
a. Date of Inspection: 10127I2015 NOV 0 5 2015
b. Person contacted and contact information: Joe Deatherage. ($65) 671-6774 \Natet Quality RegiOnal
�ipBf81:lC141S .�iP.Ctl� � �
c. Site visit conducted by: Jim Gonsiewski � �}„ _ r � � t� V
5
d. Inspection Report Printed from BIMS attached: ® Yes ❑ No. — i `�
e. Physical Address of Site including zip code: 2000 Lowery St. Winston-Salem. NC
f. Driving Directions if rural site and/or no physical address:
g. Latitude: Longitude:
Source of LatlLong & accuracy (i.e., Google Earth, GPS, etc.):
II. DESCRIPTION OF INJECTION WELLIS3 AND FACILITY
1. Type of injection system:
❑ Geothermal Heating/Cooling Water Return
® In situ Groundwater Remediation
❑ Non -Discharge Groundwater Remediation
❑ Other (Specify:
2. For Geothermal Water Return Well(s) only
a. For existing geothermal system:
Were samples collected from Influent/Effluent sampling ports? ❑ Yes ❑ No.
Provide well construction information from well tag-
b. Does existing or proposed system use same well for water source and injection? ❑ Yes ❑ No
IfNo, please provide source/supply well construction info (i.e., depth, date drilled, well contractor,
etc.) and attached map and sketch location of supply well in relation to injection well and any other
features in Section ,[V of this Staff Report.
3. Are there any potential pollution sources that may affect injecti❑n`? ® Yes ❑ No
What is/are the pollution sources)? Chlorinated Solvents
What is the distance of the injection well(s) from the pollution sources)? <100 feet
4. What is the minimum distance of propose d injection wells from the property boundary? NA
5. Quality of drainage at site: ❑ Good ® Adequate ❑ Poor
6. Flooding potential of site: ® Low ❑ Moderate ❑ High
Rev. 6/1/2015 Page l

WQROS REGIONAL STAFF REPORT FOR
UIC Program Support
7. For Groundwater Remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ® Yes ❑ No. If No,
attach map of existing monitoring well network if applicable and recommend any changes to the groundwater -
monitoring program.
8. Does the trap included in the Application reasonably represent the actual site (property lines, wells, surface
drainage)? ® Yes ❑ No. If No, or no map, please attach a sketch of the site. Show property boundaries,
buildings, wells, potential pollution sources, roads, approximate scale, and north arrow.
4. For Non -Discharge groundwater remediation systems only:
a. Are the treatment facilities adequate for the type of waste and disposal system? ® Yes ❑ No ❑ N/A.
If no, please explain:
b. Are the site conditions (soils, topography, depth to water table, etc.) consistent with what was reported by
the soil scientist and/or Professional Engineer? ® Yes ❑ No ❑ N/A. If no, please explain:
III E VAL UA TION AND RECOMMENDATIONS
1. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ® No. If yes, explain.
2. List any items that you would like WQROS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item;
Item Reason
3. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition Reason
4. Recommendation
❑ Deny. If Deny, please state reasons:
❑ Hold pending receipt and review of additional information by regional office
❑ Issue upon receipt of needed additional information
® Issue
r
S. Signature of report preparers); R-
Signature of WQROS Regional Supervisor: ALY -
Date: J 01 3 1 b
Rev. 6/ 1 /2015 Page 2

W¢ROS REGIONAL STAFF REPORT FOR
UIC Program Support
IV. ADDITIONAL REGIONAL STAFF REVIEW COMMENTSIATTACHMENTS (ff Needed?
-l-he inspection was conducted on October 28, 2015. Mr. Glen Price, ❑RC with R&A Laboratories in
Kernersville, NC, accompanied DEQ personnel. The Site was in good condition with easy access to the
injection/monitoring wells. Groundwater sampling will be conducted on November 4, 2015. The next
injection event will likely occur in June 2016.
Rev. 6/1/2015 Page 3

t
WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW RE0UEST FO '
Date: uctolun h 20 i s OCT 9 2015
Wins1, n-3aleM
To: WSRO-WQROS: Corey Basinger / Sherri Knight Re zonal Office
From: Michael Rogers, WQROS — Aninial Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax. [phone] E-Mail- Michael.Rogerstaincdenr.gov
Permit Number: %k I041100118
B. At t licant: 111B- Iue. ifaroner Viakt PriidueIsf
C. Facility Name
D. Application:
Permit Type: Groundwater Reniediation Well
Project Type: Renewal
E. Comments/Other Information:
❑ 1 would like to accompany you or) a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review_ comment. and/or action. Within 30 calendar days. please return WOROS Staff
Report. ^ t. - - -
When you receive this request form, please write your name and dates in the spaces below, make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above.
RO-WQROS Reviewer: _ T []ate: r' 1 � J i
COMMENTS:
NOTES: Since this is a renewal, you can pass on doirn
not. Just let me know if you agree with hermit renewal,
a site inspection or

WATER QUALITY REGIONAL OPERATIONS SECTION
APPLICATION REVIEW REQUEST FORM
Date: �, 2015
To: WSRO-WQROS: Corey Basinger / Sherri Knight
From: Michael Rogers, WQROS — Animal Feeding Operations and Groundwater Protection Branch
Telephone: [phone] Fax: [phone] E-Marl: [e-mail]
1 Permit Number! IN lift{Ifl09.4
B. Applicant: kRR. Ince ilisrrtu+ Vlli►kr PiiAiir191
C- Facility Name.
D. Anniication:
Permit Type: Groundwater Remediation Well
Project Type: Renewal
E. Comments/Other Information-
7 1 would like to accompany you on a site visit..
Attached, you will find all information submitted in support of the above -referenced application for your
review. comment, and/or action. Within 30 calendar days_ please return a completed WORDS Staff
Report.
When you receive this request form, please write your name and dates in the spaces below. make a copy of
this sheet, and return it to the appropriate Central Office Groundwater Protection Branch contact person
listed above..
RO-WORDS Reviewer;
Date:
COMMENTS:
NOTES: Since this is a renewal you can pass on doing_a site inspection or
not. Just let me know if you agree with permit renewal.
Fr7RM. WQkt}ti-ARN . -1. 09'61a Page i n$ i

Mccray, John
From: Wang, Shuying
Sent: Tuesday, April 05, 2011 3:52 PM
To: Mccray, John
Subject: RE: Additional information response Flakt Products permit renewal (W10400098)
Thanks'
From: Mccray, John
Sent: Tuesday, April 05, 2011 3:24 PM
To: Wang, Shuying'
Subject: Additional information response Flakt Products permit renewal (WI0400098)
IVis. Wang,
Attached is an additional information response I received January 31. The information provided is their response to our
question regarding the lack of down -gradient monitoring. Also, the recovery well system will be deactivated during the
injection events. This will allow for samples to be taken from recovery wells 5 and 14 to monitor possible down -gradient
propagation of contaminants as a result of injection.
Best Regards,
John Mccray
From: Wang, Shuying
Sent: Monday, April 04, 2011 1:14 PM
To: Mccray, John
Cc: Slusser, Thomas; Knight, Sherri
Subject: RE: Flakt Products permit renewal (WI0400098)
If you ever been in field to what how an injection is performed, it will not be unusual to see some injectant mix flows
away from the injection well or point because the injection operator tries to inject what volume is permitted at the
proposed (or permitted) injection rate. If the volume and the rate is not site specific, or if the volume of injectant is
more than the formation and well can take hydraulically (inject too much or too fast), injectant fluid flowing out from
the well/point will occur.
"at the maximum extent" means as site specific as possible. I did not observe overflow at the Flakt site because I have
never been the site to inspect the injection activity.
Wish this help. if i did not answer your question, please let me know.
Shuying
E-mail correspondence to and from this address may be subject to
the North Carolina Public Records Law and may be disclosed to third parties.
From: Mccray, Sohn
Sent: Monday, April 04, 2011 10:27 AM
To: Wang, Shuying

Cc: Slusser, Thomas; Knight, Sherri _
Subject: Flakt Products permit renewal (WI0400098)
Shuying,
Can you please explain your statement "Overflow of injectants on the surface was observed at an injection site.
Apparently, consultants and subcontractors try to inject what, in term of volume, is permitted for the site. In order not
to waste money and not to damage the work environment, the volume must be site specific at the maximum extent."
Specifically those parts that are in bold text. Did you observe overflow at the Flakt Products Site specifically? And what
do you mean by "at the maximum extent?"
John McCray

Mccray, John
From:
Wang, Shuying
Sent:
Monday, April 04, 2011 1:14 PM
To:
Mccray, John
Cc:
Slusser, Thomas; Knight, Sherri
Subject:
RE: Flakt Products permit renewal (W10400098)
1f you ever been in field to what how an injection is performed, it wilt not be unusual to see so3ne iniectant mix flows
away from the injection wel4 or point because the injection operator tries to inject what volume is permitted at the
proposed (or permitted) injection rate. if the volume and the rate is not site specific, or if the volume of injectant is
more than the formation and well cR-i take hydraulically (inject too much or too fast.). Inlectant fluty flawing out from
the well/point wifl occur.
'.at the maximum extent" rneans as site specific as possible. I did not observe overflow at the Flakt site because I have
never peen the site to inspect the In#ection activity.
Wish this help. If I did not answer your question, please let me know.
Shuying
E-mail correspondence to and from this address may be subject to
the North Carolina Public Records Law and may be disclosed to third parties.
From: Mccray, John
Sent: Monday, April 04, 2011 10:27 AM
To: Wang, Shuying
Cc: Siusser, Thomas; Knight, Sherri
Subject: Flakt Products permit renewal (W10400098)
Shuying,
Can you please explain your statement "Overflow of injectants on the surface was observed at an injection site.
Apparently, consultants and subcontractors try to inject what, in term of volume, is permitted for the site. In order not
to waste money and not to damage the work environment, the volume must be site specific at the maximum extent.'
Specifically those parts that are in bold text. Did you observe overflow at the Flakt Products Site specifically? And what
do you mean by "at the maximum extent?"
John Mccray

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: January 21, 2011
To: A uifer Protection Central Office
Central Office Reviewer: John McCrav
Regional Login No:
County: —Forsyth
Permittee: Flakt Products, Inc.
Project Name: Former Flakt Products
Application No.: WI0400098
L GENERAL INFORMATION
1. This application is (check all that apply): ❑ New ® Renewal
❑ Minor Modification ❑ Major Modification ® Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: January 21, 2011
b. Person contacted and contact information: Glenn Price, local contractor of MACTEC in TN. (336)-996-
2841
c. Site visit conducted by: Shuying Wang, WSRO
d. Inspection Report Attached: ❑ Yes or ® No.
2. Is the following information entered into the BIMS record for this application correct?
IZ Yes or [--I No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b, Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e. Regulated Activities 1 Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Infection Sites:
(If multiple sites either indicate which sites the information annlies to. cobv and haste a new section into the
document for each site or attach additional 12ages for each site
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number: Winston-Salem East 36080-2A-TF-042
d. Latitude: Longitude:
11 NEW AND MAJOR MODIFICATION APPLICATTONS this section not needed fipr ren xvaft or minor
modifications, skip to next section]
Description Of Waste(S) And Facilities
1. Please attach completed rating sheet. Facility Classification:
FORM: 20110121-WI0400098 1

AQUIFER PROTECTION REGIONAL STAFF REPORT
IV INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed -loop groundwater remediation effluent injection wells, in situ remediation injection wells, and !teat
pump injection wells.)
Description Of Well(S) And Facilities — New, Renewal And Modification
1. Type of injection system:
❑ Heating/cooling water return flow (5A7)
❑ Closed -loop heat pump system (5QM/5QW)
® In situ remediation (51)
❑ Closed -loop groundwater remediation effluent injection (5LP'Non-Discharge")
❑ Other (Specify:
2. Does system use same well for water source and injection? ❑ Yes ® No
3. Are there any potential pollution sources that may affect injection? ❑ Yes ®No
What is/are the pollution source(s)?
What is the distance of the injection well(s) from the pollution source(s)?
4. What is the minimum distance of proposed injection wells from the property boundary? 30 feet
5. Quality of drainage at site: ❑ Good ® Adequate ❑ Poor
6. Flooding potential of site: ® Low ❑ Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency of monitoring, monitoring parameters, etc.) adequate? ❑ Yes ® No. Attach
map of existing monitoring well network if applicable. If No, explain and recommend any changes to the
groundwater monitoring program: No monitoring wells at the southern site of the injection area were proposed
to be monitored. In addition to the proposed wells, RW-I0, RW-6, and RW-14 should be monitored for the
proposed parameters, and a new well about 20 feet south of RW-10 should be installed and monitored in order
to monitor weather the injection will have any adverse impact on groundwater quality and the migration of the
plume.
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Infection Well Permit Renewal And Modification Qnly:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turgid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes ❑ No. If yes, explain:
2. For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No. If yes, ex lain:
FORM: 20110121-W10400098 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
3. For renewal or modification of groundwater remediation permits (of any type), will
continuedladditionallmodifzed injections have an adverse impact on migration of the plume or management of
the contamination incident?-❑ Yes ❑ No. If yes, explain: Groundwater monitoring data of the proposed
infections will be needed to determine.
4. Drilling contractor: Name: SAEDACCD INC.
Address:
Certification number: 2332
5. Complete and attach Well Construction Data Sheet.
See application
FORM: 20110121-W10400098

AQUIFER PRurECTION REGIONAL STAFF REPORT
V. EVAL UATIONAND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application: With the pilot test result, detailed
calculations showing how the proposed injection volume and concentration in this application should be
provided.
2. Attach Well Construction Data Sheet - if needed information is available
3. Do you foresee any problems with issuance/renewal of this permit? ❑ Yes ❑ No. If yes, please explain
briefly. Not for sure. Concentrations of contaminants in groundwater increased in a deep well (RW-10) seven
days after pilot injection event, which may be an indicator that the injection pushed contaminants down into a
deeper zone or bedrock.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item
Reason
Calculations show how the proposed injection
volume and concentrations with site specific
data obtained from the pilot test.
Overflow of injectants on the surface was
observed at an injection site. Apparently,
consultants and subcontractors try to inject what,
in term of volume, is permitted for the site. In
order not to waste money and not to damage the
work environment, the volume must be site
specific at the maximum extent.
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition I Reason
Additional wells need to be monitored. I See Section IV Item 7.
FORM: 20110121- W 104000g8

AQUIFER PRu TECTION REGIONAL STAFF REPORT
7, Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ® Issue upon receipt of needed additional information; ❑
Issue; ❑ Deny. If deny, please state reasons, For additional information needed lease see Section V item
4.
8. Signature of report preparers):
Signature of APS regional super
Date: L o
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: 20110 1 21- W I0400098

A UIFE OTECTION SECTION i N,CK(}eptJ of ENR
APPLICATI REVIEW REQUEST FORM
DEC 10 2010
Date: I]ecember 9. 2010 W 'nston-salem l Regional OWce
El Davidson, ARO-APS ❑ David May, WaRO-APS
�u ❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ® Sherri Knight, WSRO-APS
❑ ray Zimmerman, RRO-APS
F m: John McCray, , Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E Mail: iohn.mccray�&cdenr._g2y
A. Permit Number: W10400098
B. Owner: Fred Godley
C. Facility/Operation: Former Flakt Products, Inc.
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
I. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon ❑ GW Remediation (ND)
® UIC - (51) in -situ groundwater remediation
For Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: ❑ New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ® Renewal w/ Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-AP5 representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
Vry
RO-APS Reviewer:L Date: P D
FORM: APSARR 02/06 Page 1 of 1

AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: December 9, ?010
To: ❑ Landon Davidson, ARO-APS ❑ David May, WaRO-APS
❑ Art Barnhardt, FRO-APS ❑ Charlie Stehman, WiRO-APS
❑ Andrew Pitner, MRO-APS ® Sherri Knight, WSRO-APS
❑ Jay Zimmerman, RRO-APS
From: John McCrav , Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
E-Mail: j ohn.mccrUCamcdetu. gov
A. Permit Number: WI0400098
B. Owner: Fred Godley
C. Facility/Operation: Former Flakt Products Inc.
❑ Proposed ® Existing ❑ Facility ❑ Operation
D. Application:
I. Permit Tjpe: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ IrE Lagoon ❑ GW Remediation (ND)
® UIC - (51) in -situ groundwater remediation
Frei- Residuals: ❑ Land App. ❑ D&M ❑ Surface Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
Z. Project Type. ❑ New ❑ Major Mod. ❑ Minor Mad. ❑ Renewal ® Renewal w/ Mod.
E. Comments/Other Information.: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSSRR.
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer.
Date:
FORM: APSARR 02/06 Page I of 1

flakt
Subject: flakt
From: Sherri Knight <[e-mail]>
Date: Fri, 27 Mar 2009 15:53:07 -0400
To: Thomas Slusser <Thomas. S [e-mail]>
I looked at this site yesterday. I thought I would get the staff report out today but I'm not finished yet
and I have a hair cut appointment this afternoon. I'll try to finish up on Monday. Site looks good. ❑K
to issue the permit.
Sherri Knight, PE
NC DENR Winston-Salem Regional Office
Division of Water Quality, Aquifer Protection Section
585 Waughtown Street
Winston-Salem, NC 27107
Voice: [phone]
FAX: [phone]
E-mail correspondence to and from this address may be subject to the
North Carolina Public Records Law and may be disclosed to third parties.
[ t)t' 1 3/27/2009 4:07 PM

AQUIFER PROTECTION SECTION
_APPLICATION REVIEW REQUEST FORM
Date: October 16. 2008
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRO-APS
❑
Andrew Pitner, MRO-APS
❑
Jay Zimmerman. RRO-APS
Rf• E I-?
t1G r
W'HSWn- _aL„
k�nafolnpy
❑ David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
® Sherri Knight, WSRO-APS
°m: Thomas 5lusser, Groundwater Protection Unit
Telephone: [phone] Fax: [phone]
�— E-Mail: thomas.slusser a_�ncmail.net
A. Permit Number: W10400098
B. Owner: FLAKT PRODUCTS, TNC-
C. Facility/Operation: FORMER FLAKT PRODUCTS SITE
❑ Proposed ® Existing ® Facility ❑ Operation
D. Application:
I. Permit T1pe: ❑
Animal
❑ Surface Irrigation ❑ Reuse
❑ H-R Infiltration
❑
Recycle
❑ 1/E Lagoon ❑ GW Remediation (ND)
®
UIC - (51) in -situ groundwater remediation
For Residuals:
❑
Land App. ❑ D&M
❑ Surface Disposal
❑
503 ❑ 503 Exempt
❑ Animal
2. Project Type: ®
New ❑
Major Mod. ❑ Minor Mod. ❑ Renewal
❑ Renewal wl Mod.
E. Comments/Other Information: ❑ 1 would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
® Return a Completed Form APSSRR-
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU,
❑ Issue an Attachment B Certification from the RO*.
* Remember that you will be responsible for coordinating site visits, reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above_
RO-.APS Renewer: �,.v�,u�t Date: f Ca 27
FORM APSARR 02/06
RECEIVED I DENR I DWQ
Page 1 of 1 AQUIFFR PRflTWTIO SF,CTION
OCT 112008

Mic6el F. Easley, Governor
North Carolina Department of Health and Human Services
Division of Public Health . Epidemiology Section
1912 Mast Service Center • R216gh, North Carolina 27699-1912
Te1919.733-3410 ■ Fax [phone]
.tune 21, 2004
Carmen Hooker Odom, 5ecretar7
MEMORANDUM L'-
TO: Evan Kane
Groundwater Section
FROM: Luanne K. Williams, Pharm.D., Toxicologist` \
Medical Evaluation and Risk Assessment Unit . M n
Occupational and Environmental Epidemiology Branch o
North Carolina Department of Health and Human Services
SUBJECT: Use of ISOTECT4 Products by TMC Chemicals Incorporated to Remediate Groundwater
Contaminated with Pentachlorophenol at the former Ritter Millworks Site in
Wrightsboro, North Carolina
I am writing in response to a request for a health risk evaluation regarding the use of
TSOTECTM Products by TMC Chemicals incorporated to remediate groundwater contaminated
with pentachlorophenol at the former Ritter Millworks site in Wrightsboro, North Carolina.
Based upon my review of the information submitted, I offer the following health risk evaluation:
Some effects reported to be associated with exposure to the proposed chemicals are as follows:
0 Exposure can cause severe irritation and burning of skin, eyes, nose and throat
(Meditext — Medical Management by Micromedcx TOM -Es Plus System CD-ROM
Database, Volume 61, 2004, New Jersey Department of Health and Senior Services
Hazardous Substance Fact Sheet TOMES Plus System CD-ROM Database, Volume
61, 2004).
• Inhalation exposure can cause coughing, wheezing, and/or shortness of breath
including asthma -like allergy. Future exposure can cause asthma attacks with
shortness of breath, wheezing, cough, and/or chest tightness (Medical Management
by Micromedex TOMES Plus System CD-ROM Database, Volume 61, 2004).
■ Inhalation exposure can cause severe respiratory irritation and inflammation leading
to shock, coma and seizures (Medical Management by Micromedex TOMES Plus
System CD-ROM Database, Volume 61, 2004).
Uxstioa 2729 Capital Boulevard - Parker Liocoln Building • Raleigh, N-C 27644 An Equ. l Opjmn mw Fmploy­

Chemicals proposed for Use may ignite combustibles such as wood, paper, oil, etc).
The chemicals proposed for use must be stored separately since violent reactions can
occur. The chemicals proposed for use are not compatible with reducing agents;
powdered metals; strong bases such as sodium hydroxide and potassium hydroxide;
alcohol's; and hydrocarbon fuels. Extreme caution should be taken to prevent
hazardous explosions from occurring. Based on the information submitted, there
will be cabinet shop workers and residences very near the injection area.
Measures should be taken to prevent fires and explosions from occurring to
protect workers and nearby community. A safety plan should be developed in
case there is a fire or an explosion. The addition of a metal as being proposed
can act as a catalyst which can increase the risk of an explosion during
decomposition (Hazardous Substances Data Bank TOMEs Plus System CD-ROM
Database, Volume 61, 2004).
* Store in tightly closed containers in a cool, well -ventilated area away from moist air
and combustibles. Containers may explode when heated. Runoff may create fire or
explosion hazard. Chemicals proposed for use beat up spontaneously when
decomposing and could start fires. (Hazardous Substances Data Bank TOMES Plus
System CD-ROM Database, Volume 61, 2004).
If the products are released into the environment in a way that could result in a
suspension of fine solid or liquid particles (e.g., grinding, blending, vigorous shaking
or mixing), then it is imperative that proper personal protective equipment be used.
The application process should be reviewed by an industrial hygienist to (1) ensure
that the injection process is done in a safe manner, and (2) the most appropriate
personal protective equipment is used.
+ Persons working with this product should at least wear goggles or a face shield,
gloves, and protective clothing. Face and body protection should be used for
anticipated splashes or sprays. Again, consult with an industrial hygienist to ensure
proper protection.
■ Eating, drinking, smoking, handling contact lenses, and applying cosmetics should
never be permitted in the application area during or immediately following
application.
• Safety controls should be in place to ensure that the check valve and the pressure
delivery systems are working properly.
• The Material Safety Data Sheets should be followed to prevent adverse reactions and
injuries.
• Access to the area of application should be limited to the workers applying the
product. In order to minimize exposure to unprotected individuals, measures should
be taken to prevent access to the area of application.

• According to the information submitted, there is an on -site water supply well that
provides drinking water for the cabinet shop workers, and there are private and public
water supply wells located 75 feet and 0.5 miles from the injection area, respectively.
Efforts should be made to prevent contamination of the existing wells or future wells
that may be located near the application area.
• According to the information submitted, the nearest surface water drainage is Ness
Creek located approximately 700 feet west of the site. Efforts should be made to
prevent contamination of the nearby surface water areas.
ha summary, extreme caution should be taken regarding the use of the chemicals
proposed. Safeguards should be taken to prevent fires, explosions, and injuries from occurring.
Please do not hesitate to call me if you have any questions at [phone].
cc: Becker builders Supply Company
Mr. Page Teer
4614 Market Street
Wilmington, North Carolina 28403
910-791-7761
Dr. Charlie Stehman
Wibnington Regional office
Groundwater Section
127 Cardinal Drive Extension
Wilmington, North Carolina 28405-3845
910-395-3900
Mr. Bob Hollingsworth
Hollingsworth Cabinetry
2913 Castle Hayne Road
Wrightsboro, North Carolina 28429
910-251-1490
Prasad Kakarla
In -Situ Oxidative Technologies, Inc.
51 Everett Drive
West Windsor, New Jersey 08550
609-275-8500
Kathleen Roush
Mineral Springs Environmental
4600 Mineral Springs Lane
Raleigh, North Carolina 27616
919-261-8186

(�p amecl*
July 3, 2014
Mr. Thomas Slusser
NCDENR — Division of Water Resources
Aquifer Protection Section — L]IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Subject: Injection Event Record for Injection Permit WI0400098
Former Flakt Products Site
2000 Lowery Street
Winston-Salem, North Carolina
AMEC Project 3031.05-2007
Dr. Mr. Slusser:
On behalf of Flakt Products, Inc., AMEC Em ironment & Infrastructure, Inc. is submitting an Injection
Event Record for InjectioATOMI WI0400098.
Should you have any questions or require additional information, please contact Joe Deatherage at 865-
218-1049.
Sincerely,
AME E ronment Infrastructure, Inc.
Ricky A. Rya P.E.
Senior Principal Project Manager
Enclosure: Injection Event Record
K. J e Deatherage
Senior Environmental Engineer
Melody Christopher, ABB ( wlelectronic and hard copy enclosure)
Nelson Walter, AMEC (wlelectronic enclosure)
Lakesha Dunbar, City of Winston-Salem (wlelectronic enclosure)
Robert Prestwood, City of Winston-Salem (wlelectronic enclosure)
Alan Griffith, Griffith Enterprises (wl electronic enclosure)
Sean Tyson, Pratt Industries (wlelectronic enclosure)
AMEC Environment &t Infrastructure, Inc.
9725 Cogdill Road
Knoxville, Tennessee 37932
Tel [phone]
Fax [phone]
amec.corn
Jai 0 7 2014
Wow ou'01iry R
�raf�ms' 69bnal

-ni ECTIDN EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number WI0400098
I. Permit Information
Flakt Products. Inc_
Permittee
Former Flakt Products Site
Facility Name
2000 Lowery Street, Winston-Salem, NC
Facility Address
2. Injection Contractor In€ormation
AMEC Environment & Infrastructure. Inc.
Injection Contractor 1 Company Name
Street Address 9725 Cogdill Road
Knoxville TN 37932
City State Zip Code
($b5 ) 671-6774
Area code — Phone number
3. Well Information
Number of wells used for injection t5
Well names see attached Attachment A
Were any new wells installed during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells —
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies of form GW-Ili far each
well installed.
Were any wells abandoned during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include Avo copies of the GW-30 far each
well abandoned.
4. Injectant Information
Catalyzed hydrogen peroxide (Fenton's Reagent)
Injectant Type
Concentration 11.1% (oxidant)
If the injectant is diluted please indicate the source
dilution fluid. Potable water from fire hydrant
Total Volume Injected 26,678 gallons
Volume Injected per well: varies {see Attachment A)
7. Injection History
Injection date(s) 61312014-611612014
Injection number (e.g. 3 of 5)3 of 3
Is this the last injection at this site?
❑ Yes ❑ No
® To Be Determined
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECT19N WAS P ORMED WITHIN THE
STAND S LAID O N THE PERMIT.
SIGNATURE OF INJECTI04CONTRACTOR DATE
Ricky A Ryan
PRINT NAME OF PERSON PERFORMING't'i-IE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection, Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636. Phone No. 919-733-3221 Rev. 071Q9

WELL NAMES AND VOLUMES

Total Volume Injected Per Well
Well Name
Total Volume
(gal)
DLIW-15
1,774
DLIW-10
1,500
DLIW-25
1,773
❑LIW-2D
1,505
DLIW-23S
1,467
DLIW-23❑
1,505
DLIW-245
1,498
DLIW-24D
1,509
DLIW-285
1,491
DLIW-30S
1,495
DLIW-325
1,474
DLIW-34S
2,575
SIW-1
1,958
SIW-3
2,591
SIW-4
2,573

amec'0
July I7, 2012
NCDENR — Division of Water Quality
Aquifer Protection Section — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Subject: Injection Event Record for Injection Permit WI0400098
Former Flakt Products Site L7 V. ef5' 011' }%6,4 ' r)
2000 Lowery Street
Winston-Salem, North Carolina
AMEC Project 3031-05-2007
To Whom It May Concern:
On behalf of Flakt Products, Inc., AMEC Environment & Infrastructure, Inc. is submitting an Injection
Event Record for Injection Permit WI0400098.
Should you have any questions or require additional information, please contact Joe Deatherage at 865-
218-1049.
Sincerely,
AMEC E&1, Inc.
Ricky1A.ywan, P.E.
Senior Principal Project Manager
Enclosure: Injection Event Record
�.. 61 0��
K. Joe Deatherage
Senior Environmental Engineer
c: Melody Christopher, ABB (wlelectronic and hard copy enclosure.)
Nelson Walter, AMEC (wlelectronic enclosure)
Russell Byrd, City of Winston-Salem (wlelectronic enclosure)
Alan Griffith, Griffith Enterprises (wl electronic enclosure)
Sean Tyson, Pratt Industries (wlelectronic enclosure)
Correspondence-
AMEC Environment & Infrastructure, Inc.
9725 Cogdill Road
Knoxville, Tennessee
37932
USA
Tel [phone]
Fax [phone]
an]Mcom
RECENEDIDENR/M
JUL 2 U 2012
Aquifer Protection Section

..ECEIVEDIDENPOK
INJECTION EVENT RECORD jo 2 0 2012
North Carolina Department of Environment and Natural Resources — Divis4ffPYft1Ri%edon
Permit Number W10400098
1. Permit Information
Flakt Products Inc_
Permittee
Former Flakt Products Site
Facility Name
2000 Lowery Street, Winston-Salem. NC
Facility Address
2. Injection Contractor Information
AMEC Environment & Infrastructure Inc.
Injection Contractor 1 Company Name
Street Address_9725 Cogdill Road w
Knoxville TN 37932
City State Zip Code
{ 865) 671-6774
Area code — Phone number
3. Well Information
Number of wells used for injection 101
Well names see attached Attachment A
Were any new wells installed during this injection
event?
NYes ❑No
If yes, please provide the following information:
Number of Monitoring Wells none
Number of Injection Wells 92 (contained in 47
borings; two copies of the 47 GW-lb forms are attached)
Type of Well Installed (Check applicable type):
❑ Bored N Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies of form GW-I b for each
well insralled.
Were any wells abandoned during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection
Please include mo copies of the G W-30 for each
well abandoned
4. Injectant Information
Catatvzed hvdroaen peroxide (Fenton's Reaeent)
Injectant Type
Concentration 8.5%-11.3gc
If the injectant is diluted please indicate the source
dilution fluid. Potable water from fire hydrant
Total Volume Injected 175,625 gallons__
Volume Injected per well: varies {see Attachment A
5. Injection History
Injection dates} 411112012-612512012
Injection number (e.g. 3 of 5) lof 3
Is this the last injection at this site?
❑ Yes N No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STAND S LAIDUT IN THE PERMIT.
-7 J o /I? -
SIGNATURE ❑ NJE ON CONTRACTOR DATE
Ricky A Ryan
PRINT NAME OF PERSON PERFORM [NO THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221 Rev. 07/09

ATTACHMENT A
WELL NAMES AND VOLUMES

Well
Name
Total Volume
�galj
DI W-16
110
DLIW-1S
1,700
DLIW-1❑
1,628
DLIW-25
1,568
DLIW-2D
1,662
DLIW-3S
2,738
DLIW-3❑
2,639
DLIW-4S
1,835
DLIW-4D
1,847
DLIW-5S
1,898
DLIW-5D
1,844
DLIW-6S
2,209
DLIW-6D
2,247
DLIW-75
35
DLIW-7D
233
DLIW-85
2,200
❑LIW-8D
2,202
DLIW-95
1,770
DLIW-9D
1,917
DLIW-105
2,144
DLIW-10D
1,973
DLIW-11S
1,614
DLIW-11D
1,659
❑LIW-12S
2,171
DLIW-12❑
2,069
DLIW-135
1,789
DLIW-13D
1,653
DLIW-145
3,037
DLIW-14D
2,978
DLIW-155
2,855
DLIW-15D
2,840
DLIW-16S
1,918
DLIW-16D
10840
❑LIW-17S
1,844
DLIW-17D
1,884
DLIW-18S
1,998
DLIW-18D
3,152
DLIW-19S
2,468
Total Volume Injected Per Well
Well
Name
Total Volume
jgaly
❑LIW-19D
2,989
DLIW-20S
2,150
❑LIW-20D
2,313
DLIW-21S
2,188
DLIW-21D
1,993
❑LIW-22S
392
DLIW-22D
1,625
DLIW-23S
2,393
DLIW-230
1,954
DLIW-24S
1,927
DLIW-24D
1,938
DLIW-25S
2,417
DLIW-25D
2,181
DLIW-26S
1,927
DLIW-26D
1,841
DLIW-275
1,776
DLIW-27D
1,889
DLIW-285
2,076
DIW-28D
387
DLIW-28DD
1,655
DDIW-29
1,928
DLIW-30S
1,710
DLIW-30D
1,597
DLIW-31S
1,729
DLIW-31D
1,508
❑LIW-325
1,834
DLIW-32D
1,728
DLIW-335
1,880
DLIW-33D
1,729
DLIW-34S
1,591
DLIW-34D
1,601
DLIW-355
1,870
DLIW-35❑
1,822
DLIW-365
1,561
DLIW-36D
1,377
DLIW-37S
1,223
DLIW-37D
1,514
❑LIW-38S
1,957
Well
Name
Total Volume
(gal)
DLIW-38D
1,759
DLIW-39S
1,520
DLIW-39D
1,416
DLIW-405
1,451
DLIW-40D
2,350
DLIW-415
33
DLIW-41D
74
DLIW-425
40
❑LIW-42D
112
DLIW-435
1,608
DLIW-43D
1,501
DLIW-44S
2,332
DLIW-44❑
2,082
❑LIW-45S
1,951
DLIW-45D
1,958
DLIW-465
1,501
DLIW-46D
1,617
DLIW-47S
1,577
DLIW-47D
1,501
DLIW-48S
95
DLIW-48D
904
SIW-1
1,513
SIW-2
1,517
SIW-3
1,493
SIW-4
1,483

ON RESIDENTIAL G (,onus Rico
NQTth Carolina Dopartmanl of Eavimninnent and Nduril Rewurew, Division of Weirr Qualiy
wELjL comAr-roR c>E autcAnon r 2675
1. WELL CONTRACTOR
WWI Cerltrestor PrOO( ual) Name —
Wel Contradar Compshy Name
NBS Nqq�fieid Of,
Skeet Address
Fort mill SC __. 29715
CRY or Town Slate ZIP Cate
8� 03 s W-2189
Area Cade Phone humbW
I WE1L INFORMATION:
WELL coNsTRucTioN PEAmrt*)M04QM98 -
OTHER ASSOCIATED PENRMIT/(t apyNartl.)
SITE WELL {b fir,P�Ierr. DLL 1W5_ & Q�iW0 _,
3. WELL USE (C?rack one Box) IMoniD" a Mw WdPI1PtMG0
b*ustrWVCommerdMQ AprkulLral❑ RacoveryO Inlardanllf
WGINSOM] Olio O (Stine)
OATS DRKJt 90 1 j(I $117
& WELL LOCAMM:
2DG0 Llzwer]1 St -
(SL'aet Name, Huinbwl. CO*TAO lty. Suedrk'on. Lot No . ParoM. 71p Coee)�
cITY: Winston-Salem cauNrTY Forsyth
TOPOGRAPHIC IIAND SCTTNG (ci sppnyrSarabak) ^^
C0096 ovarky dtet ❑Ricpe ❑Oder
36' 5' 30.5800"
80` 12' 47.5200"
LstlMaAarpitude seine (BPS aopopraphk map
{ioeeNian of well' mwt by shown or a USGS *o m* arOwlechud ro
?his Ibrm d nor usk)q GRS)
e. FACtt1TY (Name of the business where the well Is leaded.)
-Former Flaki Products. Gon nal Z
1`300y Nerve Fadifty IUa (If app>laiW
Street Address
C ty w Tcwi stale ZIP Code
AMFC - Ano ❑pathos"
Contact Name
1-4725 Condili Rd
KnnXydle TM 37932
[:Iffy or Town SErie Ztp Cade
( ANS 671-6774
Awe oode Phwe ojwoor
e. MLL DVAILS:
a. TOTAL DEPTH 73 ft
b. DOES WELL REPLACE EXISTING WELL? YES NO CI✓
c. WATER LEVEL ftlow iep of Casing _5Q— FT.
(Ux '+' N Above Top or Cas ne)
d. TOP OF CASINO Is 0 _ FT. AD eve Land es'
'Top of oeaina h Nnaled e11or bei0w tend suKsee may write
a varlanca In aocordarve wth I5A NCAC 2C .011 S
: c YIELD (ppm): METHOO OF TEST
N. bISINFECTION: Type Amount
p. WATER ZONES ("gth)
: Top Bottom lap Bctlom
Ter__ Bottom Top Bc=rh
Top Sodom Top BodDrn
Thtettaaaal
T. CABING- Ueptr OlemtaW 9Yaigln IAabele)
: Topes_ Soften 55 FL J 2-F" _ SC ED CP11C
Tep_Q_- Sott m_" FL 1.25' sc 80 CPVC_
Tap Bottom_ Ft
0. t3ROUT: Depth metwul
Top 4 _- Bottom 52 Ft.lonland
Top 9attom—_— F1.—_-__ __ . .
Tap Bptlorn Ft.
9. SCREEN: Depth Diameter Slot S W Materiel
: Top ft55 B0ftM b660Fi�`in. 0.4E In. CFVC.._—_
Top_ i$sr BoNcrn 72 Ft_L25- 4.Q1 In CPYG
Top Bottom F1. K in --
:10. SANOMRAVEL PACK.
Depth S&a Ntaterial
Tap 64.5 Bottom_ Ft #1silica -
Top-g—Bottom_m_ F, 01 Silica _
Top flotWm F!.
: M DRILLING LCG
: Top Bottom Farmagar, neacnpbor+
0 1 T3 sittv sand wilft rg&hinj�[yLs
1
11
1
1
1
42. REVAItiM
30165 sand seal from 52-53' and 60-64.5'
IM IOM S'rA1aW1Oe, MV TINT A00rh' Or YM
T(1 CMRER
S)ONA JRE OF CER"iFIM Lt_ CONTRACTOR DDT
Robed Millet - --
PRINTED NAME OF PERSON CONSTRUCTIN13THE WELL
Form OW-1 b
Rev. Voll

dA r
1. WELL CONTRACTOR:
Robert MeE
Well Contractor (irdiuldual) Name
sSfdiiGC4_ Inc._^
well CvMncW Conw" Name
Northfield Dr_
Street Address
fora 14dt SC 29715
Cky or Town Stall zip Code
(803 1548-2180
Arse cede Phone *m*vt
!. WELL INFORIMATION:
NELL GONSTRMTtON PERMFTs W N00088
01HFyt ASSOCLATEE) PERM'rCr"kabo)
SITE WELL ID r;ranpdraeere) DLIW-4S $ DLIW-4Q
3. WELL USE {Chad[ One 804 M"Odng❑ Mufjk0d P1fO[]
I rrdu eO is VCom rrwrJal ❑ Ag rktdYlrel ❑ Recomryp Motion If
Irftadanp Oew [7 list use)
4ATE DRILLED 11112111
4. WELL LOCATION:
2000 Lowery St.
(S~ Nara. Numawe, C*u"uW Stb:rle M Lot Ne.. ?erael, Dp Cade}
errY: Winston-Salem couNTYFor—aD-b
TOPOGRAPHIC) LAND SE-TING: (dwKi appoprL4 bm)
t]Sbpe QVexeY abet ❑Ridge ❑Otter
36' 5' 30.6200"
80' 12' 47.3700"
LatltudeADr g lixie source' 03PS Ljopograpt,Ic rup
{kcaocv? of wee must be shown or. a USGS tcpo mup aodoladwd to
lhle farm If not askv CPS)
8. FACKJfTY {Name of"bus1r*sg where iht wall is bcalod )
Fie[ FlaktLradwj2S __ 040 QQ17
FwSV Name Fadlty OF (iI apple")
2D00 t-owP_ry St _
S11161 Address
_Winaten-SalAM NC 27101
City or Town State Zip Code
AUEC - Jcie Oeatherarse
contact run*
_14725 Cnadill Rd _
trW*V'Address
nc'exvak TN 37932
CBy or Town state Zip Code
71-677
Area node Phone nxnber
e. WELL DETAILS!
a. TOTAL DEPTH: 75 $
b. DOES WELL REPLACE EXMTMO WELL? YES O NO L/
c. WATER LEVLL Bwaw lop of Casing: 50 FT.
(Use'*' If Above Top of Caahgy
NoN ll S N U4 L WELL CO 1R11L" ON RECOH11
Nordi CnmIku Depenmutt of Emimnment and Nduml Remu-mitt- DivWam of Wallet QWdlr
WELL CONTPACTOR awmCATHON N 2675
d_ TiD! OF CASiNp It _Q_ FT. Above Lard Surface'
'Tap of CO*V ter mlrubad Mt batow WM uafwm nosy require
a rensrxa la boomdance weh 15A NCAC 2C 011 A
: w TIELD ilpmy. METHOD OF TEST __._
t. D13INIrECTIOM: Type Amourtti_
WATER ZONES (daplh):
: Top _ Bottom Top BaRa+n
: Top Bohora Top BORnm—. .
: Tep_ -Bottom- Top BAw_
Thklcnaad
:7. CASINO: Depth Dlamete► "M Material
Too g--_ aotton,�>� Ft. �.20 GPVC
: Too _ -- UOVOm31 Ft.
Top Bottom Ft.
e.ORour Depth Materiel Method
: Topes_ Bottom-57,5— Fi Porftnd _rrer m
Top K~ Ft. _
TOP. gotta-r Ft. _
/. S4CRM. Depth DWV101 $Wt UN Mautul
: TopJL'[_ Bauam66 Ft. 115 IA 4,01 to 0P]C0
ToP�_ Bolt ln_Z5_ Ft 1.25 tn. ._Q_Ql zn _GPYf,____
Top«. Boft, Ft 10. n
: 10. SAN=RAVEL PACK:
Depth Size letetafial
: Top $6.5-BotMm_$G— F1 bi 15-lica_ _
Top 5$.5 Banorn 66.4 Ft. #1� Silica
Top Bcticru Ft.
: tt UKILLING LOG
To Bottom Fwnalbn Dmcripticr.
' �--� j5_-- � send 16rtttl dbfRe Irytarvp�__
1
. r
r
i
12. RENAM0:
30/65 sand seal from 57.5-58.5' and 66.4-68.5'
I Ino Pe441' C"Try THAT THO WFU wta 00►ta'f1et1G=Iw AOCOMANDEWW
• ����6�TAAOARM�V��D T�IIA7 Appp► pF THi
OF CERTIFIED MAL CONTRACTOR- Tf
PR*VW NAME OF PERSON CONSTRUCTING THE WELL
F Cum G W-t b
Ray. 2M

� for f
I. WELL COIITRACTOR:
oavid Browu
- WOV Contraclor (bdMduat) Marna
Saedigggo Inc.
We!I Corwactor Ca.Towy Name
9088 Northf ld Dr.
Street Addteu - -
71
Cly or Town Sole Z+p Coda
8( 03-M8-2980
Am node Phom number
2. WELL INFORMAT10N'
WELL CONSTAUCTION P_Rwf M 0Q a
G-HER AS$OCLATE D PERtYpT"epenum)
51TE WELL ID W appi,abb) DL1W-5S & OL•l --5D _.
3. WELL USE (C:%O One Box) Mc Aorlay Z M opoIPuDIlt:0
htdveVlel+C.mnwrdd❑ Ag t A ra' C Recova7 ❑ irisetbn d
wgawo O'Jw►❑ (!aline)
DATE OHILLED I IM 11
■. WELL LOCATIQM.
2000 Lowery St. _
(S-0 Name. N4rnb&'k Can'MMY. Ssbdvlacn, IA Me.. Pena• I1p Colo)
crrr nston-Gal _ couNTY Dolsvth
TOMORAFM a LAND SEif WG: (dwd awopHlaia bmo
C i$kM* E7V@Wy dVllt DRiOya ❑ DPW
36` 5' 30.6300"
8T 12' 47.2900"
t&#1IvdVomgLWa &Km: V3P5 [3apWsptk map
(b,-s Y w d we# mat be arrawn Cn a VSGS iopd map endaifechadso
Mir form if" L rrp OP5y
3- FACRJTY [Name of Ifna busV*53 where ate wet is WA19C )
Fedit Hama Farsty IDi (rapplicable)
Sires: Address
Cky or roam Stale zip Cc"
AMFS, - JnA DnathpranQ„
contact Name
M almp Address
kSnnyvilie_ TN 37232
CAry or Town State Lp Code
1 865 75$ $71-$774
Area coda Phona nXnba•
C WELL DETAL'-' 70
a. 7OTAL DEPTH: -ft f% R!
b. DOES WELL REPLACE EXISTING WELL? YES r) NO W
e. WATER LEVEL BM;;-w Top of Caaldp: a51 RI AFT
(Use f Move rop of C Wog)
NoN RESIDENTrAf- wsU CONE RIlCT10N HKCORD
blurt+ Carv:ins Dtpestmem of Envirowrant sad Natural Resonroar Div Woa of Wag or Quality
WELL CONTRACTOR CERTMCATION # 4155
a TOP OF CASING is - 0 _ F T. AzArm Land Sumacs'
'Tap of caairp W-Anted Wor below land swdoce may req*a
a verar pe Ir excrdan�* with i 5A NCAC 2C .011 S.
a. YiEL13 (qpm) METHOD OF TEST
E D1&PIFECTt0N-.Type Amount
% WATER ZONES (depm).
Top l30'tom Top__ _, BW*m
Top _ Bottom__- Top Beaom
Top Bon" Tap Bettom
Thtckneeaf
7. CASING: Depth awrnster W@Mht Nlalorl.I
Too Q-Ba:orn�`L_FL1. 25" 80. GFVC
rop.2lea:t3rtl ESr't & 80 CP]I�- -
Top Bolcom_ — Ft_
B. GROUT: Depin Maweel McOw
Top_ GoOom_' 2_ Ft. PCfjQnd JMM
Top Sollom rI
Top Boron- _-- FL
$ SCREEN: Depth Own~ Slot Sbte Materw
Taps, 0-rom84_ Fi_12 M. Q_,=_0i In. QPVC
r*gs5e*pr i 70FL t2, a+ 4_�1 I'L CC
Tap_ Solixm FI- it. In.
1O. SANMRAVEL PACK:
Depth Size 10.41'lrlal
Top 53.5 Be:tcm-U&- Ft #1 silica
Top >4 __Bottom 7j _FL 01 S1icia
. Top t3ctlpm FL
41. DRILLING LOG
70p ScOom Formation Dnr-Iptmn
"73 sitU saLgy clay mtt rgQh
1 and grayal nt
1
1
r
J
1Z. :
30165 sand seal from 52-53.5' and 60.5-64'
IDO.EtMYCl*rFVTnATTIN WOlVMCONSt1=WWAOrJOII ANXYOH
ilA WAC7C. ST WlCTOON:TANDOM. AND TINT ACOPT Of YW
1M+OCaIO WAS CM TO wliL DNa>FR
SIGNATURE IFIFp tYl LL CCP(T FOR
PRRVTED NAME OF PERSCN CONSTRUCTING PiC WELL
Forlrl 3V4-1 b
Raw 2M

dd o-
}r
3
t. WELL CONTRACTOR:
iller
Well Contreclw (tr.dvdkia4 Name
Saedacca Inc.
We': C.atrartor Company Naga,U6814orthffeW Dr.
r
Strecu Ade roes
Eat M111 SC 29716
C-ty or To,tir SS.ta Zip Cnca
$f03 -W-21 BQ --
Ares code oho, * r utibk r
2. WELL INFORMATION: r���7O
WELL CONSTRt,ICMki PERMIT'i� V 4 _
OTHE'i ASG0CVAT£O PERMrT#X appic"f _
SITE WEL_ tD rl!M"Otrablet LI1N-6S,& [7LIV 0
S. WELL USE (Check Crta Bak) Mw4ta4lr9 ❑ IV..u-AdpWVPtbic C.
kidustrla:lComrhe,d et ❑ Agdcuaural G Recovary C Injxson +i(
Iftew. 0 Ott+g•z; {lituse}
DATE DRILLEDA 1-12- 1 1,
4, WELL LOCATION:
2909 Lom2ry
(841+1 Narae- Ntvbwa. Corr.nasy, 8ubrlr.alr. UAHe— PvlCw 4p cafe)
rITY: 11Virl tail -Salem COUNTY Forsvth
Ti']F+OGRAr 41C I -AND SeFT'NG! tdiecx Wpreprirte I-j
[TStope L Valley stgat rrimge
36° 5' X6300"
80' 12' 470100"
Ln1N �dedlcrb h de txxoe ;PPS '-70pographlo rr.aa
{bcrflan a/ wee must be shWM a; a USGS fope mad s,-�dei! wnae to
On Iarm (l rof u�ft OP5)
a. PACrLTTY (Name a the bkwlinesa where tr* weo to tnrattets ,
Fnrmprr_Plaki Pun urfs onn nol 7 .
Fad7ty Narr.p Facalt/ Do (if ap;kab'e)
MOO L fiWELN -St
SUBat AtlgrosS
_10f1 f�tan,SalP,m _hlG.,27iQi
C4 or Tpwr $Late 4 Coda
Cvr tact Rama
25 ,andill Rd
Malll'g Address
. Knnxvillr� _�- _ TN_ 37932
City or Town Swto ft Code
( 865B -fT&9!6 671-6774
Area Bade Phelte nvTber
8. WELL OUTAIL,S-.
a. TOTAL DEPTH-_70 ft
b. DOES WELL REPLACE EXITINO WELL? YES n NO L(
C. WATER LEV EL Belmv Top of Caa;rq:
(Use "+' 11 Ahovw Top of Castrtp)
SON E EN77AL WELL Co •STKVgPON WORT)
NWh Carolina Nparattebt o!Emtrorscpat and Ka tuel Rosourees-Vvliior. afWatcl Q¢aaiity
WILL CONTRACTOR cinivrcATToii # 2675
d. Top OF CASING IS Q Ff. Above Land Svisra'
'Top of caeirg tar mlra*d aVw W3w land surface mey reGti•a
e wide r-ee !n axflrMm with 1 &A NCAC ZC .4118
a. YIELD (gpmr. _ _ METHOD OF TEST
f. 131S'.NFECTION: Type Amount
= g. WATER ZONES (depth):
Top Bahgrl_ Teo _ BaNwl
Tap , 9oitcr� Top BeWm
Top aottnr ieq _ 9aflan�
7f5kkreaeyl
T. CASING: 049th DtafnaW Violght IIAatsrlal
:Top-4 _6otlam_S5 _FLU Sr SD GFVc
Top 0 Bottem_6 _ Ftj,2r", �t F'&
Tcp 130tom R. ,—
S GRDVT: Nptn Mateflal meow
Top 0 6&''cm 52.8 Ft Etxda'9d _'Fwie
'op eofto m_. , R
Top Bodcrn F! _ --
lk SCREEN: Depth Vitndtar Slot Stxe Materia
TOP 1m Bottom- 4Q_- - FL 2 V. -Ul in QPVC,
T017-6 -- BAltafiLFL i.25 tL _LLL fry QPVC
Top Bottom Ft. Ln. In,
V. SAND?GRAVEL PACK:
44091A Slaw Yetergl(
Tap 53.9 Bd.�m Fes_F'.. �_ Silica -- .
Top_(A_a&..crn_7Q_ F: 91_ 81lica
Tap sar -n F
11. QRILLINC LOG
Top Bottom Fornl9Aon DOSMpLOa
l_7q _Ci tv clam sa c
r
r � _
-1 -
r
1
11L REMARK8:
30165 sand sea[ from 52.8-53.9' and 61--64'
i 00 rIIIII111119Y CWrFY III AT 00W R147M IN ALOMWJa:i W TM
• IGA WAG X WELL tiCIN4'RV.—n3P14rAMC'N4M mm TWAT A o;IPr OFTme
REOM IV6 My_11 FTpVUI) T -K WELLG1VNM
Z� lM f z fr
3!UNATO RE OF CEffn17 FD 'AT-1L CQWVA DATE
12a I?cga-7 Mt c.ueR-
PRI.NTEP NAME OF PERSON CONSTRUCTING'K WELL
For•+ GYy-14
Rev, 21%

&4NR,ESMENTIAL Nysm.CONSURUMON RYCORD
North Ctrolira Dowin=t of Env L'onmor t and NeLu rsi items: kzr• Diyui a of Water Qludi�
**'ELL CON11'RAC'TOR CXjrriFIcKrj0N 1112675
1. WELL CONTRACTOR:
.Robert Miller
Well Ca•,"Mr (Ir4l due Harr.O
VWoLI Contralor Company Ha-e
1058 I
SaW Add: ass
Foa Mil 6 Q 2U715
C'ty or T~. State rip Coda
L803 y 48-2180
rae pads Phene wimber
2, WELL INFORMATION:
IYE',L CONSTRUCTION pmmfidWI0400098
7TFI .R ASSOCWTED PERMIT/(t apptlralls)_—
wr waL d7 DLIW-78 &
1. WELL USE (Check one Bw:q kfonlorny Q Ll
rlduatiUCOmt Wdei n AC-Icu.turo NI Rasavaryn lrl.adoh fif
IrHpanono Otw C plot use}
DATE DRILLED IJ-1.Z-1 1
R WELL LOCATION:
2 00 Lowery S,
(Skeet Pane. Nwmbds, Corrrmoo.. SubcNoW, LW No, °ucs , Zip CoCs)
cTy-.-Winn-Sal m co,.NTY_FI?rg-yth
TOFICI 4pF11-' I LANDS ET71MG: (d" 4w%,Aa boot}
OStapa CIVA;:ey flat []Ridge Pfter
36' 5' 30-6800"
80 12' 46.8100"
LaLwdalle,vbdesoure: O�&PS ir] Kt-aanlcmap
r>--&dCw' od ow mud 6e slxe wn on 6 UWS tope Tian are arac_ne 1 fe
:h15 IU it not usuh!g e3PS;
S. FACILITY (Nu a of the business wure tv yell B laeetml)
Fcucaar-Flakf Pradttct-, � MQ 0017
Faea,ty Name faddy •D# Of app'"c a)
2f1 M 1 rowery St`-- -- ---
Shlaet Address
_._ NC'2Z1 M
city or Town stale ZJp Cade
Contact Mama
9725 Qorjdjll-Rd- T
Ne tng Address
_1Knoxville - TN 37912
My or Town Slate Dp Coda
I965 - 0&ffiftQ71-f774
Area cols Phpno namber
B. WELL DETAILS:
a. TOTAL DEmi 70ft
bs DOCK WELL REPLACE E)(ISTING WELT-7 YES 0 NO GI
c. WATER LEVEL Below Tap orCrim inp: SO _FT.
(U%e '*'It Abode -op of Ceshg)
d. TOP Of CASINO IS 0 FT- Above Land Sa(im'
•rap of om;np torNnatsd etfar Delax lard el 1w meyM+ke
a Variance M accords rce wM i'_A NCAC ZC .011&
w. YIELO IS pm), IdET140D OF TEST
t. DISINFECTION: Type Am ord
: g, WATER ZONES (depth;:
Top Bottom _ Top BoMm
Top Sum Top Bctom
Top SoUorrl Toy SC901
Tldcknessl
7. CASINO: Depth Diameter Weigbt Material
Topes_ 8lftm j5 Ft 1, 2 5-
Top— eolSxn Ft
a. GROUT. Doptt. Moterlal ktatTlad
Top-Q—Bolom-U __ - Ft FQftnd� Remit
Tap Boiam Ft
Top S-U%wrl Ft.
IL SCREEN: Depth Diameter Slot Shm mom
Tope 9w fan3�_ Ft 1.25 IR. -Q ;n. Sj($�
10, SANDIDRAVEL PACK:
Depth Size Mouripl
TopAA—ez�bcL&L—F��- Mica
Tape-,�Bauom-T - i L sSlice
11. DRILUNG LOG
Top Sawrn Forr�wrlan Des ri"or.
0 170 — l 'i
12 RENA M:
30/65 sand seal from 53-54' and 60-64'
DO P-kM-FY Curti.wr'a Ai T • IS WL WM CGNorRilt enIN AC YRTH
• 154 HCK: tC w41.L CC.IGTRJC TION S'TANII i06, XND TWAT A CC`-f 01" nr S
11 MC= 10E eM TC TK- AEU OVMa R
60.YATTIREOFCERiIFIEDVY l.C9ATRALar0—R DATE
1�uz7 m d tc �2
PRINTED h"E.O= PERSO4 CONSTRUC"nNO THE WELL
Foyn GW-1h
Rev. 20

NON BESIPE1VTML VQLLC' NURUCi'[ON RECORD
North Garonne Department of Enyimnmont and Natural Act rws• MvWon of W WV Qv Q fty
WELL CONTRACTOR CEJUIFIC'A110N r1 2675
I. WELL CONTRACTOR:
WWI Carhyeg4r OndlvliAWj Name
sSaedaaC Inc.
Well GonlraCkx Company Nprne
g488 Northfield Dr.
9treel Addmm
CNy w Town ftle ap006
L803 _-) 548 -2180
Awn code Photy number
L WELL INFOR AMN:
WELLCONSTRUCTI1O+i PCRmiT*VVI0409M
OTHER ASSOCIATIM PFRM! 0(0 aaplcab6)
BITE WELL ID r(e cppaotr.) LQ IW-88 & DUMD
d. WELL USE !Check One Sox) Mor>1larirlp :] lrhrrd48VPLbIIC C:)
InduetrlaMommerual Q Aeda hual [I Ramvaryp InJxken d
rrQaronl ) Cthor (- (let ueo)
DATI= DRILLED_i l-1 2-11
4, WELL LOCAT*N-
2M Lowery St. _
Name, Man Sowr Cammunay, SuLdMrar4 Lot Nick, Pwuuo 4 Coda)
cfty: W miLorn-5 Iem culmr FQLsvth�..
TCPCGRAPHlC 1 LAND SFrrtidd- (ceedk Lmrwwm bc4
CSlops t7Valley rd'�Iat URd" jother
36' 5' 30.6700"
80' 12' 46.6600"
I89!veellongpatle source: LPPS L]ropoBrNnh.c mop
!IvoaMw a *qW r»ud be smwn on a USGS lopo mw endstla Aed to
Uwa Aum A' Fpw Ueft GPS)
& FACILITY (Name or the business where ItaweI In located.)
Farmer F'lnkt Prodtjctq ❑nn 0017
Fedoly Name Fad" it* (if aponable)
2,001 nwpry St - -
Steal Address
VOnAtnn-,';;a1EIrT!
C:Ry or Town stole zip Code
Canhot Nome
�i7_ 'S randlll Rom_
Malirg Addreae
Knoxville TN 37R32
Clly or 7wm Stale ZIP Code
( 86515fiftV.T&t-671-6774
Area cads Phorre nrrrber
A WELL DFTAIL S:
a, TOTAL OEPTHi 71 R
b. DOES WELL REPLACE EXIsTiNG VMLL? YE8 n NOIV
c- WATER LEVEL BWow Top of Casi-y. 51 _ lFT.
(Use'-' IfAbow Top of Ca6kig)
d. TOP OF CASING 15 _ _ PT. Awve Load Sorlsae'
'Top of caalnp :emlklelad afar bwow lard aurtace may requlre
evia its we In dccadenca With 15A NU 2C .0119
e. YIELD [t?Lxnk hlETlioe OF TtsllT
R 018ONFPCTIOH: Type Amount
W WATER ZONES;cbplhj:
Top Bottom _ Top Botlorn
Top Bottom Top _ Roftri—
TOP_ accom . -roP-- - Batlo^i
T h IckrigwO
T. CASINO: Depth DwMft%r Might Aietarlel
TOP. 13 Batton r Fit 1 26" ssc $Q GM .
7oP �_ . eoltcrn FI 4.25" o Sr PyL,r_ .
S_ GROUT- D 6M Netedlel iretNA
Top- 0 _ Boltam 63.8 Ft. POr lam _ Iremle
Top_ Bodor _ Fl —
Top Morn Ft
e. SCREEN: Depth Diemater SMSloa Nwarfd
Top 0 BoUom_M_ Ft. 1 251n. LQ In. SMQ
Botivrn FL�Jn. tn-
10. SANDOGRAVEL PACK:
Depth Size Mahrlal
Top,-y5J__Aobor:� 1�12__ Ft.,_#1-- 6lilc�
Too6447Bo"-Zl _ FI. #1 Silica _
lot: k3atlora F t.
I I . DRILLING LO(i
Top BopGrn Formation DaacopW
�1Zi� djM sand
1
1
. 1
1
12 REMAWS:
30165 sand seal ff4.r.11..53.8-55' and 61.2-64.7'
1 OO HElit'rTY C Url" TNA7 TMV90 WINS 000WRI1CTEOel ACCAIIQI IN WRK
• ISA NGC 9C. 6*UC4rWrKXTKMSTOtDAP 6, Nil RYU AL CWf OF Ras
Nr aHASeLAMM MXDTbn-[Y&LL0yA%A
b'y ATIJlRE OF CERTIFIED WEU CONTRACTOR RATE
/itL.�r7L
PRINTED HA.ME OF PERSON CONSTRUCTING THE WEU.
Fow ow -lb
Rev. 2M

E5'I rT&ELL COMLI&FION
North CmIlr& rAV 1merit 4 Envitorumat and Nuwal Rveouroes- T IAWon of Wster QL49hy
(6
W &U, CONTRA(JOR CERTIFICATION 4 2675
L WELL CONTRACTOR:
Oeft Wier
Well Ccnf oW (w4%4dj&) Nam
SoedaQc
Well Cenbe tw Compery Nafrta
Steel Address
C 1y or Town Stale allIcaft
C$23—r 5-0-2180 Area Coda Phone nttrrbw
2. WE LL INFORMATION:
WELL CONS T RUCTION PERMtT6 W10400098
OTHER ASSOC ATE PERMTT#Cf gplo W)
WM WELL tC Waopaoaltls} QU -Sai3k Du VMa
]. WEELL USE [Check One Bo; Moillodog­j MunldpWrubft 0
IndLMWtailCOrrlPTf (dAI N Apn06 Mkni l L1 Rw vwy l I mptdlort if
.1198SDnC: Othr I 1 (1st use)
GATE DMLJ EO 1 i--12-11
4. WCLL LOCATION:
2000 Lo +e-nt 5t. _
i91r ' Name Nw"@, 0omm4nit3r, t'nEbdlvral0n, Let Ito.. P" f?p (&)
CITY: Winston -Sale n-_- COUNTY FQMYk
TOPOGRitPH1C I LJWD SE-mNG3 (at" arrfirowaYbctd
+ ]Siape J Ys lay J(Fht 17 Ridge 00tb&r
36* 5' 30,6800'
80' 12' 46,5100'
La'kudeAoiplude source: QM LifoVVraphfc map
05mw-n of wed rfWaf be shown urt it USO3 t'cpo map andatre--�aa !o
%4 form rrwfashy OPS)
B. FACILITY (NWW of the bus;frees whore the vw* 131omto&)
Fnrmet Flakt Prndwjr
ct non nn47
Fac" Name
I
Fedlgy ID# (U appli sgla)
--2(M nwArygt_ -
Street Address
--
Wi ,gtQr,-yak--m�
Cly or Town .
— _ - Nr 271 iri
Stale 7.1p Code
AMFC - .1 A erti+iP.fF3i�.s�
Carted Nero
Meairtq Address
KnoxviJl
TN -ug32
,,gy or Town
stew Zip Coda
cM5jj 671-6774
Area code Phone tvimbar
B. WELL DETAILS:
a. TOTAL DEPTH:3tflL - -
b. DOES WELL REPLACE F-Xlgnh i WnLL7 YES NOW
4. WATER LEVEL 6e10w Top W Cwing: al .. T.
(-Ao'•' N Ahme Top of CaerQ)
'4, TDP OF CASINO IS C FT. Above La)a 5u11C,$*
•Top or caMV ism inakd atror betaw land surface rrwy requ"
e vadenos Ir scoordeow wth 16A WAC 2C .018
a. YIELD {gprnj: _ -- METHOD OF TM
L DISINPpCTION: Type Amount
p. WATER ZONES ,depth):
Top 8nnont_ Toq� FlOtlefn
Too—. Botbwi- icp_____ —BAXT
Top BOttorn_­ Top BOWM
Thlckrm"
7. CAB LNG: Depth Dlamotor vhlptlt luarld
'TOP-0— _ _ fioborr56_ _ t ! -i 2_-M QPVG
Top- Q- Bctlarr�_
Top Batton FI- --
8, GROUT: DeoM 11 ato -w Method
: Tapes Bottorr�,�.. F',.�4fElHI1C1 �_ YFffi]'I]@
Top____. Bolton Ft.� -- — ,
flap Baborn Ft
IL SCREEN: Depth Diarna;rr 8101 SI>m Not" al
Top_50 - 9tlt oa �_ Ft y ln. - 1n.. c`
TopQ§— saw 71 FI. 1.26 I% 4.09 in, , CPVC
TOP. _ t30t:ar Ft, - _Jn. ___ h _
10. SANDIGRAVEL PACK:
Depth ShIs malwial
Tcp55 BWm, 61. _ F1ill -fig
Tcp- f�5_ _Bofiom_L^ Ff. #1 suica
Tap - 8010m FI._
11. DRILLING L04
YOp Bottom Fortllallon DeacgtIon
1
1
f
1
: ix Rl:Y.ARXS:
30f65 sand seal from 53,6-55' and 61.4-65' _
100 HVEAYOERM TFMT In INVAU YI& CORNTIV.XTfW INACpQILr]NR; , %4M
: NN WGOC 7r. W13L . 0ONSTRUG- N 81A1 MA X ANu' n4AT A COPY OF fl-U.
BFBI Pra01rld1iD f0 TW WELL OV*ftA
ilia -Ill
siGNATURE of CERTIFIED WELL C: R RAC DATE
fr-69efZ? %b[ AYL
PRINTED NAME OF PERSON r0kSMI.K.TM TW WFLL
Fam GW-1b
Rev.. 2"

�r
I. WELL COHTRACTOM-
RobediMIDer
Well Ca'Yrae"or (hdiulduaq Name
�aadacco Inc.
wea Corltrecw Comperay Nose
900 Noitb,fleld Dr.
SVW Add re"
— Fort Mill SC 29715
Ctiy w Tow 5hte Zip Coda
A-3 K
free oodo Phone ruTdxw
I WELL INFORIAATION:
wr-LL Cons-rmC`TON PERMr'f/._IA 000$S
OTHER ASS CIA-FE 7 PERMITpr w0baoa3
SITE WELL 1D"av b b.1 DLlW-103 & OLI -100
3, IWELL USE (CTedc One Box) MortRodnW ) Munla7 9WQb'IC ❑
InduaWstrt4wo rd81L AgrtuilRnaiCl :Iwzwry! ii InJeCSen,(
IYgsdcno Other 2 (Est use)
DATE wtmuu.11--12-11
4. WELL LOCATION:
2000 LQWeLy $1.
(SYeet Nome. NurbeM CanvnunRY. 8utl4401oa Let ho:. Pettit, aP Ceder
CITY: WlnstwSalem COUNTYFOtS
TOPOGRAI'M r LAND SETT NG: td" appiW4&% bail
❑Slope L VXPOY UVW 0111doe ❑Other
36° 5' 30.7000'
80' 12' 46.4200"
6aNudellorsgRt,do source: 6A3P5 �opoyrwltt map
&Mkn of wW maul as *Nhwn IXi m USGS logo map wdallsrJW tc
dille:turm fatal fj," GPS)
$- FACIUTY {h sane of lhe hueinoss whore Gee wsl is located.]
Faddy Name rao.:y"{M epp0wb1e)
Mo(I l amLeni Rt
Stress Address
—%dinRton-Salem jyC 27101
CRyor Town State Llp Code
.AMFC' - ,100 EleathFiraoe
Cartect Nano
9725 Coad►llRd-
Ma07ng Addrras
City or Tom S.ate ZIP Code
Arm adds Phaseru nber
9. WELL OETAILB'
a. TOTAL.IDEPTH- 71 ft
b. DQES WELL REPLACE E7@8T1NO tftELL1 YES'.) NO GV
s. WATER LEVEL Below I'op of Caslnp: 51 —f-T.
tLha 'F- If ►shave Top of (Snt g)
NoN.RESIDEN77AL WALL Cols E-_RI MON RECORD
Borth Camlim ileparirneM of SnvIwmrbat and Noturxi Resouraa• UlvWoa of Wa* Q.%I ty
WELL C:O.YFItAM)R C'ERTIFIcATjow Y 267S
= d. TOP OF CA9iNG IS.(3_ FT. Abov9Land Sur1aw
'Top of eesiV wnunated atlor below land wrfsoe rwy requre
e va1Rnoe to aoMm9rice 0,r I &A .YCAC 2C .D118
a. YIELD Igpm) NETHDQ OF TE81
f. OM WrECT1ON: Type Amount
g. WATER ZONES (deem):
Top 13*W Top . r90w
Top _ _ 80:totn_ , Top Bottom
Top 8r:torn Top , 8aftom
7Alcknsas<
7. CA81ING: Depth ohimeter Weight Materw
TopQ__Behan:-o F1-I..Zb;m PVC
Tap Bottom Ft
:8 QRDU":: Deptn Neteriel Molhod
i TSv�_ 59— F► EQAAl d _
• Top Bcr F7 _.— . —
Tas . Botoer FL
9. SCREEN: bop% 1318"bd Slot Biro unarm
Topes_ Bosom- 81 — Ft,,�in• . Q QL in. _Q
ToP_ae__ BMLom 71 Fri t_25 rrt 44Q1_. In. SO& -
Tap— Hotlun+ FtJn. In.
10. SANOFGRAVEL PACK:
Uopth at" "terial
Top. 55 _80co T 61 • Fi.A_ a51lic
TopBvttam 71 Ft.
It. ORILLINO LOn
Top Hounm Fove11or UesodpOw
30165 sand seal from 54-55' and 61-65'
i M Witu t'CFAWY rTMT rles NMI7 WelYa'ie AODDWACEH
•15ANCAV2.YAU0DIITIfJCT40N MlaMlh�ACQr4ITHa
wCtc�A mom PMAIMIro Twill IYEiL OVOWL
SIGNA� MTFF!ED WEL 700147RAOOR DATE
f�-c�a�rrr /Y11cC.C%Z
PRINTED NAVE OF PEROGN CONSTRUCTNe Tt IC WELL
Form Q W1b
Rev, i109

ew
1. WELL CONTRACTOR.
Robert Mille[
Wa.i Contractor (InclivldwW) Kamm
Well Contraeor Gornpany Name
908 Nortift1d dr.
Stre.�et Addres■ C
Q(
Cky or Town $tots ZIP Cade
( 803 ,
Am lode Phov ntAnber
t WELL INFOR11U1TION:
WELL CO NIS TRUCI ION PERMIT/ W040M98
OTIiER ASSOCIATE0 PERhMTa(y"Pkahb)
srm WELL IO i[r wo-o bei Q - ❑LIw J 1 Q
3. WELL USE (Chock One Bax) Monft&V D M1 MldpsuPub3cG
M%mtr ia K amme rda I p AGrlcufhxalp RecoueryI- t dionof
kripatlonrp Otmof G (Mt use)
DATE ORILLPD, I j9-'ij ,_
i. WELL LOCATION:
ZOM Lower1C SL _
(Street Homo. Numbon, CmvwA*. 9wb*Aolon. LO No-. Pw*K as Code)
cay: Winston-Salem couNTY Forra)o__
TOPOGRAPHIC I LANO SETTING: (dwck eWop m Wmr)
QSWpe LIVaWy trial ORkW pother
36' 5' 30.7300"
80' 12' 46.1200"
LodhWcAangNude aatme, QCP3 : 1ropograph1c map
(raca6w of w*d must be sherwre w a U5GS repo map andsJUM adld
IMS Arm it pot U" GPS)
E. FACIL.rrY (Name of bho txrs,roee wheee to veo l is totaled.)
FnrtnerFlalsf Prndyd g ❑n4 n017 _
Fac^ Namur Fatirty'LN (if applicable)
20nn I nwary St-
SIr"I Addrena
WIn_stnnFilAm _ _ -NC _ _ 271Ilft
City or Town State Ilp Code
AmFC -,Lae Deatherane
Contact Norm
RZ25 rwelill Rd
MWIing Address
City a- Town slats rap
r 865- 54+671-6774
Area Code Phore number
8. WELL DETAILS:
a. TOTAL DEPTH. 71 R
b. ODES riELL REPLACE EJti6T1NG WELL? YES ❑ NO4r
c. WATER LEYEL6etvw Top of Caft. Rf}FT
(Use'•' K Above Top of Caarrq)
N9_N.fiFA1D&1YT1AL w i.L Gi3NsrRUL:110114 RECORD
North Carolina Department 0fFov4o111 Brit rmd Natural RMV MS- Divlaion of Weller Qwwi!y
WIELL CONTRAC70R C,'IPATIFICATION M 2675
d TOP Of CASING !S 10 _ _ Ff. Abwo Lend Su foco'
'Top of caslrq 4vrdnersd aver fiMow land turhto mar requra
a verfance to ■acwftncs vAh M NCAC X .D • I a
a. YIELD I9pml: NiTHOO OF TEST
f, DMINFECTlON: Typo Arsount
WATER ZONES (eopth).
Top Bottom Top 6Mrn_^
:Top--- --Bottom—.--- Alp Bottom.
Top Bottom-- - Top----_ Botlomi
Thlckamaol
T. CASING; Depth DiarrIew Weight wt.Hal
TOO Q., aoaorn_K_ FJ,_LZE— 8) Sd'�CG—
Top —_ Bof1MM_ Ft.-1,26* & IQ
Top 1306=__ Ff.
e. t3ROlfT: neptn Motertal Mletttud
Top 0 wt—> 4_— Ft - 20daati Trernie
Top (4011om FL
Top_ Bettors Ft
0. SCREM Depth Dlematrr Slot Sire Mrtorhl
Top 56 Bottor: 61 Ft. J2 �i . Q U :v Qp3L
Top 66 scam 21 Ft.�_�� 1�.G1 in Mrl
Top aworn Fr• _ -1 _ _ in
ND. aMDIGRAVEL PACK+
Depth atte MotoAal
Topes wBalsam 6a.3— Ft #1 Mica
TopA5—Bottom_ 7i,A_ FLU,!
Top IMorn— Ft
11. DRILIWO tOG
Top Botlorn zorrnaiwrt Deacripilon
�! 71 Sib saacs
1
IT
1
_-J
F
1
12. REMARKSe
30165 sand seal from 54-55' and 61.3-66'
I M Mat M {xrtTFe THAT Pb WILL WAS CONSTAL)CM M A00011M)OWN VAIN
• 16A Nl=X, STAerCTOr STAMOe,AM AkO Y MTA 00" OF THS
TpR.
► 9 I1
t'iATL� OF CERTIFIED LL 'CONTRACTOR DA
PRINTED NAME OF PER30N CONSTRLJCTMK3 THE WELL
Force GN•1b
Rev. 2"

�■ a
IYN.RESIDENTLIL Mil rQysUMI—_ -101r X&CORD
'EOM C6MHU I7erurtreieet drvAYlrof MbI1t VA NaMMI RsaatrM- Di►rsion of Water Quality
WYla. COMRACrOR CERT1FICA111ON r 2675
1. WELL CONTRACTOR:
Wd1 Contraram (lydMptmi) N wm
Weil Contractor Company Name
Sheet Addm a
_ $C 29715
City or Town StaleLp Coco
c 843 548-2180
Area code Phone rturnber
Z WELL INFORMATION:
WELL CONSTRkiCT:()N PIE RMrr4. WI NO 8
OTHER ASSOCIA7E0 PERVIITS(r.Mlwhlry _�-
SITE WELL I Oil' q p imbis) OLf -12S SDI -1
S. WELL USE (Chedt One Box) Monitoring ❑ Mu*c1mWUb6n0
Indusbi"ommartial O Aancunsual L] Reoorwy(:; Ys]6C1g If
begat n Other(] pistuse)
DATE DRILLED _11-19-11
4. WELL LOCATION:
2000 Lowery St.
(StroW Piww N, mbws. Cemmfnky. bti,trR.-sim Lai Nw, Pa mL Lp Code)
Crrr:ygnston-S alem _ Coven F MY! h
TOPOGRAPFMC r LAND SETTING: temm appopmobw
CS -'ape ❑Valley 0Ie1 ❑Ridge (jdhv
36' 5' 30,7400"
80' 12' 45.9400"
LanAwlomnwe source: MP3 0rDpoyrapllk map
{rocaecal of tiro rnwar ba &Wwn on a USG 1*0 map enoaftfawOR
rho rbrrn if not sing GP$}
5. FACILITY (N Iamn at the buelnesa whore tam well is icor:ed-)
F"ty No rrra FedWy IDE (If applubb)
Street Address
- ]dmiQn-Safam _ NC 27101
udy or Town Slate ap Gode
Contact Nerve
R725 c- andill Rej
p Addrras
Knosnrille IN 17932
City Or Town Slats ap Cede
1865 671-6774
Araa Cade Phone number
6- WELL DETAILS -
a. TOTAL UEPrH;1] fl
0. DOES WELL REPLACE EXI&TIN0 WELL? YE ❑ NU LTV
C. WTIrR LEVEL BODW Tap of caslrp! 50.07 --Yr.
(use'+' If Above Top of Casing)
d. TOP OF CABING iS _Q , FT. Above Land Surface
'Top Of -ahg twrn;natad War below lend suftce rrrsy require
a ve'ia+Y� �n ac.:oraenae veldt 1 tSA I,tCAC �C OT s 6
e. YtELDIgpml- METH000F TEST_
! DWINFECTION:Type Amount
WATER ZONES (depth):
Tap- tlwom Top y boV. m
Top__ Botb7- ._ _. Tap Bean. _
Top _ Bow'n _ Top—_— PAtmrf .
rAlslta.aa►
7. CAaIkG! Depth aaswlehrIEh1 asatarM►
Top Q _ Bdtorn� 1 25" SC 80 CCVQ
Top �^ t3arotn �� Ft._ 1.25 5C 8Q CPVC
Top Bottom Ft.
a. GROUT: Dept 1101e191la1 Method
Top, ___ Bottom- 54_ Fi PCdar►d Trwi2.�_
Tap Befmm FL
Top Bcitare FL
L SCREEN: Depth CMenebr Slot Bbn Metltrlsl
Topes_ Bottom- 61 _ Fi. 1-25_1n. 0-01 In. CPVC
Topes_ aoffam_Z.J_ FL 1 .25 in. 0 01 In. QFVQ
Top Bodoni FL In. in.
10. SANDMRAVEL PACK --
Depth Slav lltdarhl
Top_K __-_Bottom 0j2 Ft. #1 SHICg_._ -
TOP­g_ _71— rt.-91 ,$ ilCa
Top Botom FL
II. DRILLING L03
Toy Bottom Forma4or Doecripcon
io f 71
1
1
I
1
1
r
r
51Ity "CA -
1 x. REMARKIII.
30f65 sand seal from 54-55' and fs 1.2-fib'
I W MEW C cMWIF74AT IM WELL V4M 0101W161CTEo W AOXftWCt MTI�
• 16R YMFLL C.aefrtltaJrgel SrAMOARP6. AND T►µT A COPY OF 111A
FS! To DVMER.
SIGNATURE DF CERTIFIED 4+QNTRI1L`70 DA.
PR%NTF0 NAME OF PERSON GAtiSTROCTING THE WELL
Rev- 2"

■µ 4
1. WELL CONTRACTOR:
..Robeft Miller
We" C nb'ottur (hldhddua)} Name
Web Contractor Company Marne
ki Dr.
Str"t Address
City or Town Stall. zip Code
M 5 548-2100
Attie coda Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMrr* W(0400M8
OTHER ASSOCIATED P•ERMrMV•pptla6Ml
SIM WELL in4110q cw.> DLIW� 8l DLNV 13❑
3, WE L VSE (C neaa One Boy) %WiltorkV ❑ Mw***@Pubk 0
nd ustr I aVCcm mwdal [] Ayrleullural0 Recovery LnJacOm j(
n1ga4on[I Other l3 Q!at use)
DATE DRILLED 11-10-11
4- WELL LOCATION:
Obvut Momo, Numbm, Cammmnsy, S•4WuIM :.ol Ne, Pip Lp Caere]
crry. MnstDn-Salem couNTY Forsyth
TGPOGRAPHIC I LAND SETTING: (dwca opp t*9
C1SIDpe ❑ Veley at1at 0111d9a ❑ 0har.
36" 5' 30.7700'
80' 1 z' 45.8100"
L96YWeAwv%)* awcw V3PS ElrapWropik map
( caffon of wail must ba shown on a USGS 1=0 map errdafwt ed 10
mla kum If real esln; aps)
6. FACILITY (Name of the husiness where do wall is Focxtod.y
Fnffn jr RAW PmdwIN _ MCI QQ17
F adlity Name Fet:Mty IDt1(M appkebte)
20M L-nwnry St -
Sweet Address
NC 271(11
C" or Town aale 4 Cade
Comex Name
9725.Cgae il�.. _
MMMnq Address
Knnyvilte TN 37932
Cky or Town Stets zip Cope
671-6774
Nes Cade Phone nk moer
a. WELL DETAILS:
a TOTAL OEPTW-71 ft
b. DOES WELL REPLACE "STING wr;LL7 Y£Si] }qiwl'
C. WATER LEVEL BW*w TOP of Casino 50
(U".. K Above Top of Ca")
NoN REuPENTML WELL CONffRiI MON RF ORi]
,4nrth Caruiins Nportinent of gaviro went and Nature! Rasources- Division of Wear Quality
W V1-1- C'DNTRAMOR CERTUIVATION N 2675
d TOP OF CA81NQ 18 Q
FT- Above Land Surface'
'To p 04 o"np terminalec @liar below lend surleae may require
a verW nee in aw"danee a* 19A NCAC 2C -0 11B
r. YIELD (gpm): _
IIETIIOD OF TEST
f. OISINFECTION: Type
Amount
a WATER ZOKE3 (deFth):
Top_-------_ BoMm
Top anllrxn_.___�
Top -- Bottom---
— Tap— — BOtmm
Top Bottom
Top Botio/n
rnlckness)
T. CASINO: Depth
Dleettrw tlVrlpht Mellow
Topes__- Bottom- 56 Ft 3. & _ Sc 80
Tapes_ Sot'om F� FL1,2" 09.
Top Sottnm Ft
a GROUT: Depth 1411;IrAe} M911 d
Top 0 eottom-&U- PL,2M1Ud-- Tremie
Top Bottom R.
Top Bohan Ft
fR ACRE Depth 61 Dlartteler Sld Size Matartal
Top �oitAns_ft&FL 125 n. Q.Qj in. CPV
:Topes Aotttlm 71 FL 1.251n- Q.DI ;n` _-
Top Hahne FL In. In.
' 10. SANWRAVEL PACK:
9 DMM 61.5 MM UtIortal
Toy S9libm,U_ Ftjlft-_ 91iira _ ---
Top 66Botiom FL
: 11. DRILLING LOG
Top BOOM Fom. *bDn NtmpWn
-0 - J�
1
1
1
�J
12. RNMARI[A:
30165 sand seal from 53.9-54.9' and 61.5-66'
100 Mt'. tm 09MIFY TINT TM yrf M W" DoNIrT►=M61 AOrJ01e]R= VM
1e4 MAC. X. VAU L COMMiCrOO STAM APM AND TINT A 00" OF rip
TC rM 4Y$L ovo"
SI 'PURE OF CERTIFIED WELL dWRACTOR MATE
Rohe_+t Millar
PRINTER NAW OF PFRSON CONSTRUCTING THE WELL
Form OW-tp
Rev. 2M

.Nor sm wT
r,
North CwAlan MpuimerA of Unvironawd end NCUM Rese'lraoa- INvirlou of Water QmUty
Is,.,. wEu c otfr►ucTox CER'MCA'F N # 2675
1, MILL CONTRACTOR:
RobeitMllet
wd �l C.o,r,ftckw (In mcklui) Name
�7��45�111!�e•-• Well Co*eoW Company Name
9080 Nadhfield ❑1.. --
SU*at Addroee
Chy or Towp SW& 4 Code
(En 3 548-2100
Area code Phone rnmrber
2- WELL INFO RMAMN:
MA-1- GONSTALIGDON PSRMIT/-t%AQ(H$
OTHLR A66DCIATED PERMrftl(i q*OwGe
plrE vvELL I� li(reap k+eCle Qk �.�145 �i Q LIIIV 14 f3
S. WELL u 9E (CRadr. 0rw pox) MorlLnrin917 MkM*Jp84PubI;Q (.1
Ind uatrlal+Camn+ dal❑ AUrkxik"l0 Reoovwy[I I*j Zonh(
"utlonrl OUwC) (latuaa)�_..
DAY'E DRILLED, L-M 1 {
I, WFI-L LOCATN]N.
2000 Lowery St. _
(-%-W Hare, Numbers. Coromuntr SLbOA",L Lix fio , aa:.al. 7Jp ode
crrv: Winstoi7-Sa1em __ _ -_ Q*uN-Tr_FgjsA _
TOPOGRAPI tiG f LAND SETTWG- {cheer apP%*Aere bowl
J&Dpe LDVILky eld :IR" L101her_
36* 5' 30,4200"
80' 12' 47.8500"
l edtuneJlorgllude aaraon: LaVS {_]ranogrephk map
(bc Nm of weft must be &flown on Ii USGs kpo nw anantlechadlo
tMe Axm tllrnf ual?u GPS)
& FAMITY (llama or the busnooa vfia a tr* wall e9 Ix artwd-)
FnaWr Elak1 Products
w 0017
Fusp:ty Nampa
_•1 _
Parity it)$ (H Bppllcabia)
�2MO1.nwnrt_Sf_
Shot Addralla
ibs#oo'Sxlem _
_. - NC 2710.9
CRy a►'rovrn
State 71p Code
eraae
Cw0d Nacre
OX25 Cnadlll Rd-
Mdi rg Address
- - --
JSf anditi -
Coy or Torn
--- - - TN UP32
able Zip Gwa
( BOA 5 6J— -fi7-74
Area code Phone nranber
a- WELL DETPJLS:
a. TOTAL DEYrMi-Ma
b. DOES WELL REPLACE EXISTIN13 WELL? YfiS n NOW
c. WATER LEVEL. Balvk
(Use '+• If Above Top of Ca ft)
it TOP OF CASING 19 _ Q_ FT. AL ow Land 8ixfavo-
0p of =Ing "meted alloy ba}mr land Wfeea m+y rop,v+e
A VW0rxx In eCCONW06whir 1tSA NGAC 20 .011B.
A YIELD (9pm). M9THOD OF TEST
f. DISINFECTION. Type Arnoua!
g. WATER ZONES (daplhj
Botlorn - Top Botlom­
ToD _ Botlom Top Kett nL2 J —.
Top___------Bok)M lop.-. — Bottom
Thkknaeel
.7. CASING: Depth DLemeter tt601
Top-2 Bottom 65 -- =1. 1.2§" & BO
Top_ D - -.. Bonm--aL- -t. 1.27 . � 8Q
Top Bottom -I.
S. GROUT OgAh MaleAal MW"d
ropes BoUorn -. __ _ I L�rkd — 7rertlie
Top_ Stem"--- ...... Ft. -- --
Top 9ottorn FL_
9. SCREEN: Depth Diamrater Slot size amewrsal
;Topn_.YFt-1,2ln• -Q.L In CFYr
Top '� . Boftnj PL_71�,5 In. . 9.C1 _ In
Toff Boa= FtL_In. In.
14. BANDIGRAVEL, PACK:
iSerlH Sloe MamrMi
Tdp.K--8oftm1Q`_ FL #I -alltw
Too Sown FL
11. ORILUNO LOG
Top 00" Fnrmatlon oes'• Jipwn
30165 sand seal from 53-54' and 60-64'
100 HBV Y r;ETMN TI AT rMMt -I W400N6tHIJ= D INAODDRO 1 MWT11
• MAWAC W, Y*ILnpaleTrexXr SYAH ApMAN0 THAT A OCW OF TMs
73 � �To aw+Fx.
11 ZI 11
sgNAiIJRE CERT1F1B0 WELL i:tlNTrth�DR' OA
Rob.QN- m:Ilrr
pwrm NAM of PIERSON CO URUC'TING THC wru:
Farm OW -lb
Pow 2M

No WILL C2MUEBON RF&gRD
North CaroltmTkT4rbmnt 0f"Eavironmant and Nate W Reeourow . Dfylsfa: of Water Ouallty
r W191.I, COYrMCroR cmnrICATIoN K 2675
1, WELL 09NTRAC VR.,
We Cart ractar CrAvidual] Nam
! Wel Cor,Lamr Cwnp" MOM
N!grthflgld Dr.
Suet AWfe"
GRY or Town State Z p Coda
803 54.8-2180 y
Aran code Phorw manber
2. WELL INFORMATION -
WELL CONSTHUCM4 PERMIT/ WlQ40 0()g§�
❑TIi@R ASSOC ATFA PERt,Rflf(Nsa kaft)
arrp wFu in otir 1.i ❑�. A-15S & 1XIVHR15o
3. WELL USE (Check Ora Box) %WlWrg❑ MunkipatlPubMeA
ndua "Vwrlwrdel ri AotctRttrW [7 RacovaryCl NjeC/DaIf
"allonL7 OlPwr U (80 use) _M
DATE DFJLLEDjj:Q0-1 i
4. WFi L LOCATION:
240a. IwgWelYSt, _
�t3barl!dams. NtaabPM Ownausft, ai.AWdon-LOtNc, P Ly Code} -
cFTr Ins on-5a cAuwrr Fors
TOPOGRAP4f:01 LMD SETTWG [c�aoc rppegrAre anx)
(aslapa I]Valay utlat I IRldge GOtI►et___ T" .
36' 5' 30-4500"
80' 12' 47"6100"
LatlWddiDrrpwM eouce7 WPS ryopopraptrc rw
j N00ftr of WOO moat be Shown cr 4 I/SVS Wo map a'KWdoChed to
thlfs kVM Ae MR U1 ng CPS)
i. FACUJrY (No -no of Ira buskreea whom t,* woo lg !omtad.)
FsdUty Name
F-allylDR {If appFlcabie)
200Q I awelv.s#­
5!oet Addmss
AwaatQtl-qaiem
DC 2710
Ctyor Town
sille zlp Coda
AAEC- JW Df attteraae
C4ntad Narita
9725�, _ ll Rd
Mdklg Addrasn
�. ----
�SLlii villa
CM]r+rr-town
_ IN _ 3793
mis Zipt'.ode
i mis si a a H 5kt§D
Argo eo4s I %nne nyrnher
& WEL4, O£TAR-3-
a. TOTAL 17Esrnf ."73
b. 041.8 W` LL REPLACE EXIST1#0 WELL? YES ❑ H03(
c. WATER LEVEL Uow 14p of Caskic. -52 F%
(Use'r' N Above rop of Caalnq)
d. TOP OF CA3IN0 0 �� Fr. Above land SWIM'
'Top of casing terrnk►rmd etkr belar land surface may require
a varlsnce IFt aeaardanco w* 1 SA XrAC 2C 011S.
e. YELD (gpm): mm+00 Ott TVST _ .
F. DMfN0dCTtON: type—� _ An*unt _
% WATER Z0*116 (daplh]:
Top 8attori Top Bottom
lop Dattorrl_ _--- fop goaom
Top Solo i . Top 9attam -
Thicitnaeel
7. CABula- Depth Olaaneter V111aight mate"ll
r4v�_ 60twm- 56 Fr.__]. E— SC 80 -,cPYS -
Top--Q _Bvtlomj" Ft,_9,,21'- 5980 MtQ—
Too Botlorni Ft
8. GROUT: Ile* Fatal mill tul
Top _ 8vtiom66 Ft f gdaol _ TMAie
Top Bottom
Top 80ttun FI-�--
L &CftaN- Depth O#arrkAv SM 81ze Apresriel
Topes_ i3&W_ _ Ft._) _15A .,IQL In- _QFYQ
TOO E� Bodnrrl 7 - - FL_J_tR . O-QL I!, CPVS;
Tap , MloalFL___Jn h ---
10. SMIDMRAVEL PACK:
Depth abo iAaFertal
TOpf? smom" Oa_ FL 01 .
TDp_$7 BoWm_n— Ft. #i-
:TOp_--,-_Notlom FlL _.
11" UPotlIHG LOG
Top Adflnm FormatWn Daaralptton
1
1
12 RENIARKS,.
30_ /65 s MLWal fram SE-,';7'and 6-4-R71 --
t u0 t 'l cmTry rwi 7)is YV=,1 WAS CY.Jtlelst.lt = at AwaptOmmVat"
{aA WAC 1C. VW-U t*irTe; ys:lk aTPAUVug IMTtMTA07'tCr TM
=cFl?9,ED'r0 ill: OYPIFJt
_ ►� 2.� 1 f
SIGMTME OF CERTIFIED M gOl�iR�IG°IbR DATE
= PRItr fffi hAME OF PF.RSaN M THE W 1L
Form t3 w b
Rev. Me

,w
NUN RESIDEA7 L WELL c NS-11-RUC-11oty R1EU[1iW
hQlh Cwulir.a Deparlmeat of Enviru mrx.i and Nalural Reaourtm- Di visioe of Waier Quality
WVLL COKfRACTOR CgRTjmrATIt' N fT 2675
1, WELL CONTRACTOR.
R�rt Miller
Wall Gorg uWr (Ill Noma --
daM Inc-
S Well Contnalor Compony Name
Dr.
Streal AWreaa
Fort Mi 5Q 2971
City or Town Stab Zip Code
L03_..j .54IL2180
Am coda Phone number
1. WELL INFORMATION:
WELL CONSTRLICTIO]N PERM-T# W104OM8
OTHER ASSOCIA r EO PERM(Tt(IfaW4obrr)^,_
SITE WE'LL is acdwpr ,m DLIW 10&Dl.iW-160
]. WELL VW {Crook One Boiq IIAonl%D*V ] McOmpoWub k 3
klduWMWCammer II] AgricaNpal❑ RecoveryLl InJaCyon lif
IW4910no other ❑ (1st usa)
BATE DfULLFD 12-16-11
i. WELL LOCAM11:
2000 Lowgry St.
{A►wt hwra. INar-bars, Omamunty. eubdMalrn, Lot No. Paraw, Zip
cay. Win1ton-Salem owwy Forsyth
TOPOGRAPHIC 1 LAND SET'ITNG: Ldw* I I I - Pa `war)
❑slope pvsley &let E)Ridpa [] ftI
36" 5' 30 4400"
80° 12' 47.3600-
LatdwaalbngXds soww BPS pro"aphlc map
Ixasnon of t+W mud be ar:own on a USGS tops map andeffachad to
1f93 Ibrrn N flat U*J GPS)
e. FACILITY 1Name of the bus kiesa wf e(a Cw wen is kKated.)
�FoIDner Elakt Products w0_0017..
Fadflty Name Fadlty IDS of apWab'a)
SL'aat Addroaa
Cfty or Town Stone Zip coft
Cvnted blame
9725 Cme ill Rd
Waking Address
Knnbtvilte TN 37932
CRY or Town Stabs Zip Codo
r RASA 3B9•Br,,r1•iF671-6774
Aran c4do Ptwno number
9, WELL DI=TAlLS:
a. TOTAL DEPTiI: 7Q It _
b- DOES WELL REPLACE PJtISTiNG WELL? YES U NO rid
c. WATER LVat Below Tot: of Caalrry:-49,3, —Fr
Nos '•' If ACove Top Cf CBS CV)
d. COP OF CASING Is _ 0 FT Above 1-aid Swim'
'Top of t"N 'Arrrd'eted odor below is sudwA msy r"Wre
a varlanoe In aCCOrdarlca wllh 1 bA NCAC xC 011 a.
.. YIELD (gprn): NETHOO Of TEST
I. DMINFECTION: Type Amount
�, tIW1TEFi �QlLEff tdt�pMtx
Top 6oftm Top _ so -tom
Top BOWM---- Top Rottom
Top Bopom TOP-- soften _
T'hickrional
T. CASINO: ftpttl Ohs lobsr Wetghq 1hhAa1
Top,Q_ Hottem. 15 . Ft.125_ �Sc 80 CM
---
Top Bettern Ft-
8. GROUTD►M klataMl Afrlllod
_U_ _ _ P-arlaad Tremis
Tap Hoftrxn Ft —
Top Bottom Ft
0, SCREEN: orptn Diamakar Sint 31ns Material
Top- - t3oftem_f Q_ Ft. 72&M QM in.. CE!YC`-
Tw- _ Wom_ 24 _ F1 _25 In 0_01 r - GPiC
Top Sort" FL In --- :r.
1Q SM134GRAVEL PACK:
Depth Sho Matarfaf
Top-,%-0QWrr_N FI. #1 - -- .Slli-a
Top_ _norlo(, ri
Top— Ballorn_ —_-- F I --
11 DRILLING LOG
Top Herto.n
0 t ZO
1
1
1
1
r
Forraticn Descrlp9on
It 1116MA11".
30165 sand seat from 53-54' and 60-64'
I GD HWe§V CWWV fMT Thal V4U Y1Af: CIOMarrkXM IN ALCUIC AM X wIM
IAA WAC r- YrF.LL to WAUCrM VA!lQOM. Ard T HAT A CWV OF TM
A PRDV0w T4YYF.L0V"ft
WININTGRE OF MTIFIEVViELi7CONTRAd15R DATE
RoW Miller
PRINTED NAME OF PERSON CONSTRUCTING THE WFU
Farm GYY-Ia
Rev.L09

NO r' SIDENv u oil AEroxn
North Carolina Dopsrtrrat of Environment and Naluml Reaourxs- Divisioa of Water Quality
•rr, ..^ WELL CONTRACUOR CEWTli~•iCAMN Of 2675
1. WELL CON T RAC MR'
d- -.. -
WON COMM" (IndMckjo) Name
SaWacco Inc.
W*0 Con!*Vff Com wy Name
988-NQtthfleld Q[-
SMMt AC dress
C4 or Town Stain no Code
D180
Area code phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PEIRMITe VVIO400098
OTHER ASSOCIATED PFRAIIT" epplcahej
SIT[ WELL IDAWopokeele] ❑LIW-17S & 0LIW 17D
S. WELL USE (Ch" One Barg MortlWWV 0 MmlclekPublk 0
InduetlwCam wosl' AprtwhunW p Row%WY❑ INCH n it
it Pl onr} CMar 0 (sit use
DATE DRILLED -1
a. WELL LOCAT1OM
2000 Lowed St_
(Stroa: Ha", Njmbm, Ca+xnj;;-* &rodnMbn. Ld No., Pardl. ZV ccda)
cm Winston-Salem couN7y Forsyth
TOPOGRAPHIC/ LANC SETTING. fo" aporopAtla bob
QSlope ❑Veley W1at ❑Ridge QOTW
36' 5' 30.4700"
80' 12' 47-2600"
Lathudadl Nude source utws ❑ropographiemllp
(lotaaYoa at W"MuW be shown un a USCS tope map arrdatted+ea to
bY3 fbmn a'net =VV GPS)
8. FACILITY (Nam* of ft boehoaa wrier+, the well In Iocoiod )
Faculty Name F'adlhy Ice (I a ppFeaCb)
Sweet Add re"
Gry or Town Stella ZIp Code
QZ25 Crx3diil Rd- --
McWag Address
Kr;lnla&k -- TIC 3ZO2
CYy or Town S`Iaea 7Jp Cade
cBas•671-6774
Arta code Phone number
e. WELL DETAILS:
a. TOTAL DEFTHa 70
b. DOES WELL REPLACE EXISTING iKLL7 YESO WY
c. WATER LEVEL Below Trip of C*&kV:
(Use'-' it Above Top of C46r►0)
d. 7OP OF CASINO I8�_
FT. Above Lard Svtaor
'r., of onkq brMlost$d Atlor below land sud*M may mq,ke
A vartwxeIn socordanae with ISA NCAC 2C .0118.
e. YIELD;gpm):
METHOD OF TKST
1. DISINFECTION: Type
Amount
O. WATER LANES (daptn):
Top - Battor r
Top Bottom
% Top Bottotr
- Tap Bottom
Top Botlorr,
Top Bvtbn+
T'hlaknONJ
T. CASING: Depth
Dki neler 1Maghf Material
Top A — Bottom 55 FIL _ -cip QQ
Top Q Battom�y�� FI.I�ZE^ 5c 80
Top Bottom FL
8. GROUT: Oepfri kutedal Msttmd
Tops_ sown- U - FL-Rgj&xt _ Tremie _
Top Bottxn Ft
Top Bonrurl FL
e. SCREEN. Depth Dlametsr Slol SUA Moudal
Topes Satlorn—H _- rt l _25 n. 6�41 In -Qpyl�
'Top 65� oDYlarnl4 ._ Fi 1.25 . -Q-QL in -QPVC
TOP eotlom F I - ;n. M.
10. BANWGRAVEL PACK:
Depth Stts lAatemel
Top-G4 Bdtam 60 F'. #1 Silica
Top-AL—JBonom 70 FL 1
Top Salaam_ _ Ft
' 11. DRILLM LOG
Top Dcdaa7 Forrns%on 3@zapl'ar
o�J31s _—
. �J
1
J
12. REMARKS.:
30165 sand seal from 53-54' and 60-64'
100 4DkWY CtHTIF'r •>UIT THe W EXI. VM Q0PM l=1!DNAbWFW" WTH
• t&AW-SCX. DONSYRIJCMMSTMeM1aAIDTFATA.00"OFTIMS
PAXORU To T tAetL 0"W
6 NATU E OF CERTIFIED L CONTR14CT
PRINTED NAME OF PERSON C048TAUCTING THE WELL
Form low ' e
Rev- 2"

IV RESIDENTIAL WELL CONM UIUMN RFCORP
NVAI1 CAM11ru Vicpartm-tat of Enviroainenl w'd Natural Rc"urces- T)i%istor vFW&W Quality
WILL CONI RACTQR CERWICATION Ir 2675
i. WELL CONTRACTOR
Weft C fftcur [''od%ldu&I) N sma
Welt C-ont'9.yp C01T.Pany Name
Street Address
Eort Mill Sc , 2971S
Cry ur Town 514Lte Zip Cgde
1803 s 548-2180 —
Am cc4s Phone nuTmet
d- TOP OF CASING 1S -0 FT Mow' and Surface"
'Top of ❑aNng Wwrrinstai afar below Iand s.x'aos maymqutre
a varlanos In acccrdarow rA h 1. SA NCAC 2C AI13.
: a. YIELD 19 cq
METHOD OF TEST
= f. DISAHFIICT'IRN: Typo
Amount
¢ WATER XONts t4sptttl.
Tap Bottom
Top _ B&Lorn_
Tap 80aoln_
Too Eot: n—
Top SaWm
Tcp Bxcgt--.
ThlcknWisvi
2. WELL INFORMATION: ' 7. CASINO: Depth Dierauar Weight
v,tEL:- CONSTRUCTION PERIA ITS Wl0400098 : Tcp_L_ eavon S_ Ft _1,25" Sc 80
OTHEF ASSOC WTEEDPERMrTWi{>twombul
sfTz WELL to rrttew ow*) LIU AS & QUw 18❑
S. WELL ilSE ICf*ck Ona EWnL} Moratvnnq ❑ Mtrr*Voi4-Ak U
lnduatdal►carrrvrdeI ❑ Ag&uft, re110 RswmV c irjec9w d
"atom Other a (Dot ufel
wx DRILLED 12-16-11
4. WELL LOCAWN:
2000 Lawery St.
[STOW Means RumbsM CoMminay- &"Nig7en Lot No.- PW=& Zip C•xe}
CITY: VYtgn-Salem C3LJN-FY Figrs
TOPOGRAPrI C.1 LAND SE TI iG7 (dwm* mp¢uprri■ bm)
cs"e t-vaky 0�-Uat t~R*o ❑O ar
361 5' 30 4909'
80' 1746 97W'
LarL.danvW+gI%xk mwoe: O r,M 0TO-Mrspn1c map
11ccaton of Lwat m4W bs sf►owrt on a '15 5S We map amattecoad f9
Lars tom if sid vamp Um
15. FACIL.IFY {Wrote of the Isw.>Rets wit pro 1-e wO % IotweC )
Fo mec Eaki 2roclueft 000,0017
Fad* Name FeCaty IDS (IT w0ceNO)
Street Addmw
Wingitonz.gaigmNC 2n0l
City or Tdvrn state 40 Colo
AbdF(r-lne Dzatharana
Contact Natty
9725 C:aedill_Rd_
IVU,rig Address
—Knnitville_ N 37932
GtyorTwn State aocam
[ SS5+�671-6774
Ar" cods Phone nLZrk r
4. WkLL. MMLIS:
a. TOTAL OEPTN:. Witt
e DOES WELL REPLACE EXISTING AIELL7 YES ❑ No q/
c. WATER LEVEL Be'aw Tao of ,.arng 4a --
(Use '+' M Above Top of Cesny)
: Ip_ k - . -- EalToel-Lv-- Ft-.25 -2k-Q C
VAISMaL
cm
GPVC
Tag BvtLom FL
AI. G40ilT Depth ARasaAll+ A*a=hod
TDpJ_ Saticfm 53 Ft ftakla _ Trernte
Top Boporh Ft, _
Top BcWf, Ft.
S. SCREEN: Depth Ltuneter slat Star metarW
Tapes Baton- a - F t-- ,25-;r 0.01 _ H. _CP11C
Top 75 kSelldm80 F:. 1.25 Ir 0.01 in- QPVC--
Top BetlCm Ft. In ..� In
10. SANDiGRAVEL PACK:
Depth SIX$ UMPASI
Took+)�aollarn�4-- — 't#1-- _ Silo �.
Tva Bottom � t
11. DRILL NO LOG
Top Barran Fdrnabon Dracip5on
0 80 5iIts and crave w/some rock
1
i
I
f
i --
1
1 _
1
12. RE KARKS,
30165 sand seal from 53-54' and 60-74'
I m r"EV CMrwy Tr ^T T►ae wiFL. MLAS OMITOX710 tMACpDflD"A WvnI
TM#CAC =ACJL OOWTK CT'olW SrAWARne. AV »HT A OWY CF TM
. Rl� T 1 YSRL CA1!"Jr
NATURE OF CERTIFIED*ELL CONTRACTOR CATS
PRINTM 1 4VjE OF Ptft$04 CON SM. UCTIW THE WELL
form GVJ" I b
Rev. VD9

No v REsmENTm wuj, c0&UBj&no RL
North Cam Na Dameat of E-whrownitm And NMund Re mmu- DIvlslop of Wader Quality
WkLL CONTftAC1'OR C IRTRICA1TON p 267S
1. MU CONTRACTOR:
B
Wel! Cantnt*W (MMl&A Nana
'awagco IM,_
�We/ Carftdse Company Nona
�y�n asc_r N2=eld Qf-
Sbse1 Addre"
C.hy or Town Shea ZIP CMS
Lan -) 72 180
Are* code Phorio el mibw
?_ WELL INFOR1AATIOM:
Vv;LL CONSTRUCT" P`rRMJT#YPQ4M98
OTHER ASSOC1AT ED P ERMITi(I applclp Ij
SITE WELL ID #M gt0o&W*&LIIN-195 A QUALI9D
a. WELL ME (Chaae elan, Box) WnitDnn0 a MurklpaAlut:llc 13
1ndva'stpl/C"MWvdsl U Agricultural C Rewvery [1 Mj--llan it
Iralpstonn Other ❑ 0M E'SS]
DATE ORILLEOM7Q0-11
4. WELL LOCATION:
-29M Lowery $L
(srket Larne, kun*om. Can ro*. 9tr dw*n. Lot Ha, Pear, ZIP Cads)
crrY: lrl R-Salem cowry ForaAh
TGP00RAPHlG IIANU 8MWG: (d" appralelrtbbwo
n&vge nvokey Ufhat uftpe DMe
36' 5' 30.5000'
80" 12' 46.9400"
Lattuda+l0ng1kKIek0u0oe VbP5 []ropDRWkmap
{knoim olneR meal Da MDrat On 6 [ISGS top* me1P 0rJdPWad+ad to
+Ids b(m I nW using OPS]
S. FACILITY (Nome al the 6wlnoss where iota wW is locuted-)
Fnamr Ftakt P[nd> sots (MID 017
Faalhy Name FadMy IDrF ff "PSMM)
?-EKE E_ombm lit- -
Mnstan-Salem T AEC 271Q1
iAy or Town 8" Llp Cade
�L .Ina ne;0hera0e
Cor"oll Nome
41161 q Addreea
Ko xvuja._— TN 3793�
My a Town t3 b Slp Cods
( so &w671-6774
Ivea cdde Phone number
Q WWRLL MUMS:
I` TOTAL OEPM: 71) R
b. 00" WELLREPLACE H7<1 MO WUL9 Yrsn No W
t. WATER LEVEL Berdv lop of Caa4._50_-- . _ _____,FT.
(Elea'+' ItAW" Top of 06* p)
d. TOP OF CASINO 18 .0- —_ FT. Abova tmnd St,rW4'
'Tap of otalna *Mn n[cc door Wuw land surftcA may roquke
a vagwra In acoordanco %11h 1 M NCAC 2C 011 &
s. YWI1) (gpmk METHOD OF TEST__
: L DUMFECTION: Type. Arrlotol
:a. MUTER ZONES (dopht
T*_ _ _
bmofrL__.
_ Top
__ .- Bo*m_ — - -
Top- . - -_-_
. Bow-r_
Top
BotioM—
Top _
13ottorr
Top
_ t3Mrr
Thie=kr►swl
7. CA dtNG: Depth
Mtriota r
Welghl Material
Top 0
i,)u=.3&55 Fl. t 25"
5c Ba CF11C- --
TaP_D_
3a11 J�FS�,��._
TOP
Bnttam
Pt.
6. GROUP
Depth
h%whil
MAodpd
Top_L—8o0oMj3—
Ft—R=glcl
_
:Top
BQQMn
FL
—
lop
Dolborn
Ft _
B. SCREEW. DIpM Diameter Slat Slag Malefw
=TDP_55 PxWfn- 60 FL_L2,�_In. k4t_ 'n- CPVC
Tdp_ffL_ 80WM 70 _ Ft 12 -In 0,01 4L GM
Top . — Botlom FI,—ln. In.
19. SANDIORAVEL PACK_
Depth sin Materiel
--
Top. BA . 5002m -?o FLIJ II1ce
: Tap BaronL____— FI
11. DR111.1NG LOG
' op Bollom Cormaoon c4s&p3m
I
42. RFJdMXB-.
30165 sand seal from 53-54' and 60-64'
ICOMpvwY our ry nt%T rM YYr'1,.L~ 00M6rAMED INAi7P0Rr.VKf YwrH
10 MM aC, Ym L COWROMM n'AWWJM AND TMIRT A CDPY of TI rH
eaHr M410tiI TO
+( 2 t I r
t31[3NA OF CERTIFIED WF1L CDNTRAG°f TE
_ M
�,__
r'RIF�fiFla NAB pFft80t'1 COiJSTitUCT1�IG TIC W!?I 1.
Form GW-1b
Rey. 2M

NON DAY ll 511],_ ENTIAL WILL CONSMUCTION_WORD
North t'A"lgA Dcparfrmnt of Povtrunmoel eAd Xahllltf Re4ourcaa-1)ivialoq of Wow QuAllry
wr LL co TaAcraK c-EwmicAnoN # 2675
1. WELL CONTRACTOR
Vuea C-trtu*( (WW WmQ Nome
Wtli CmUaddr Campeny Narrw
Stroet Add Pon
Fort Milt SC 2071§
Clly or Yown aw ap pally
803 154IL2180 _
Area rode Pfic" rn+mtitar
2. WELL INFORMATION:
WELL CONSTRUCTION f4-.K 17E_W10400008
OTHFR ASSOCLATED PFRW-I"■A**bh)
em WELL ID l(F aPPkaoM1_DL111}i-20S & DL -Z4o
8. WELL USE [Check One fto Mo-nWring ❑ Munk*sWLoso l
Lndr. nlnriieCommerdal �J AgrlalRurai [' Recavory;� InjodJorr d
Iryatl., j Otham (Rat„ae)-
DATE ORILI eD
4. WELI. t.00ATION:
2QQ0Lawelj zl. _ -
;sl "t N:", 4 umL-". COMMUnRf.8*drfs"bXNo. Pumr. 7pCmW
CITY: W n,9Wn-,aJ!8Q CGUHrYgJjHVj._
TOP O(3RAP" C f LAND SETTM- imhoo* t4pwAmtm b*
us" uVa%y whe EIR40 ucrwr
36' 5' 30.5100'
80` 12' 46.7600"
tstRudnikrlpAude aarca: WPS r7opopr3prd: frlap
(lace11a4 of we# munt be Wow on a uSGS foapo crap anarltt dw to
thl8 A7rm If col 4a N OFS7
& FACILITY (Alarrw d he bu4mm w1jece the w" le wmlal.)
HIM
FAC Alty Name FWAY"(rap Pkabfe)
20001nS6lP_I'V 91_ _
5tr*;A Aaldmu
_ ]MmtnnSalem
:fty Cr Town SIM0 np Cade
[kw*sd NNarm
MoMM Address
G4r or'Town Slate 21 P Code
r M jg -%flowwmhi,- 671-6774
Area oWe Pnone nunt r
a- WELL DETAILS'
a. TOTAL oEP7H:_7 DAL _
b. 008a WELL REPLACE EXISTING WELL? YE$L3 NOW
c. WATER LEVEL Below Top of CoSkSM .
IUee'+' if Above Top of Oa1ltlpj
d TOP OF CASINO IS FT. Above rood Sulfate•
'Top of 006V %rml'1o'.ed aVor balm land avdam may rNdra
a vane top h aocordance w1h 1&A NCAC 2C .a116
a. YIELD Wpmj: IaE}FlCO OF TEST
f. DIG%Fl3CTl0N: Type_ •,v Ametaat
� wATLSR zoNes [depth}•
Top_ 8atlotr�4_w_ Top BCllorn
Top _ Dotloxk__ Top aubom
Top Clow- Top Batlom
Thictneaal
T. CAOM' Depth vbv"tar Weight wiftriol
Top..0.-- Botforn 55F1 1.25"_Sc 80
BQ CPVC
Top Bottom__ F! _.---__--
a. GROUT: Np4h wadw lamed
Top` Rottom�,3—_ Fi �I aTl __ TTtmi�
Top Bodm Fes_.
Top.._ _ _ _ . BDUarM Ft _...
11. SGREEW. Depth ftimeter 8lot sits Ilaterlat
Top_ 55 Doriom �_ Ft`t2 •in. 0 01- In. _QFYC --
Tnp_ l5 Bnt:oml9 F1. 1.251n. --QM- l n _CE!YC
Top oouorn Ft in, III- ---
10. SANDIGRAVHT. PACK:
Depth stm Kafatlal
Top_f&--Bd1oo_N--Ft#_ No
Top_(jj__Prlttnra_M_,__Ft #L_ Sijo
Top fiaarorrt,� Fl _ _
ll. DRLUNG LOG
iAp PAAk rl ForrnatJoi Doormptan
170 s�lu GJ m sand -- _
1
�t
i
12. RF-. AM&,
30/65 sand seal from 53-54' and 60-64' _
IGOHumaOyl"THATi''asYMuy"CONamU W01ACf. N MCF.0711
•$MN*%DA llAL0001fir►RA"t[Gt+VrANo'4ftAteTMIACONCOTM
wlaeelat aim t+f�.LCAaMeL
_ Atid t
SIONATVRE OF CFRTIFF'OV0ELL CONTRACTOR DAV
r3�27 fc.tt,;�2._
= PRWim6 W11AE OF FaSON GONJnV'X— NQ THE WFU
Folm GW1b
Rev. 2MO

NON RE DENTUL WELL COM911tuMON RSCORY
North i'u olina Dwartmm of Pawirara m and tti"W Raaucas Diviaioe or Watar Quality
WELL'CONTRACTOR CERTMCASIVN ■ .3351
1. WELL CONTRACTOR:
MichaW ffison
Wel: Coraactor (u0vWuaq Naha
❑❑ �w1et4� C�oo1nv,s,��C�a.,,oC�r,,C,,al� rr ow Name
r.
Sbv@t Addmt
Fort Mill SC 29715
—CKy orTmm state Zip Coda
8t^ 03 i 548-2180
Ana code Phone number
2. WELL INFORMATION.
WELL CONSTRUCTION PERMfTSW9400_
OTHER ASSOCATEn PF RMrT1(Y ep0tadv
SITE. WELL io",pprrawo OLI --21 S & D�IW-210
3- WELL t1Sfs (C wk One Box] U0610wo ❑ MunMowpubll4❑
1ndv0rW 'Connent al ❑ AOiulfiurai ❑ Rmmy ❑ INadbn d
Irafyabona (After ❑ (I''at uae)
DATE D/tILLFTI 11-19-1 L,
■. WELL LOCATiDN:
2000 Lowery St. - _
[,Street MUP6. NV-W4M. CornmwFfy, 9ub&VAMon, Lot NO., PWW, LpC XIO
CfrY: Winston-Salem ❑aLwy Ffgrrgh
TOPOGRAPHIC 1 -AND SETTING taped app►opiebb*
r f%loi* ❑ Vauay e$41 ❑ RiMge ❑ Clher
36" 5' 30.5600"
8W 12' 46 5100"
La+llt>deJlonQlh�de eau ce. BPS ^tovagraphlc map
(kmedan of **IV miaf be shown a: a 0SGS fopo map ReKjw Shcadb
^3 fhrfn A rta uw..7 GPS)
S. FACILITY (Name of Ta huvevcs wrtera the well la Ibcatae.)
Fnrrtuar Flakf PrgdkXj5, . Wo ❑I017
FedA1y Name Facility ID# [4 spgigble}
2f}fln I nwafu St
Street Addrou
_WnSlartCity or Town ~ State zipco"
AM F r - -Im Oeathetatia
(]Conrad Nanie,,,���� p,,,n
�Fwdill R'4-
Maift Addri
}(normllle TN 37932
Cloy or Town State Zip Coda
(865 571-6774
Aw ooAa Phone notst
S. WELL DETAILfi:
a. TOTAL DEPTH:-70 fl
b, DOES WELL REPLACE EMTTNO VOELLi YES ❑ NOW
c. WATER LEVEL EWow Tap of Cadny: 5CI.-,FT.
,U&e • tf Above Top of C&IN)
d. TOP OF CASING !S J_ FT. Awm Land Surface•
'TOO or aslrtp to-Tw aed wvr below ww twrfaae MSY►aqulre
a vadaLim In aowUsnoo voth I NCAC ZC -011e-
e. YIELD I4pm k MIIFTKOO OF TEST
1. DINNFIECTMN: Type Amoent
9� WATER ZONES (depth)
Tap Bortnrt Top— Bottom__.
Tap_ - _ . -- Bottom TOP _ Rotwrn-
Top Bottom Top Bolton
TtliekrreaW
T. CASMG: Depth diameter Vlhfyht a rteriel
Tap- Q - _ Bo7orn 5r FLU_ ySc 80 !Q?vG --
Top 4 _ BodDm Q5 Ft. 1.25" 60 _CPYG
Top - Boffbm FL
E. GROAT Depth Mata40 Menwd
Top_ Q _ Bo t rn 53 ,_ FL POALaDd TIamm
Top Bohm FL --
Top— Bottom FL,
:4. SCREEN: Depth Diameter Slot S4a "Burhl
Topes_ 13otlom -$O--FL 12.5 k+. 0_01 h QPVC
Topes_ RoMm 70 Ft. 1.25 in 0_01 In CFVC
Top _ Bottom Ft tn. In.
10. SANMGRAVEk.PACK:
Depth labs Mw*rwi
Top ' _Boftm w Rju ____ Sd1Cfl
• ToP_..� BorGOrrt1� F1, Sfta
Top BottGxn FL •,
11, DRILLING LOG
Top aotlom formation 002Crlptlon
JL—_I 70
r
1
�1
1
1
1
.�J
1
1
12. ItEMARIG'1_
30165 sand seal from 53-54' and 60-64'
100 Hditwcax`Fvy THAr V"CONSTi1LX L0INA0000MAPIMW74
• HA WAC M T ANMnde THAT ADDpv of ri%
11460R0 L
$10111111MIRE Of CERT1F*D WELL CQNT1iAGrfO WITS
Michaellil agn -
PRINTED NAME OF PER" CONSTRUCTING THE WELL
Form GW-t b
Rev. 2Jd4

�r a
'�.,..�'
1. WELL CCNY ACTOk
Michael Wison
Waft Cont+aclor 0-de iduaf] Name
Sr
Wall ConVOCIOr Company Name
Street Addfs/s -
EQrt Mill SC- 29715
City or Town %%te ZIP Goo
(803 f 64 -2180
Arne Bode Phww rarnbat
Z WELL 1NFOR16ATION:
WELL CONSTRUCTJON PER1AfTeVAM-0$.
OTHER ASSOC IATr-D PERTMFTS(e■pokaaw)
SITE WELL ID*Nappataha) pLJW-22S $. QLIVV-2?D
S. WELL USE (ChetB One Boxy Monbodng L] h!unk*mVPubIIC❑
Ind uWallCont"ns lai ❑ AaftPhKel ❑ Rixawwy ❑ w+ledlot+ of
Irr1Vvbcn❑ Other [] (Fat uee)
DATE OR4.LED 11 - -
a. WELL LOCATION:
2000 L ower►1 St.
!Srr+n Yana, (rumbas Ganwewft, Bybdil b a1 Lot No.. Pw . Dp Cvwl
CITY: Vkston�alem axiNTY FOrB Lh
TDPOCARAPHIC I LAND SE MN G' (duct aepraprta bar) ^—
08lope ❑Vaeey UeFlat CRldpe ❑Other _ _
36' 5' 30.5900"
80' 12.46.3000'
L**A*AonQ:tulle aourw: MPS L-Topoynphfa map
(kesawl of wteN most bo alrowrr on a USM Mpo map $now$Ghw ro
MI8 Avrm Mnd u3wV GAS]
S. FACILITY (Narne of the buiiineae whom >he woo is localad.j
«_ .
Faboty Name FarAlly Of (J appgoabfe)
S'Jee1 AMmas
Winstnn-5alam �W C 221ni
City of Tuwr Stttte zip Coda
AUF-C Ina DeatheranA
Cwbld Name
02S Gmdill Rd_
McNov Addreu
Knoxville IN U932
City or Temn Seta zo Code
I g6s, 75fta!fftt 671-6774
Araa Bode Phone number Ill. MU. WELD. DETAILS:
a- TOTAL DEPrH:_7Q_Q
b- DOCS WELL REPLACE EXAM NOtfyELL7 YES NO
C. WATER LEWL Fallow Top of CaaInc ,-,U_([1 _. . ,FT.
(Else �+' if Above Top of CaaJng]
i.t .��.. K.w
{
uItl�tvlii�i i�IfliTaR�^C 0;
LqA KESIDENHAL L; F," QQNsrRuCTjqN RLcoR
4orils CSrIe!'rru Dopartment of Environment and Nahual Resources- Division of Water Qtulity
WRLL CONTRACTOR CERTIFICATIONS 3351
d. TOP OF CA$N O 18 Q FT Above Lard Surface*
'TOP Of C t "larnurialed Wvr bek?w land t1ilm may roarim
■ vetienoa to ecoor ks wtn 16A NCAC 7C 0.10.
�- YIELD (ppm): _ METHOD OF TEST
I. IRSINFfiCTION: Type Amount
9. WATER ZONES [devtn,
Top_- . Boncm Tap. Bottom _
Top Bounm Top_ . Bottom___._ . ---
Tew Borvn Top BodeTrL_
Thk! newel
7. CAMO: Depth Dune, welobt Mionric
Top 9 E000m-5 - Ft., ilk" Q &flv(;
Top-q— aolwm&�— Ft. 1.25" ! cpvc - -
Top BDnom Ft.
a. GROUT: Depth Mau"* ~DO
Top 0 Botfbrn-fa-- Ft. Portland _ 12MI! —
Tap-_--- Bobor Ft --
Top Bof rn FL
e. SCREEN: tlapdt Distnater 3W Skm IlTaterlal
: Topes_ 8otlam—§L-- Ft 1-25 ri 4.Q1 N.
Top-W aetmmFt. 1.25-In. J191 In- QPVC
Top tlormrn Ft In. In.
16. SAND)GRAVEL PACIL•
Depth Slta IMotortal
: Tops54—BottoM60 Ft #1-sibca-
Top-2L—Bo" 70 ^ F7 01 ska
Top, Bottom F!
t t . ORILLING LOG
Top Bottom Fomwf,oa Oeecrpdw
01 74 sty ,fill = sud
1
1
1
f
12 RVIAM:
30/65 sand seat from 52-54' and 6"4'
I L* tiftM CCfi 11FY WA'[ TM WOO V*3 0001e7lilCTFD N ACCOnDrr44 MTn
;16AW-AC2Q.AWtLLCO DM et AND 7 AAT A CDPt OF TPM
: RFC'd9fl T J'rI ■ �r
91U
NATURE OF CERrLnM WELL CONTRACTOR GATE
PRINTED NAME OF PERSON CONSTRUCTING Trffr WEII
Fatm GW1b
Rev.Z09

0 �ev �
'► ow
1. WELL COitTMCTOA:
Wait C611raCtW ON M U41) Marna
Saadamo Jac,
We11 Cows i r Company Name
20§0 Notth5eld Dr. _T
Street Address
Fo1M1ll SC 29715
City or Town - state np Code
8u $46.2164_
Aroe Cods Phone number
2. WELL INFORMATION:
WEL- C0MSTRLICIION PER M1TA W10400098
OTHER ASSOC'ATEO oERMrT*(1 sppilcehw]
SITE WELL io sm rpplratss)DLfW-2M 8i 0LlW-23-D_
3. WELL USE (Cheri Ore Sn4 Iuoneoratp ❑ MuNdpwiPubtic ❑
Ind vp7risWAmmerckl ❑ Awicuttural b Reaavery 1; 1Mect on it
ItTSQaVorij Other ❑ (sat uaa)
DATE 0MLLEV 11.19-11
4. WELL LOCATION:
2000 Lowery St.
(9res! Noma, Mumlwti Cann'-trMTl. EvalMakn. tioS Ma. ParaM. ZpC*"
CITY: I 8 - CDwTY or h
TOPOGRAPHICrLAND SETTING: Id.dtAItg I II bMQ
Llstope (:)Vdey etel ❑Rldpo OMM
36' 5' 30,6100"
80' 12' 46.1100"
La!ltudeAorgEudrsource: g,PS ❑ ao"raphk r%p
(kswfion of wee' must be &Vt n w a USGS topo male w4adarhaM10
Ihx form E not u amQ GP5)
Ii. FACILITY (Name of the buslnces where ire wee la IDcWad.)
—Fnrmer F lakt Prnrincts QQQ 001 z
Feci ty Name FO11ty DO (if epppCAbW)
70M l nwpry_ St_
Streel A&Ilmm
Winstnn.SRlem MI. , 27101
Cty or Town sub tip Code
AMEC - Joe 0 _a harems .
Contad Name
972..E CI Ill Ril
MaEnq Address
9110yXille _. _.Tltj 1793
Cry or Town State Zip Coda
t_ 865.6 ffL+k671-6774
Area =de PWv number
1. VALL DETAILS:
A. TOTAL DEPTH:_7( ft
b. 50E8 WELL REPLACE VUSTWO WELL? YmS L NO V
c. WATER LEM Below fop of CUM97 50 FT
oJse '.- If Above Top of CeWnQ)
NAM RESMENTML WELL CONS L'CUION RECORD
Nlorth Catalina Depwimcnt of Env�uirmwt and Natural Rtwumea- Division of Weer Quality
WELL CONTRACTOR CERT ICAMN J1 3351
d. TOO OF CASM M Q f-T AbM* land Surlaae^
'?op of ceehQ tMMIr tad auor below land sudace may raqu'rn
a varter" In a=rdance wNh 15A N('AG 2C -0114
e. YIELD (qpm]: IaETHOD OF TEST
r. DISINFECTION: Type_ _ _ Amount
S WATER TONE& (depth):
Tap Bottom___---_,__ Top Bottom
Tap Hotorr_ Top MrGrn
Top Bottom Top Baitom
Thkkneae!
T. CASING:' Depth Diameter Ymstri NsWrlal
:Top 0 Bottom _555 ft.UT'Sc so CPVC
Topes__ Sodom 65 Fl 1 -?-5'* Sc 80 CPVC- ..
Tap Bvltam Ft.
q. oRDUT Gepin Lutedrl Whod
Top- (L Eottom 525 Fi.p21jaL1d Tremie-___
Top Bottom Ft
Top_ Bottom Ft.
0, SCREEN: Depth Diameter Slat Bi:e Malenal
Top-5§� Bottom B��Uy FL�In. _Q,QL in. �_
Top �+�{j— $UttarTr_ 70_ Ft, i_2rS in- Q_41 in- Qpy�t-
; Top MMM FL M- Ln
14. &4XO1 idIMVEL PACK:
O■pth tltse llpbAal
Top 4 &*,t rn 60 FI. 01 siiira
yap_MA--Bou" 70 rt-U — §k
Top 6ot!om =L _
II. DRILLPOG WG
Top RvtMm FWMtktn DaaC Oon
; ��r�4 61ik11 Ci$VOY r��
1
1
i
1
1
1
1
1
30165 sand seal from 52.5-54' and 60-63.8'
I 00 "U" "Twy TENT WAS COMTFAP= W ACCORDMiM YMTH
• +eA NCAC 00 as THAT A 00Fr OF THaor
J
��I I
NATURE Or CERTWIED WELL CONTRACTOR DATE
PRINTEU NAME OF PERSON CONSTRUCT** THE WELL
Form OW-1 b
Rev.ZM

64ft""
NONRESIDEJ LIJL WELL CONSTRUC-nO t RMRD
North CA.,41na Depar t of Grirommnt aedNatwid Rworoes- D:yisioo of Vaier Quality WELL CONTRACTOR CERTIFICATION M 335J
1. WELL CONTRACTOR:
midnl Mum
Well ConrscW (WMdael) Me me
SaedaCC4 10,
Wei Cortractar Company Name
}$ NqIeld Dr_
Street Addr"$
FQd Mill 29715
Ckyor Town Stow Zp Coda
L V3 1 548-2180
Area code Ptwnanwrbar
I WELL trfFORMATIOW
WELL CONS7RVCTK7N PERMITS WI0400098
OTHER ASSOCiATM PERMITr;i vokatas)
SUE WELL IOsnf,Pocs ledXlW 24S $ DLIW 24D
3. WELL USE (Che* One boxy Monk*v tI kluadpsuPutie o
IrOL*trlaVC-orrmatclaI ❑ Aydwi Ural ❑ Reoomya ip,lacosn N(
IrelQ@Wr C] Othw :D t%w use}
DAM DRILLED 11- 11
4. WELL LOCATION:
2WQ Uwary 35t.
(3teat Home, Num4srs, Cam ndNry, 3WxrA&W. Lot ft.. parost 4 Owe)
cm Wln3lon-Salem omrm.Forsvth
TOPOGRAPHIC IL AND SETT 44: (crwe* a -I I tar"
[7SI)pe L7Vallsy WVUt ❑Ridge OC*W
36` 5' 30-6100"
80` 12' 45.9100"
L.a+Jnidallor hW@ source BPS LTapCgraphlC map
perca[ion orwoll rnrislpo =pawn on a t/SGS ra[o m,p andaladodJD
{brs bw,, it rwl ruslrig GPS)
S. FACILITY (Name of the Ousinesa where the we1's WMed.)
Fanner F _- MAM17
Feci.Ry Nana Facilty IOa (Vappka bla)
%fn I nwar'11 't
Sheet Address
Cty or Town Seta 7Jp Coda
AMEC —Ina DiRaffigrgns _
Coned blame
9725 Cnntiill Rd
Uzi" Addire"
Knoxville IN 37932
City or Town stow Zip Code
i 8FLS a 758&0519� 671 -67 74
Arse oo4s Phww nwnlw
8. WELL DETAILS:
a. TOTAL DEPTH:-7Q ft.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [V
c. WATER LEVEL Below TOP of Caa+np 50 FT
(Use'*' H Above Top of Caft)
d. TOP OF CA 140 LS (� ��- ^ FT. Above Land Swiace'
'Top of C"rq terminated OVvr beruw lard surface may rngA-a
A vartarge In acronjism;e wllh 1 SA NCAC ZC 0116.
s YIELD [IIP M. METHOD Of TE87 -
E DISINFECTION: Typo __, Amount
P. WATER ZONES (depth;:
TCp Bottom Tcp Bvom _ -
TGP Bottom`-_- Tap _ BVIurn _ �^
Tap Bottom _ TOG - Lwtom
ThiakneW
7. CARING: Depth Diameter 1Ma OM Madrtal
:Top 0 Bottom_ Ft._I U' SC 84 . QfnLIC _
Topes_ ButtomQ_ FL 4.25" 5c A0 C PVC
B, GROUT Ospth i"kerial moftc
Top_g__Boum 52.5 Ft Paltarly_ Trw-w
TOP $Qttorn Ft --
Top Hattbm FL
tE 0CREZN-- Depth Dlametor slot stte Mabrlal
TOp•5.5.— Holtorn 60 FL 1.25 in. _Q.Q.L In QPVC
TQPft�_$ottorrl . -FL 1251n. In CPVC
Top Soltarn__ Ft In In
: 16- BAIAORMVEL PACK -
Depth Stta Material
saaw, 80 FL#_ .Silo
: Top $4 _ -_Bof --70— FL #I $JliCa
Top ft tML-- FL
11. DRILL iNG LOG
Top 60holm Fonr.ailon DesulpWn
r
r _
1
�J
r
1Z 11�IAIplf1:
30/65 sand seal from 52.5-54' and 60-64'
�IcOWjOWflitterTNUTMVMLOMCOMSTIMJCMNAGOOaOillCa► M
• ISAWATIMP
:rA01W00.A14TFNTACWV*3 TM
Vf
RTIFIED WELLCOrfTRA' I-O—R VATS
lC _Wflion
PRINTED NAALE OF PERSON CONSTRUCTINO THE WELL
Fo m GW-1 b

No N RmDENz7AL wKL,. c. N Rif nh t)
North Umitaa Dqw nwt of Envirowwt AnJ Hatural Resources- Division of Walcr Quality
W)r.1A. CUIY'i';tAC MR CX1MFlCA710N rY 2675
1. WELL C(+HTRACTOR:
Robert MjUer
OM Conndw ( M-OduaP, Hatne
Wor Cor.tradw Compemy )yarn
Street Addrvna
t 403 ) 08 2180
Ame cede Phone cumber
Z. WELL IN11ORNAT1OH:
WELL CONSTRUCTION P`FnM(rs W1040d�$� ___--
OTHER ASS4C1ATED P=R?AIT'i{I apptoaba}
SrM WELL 044 fmK&-Aw)_DLI -25S& DLIW-25❑
3. WELL USE (Ch" One BDi, 6 w4nd% J 3Arr 4gkP,.ot:c •.Z
IndUSbisUCDrnmesd210 A40Wltural p R;omv yCl In'adlon d
Irrlgasonr- ❑itw ❑ ow vas)
DATE DRILLED 11-
4 WWELL LOCATION:
9Lowery Sty --
([**0 wane. Hunxrk Camrurt0. SacVAaori La'. No., PYDM ZIP cods)
CrTy: 1�Vlnstom�alem . -_ --, cowr,Y Fors)t�
TOPOGRAPt VC ?LAND SETT $* ;3" sN roprtzr b*4
LIStnpa CIVMI*y LOB[ URrdge DMor ,
36' 5' 30 6300"
80" 12' a5 7w0•'
LadtudWorgmae wr.w. t:&Ps 'Js DDoOti►Ardc rwp
(ioaeUDr p(warl cruet Lae sAorm = p USGS :coo map awaLmChad ro
tars kem.. N not narrq Gr_'8J
IL PAC UTY (Narra *! this bou is heal wl spe fra wag Is t1 tad.)
Facky Namo F66111y IDf (d appocabie)
SwwlA fdreel
Clly or rlrwn State LEp Code
Contest Nams
MaI1 K AddrM
Char or Town SIRIs 21p Code
Aron code Pharra numbot
IL WELL DErALS:
s. TOTAL DEFMI.. 69 {t
k DOES WELL REPLACE EXISTil!WG WELL7 YFS r-L h0.11
c, wAT'FR LEVEL BO w Top o(CaUx. 51 -T•
!L%@ -+' IfAbm T(p a Co ng)
d. TOp OF CASWO i8 1) FT. Above Lind &ffaW
'Fop or adnp lemftnsied Irilw Wow 1904 Adam rely nqLVs
a verlarra In OMMADM wNh 15A NCAC 2C .0119.
s. YIELD {gpm):
VIETHOO OF TEST
t DISINFECTLOW Type
Amount
g WATER ZONES [dearth;:
Too_, _ Botbm
Top BOflOM
Toe BoWm
Toe Bu&,rr �
Top Boticm
Top_ _ ftaam
rnfekrrgsa!
7. CA31MCO: Depth
Okunrier WoTght IAatordai
Top_ BWdom 3 54 =L 7.26" _ Sr _QeyQ
: Top 0 .� ODOMn 64 --L..
Top Bottom FL
;. C#tOUT L�ep1h fee•nr;51 AAe�od
Tvp-k— Seltm 53rt Pam_ Trepila—
Tep Bonom R.—
Top Baltcv Ft
S. 8CREFK Depth Ofamebr t;reltlme Wo*rkl
Topes_ Sodom, A F1. f 2 In. _QM_ IR CFVC
exlomjU_ Ft._j2L5_Irh _Q&_ ka CPVC _
Top Bottom FL Tel, ib
74. SAND)GRAVEL PACK:
LkPE+ Stra 1Arlplill
Too-,51____scrorn_U_ FL0_ Me - -
:Too 64
Tcp L3ottacn FI. �. — _
11. OWLIUN0 LOG
Top Bohan ronnaLion Uoscdp Wn
30/65 sand seal from 53-54' and 6D-64'
100 HMWSER WY TI W" MU WM OOW RLCr ONAMPOP UYOTH
• tM WA.0 iR. VC.LL C0H3r"WTIOM STANDAF 4 A4i THAT AOCPr OF THIS
RELCM rW XE-H PRWIDEp TO THE OWOWL
sta"A-URE at CERWWO WWEL1. WNTRALfDA DATE -
T4-)iP—g*W I'?t(.Lc9e—
rerm GW-1b
Rnv. 2M

!_i ON RESIDENTW WF1.I, COM?FRUMON RECORD
North Carolina Dapanment ofErtviroumeal and Natural Rtwures- Division of Water QU21.1tr
ti WELL CONTRACTOR CCRI-1F1CA-110N 0 2675
i. WELL CONTRACTOR:
Robert Miller
Well Contractor (Indlridual) Nw*
Sil%lopeo Inc.
Wei Contratlaf Company Marne
9088Notlhfteld r_ _
Street Add � drwu
LTl - �od lll Y.0 _ _b41 -5
Uy or Town State blp CON
(B03 548-2180
Area rase Phone number
2- WELL INFORMATION:
WEL: CONSTRWTQN PERMIT0 NR 00098
0rMFRASSOCkATEDP`eRVTT14M upkeehe) _
8lTEw£LL il)tllyepallrahl.; OLI��CS pLIW-28D_
3. WELL USE (Ctwrk 0M Sex) V*nitormg p Munlcpac+Puosle L
mduatUVCommemLdl ❑ Ayrftuitural C7 Recovery r} Injeetivrt FY
WGasfooLl Other ❑ (13t use)
DATE DRILLFD 12-jk:.
4- VVELi LOCATION:
2,00 LowerY,St.
rSviw Nome. Mu "al C-01 *y, &O" vr, Lot no., aaro.c. Lv roar)
cry Wirt& n-Sa couwY±AMr yth
T OPiDGRAMC 1 LAND SETTING: Edrd eppoprlms"
Q$lopa C)Vd" 1(Flot ❑Rklpa OMW
36' 5' 30,2900"
80' 12' 47-3800"
LelludelbnalhAs axne: JaPS [?'opearaphk mup
00C.Mion of MO rnunr be shown on a USGS bpo mop er+0ene l'&J ft:
INS form tf no! aarnp 3a S;
ll. FACILITY 1Name of the buslrtoas whom ttre we0 is Iacated.)
Former Flakl products MO MIX
X
FacHily Name FaCSlty Do (if epplIcable)
Smoot Addraas
Clay or Town Snits Zip Code
Canted Name
TN
1HMIry0 Address
CKy or rown SUN Lp Coda
t Ii�� �671-$7I9
Arc@ code Phone number
G. WELL DETAILS:
A. TOTAL DEPTH: 71 f
b. 00E3 WELL REPLACE EXISTIM0 WEL17 YES D NO rj(
c. WATER LEVEL Be. ow Top ofCesina• 48.75 Fr
lJw '•' tf Above Top oI Coslna)
= d. TOP OF CASING 13 ❑ FT. Above Lam Surteoe'
'Top of =0V oem+lnetsd eVur befew +and surface may r*W's
a vuisrx* In scconJunca wkh 15A NCAC 2C .01143
a. YIELD (spat): 111ETNOD OF TEST
f. DISINFECTION. Typo
-
Amount
a. WATER ZONES (dWbt :
Top Bollorrl
iop
tiettorn
Yet)- 8ottwr
Top.
Boma
Top Bokcn
Top
Sworn
Thlc#rNael
7, CASONX Oepth
0'- - I
WWaht Mo%f*l
Top -4� Botrom55 F! L2�"
JiG $Q QPVC
ToP-k _- Be— _66^ Fl5:_0
CYC —
Top UUW
FL
_
S. CROUT: Depth
Memo, Method
Top_Q Bottom_ Ft. Poftnd
Top BoStom ,
FL
Top__ Bottom
Ft
_
/. SCREEN: Depth
Olamater
Motguto Material
' Top a 3otbm_QQ__
ri._12&h.
0.n in. CPVC
Top 6 BoltormZ . _
FL__] 2&r,
_0.41 in
Top _ Wtorn
Ft Irl
In.
10. SANDIGOVEL PACK:
Depth SbM MatlrNl
Top Q5 .Bvltorn_Zj FL 41
Top Bottom _ FL
71. DRILLING LOG
Top Bosom
0 1 71
1
1
1
1
1
1
Formoton DewpWn
,j>< I�LniAltxa:
30/65 sand sea] from 53-54' and 60-65'
t 00 MORM C®RFt T K%l rM VAU VM Od1(1"941M of AC4 OF"J LE "11H
• 1aA NOA!' 7G OpNtRtlCllpi.ZSAlgelt0a, AIO ttMT A Dbac' Oi TMe
t TorHEWPLAmm
iVR OF CERTIFIED WELL CONTRACTOR DATE
RoWd Miller
PRINTED 4AM OF PERSON CONSTRUCTING TILE WELL
Form GW 10
Rev. 2M

1 Y ON RLVD§YyTIAL WJ&LL CONSTRUCTION RtCORD
North Camlrna Depamincnt al' Environnxnt and Nuurat Resources- Dlv;slon of Weer Quality
W VIA, CONTRACTOR CERTIFICATION it 2675
1, WELL CONTRACTOR:
Well Corrraclor ondlvlduaq Hama
SaedaccQ Inc.
Welf Contactor Cwrpany Nerve
9088 Northfield Dr.
Street Addrm
F!2rt mill SC 22715
C1ly or Town stale zip co/S
Area code Phone number
2- WELL INFOI'MATION:
WELL CONSTRUCTION PERMrTt WIQ400�98
OTHER ASSOCIATED f-ERIrN "appleblrj
SITE: WELL In "wo bw) DLIW 27S & DtIW 27D
3. WELL USE (Chodt One Boxy Mooring ❑ MunldpeWAft❑
h+duatnallComtrismW q AgrlMUal ❑ Row"ry C Injacoon it
Ierlpanonfl Olher[3 (lotua0]
DATE oRat En- 2• i 6-- f —
4. WELL LMATION:
2000 Lowery St
QSo" name. Nurrawii, Larrmrft. SuedrNabn, _ci No. PMoM. Lp Cody
CITY: Winston-Salem ____.—couhTY Forsyth
TOPCICRA-HIC1LANOSErr94G: (d+ouapprcpAaOobcx)
❑Slope ova@ey L&lat C IRldge COt
36' 5' 30-3400"
80" 12' 47-2800"
uawdanongMude aCLrfO@: pj3R5 ;�T'ihpvprepttic may
(Axcofw or wO must be shown on o USOS wpo meta andarhraw to
thm .lorm if no! ua41g CPS)
6_ FACILITY (Name of the bueL u "em tim w(A A iccatea.]
FnrmPr FLakt P_rsxil& ion DIi'I.7. - - -
Fadlty Name FaoSly It7R (if epprlcabla)
?QM l nwAry St_
,heel Addrou
W stern-Sa1Qrr1 _ _-- .lSIC271 M
City or Town Stale Zip Code
AMFC - -lrxs Dy-nthr!,raae _
Concoct Name
2729; Rd
m0ng Address
pie - TN 3793�
City or Town stele Zip Cod@
4 ASS _ 671-6774
Are@ code Phone n•ATtber
S. WELL DETAILS:
a- TOTAL. DEPTH:- 74 ft T
b. DOES WELL REPLACE EXISTING WrELL7 YFS :� NO IV
c- WATER LEVEL Below Top of Casing: AB,55_FT.
(Use',,'[( Above Top of Caslq)
d TOPOF CA31Na Is 0 FT. Above Land S:trtaoe•
top or csatg l mrtaled allor below land auftm may repute
e vsdair a in, econrderxaa wMh 1SA NCAC 2C .C11a.
e. YIELD (ypml. IAMOD OF TEST
L DISINFECTION: Type
Arnoum
: s WATFX2011£3 (deplhy.
Top Batt— Top
Bo`.19n1
Top Bottom Top_
84110m
Top Bottom Top
--3aHom
T h k Irn eta)
7. CASING: Depth oloww"i,
Wright Matodal
TopQ^ 80om_6 FL &F
_ >�Q QPVC
'TOP-Q-- "orn U . FL1,6
SC_.60 -QM
Toy Bottom Ft,
' S. GROU T: 0*1h adaw-
a I Matttod
Top-Q- . Kvttuen 58 FLPOrdaAid _
Top Bottom_. FL
Top Bctlorn Ft___
& SCREEN: Depth elarnoter
$foe Sin N teeki
= Top -t2- 60AA xT 4W 6r3FL-1.2&in.
-Qai In _ CPVC
ToP 9$L69 ^. 74 Ft f _25 in.
_�.�1 irk GPYC
Top Baton Ft In.
- in.
10. NNDIGRAVEL PACK:
36 Depth Slae
Malettal
Top fl S 9 Bottamjj�_ F1.9L _5i
Tap-6QfiB6r.ken 14_ FL• #1 - si&
Top. holism- Ft
11. DRILLING LOG
Too Bottom Fprrnalor DesolptFon
0 _1 -4 , san si RV-cifts wI some rock
1
1 .
1
,iz RL:rlAnlcs:
30/65 sand seal from 58-59' and 65-68'
t 00 HMO. CEF" a TIMT Tli" ATIMvMMM COMCriaIGM kA0001"MIX WTM
Iva L Cd 11FMICTrON STAxt]MM ANOTHAT 4 oa►r Or THb
VKNKqD TKO E %4L gm4cp
BAMTIURE OF CERTIFIED WOLL CONTRACTOR DATE
: PRI NT£D NAimE OF PERSON CoNS1'RuCT+N0 THE WELL
Form GW1b
Rev. 2LDif

�r
I WELL CONTRACTOR:
WAIF Ger"Clor (%%KluaF Name
Saedacco IfIc. ,.
Well ccrt,,aaar Cdrnpwy"arm
%M8 Northfield DE,
SbvA Address
_tort Mid SC 29715
Cly or Town Std* IJp Cade
t_QJ�_i 8-2180
Area code Phone n.Ao**r
2. WELL [NFORMATiON:
111=LL CONS'RLCT ON PFP,ASr % wi
CTI-ER ASSMLAIFD PERMr-s(r a;vi cabi; DIW-28
Skit£ V0* LL IC+ /!F ePPAv]!_-
3 WELL USE (Check One Boo My*o*V ] IuIIRlkaprVPtlNica
kt:geWLI Lathe. d (IM ww)
DATE ORILL.EO 12-4041
4. WELL LOCATION:
2QaD L ry St.
tSMt Nuns Nw1*4M ccm%wll'1. Swb4A &&%'%Lot Me., PeAaL Zw Ceeai
cITv: Winston-Salem =mry Forsyth
TOPOGRAPHIC 1 LAND SE77ING• [t'nd1 aFR'>a� twp
7&opd UV" U 1M Ejftge EjCt-or
36' 5' 30.31GO"
80' 12' 47 1200"
LantLdsl'angthaee &owce: WoPS 0FoKg-spNc map
(kc 00n of w9f must be of wrr on a USGS 1cF*.-x* end+usr.&a to
Nwa brrr: F ROt t,srq Gps;
6. FACtUTV (ka(re of U bLl*086 whov W wea is Iac.Mad i
—Eormer Flaki Emdtlets aD00017,
FttdMy Nau-no Fadlry tDI (M ■pplCaplEj
Skeet Addnesn
--Mnsfon--Sa1em NG 27ini
CRY o- Toren Sw:e Lp 00dv
Aiid.F-C Arm- L]eaiht-rane
Co,,I%d Nance
kla4ng Address
Knnr►rillra IN 3791
City o• Towr State L:p Code
[ 8B5�671-6774
Area code Phone numw
S. WEL,i DUA1L3:
e. TOTAL DEPrH:-70 ff -- -
b. DOES WELL REPLACE E]r)STIHO HELL? YES C NO U/
s- WATER LEVEL Be!Ow Top o1 Csswq 48.35 _FT.
(tlsa',' H ACove TOR of Caslrq)
LVO RESIDENTML WELL CONSTRUUIQN itYCORD
North Camara rlrp - -16- LavkoamCat and NRuni Rowunm- ❑irWon of Ttlator Q[wity
wGLLCQYtRACTOR CERiincAmN is 2673
: d TOP OIR CASIXG Its -0 _ FT Abpn Land StxUcs
'Top o: casing wm..wv%d eVor bolo* kind ornate rMy requNe
a rar'Shoe Ira acwrdancs w 1h 13A NCAC 2C .D' 15
w YIIELD (gpm) METHOD OF TUT
E DISINFICTIC14: Type Anwtrnt
y. WATER ZOMES [depth]:
Too Benarn Top Swom
Top 9ellsrn_- Tap Wont
Top &liars Top Bonorn
7 hICR Aee 4
7. CASINd: Depth pimfehr Vltelpllt atartuNl
Tpp_� H*V. ,rr&5— FLU Sc 80 CPyc—
TOo FL --
Top Boxem FIL
a- a�an Depth 1++nrnal Atr[hoo
Top 0- - nenom 63 RL Parlim1d 1fefTlle -.
Too Bc:wm FL
TOP - Behom FL
f. SCREEN: Dep1H Dbs7WAr Stet Stec MaWrtal
Topes_ acmorr 74 -_ FL 1.25-ir. -Q&t In CPVC
Top Batton Ft. tr. In
Top 5-M, * FL 4-k In
10. SAHWORAVEL PAC1f:
Dept she MM0011
Top64 3atkM 70 FL #1 - Slla
'Top. , _3r(om Ft
Trq Eo1cm Ft
11. DRIILL ING LOG
Top BoCom rornatio-I:Joa r:piw
zo a1dslsilt�'daYs w'so= rock
1
!
1
!
12. REMA"S-.
30165 sand seal from 63-64'
i ov -W'W SV OMFY -4U"tA U WAS COPM INCM Of Ac'oa11¢I CE YMT14
19A W-%C TRIICTK)h STANZA%* MOfler.T A CO:r OF TM
= SI TURE OF CERTIFIED MU CCNTR CTOR DATE
' PRiN-M NAME OF PERSON CONSTRUCTM THE wFLL
■. Yr. _w
.,._ i *.-_�._^ _• MOkra Wo
iRJmp Tiolsti k Rao. troy7.:__r• +..�ry w.. .—, — -. .. _ _a:'r �.l

-0
NON RESIDENTIAL WILL C0N9TRUCFj!2N RECORD
North Cerolloa Dcptftmnt of Env kmnmant and Nature( R eaurvca- Div6bo of Waei Quality
W[ILL C7DiVTRAC{'UR CBR1 i> i('Arti(HV o 2675
1. WELL CONTRACTCR:
W!I ConVoctnr (UIdMduat) hems
-Saedacco Inc.
Wes Conbedor Company Name
StriM Addtas s
Fod MW _ SC_ _ 297U
Otyy or Town 5teta lip Cot:a
( 03 541 qQ
Area oWe Phone number
2. WELL IMFORNATION:
WELL CONSTRUCTION PERMITS Wf0400ON
OTHER ASSOC'ATED PERMITS(a apodiabhO
51TE WELL * iiir w*a6w) ❑lL1V 28S&OLIW-28Q0
3, WELL USE (Check One tMiQ MoModng ❑ Mu**WPIIEEG{]
lAdUgMaLVC.OMWdal ❑ Agrt 3dWral D ReoeveryL] trQVdIQn d
"ationo Other 0 ({tat une]
RATE ML L ID 12• 10- j j
4. WELL LOCATION:
2000 Lowery St.
:S V&-A Nwr,*.. Nuoeim. Cora -4, suemrr.bn. Lm rw .work 2a Coo)
CITY. .S p§tg]- Salern COUNT-Yf2TY
TGPOORAPIIC 1 LANE) SETTING: ldrw* eFPrVO$r+" hmg
JSk" QVsky dlat []Ridge 001'.er
36* 5' 30.3500"
80' 12' 47.1300'
LarlhrdaAgt k4a Goer . Q13PS ElTapogrophic Wrap
000000 ar noo mini be Mowri W a us(7s too map ardava&wa to
iM� loan Knot uaYyq GPSJ
6. FACNJr1' {hanle of It1c Duairresa w�o� t ie ward la lo[aled ]
Faciery Name rwsky ID/ (4 applUbb)
Street Address
Wingtnn-gAk- l NC 271W
Cdy or Tour' State 79p Code
AMEG_ —
Contao Nara
9725 rQctdll Rd
Maslr)g Address
Knoxville TN 37Q12
City or Town Stale 7.Ip rode
(a" 671-6774
Area code Prone riLimber
tl. WELL UETAILS:
c TOTAL OEFTH;mft
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO Y
o. wATt_R LEvn Relnw Top of Geeing. 49 ^t T
(Use •+' if Above Top of Casrig)
d TOP OF CABIMti IS _ Q_ _ FT. Above Land Surface -
'70P of UMkV tervina03 OLW below land aurTsee may r14Ulre
a ra'tanve In aomtdor cw wM.h i SA MCAC 2C 0118
e. YIELD (ppm) METHM Of TEST
T. DI &IMF EC TION: Type Amount
y. WATER ZONES (depth):
Top Scr4m Top Sodom
Top Sottorn_ Ti*_ Bodorn _
Top 15ottoTn Top Sodom
ThGcknaeal
T. CA3iNR: Depth D1ataleI r Welght Me1w►aat
Top­0 0o0am_AL^ rLJ.2L -&,80 Q
TOPS. aotomli—FL Ug SC 80 CPVCT
Top dononi FL«
rL 4R011r: Depth
t+Aalarlai Method
Tap_Q� Bdtom5_ Ft2A_ Immlle -
Top__ Bottom Ft.
Top Bottom_ FL
IL SCREEN: Depth DWeetar Slot 3tta alaeartal
Topes_ 9ounm- 60 - FL_12 O.ti1 in. GPVG
Top 75 Botlon:-K„Ft1-25_In 0.Q1 in. QPVQ
Trap— — HOia M FL In. _ . in.
10.5ANWGRAVELPACK
_ Depth 8tae tMatariwt
:lop __Bctlorn 6QFL in
Tpa eceom SO.- - - FL. �
To Isodo n Ff.-
11 ORILUNG LOG
lop 9ottnm
0 1_71 _
�J
1
r
�1
r
rorrnanon 06govdw
12. rtc-1aARxa:
30l65 sand seal from 53-54' and 60-74'
: I cO-[llEbr CwM Twit' rnewiu WAS c0WTftK-aowA000F*ko9X ATH
• Isk W' 'XF Ott WUCTM IPMOVSK #MTIMT ACC" OF TM
Y rCa 04YNKJ1.
71JRE OF CERTIFED WELL CONTRACTOR- DATE
l PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form 3W- I o
Rev, 2X9

'w
1. WELL CONT RACTOR:
Robed Millei
Wag CoWaMf 0ndMduery Nerve
Sawa CCo Inc. Well Contactor Company Name
Streal Addreaa
_.Fort Mill —
City or Town Stale Zlp Cade
t0Qj 548-2189
Ana oode Pho" number
I- WEELL INFORIKATION.,
WELL CONSTRUCTION PERMIT$ jM040QQU
OTHER AS MATED PER.MITI(/appkwool
SITE WELL ID eMbPPtlrbele� ❑Qlw-
E. WELL USE jChed One Box) MCnflarinp (, Municip-14hibk13
IndWrtal)Cwrvnardal p Ajlrialhral ❑ Recovery 0 IrIJrolal M�
Irrig*Don ❑ Other C (eat uaa)
DATE DRILLED12-1 Q-11 !_
4- MILL LOCATI0,01'
29W Unwery St.
(SYeM Norm. Manbm Cornmwft. S.&&V!5 on W tic. Prcaa. Ala Coal
cirr; Mnston-Salem _ couNTY Far h „
TOPCGRAPHIC I LAND SETTING- xhao apQ WAty boxj
❑Slope QvaNer d lWl CRk*e 0CLiar
36' 5' 30.4000'
8W t 2' 46.9200"
Lattudmllonpkude source: MPS ❑T"raphlcrnap
Macedon ae rret1 must to mown on a USGS topc map arldoexned la
ft ton K not using GPS)
e. FACI LrrY {N an* of Me bua.nesa wneal the well Is IodaW
Fne r Flaki Nndw s -- >[100 Oal7- - -
Fasim Norm Foollity IDI (IF applicab a)
2M 11 nwPIY Si_
Street Address
Z1r3.S;?Ilri-SajP-rn - - NG _ 271Qt
City at Town Sate Zip Coda
AMFQ - Arba ❑eatherane
Coruci Name
9725 CUgdill Rd- -
IAdInd Addras3
�Knijx31ille _ N 3702
CRy or Town Stale ap Coda
(__gs&j -5e&e&w671-6774
Ama code PFone rwmber
8 WELL tMTAR..S-
a. TOTAL DEPTH; BQ ff
b. DOES WELL REPLACE a NSTINO WELL? YESC) NOW
r~ WATER LEVEL Be$ow Top d Cooing. A$_ Fl
(Uce '•' N Above Top ofCasiny)
NoN RESIDENTIAL WELL C0N9FRV.'J10N RECORD
North CaroIt-% DepaMnonl of FnviroaHmnt and Natuni Resources- Dlvieon of Wear Quality
W igt:I, (:OWIRAL'TOR CRR-rIFICA7iON $ 2675
d. TOP OF CAMG IS 0 FT Above Land Surface'
'Top of cashq Isrm'nated Wor balvw land carfare may Mquh
a varlance In eixadaacs with 15A NCAC ZC 4118,
e. YIELD(pprrij: _ METHOOOF TTIST _-
f. DISiNFECTIOM. Type Amoard
p. WATER ZONES ideptl.):
Top Ba:tom Top Bollcm
Top $o'tom Toy Bcllo'n�_ ---
Top_ Sottom Top— -- 6Ckam
ThickneW
7. CASING: 0"" Diameter Weight Matarla:
Top 0- _ Bolton 5 Ft 12 _Sc 80
Top Bodor I Ft._____-_
Top Rndam F1
8. GROur: Uopr AMterlai Method
Top_Q_--- Bou-23-- FL P odiand Tram -
Top Bottom FL _
Top _ _ eottornFL
Y. SCREEN: D4pth Diameter Slot 8taa Nato"
i Top-1 L-- Bottom 80 . FL_LZLIn. 0.01 In. QM
Top Kotam
FL
In. in.
Top Wq om
Ft
In. in.
16.11IWN04RAVEL PACK:
0ep1A
she MI MWIMI
Top ^3o40m_N_ FL #1
= Too do;lom
Ft.
Top doltom
Ft.
_
It. DRILLING LOG
Top Bottom
FQ"u or. CoWpeon
0- - 180
I
�l
r
r
12. REMARKS,
30/65 sand seal from 73-74'
i100K"t1ftyrMlVVTMWTWA Wl3LMNeCQMMUCTOD04A' 4DV" VAN
���aTAMDVgXk MQ TrHr A',7p'�YQF TF113aFrl.
804ATURE OF CERTIFIED L Ct WMCTOR DATE
Ft�t79ft Mliler
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Forrn GW-16
Rev. It[19

•40
11 RESIDENML WELL CQJS
TRI&MONSILILORD
Noah Cseolim Dopertment of Env krorunent and Natu_mI Reeojroet DivJJ00 of Watm Qrelity
`��• WXMCONTRACTOR CFRTIFICAT[ON # 4155
1. WELL GOMT 'Om
WINN Contracfsr (IndhAowO Naane
Saada= Inc.
wow corkr&dw Corrlpsay kerns
Brest Aldro"
Fort Mill SC 2015
City or Town ft" Ip code
CW _) 548=
Anla ands Phone number
L WOLL IN ❑RMATION:
WELL CONSTRt1CT{ON P£FIOITe MIQ000
OTHER A890C1ATFD PERNMM(lr swac.w)
SITS WELL IO #(vappttxw.) DLI W-308 & ❑LIW 30Q
3- WELL LIAR {Check Orr ISox.) Morlitorhll ❑ 114unlrWub.1c0
MUMMKOWMfOW 1) AgirrOAL 91.[) ReWYVyC) el*%nr{
"01100cl Ottrer ❑ (Rd use)
OAT6 DRILLco 1 Z03-11
4. WELL LOCATION:
{9000 Lowery
raar Nrna Huwb� Cairnerur!h. S.Adr4bL Peirce. �
c,Tr-VVjnsj:qpcouxrTFo%1M.
TOPOGRAPWC I LANK SETTWO! wow appoiAw bwO
❑SWR OVallsy tlilicist (3Rldge 009w
36' 5' 30 4400'
80' 1 Z' 46.8000"
LoOmMAorlpitod0 source U;PS [-]rwDrsph!c map
(boodoo Of weep must be %bowr an a US35 lapo map ordit indliNd I!)
?Ma formed naf ua#y OPS)
6. FACILITY (NA me of Ira tlAlr*ss where the weir Is Ixeoe )
s siqTJ1Mj
Fadwy No" Fadwy KM (if sWIceble)
5brel Addrass
Wtn%1nn-Sa1em ^� N G_ 27101
Cky or Town Slate Zip cc"
AMFr--.1w- ❑eathAraUt—
Cae+bac! Herne
A7?5 Condill
Rcl-
Ma*q A4dren
Knowillts _ _ TN 37932
City or Town state Z)p C046
I-$55.A .5.7I-6774
Ares code Phone number
6 WELL DETAILS:
A. TOTAL DE PTH:80fi
b, DOE$ WELL RE -PLACE Cc1[I"NO WELL? YFR;] HOG/
c. WATER LEVEL Bekwv Top of Ca" 50 FT -
("Ise '►' It Above Top at Cat ft)
iQTti;:1iUV��-i�,i!�igir
d. TOP Or cASimo w -Q FT Above Lard Surface'
'Top et ceatny lairmInsled sVor below lead s OSM M" require
s vaierxe h smmturaa with 1SA NCAC 2C .Orta.
e. YIELD (S r rt)- _ METHM OF TFJT,
t. D1S114FECTION:Typa - .-, Amount
: t WATSR WNE.d wed]
Top 80torn
Top_ _
Beaman
Top Goftw
Too
• BoWTo
Top g0ttor _
TOo
I3M y*I--
•
Thitknesa+
7, CAAIkG- Depth
olarnafer
Se �.�MAIsiM1el
Se so SCLLY�
Top 0 Rottorrt 75
Fl-1,2_
S.K M
Top Bottofn_ -
- F t
- --
: d. dr1�0LIi. PePtT Measr4l Me1rIaJ
- UA..�[._._. BOtbm&l __ F' ftff fi[ rMMje
'Tep B0t 1!—_ -F __ -
Top Bottom r•
R *MEW. Depth abmmw "No ulbbl
Tq L&— i !�. 70 Fr. 1.L M . IM in. _QNQ._ _
TOP 76 - _ BO kfm OQ__ _ P. 1,26 {n• _QLQL R. _CEMrL__
TOP • Bottom Ft it. In
0. SANDOMVEL PACK:
Depth dine Material
T6p_§a_6elttorrs_7Q_ FL 101 SthCa -- -
TOR,13-90tlom-&—R 01 Silica
Top Bottom_-� rtl• � _ __� _ --
11. ORfl UK LOG
TOP WIM Fc.-Mz r, Daac+lprc')
1 _ _
r _
1
1
1
1�-
17. RiMARKS:
30i65 sand seal from 61-63- and 70-73'
t 00 4OWNI CERTIFY TWIT Tra3 MLI. MR 0pMTIU1p"WA00t1P0Y" "TH
• 15A MAC M- OpgTIF.ICYIOOTANMR00. AND TINT A poft Or ING
RMl M b r0 pVAER
ct�izg t�
SMAT13RE OF FED WELL COMTRACo-R - nAr
Dam RaMn �
PRIN'rFn NAME bF PER.IGN MMSTRLICTING THE WELL
corm rave-tb
Rev. ZK*

r�
NQ
NREsiDguu nl& CONSTRUCnON -CORD
North Camlkm Departmsnl at• Eovisvnment and NatwrJ Rosouma- Division of Wet= QueLhy
WFAX CONTRACTOR CERTIFICATION fl 4155
1. WELL CONTRACTOR:
Wall Cartracior (IrdNAd wo Nama
aaedacco Inc.
Woo Gvn"Cw Corrtlmr Name
8 NoTltTfleld ❑r.
svaet A4dnws
Fort -Mill SC 29715
City or Toren Stale 4 C 0
t 803 s -54A-2100
Area code Phone number
2. WELL INFORL1/1T0W
WELL GONSTRUC')CN F-ERVJT#VT2400098
OTHER ASSOC LATM PERMff f(l aok wa)
WM WELL ID *0 apokum) QLIYY-318 4 ,DLIYV 31 D
3. WELL USE (Check One Box) Monklq Q Munldp#LIPubllc0
Fdua WXarwro@FClal ❑ Apri" turat D Reowwy ❑ 'r*K*on of
krogfoono Olher :] (lat uet)
DAPS DFULL ID,
4- WELL LOCATTOM-
2000 LQ Cl3ry St. -
fSVW(Nanw. 146mbars, CoewswRy, S4jbd►4wm Iatlia. Pw*IK Lp tech)
coY Winston-Salem COI.INTY FgrLAh _
TOPCKWAPHC1LAND SETTING (dm*nwupr&%bw
C)Slope pvo" wrwmd i)R" L7OInar --
36° 5' 30.3600"
80' 12' 46.6900"
Ladkideftngi :de aotrce: MPS LJiopopraahk map
padatlan d 1.+ec1 mcar oo a+rok�r+ rn 6 uSCiS tip � map andarrat�'s� fo
M form P not vsvlp GPSj
A. FACILIrf LName or Cta wkwt, 1)r well ,s located }
Fnrrror Flakf Prndirr-1s (1 n nn17 _
Fadlftr Name FaCIlty IDO rIf appCca
' 2 MO I nwftry 5t_
Street Address
cor or T own slabs tip Code
AMFr -,ins Dealharane
Co Amd Name
17�amill Rd
hMalinp Afte"
Knoxville TN 37g32
Cfty or Town Stan lip Cade
C R65 —688M244671-6774
Area colt Phom number
& WELL DETA13:
a. TOTAL DEFT H:-80 ft
b. DOES WELL RFPLAC E EXISTING WEL19 YES L7 Ya qi
c- WATER LEVEL Haloo Top of Cas'np: 5Q FT
(flee if Above Top of Caslhg)
d TOP OF CASING IS - a FT. Above Land Surface'
'Top or cashy Wr .mwd avor baton land aurlava mar kaquft
■ varlancA M sawmance MATT 15A NCAC 2C At 18
a. YIELD (ppm]: METHOD OF TEST—_
=t DISINFECT10H, Ty W ArnoYnt
g, WATERZONES (dopml
Top--, Bo mm Top Bptta n
Top —, twwm I op Boom
Top Rat om_ l op_ Bobom
TTldcknaM!
7. CASMLA: DwW Olametar Mlespat MaNABI
ropes $atom $� t_ ZY t 00 �—
TOP 90 bRIT_ Ft
1, GROM! DOO Melertd MW*d
TOP--_ aatlam&,,�._ FtPodland Tmmle
Top _ Bohan, Ft
TOP BoCan FL
If. eciumm 0wh 010mgat Slat Stu Uw arfei
Top �45_r Soft- 74 FL 1.25 h. 0.01 in CPVC
Tod 7b —. 50om8Q FL 1 &M. 4.41 In. , CM
Tap Bottom— _�- FL in. in.
10. SANDMP AVEL PACK:
Depth On Material
Top 63.9 t3altom_7Q— FL MI S lica--
Top7?*TtBoftn, $D--FLj1—_ SOMS
Top._- - _Souorn.. FL
11 DRILLING LOG
Tap Solt m Fotrwl,o,+ DocmpSon
sills and fends W1 minor clay
end greyel.- --
30/65 sand seal from 62.5-63.5' and 70-74'
kCOr1[NFA ()Un"7MTRol V L VaS aA 93 RUCTMIN AOODAMU MIRK
• IM WCAC M wWU 001iffRUCTMSTANU%Rp6. AMC TMT ACOW OF Tine
r�C[71ro rMa BE PRUVIOED rYEl1 OwFR
SIGN
AT11RE OF CMIFIE10 WI3+L CalfiIlAL`T I0� QATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form OW -tip
Raw. Z"

3
1. WELL CONTRACTOR:
Quid Urown
Well Cords nr (trdwuaQ mom
Sasdacco
Watt Contrzolar Company Now
QW8 No field Dr.
Btmmt Addnaa
Fort Mill SC 29715
Oty Or Tow stale Zip Code
r 843 s 548- 2180
Ana mde Phaft r%rrd t
L WELL INFOM"TION:
WELL CONSTRUCTION PERSfrt N04ON9
❑THER ASSOCIATED PERMfrg(ifm WWI
BITE WELL ID+spr.wwotr+)DLIW-32S $ DLIW-32D
_. WILL USE jCrw&d Orte Box] MonNorinq ❑ Atu6dpe4PubUc CI
rtduzrnaYCor+rsterdol f7 Apticullursl C Rsoowryu lnloilo-4
rvadorc Dewy C (list Use)
DATE Dw uo 12-03-11
4, WEI L LCICAT10k:
2000 Lowery t.
( trwet hum, Fnr*dnn Ccmrxait; &ubdiV%im. Lw ND.. P4rwi.2lp Owe)
crTY: Winston-Salem cwNTy EMYth
TOPOGRAPHIC r I AND SETTING: (d" appmprtrle ba) ^—
rI IOpe 13YAkY flat DR056 ❑Dtrwr
36' 5' 30.4700'
80' 12' 46.6700"
Latituderlortgkide wino, JWIS OTOpeprsphrc asap
(Ioonow or ww% must be BhONY.' an a USGS rope map emdatracned to
Ihls rbrm Ilnd uMV OPS)
6, FACILITY (Name of ft ntnlnaaa wttera+na wen la lm4ted.)
Former
FatNty Name r-way IDs (Irappbc")
70nf) f awory Rt-
Street Address.
WnSjn0-SAk%M._ _ NC— 271ni
City or To" Stw'e zV Cods
Cootad Name
A72.5.r.00dlLl Ed
Maing AMroes
_ nirIM1116a
City or Taws a" ap Cove
(_$$5 6T-fi774
Ana code PtWe number
IL WELL DETAIL&
a- TOTAL DEPTH: 80 l$
b. DOES WELL REPLACE MSTM WELLi YPS (I NO pI
c. VVAT£R LE►rEL Below Top VC*". 149.69 FT.
(Use'+' it Above Tap of Cuff)
NoNRffj,tDENUAL WIRLL CONUIRUMON RECORD
North Carolina Department of & vim mmcnt and Natural Rcfour=- Division of Warr QUAIihv
WELL CONTRACTOR CERTIFICATION M 4155
d TOP OF CASINO 18 4 FT. Aw" Law Svrraae•
'Tpp oT c&Wg Urmlrrsted sVor below Isnd surtsae may regL*e
a radars@ h towdance wkA IGA NCAC 2C .011 B.
is. YIELD (Spmj;
METHODO F TENT
t. DISINFECTION: Type
Amount
8. WATER ZONES (depR)
Tp9 eofty
Top
Bullorrl
Top_ Bottom
Top
Bawlom--
Tap_ _ Bottom
Top_
_____ Bottom
Thlp(tneael
7. CASINO: Depth
I71aeteler
W11pht alaterhal
Top 0 aot:om65 Ft_ 1 250 Sc,80
Tvp_Q_ Botom_Z� Ft 1.2V
Top Bottom Ft
0. GROt1T: Depth Malerlas me',hod
Top 0 3otamFt._ Trem.e
Top--- bo.4cm --- FL
Top Dottorrt Ft.
R SCREEN: Depth DtalHelaf slot Sea Yatarrs.l
TOP — Batton --Zg_- Ft-12klrt. d_Qi In CPVC—
Topr_ 3own�FIGFV��Z _�
Top Sotmm_, Ft Irt In
10, RMD10RAVEL PACK:
D"Ah See Ralarlal
Top-fi&7-8otlom_7Q--FLU_ SlIkA� _
- Top 74 80Om_N__ FL � SliiCa
Top 8chom F1
11. DRILLING LOG
Top awam
ISO
1
!
`J
I
!
1
12. REMARKS:
horrrutic,n Desulpom
silts Wo Mods ►Yl sl Me clay
30/65 sand seal from 62-63.7 and 69.4-74r
100 HERM C01TVY THAT 746 08� V" 00119rIk1CMIN A000ROANCI IMT4
3A WAC 2CjhELL COaIaT CM1rTAVOFRp0. Alm TYMTA COPY OF TM
FlECxSlto =09=
( 2
SiVINATURF OF CFRTIF" WELL 66erWC15)R - DATE
PRINTED N11ME OF PERSON MNSTRLJCI M THE WELL
AMN� Rev 109

1.
4N REgE1VML WELL CUMSI'RLICTIUN RiCCQRM
North Cam IIns Depertr wal of Envlronavol mW Natural Famines- D1vitiou isf 1tWatsr Quality
WELL CONTRAMOR CER71FICA'i N p 267E
1, 1VELL CONTRACTOR•
Viol• C.orilrookr(k14W1dual) Name
Wail contractor Company Nano
2Q88Ngirthfield r
&real Address
i
CRY or Town Ertl M code
s 8U3 ; '5,48-2180
Ana oho p Phone +umber
t WELL LWORMATI0M:
WELL CGCNSTRucno. PERMITO_)8 d SS
OTHER ASS9CIATEA PCRV f iq die)
MrE WL-L_ Ib*(xeVaOcaGel DLIW-33S R DL[W-33❑
7, WELL 118E (Chopp One ftf) MaMorinq :: MunldpallPubticEj
kd"VlaVCurrna,dal r.] AGriwlhsrai ^} Roco"ryf' koctlon
Irtgetono Q1fw{l (Ia10e)�
DATE DRILLED 1 1-'2-1
t. MLL LOCAnow
2 Lwery 5.
(skeet Nome, Nunber% Cornrnwdty, s>�n, iat No,. Pwcnd 27p Cc"
CITY: Wnston7�ialem _ _, cauNTY Fo_m_At - -
TOPflpRAPHC ! LAND SETT 1NG: (d" eporapnele b*
nsiopo •-iVa-ley 1;f1a1 uRldpe {]Geier
36' 5' 30-3500'
80' 12' 46-5940"
Lss"ollohglkxle so:xws IUPS nScpDgraphi' map
(lociMon plover most be sfh� on a USQS hpo map ondarfv YW to
We Aorm 0 ad wdrp [P8)
E. FAOILrrY (Name of the buatsose where the well Is locateC.)
Farmer Flak] prorltlr•.tc 0 U 0017
Feepayr Narre FvMy -Do (Mapplicat htj
Short Address
] amfon-Salem _ _ _ _ NIC 271 CJ
c4ty or Town State 2h code
AMF� - .lee neatherana4
C ).V.Sct Rarne
A725 rnadill Rd„ _
Mall ng Addrrces
Knoxville TN 37932
rAy or Town gob rip code
1865R AM I DA974
Aran code Phone number
6. WELL DETAILS.
A. TOTAL DEPTH!-,ojL
b. DOES WELL REPLACE F)MITINd WELL? YES IJ NOW
o. WATER LEVEL Bakm Top of f:aslrp
sl>,e '+' I! Above Top of CaWQ)
ll. TOP OF CASING IS _1_ FT. Abova Land Surface,
'Top of c&Wg lermk:eted Wor below land aw fooe may mqul.o
a variance In m-vdence wM I DA NCAC 20 0118.
'a. YIELD (gpmt: _- IIEfNDD OF TEST
L DISINFECTION: Type Aswunt
: p. WATER ZONES (depth).
Top Bolnvn Tap 9a:10m
-foq— Bottom Top_ Bottom
Top Bottom Top Haltom
ThlaknoW
Y. CASING: Depth DNlmeter Weight AkIlldal
ToR_Q—BatWrn-i5 Ft1,25 scab CP.G_
Top MAorrL _ FL `-
a.OROUT: Dow AAalarlel M*%A
Tbp-Q-- "am• fit FL Portiond ._ Tre9rrig_
Ton_ Bottom Ft—
Top Soil rr, FL _
0. SCRTCEtt: Depth Diameter Sw Size Ya6ariel
To?S& Bdlrnn_�] _ FL 1.25)n p_01 In. QE�&_
Top-M_ BOMam 8i - Ft._ 12&hn' 0,41 In. CPVC
Top Bottom, Ft In. in.
$0. 6AN010RAVEI- PACK:
Depth tilt! Material
Top-74--_Botlam BQ F!.11--_ -611ka
Ted „_,BoWni FL— _
1i. DR1tL1Nt3 LOG
Tap Bottom Ferraaean Des&N!on
r
1i 12B1MA7t}t1R:
30/65 sand seal from 62-64' and 70-74'
I p011!/VRYY OEMry TIM'1 TM WEU VW C'd:S`RUUM0IN AMAMI ,"WTI•
tell NNSC r, WELL CONG-I NL 'M ETANWIM PC ri VT A 00Fr CIF TM
REOX v MS e-d I MaYlI Ea M THE M LL OWNM
SIGNATURE OF MRTFIE MLi C,OM Cffik^ DATE
- Sim fan Svrti�,
PPNMD NAME QF PERSON CONSTRUCTIND THE: WELL
Form GW-ib
Rev, 2"

ON RESIDENTIAL wFL rRUCIION RECORD
:worth Ca:utiea t of Env ianw -it and'Na,ure] Rmu raw Dhi- iior. of Wax. Q09ily
► XLL CO?YTItAf:fOR CER11FICATION g 2675
I- AELL CONTRACTOR:
a �L •1 cr
k Weil Contrector ('ndhtduel) Nwrie
I We1 ConSeCW Cor"F y Nary
1 -90H N.Q-Jrthf1& x.- - -
Stmel Address
Fort Mill 31C 29ZIS
09y or Towi Stele Zip cob
8• 03 548-2180
Am cndo Ptohe st "ayef
LVI'ELL INFORMATION'
VVELL CC'HSTRM'K)H PERM TiW10400098--
t7 DER ASSff'IATED PEfihtlTO(ospokaaa+l_
!j SITE wELL •0 rV. ). L W-M $ 2LV0 -34D
1 =.WELL V 8 E ;Check One Nook] MoNtoringC MurkJpaWPutk Ll
'ndustrlNlComrnerdal0 Agdwlturat{1 Reooveryn Irlom"if
rtSGa6onC] filler C :loot uw]
DATE t7RILLEi}-��
i. AVELL LOCATION:
I
20Q91=_o -9 St.
'k sN*1 Name, Numno e. 0;T.mwYry. Ski xN w Lot Nlo.• Patel. Do GO*
CITY: Win§ton-Salem COLHTYFomyth
} TOFOGRAPHIC I LAND SETTING: (dtadk SpartaslabU�]
1 c.alape mkkiwiey 0-mt LRidge nolher
II 360 5' 30.4000"
BT 12' 46 4400"
Ls51xaAorgttude awres jPPS Liroaogrephi: map
�orahb cl ureM rrwst rs ahcwr ari a i19GS haya map endeMeahadb
�ka �orrr, .of not using GPS)
S- FACIL€TY (dame of the ntre4neas *here t" waA to Iomtod.)
Fac!ty Nwnei =:deity ID# Of app1ra61a)
2000 1 1 uggi.n]L St
Street Address
]�lar3s#a� 31e. L. NC 3T1 Q1
' C-4 Of Tow side Zip Code
1 Contact Nome
gZ25 raadill Rd_ _
Vla'ling Addroaa
Krifil(1 ifle _ � IN 179'i7
C ty rw Town S1ata zip code
^--671-577�
Aral :ode ?horoo numoet
I k WELL DETAILS;
a. TOTAL DEPTH: T ft
b. DOER WELL REPLACE EXISTING WELL? Y�8 C- NO(V
c. WATER LEVEL Pa ow Top of Caai% A _.—FT.
psa'r' I Ve Top of C4*9)
d. TOP OF CA81xa la 0 FT, Above Land Su rfaca'
"op er Caa ng terrni-Lo d Bror haow Iana ewface mar .nawre
a PaMme .n axMarot wl'h I5A NCAC 2C .e118.
a. YIELD igpmy IAETNOD IDF TEST
L Dt81HFECT1ON: Type Amount
: q. WATER ZONES (depth):
Top Bottom Top
. Boftm
Tap &adorn Top
Bottom
Tap Bottom-- Tap
BCftwIL
ThIrknew
T. CASIN(;! D&Vh :)Wnetor
Wright M1rwrlal
_-Boltarr. 55
' Top_Q� Bottomr65 - - r': 5"
-C Do PVC
Top Botox Ft--- _
I. GROUT, Npth melerial
Nathod
Topes_ Bottom 52 - - FL_ flRl ^d
_ Trem;e T
Top Hoklom FL
Top Bn3o+n FL
ti. SCREEN: Depth Dia inter SW Size MkalofW
:Top 55 FL 1 25 In -Qjlt In Cp1LC
Top_55 - BWtom 7Q- Ft_ 1.25 In. . 0.01 in . ( PVC -_
Top _ eoRom_ -- FL In. Im
ftl. SAND,'GRAVEL PACK:
Depth Btu hutodal
AA siho
Top-64-3ot'om-M—FtA_ _ M o
: t1. OFZtLLH,G LOG
'fop Bottom 2ormallon Oescrlplon
.1 70 -
1
�J
r
r
ix. REMARKS
Aft Sr&L sands wl bgrre.St!aY
_30/65 sand seal from 52-54' and 60-64'
DC MREBr ClR"a't IVAt TINS A4 rA+r.S 00e6tR=E- lH AC0DPQ"L W kr
7M W-'PC 1C, WB. - W, ML Cn<N S-AMrlJtne, MT] n+AI A CM OF YM
FROM FN$B104(4CMM5 IC ThM-:V UOWKR.
SIGMTtiRt: OF CZ:RTIPIEI] i/VCLL CONTRACT — Tf:
% PRINTED NAME 'OF F'ER34h CWTR1JGTIhC T-1E'JVELL
Form GVV.to
Rev. VV

a
1. WELL CONTRACTOR;
Wag Contractor (tndrAduaq Nerve
Wets ConlrwAo CDmperrq Name' --
Sliest Addraaa
City or Towr 5taia Z1p Code
St St 03 ) 548-2 i 8a w
Agee cods Phwa rotardw
2. WiLL INFORWAT1,011:
MAIL CONSTRUCTION PER4TS 11U 04WO 8
OTHER ASSOCW ED PERMT#psplaft c1
arre WELL oowvprat++1 DI.M-3 .- DE0-3513
E. WELL t1SE (C1 OA Ono 13" Monrbrlrp ( I Ltunlcips6Pvbllc0
InduaftL CcrrmWa' U Agr6m&irsI C Recovery 1eg0cim
Irrloatlon-i odd C_ (W UN) _._.
✓?ATE DR1LLIFD jj—tZ:t L _
4, WELL LOGATIOX:
2090 LQWena St.
.gear Name, Num6pn, CWWNr0l, SwN114 91 Lot lib. Funw. N [Soda)
STY: Vfins n- COUWTY ]DMYth ._
TCPOGRA°HIC I AND SETT NO: (i*" epwop" D*
CJSIOPe aVIlay Olaf C:RIdgs LlOther_
36' 5' 30-4400"
80' 12' 46,1900"
Lattudeflenp:luds so:nc MPS f 1toppgrpphtc rnas
jhSoedm a wv4 moat bd shown on a 11SOS tope map arrdatlached ro
y11e"Mnot rrerrp OAS)
S. FAGILMY (Nome of the baseless w1mee the well is located-)
Fetnpr Rakl P_(^C dl iefg ()(M nQ17 - -
Fadl3ty Name Faclk IDi (If aPPkebb)
Street Address
Min tnn-Sjl003 - . NC27101
City or Town stria rip Cade
AMFr �j--QPRthU8(ie
Confect +deems
27�andiii Rd-
Mollino AWro"
1Crinrvilia TN 3732
Cty or Town stele by Case
LaB5.d -9 M H a .9 11 671-677'4
Area code P h000 nlr 01
8. WELL DETAILS:
a. TOTAL DEPTH: 70 9 _
b. DOES WELL RBPLACLrPASTING WELL? YES❑ NOW
c- WATER LEVEL Belov7op OtCWV 49_d Fr.
(lice '+• If Abort Top of Oaft)
QNREVIMNIML VMj, coriMU Uorr ucakn
North Carol Ina Departinc•rl of Fi..virunrwat ioW Nutunl Roeo•.usw DIVWon of Wattr QLiRllry
WELL coNTRA(,xuR cRR•ITirjcAj joY R 2675
aL TOP OF CASINO 3 0 FT, grove Land Surfsw*
•Tea of aaahs to rminalad allor below land rrface rlay regtare
a vertenoe Ir. a❑cardance %IM I OA NCAC 2C 0116
e. YIELD lgprrrt: ! _METHOD OFTFST
1, DISINFECTIOW Typo
Amouat
g WATER ZONES (deplh):
. 7pp _ Bottorn Tup
Boltarq
Tap gotten Top
_, Bolhon
TOP.- Bottorn_ Top
eotlam_
Thtolrosal
I. CASINO: Depth olarlaler
Welpt McAVIIsl
Top_Q_ ., BcttOrn_ffi,F4.yj5m
SC N ,Lu�- -
Topes_"Om-M_ FL•1,W
SC SQ -!QPV-Q—
Top_ _ Hodom_ Fl.
--
$. GROUT Deplb Matedal Meti-ad
: Top• 4 ^, Bcf1om U _ Ff. PaUndT _TTemie
Top Baxom FL
_
Top - Bottom 9L
A SC BEEN: Depth D*molor
Small* Mablrtsl
Fop�� Botbmja` FL 12&ir.,
�_ Lm CPVC
Top-0--aotb-20___PILs.2&tn-
-QZ- in. -CP_YS_-__.-
Top_ Donotu - - Ft In.
an. _ .
10. O MDlORAYEL PACK.,
Depth No mot"]
Top _kaj DuHomQ§0­_ FLA!E^
Top Sodom n
11, DRRJ.INO LOG
Top 9wom. Fnr Ilion Desuoor
st5 4tldaanO w/ so71e clay —
i
�J
1 _
�.1
30/65 sand sea! from 52-53.5- and 60-64'
100 !FWJIY 4'i9UM ThAf Tana WO L W d =WRXTFDN AO=WMCE ya rw
• 1M MW M yKti CCA♦IBia110 "lEiVlri"%FDK AND Tt W- F COPY OV `W
fa�rwlGynol.c ry Ylai.E orv�aa.
1t t 11
NATURE OF CERMED WELL COW AC.° R DATE
� i � 4V3�-sdrl
PRKMD NAME OF PERSON CONSTRUCTYNO THE1,HELL
FOM GW- lh
Ray, Z09

Aff NONRESIMATUL MLLL CONSMUCE10N MRD
Norlh C*WinuDeperement of l?avtmnmenl and Kmtund Reeovms. DivWoit. of Watvrguality
��... WaEu cUN'rttAc i ojt cKRTfPjCA'rjoN # 2675
1. WELL CONTRACTOR:
Wel{ Contreafor (VdhAdclao Ham*
Wel' Conlreolor Company Nlaw*
94$fNQdhfield Dr.
Sh"I Addreu
�SIC 20715
or � State 20 Code
Area cxode Phan* mm%ber
1, WELL INFORMATION.
I'&LL CONSTRUCTION PEWFTV)8 a
OTHER ASS00ATED PERVIrra>[YspleWM)
31rV WELL ID "fj*plerbla - S Aw❑
J. WELL USE MoM Orm bolt) Mor$orir,2 ❑ Munid"I/PuNic `1
ndJa$leVConrn*mW ❑ A0ewa-ws1 ❑ ReccmcyU VJeWon hr
InVationr] ❑Rw ❑ (till use)
DATE DRILLSD_1 -1,-1l
a. WELL LOCATION:
2000 LQMry St.
(SkoW Nance. 91ub*AWorL LW No. Parcel Z)p Cede)
CITY: Wifl3tOfhSglgm ccLN-Y-Egrs th
TO-IOGRAnhIC ILWO SE- ING: [check W"maM baQ
U3:" 0VO4ey Dial I IRk1pe muter
36' 5' 30.4700'
80' 12' 46-0700"
atfbidaf nrgilclda sautge: VDPS CyopoOn+PMc map
4w,gdw or well molt he shown or a USOS tqw m* arrdef Wind Rs
:his larm ifnd wrlV QPS)
ti FACILITY {Nana of thM bun kvan *hare Ih9 we4Ia locaied )
7�_
= uciRy Varno
2(''M 1 QwPr►r St
Fadlay IV V! app k4WIS)
Street Address
— jnston lepl
Y of Town
AMEC - AnA Dent ArgQA
_ h - , 271fl1
state 21p Cade
Cameo! Noma
AM; C'Mdill Rr1-
Mallinq Address
gnnxvl le
'Ld`_3 7 93 2
Cly or Tow
State Vp Coca
( 885 "71-6774
Area coda Phone nuraoar
a. YYEL L DETAILS:
a. TOTAL DEPTri:20-ft-` _
h. DOES WELL REPLACE EXISTING WELL? YES 1 NO OV
e. YVATER LEVEL Del ow rap at Cneing: A,3-_ •... _- �1.
;Uai '**If Above Top of Cash,T)
d. TOP OF CAtftNG 13 �, _ FT. Above Land Surface•
*fop of ooWv tum)ggad Wor beltrw }and surface may require
a varlanca In accord anco with I SA NC1C 2C -D11 B
a YIELD(ppm). METHOD OF Tear
f. 1311814FECTIDH: Type _ - , Amount
q. WATER ZONES (deph):
Top Bottorrl____,_! Top__ Bottom
Too fDelEalrl Top Bolb m
Top Bativtn Top_ Baisanl
Thiatmasaf
7• CA8140r Dpm Olemal*r YYalghl ~21
Topes Botlo'm-05— F' , '�_ @SZICFYQ—
Top-0— Benom65 rL 1.26' Sc 80 cPvr-
Top Bollcrr�— iL - —
& dour, Dapar rdeta" MHnod
Topes_ Bo lorrula— FL Portland _Tremle _ —
Top�_ 3Ctom•__FL
Top �atlom I'L _
S. SCREEN: Depth Olaimi ter Slot alza Note"
.Top 5' SotSom�Q �Ft �. {iUn- _QQL 1n. CPVL_
TOP-U— Botterm-ZQ____ Ft-1.25 in. AOL IrL _CPVC
;'rap Bottom FL____}rt- In
10. SANO)GRAVEL PACK:
Depth Sire Material
Toa-tffi-5%0ti0m_sL Ft #1 _ StIlca_
Top. 64 —Bswvm 7.0_ .__ FL�1` _ �ijlice
Top��fntom Ft —
II. DRILLING LOG
Top 80110m Fo mlabon Dwc *III n
11 - _ J 70_ _ silts and migdI wl Icons r.igy-_
f
1
. 1
r
►R
12- RELRA KS:
30165 sand seal from 52-54' and 60-64'
100 NBKM CMTFY TMT rc* VM.L Yana voFIRr"LK q a A AOCORD&NM VATH
IAA W-4; 2C, YYti 0318TRXrM UTAMD W"k HO n kt A CM OF THS
w ftx P T*i WELL brv+a"cR
+k h 11411
SIGNATURE OF CERTFIED WELL 6NTFAL"1— DATE
PJWT�OF PERSON CONSTRUCTING TKE WFL L
F'o7n GYY-1h
Rew.2%

1► -0JV RESIDLN L4L W w, Co s1 RUCTIM UCORD
NOTlh CrtolhesDepaAswirl afEayWcuneci andNah:rnl Reaouroce- t)lvillon of Wutcr Quo Iity
WZU (,ONTRACroIt CitRTMCA'rrON * 2675
1. Wr2LL COt4TgACTOeR
: d TOP OF CASINO 4 F-T, Above Land SxlKs'
`Top of cuing terrnlneted rider be:ow land soda:,* may r"uve
WailC�on�.n��olpc OWMdual] hhme
a variance In llOGt danCE wIiI1 1 aA NCAC 2C .011 iL
aaadjj rYI [W. -
lrca ConearCa�pNodhWdnr►ry Hartle
: e. YIELD (91mt McTHOD OF TEST
�
����Wppelgg
: f. DISIN FHCTIWd: Type_ m
Aount
Street Address
: p, WATER ZONES (dep:n):
Fort Mill -- - _ SC 29715
: Top Wmrr____ Top Bottom__,
Ch or Town State itp Code
; Top Boftm _- Top Bottom_
$i 0 - W 2180
; Top GotwR _ Top Bolt"_ -
_
Rrea code Ph" Cumber
Thickn"W
1- WELL INF0RMAI1OFI:
' 7. CASINO: Depth Dbmafer wtivtt metwul
WELL CC'*STRLIC"TFON PE RM i rOM40000 ,._
: TOP _ So1a17<_4&_r Ft. 1- "_ Se 80 .('DV('
0TIir-RASOOC1ATEDPERM(T/(Tapr*sbisj
ToP.Q Gotom 5i _FL-1,26_ 00 --c P)M,
STYE WEI.t. ID artrappk&,.) DUIN-37S $a I-LI -UP
- Top Sosof FL
S. WELL USE (Check One Box) Morgto4V ❑ Muni&pal Mubile ❑
: S. GROLTT: Depth MaArtul MAod
ndDstrlsYf orW ner-jal I.i Agricultural 71 Recovery.1 In!eo',ion d
-�P __ ao�am _ Ft Portland _
;rnpatlonu OtAor U (list U")
' Top Sottam PI. v-
q DATE DRILLED 11-12-11
Toy Bodwr Ft.
4. WELL LOCATION:
9. SCRE.EN: Dapih Dlarnslar Slot Stae t#ator4el
s ZM Lowery St_
iTop 5 _Batsm�Q,FL-12&01. _QM h CPVC
(Stvet Nm bera. Cor iff.ie . BmbsAsk ti iA No., porasi 71-p rode}
' rop_WL _ arottanr_Z0._ Ft. 1.75 Ii _ 4�Q1 In.
Ca-Y:_Winston2$alem COUNTYFOrS.srl
_.CP]CC,
Top MrWrL _ FL-_ in- In. ,
TOPOGRAPHIC t LAND Sr:-MNG: wma app was bosh
CSlape ❑VaWy 4V7st ❑Rrdge UOlher___-.
:10-SANMRAVVLPACK'
36" 5' 30.460t7"
i
Depth Sea 11116 Tilts
: Top�`�9�_Bo tomes_ F;• ELT. .!�
i ao' i z' a5.saoo'
; Tap _Botto<n-Z�­ Fl
La*udsAortpf4As same: WDPS [ Tfopoprephicmap
; Top Bottom Ft_--
(bxtJCM & Wit FADS' be, ahown an a USW AVO MW anda"C"1id b
_ -
Oils f»rm !I rraf us" GPS)
' 14. GRILLING LOG
S. FACILITY ;Hama c! Ella truslrgss tW1Wero tiye WvaY in iocesed-j
Top 50E0n PCrmatkin Deacnptlon
FPdit Noma
30(M 1 nw Ffy 5t-
Fatty IDR off ppIlCoble)
Sti"!At AdditKs
M or Set;S�._
C
AM PC. - .ina nsathert3np
7101
Contact Name
10101I tp Address
Knflxyille _
Zd_ 37932
City or Town
_
State I)p Gods
Area code Phone nm*w-
!. WELL DETAILS:
e. TOTAL DEPTH:_70 tl;
b. DOESVVELL REPLACE ErXIST1110WELi.7 YESra W)U11
c- WATER LEVEL 8mow Top of Caaing 50
,Use '+' NAt]ove Tap oI Co*g)
2
01 zo _^ silts and sa-tal wtaome ram._
.wJ!
It- REMARKS:
30/65 sand seal from 52-549 a%f4' _
I�oolit�eee+"oLtlll►YstlarTlcsthrxt.yrsecar+e`>auc�ns++rr;Qnnnn�w►m
•16A-ACW,,%%LLCMffMICT*N4TMW t8,AWh47AaDM0FTW
REOM W4 B" PFOAM TO �16 YWLLkUNIMA
• sl NATURE or- wilism) wax cOi+ Vdf&�' !� yWTL f
PRKtrvD MW OF PERSON CONUMUC T� 1
Form aW 1 b
Roy. 2MO

+r r
NONRE
North Camllna mpattment of Hnyirt,,:nrrot and Na:uml Rasoucat-1)ivWon of Wste' Qud ty
WXM CONTRACTOR CERTIFICATION is 2675
1, W£LL CONTRACTOR
Nall Cardrador f11tdlvidu0 Name
5 e
W61 COW revor Company Name
Qea Nodhfleld Dr.
street Addree■
FQA Mill SC 29Z
CRy or Tow Slate Ap Code
8� ❑3 ji 546-21 80 - -
Am code PhowmAnhe-
1 WELL [WORAIATION:
WELL COV5TRUC-'IaN PERM110 Q-YYL4 QD
OTi4ER A860CiATED PERM IT1jIr sPp*, bk)
SIT WELL lO sp wwabw DLM 38S St OJVIf-38❑
S. W[!LL USE )Check Olxr ftx)NontlDoia fT irluMol dFubla [)
Indt atAellCor)xrerGW f 7 Aptkultural Lt Rer ovM C Ir *ckn t(
irrfgeddnl t pYhar L (Nst uar)
DATE DIRILLSO_11-12-11
4, WE1.L LOCATION;
2000 Lowery St.
(9lroel Name, NLvft.w, Cco .ow ey. aLt4 Aeion,'At No., Parrs, IIp Cade)
CITY.: ins Q - Igm wju ry 0 1,
TOPOGRAPHIC 1 LAND SETT INIG: [loot ap¢opr`ala wary
nstope ❑VaEey ahst DR40 Ljafher _
36' 5' 30.5400"
80` 12' 45.7500"
aUu dMonpitude source: EMPS Fropcyrapbfc Inap
pxa7on of #W1 rnusr be shown On a USQS lope mop "aundfad (O
Ua worm 1 nct usfnp UPS)
& FACII.IN0wre of fhe huakweea where the well la tocated.)
rft non tan17
Far_,Vky Name
70no a Owou ( ;t_
Fadiby" pf apptkeblej
Smal Addteas
nM -Salem _
Nr"2Z1ni
: Ry or 1'D"
a" Zip Code
:ontact Name
S.725 rmT4iii Rd-
MaMnu Addmsa
City or Town —
Stato 74p Cade
L865A , 671&774
Area coda Phone numW
6. MLL DETAIL&
i TOTAL DEPTH:10-fl—
b. DOES WELL REPLACE EXIST11I0 WELL? r'CSU W) r#f
a. VVATL 2 LEVEL Be'cw Top of rAwkW _% ;-i
(Uns'r' If Maw Topa1CIMIkIQ)
d. TOP OF CAailwa is �Fi T. Above Land 5urfaca'
'Top of oulna tetrNneled aft below land 9urfaca may rYWiro
a verlarrce in eocordsrrce with 15A NCAC X .0115.
s. YIELID jppmy MET ROD OP TEST
f. DISINFECTIQN: Typo Amount
p WATER ZONES {depth):
Top Bottom Top , Boftnra
Tap PMIOrn_ TOPi Bof rn
,Top___.__-
Thtaknew
7. CASING: Dept), Dwmwtar V;ralpht WAOClal
Topes, Bodam FL 12jr -•&M CPVC -
TopQ^ _ Bonum-65-_ Ft. 116' s$Q CPVC
Top LWrlarn^ _ FL ,
a. 13ROUT; Csplh waver% Wtehod
Topes Bottom 5- Ft:PAttljcjL- - Tmmn p _
Top_, Down Ft
Top BDISOfn FL
0. SCREEN: O/pth Alarnahr Slot Stan Yetadid
I Top 55 : a&tan6_ Ft. 1-26 'n. _ Ql In, CFY-Q`
Tapes 9oSlam_7Q_ FL_12 _QJL_ In • CPVC
Top__ - . _ Bottom_ _ Ft.�. _ , In.
IQ - 3ANWORAVEL PACK:
DeQtn 61�e Atatnrlsl
Top 5�1 Ytlpticm _--FLU. -M SiiiCa
T0p­64 _8nlcrn_70 Ft # _ $&.A
Top _Bottom _,• FL _
11, DfiUING LOG
Top sor.om Forma&)n De"Aptron
ZQ_ silksraards wl s� r+ararg]
�J
�J
.�f V
12. REMAMS,
30/65 sand seal from 52-54' and 60-64'
f CO , lMtM Cerny TNAT TM YAU VM Cc7NarFpta'rflo IN ACOORW4•'t: VIM r
40AMCJ1,r1 WOUCOMTibJCM81AlbM06*AIM "7ACOFTOFTW9
MNATURE OF CER1FIF.aWEU COwfW OAR— DATE
m
PRINTEI] NAME Of PIF R80N COMM TIE!_ WELL
FtxmGW1h
Rev M

NoN RESIDENTIAL WELL CONS-11JIUCTION
North C -alma Depwtmentof Say.rorum rA and Natural ResDcmw, Div lsico of Water QUEty
WELL CONTRACTOR C RTIFICATION 0 2675
1. WELL CONTRACTOR:
Robert Mmllgr
Well Contndw +•tndlv)duarj Name
C.
Well Contmdor cwnpsnydame
9088 Northfield Dr.
St" Addreaa
__EQA1. d _ __ SC _ 29716
CAy or Town stalk alp Carla
8r 0380
Area Carla Pttefle 11t IPW
7- WELL INFOftM1AT1ON:
WE L CONSTRUCTION PERMITp W0400098
OTHER ASSOCLATED PERA1fTE(i'appaceb4;
SITE WELL ID 60 amkaalal {3LIW-39$ & E)LIV11-39D
3, WELL UBE {Choc* Om Boxy Monito*v [I MunlupoWubllc ❑
IndusV*WAMMerrlal ❑ Apncathrra+ L] ReaoveryC tnjecton d
Inigabon❑ Other ❑ (lei use)
DATE DRILLM
4- WELL LOCATION
2000 Lowery St.
!Street hen n. Nun%b& S COMM,", SUWM1W. tot No.. TrceL lip Co*
(;ITY: Winston-Salem _ -- COUNTY Fom)M
TOPOGWHK: i LVO SETTING: idW" appropta* bP4
08" OValtey Mat CIRM" 001111111 _
36" 5' 30.2200'
800 12' 47.3100"
LatllW&1 r1yt100e lerxca: 663PS CirapogrepNC map
iJrxafJaR o1 N111 most be SiIo3VrI on 4 USGS lc�v mep ardr+lfac.'wdlts
ails lorrrt at'ndt uainp GPS)
iL FAC UTY (NUA of the bualneas whore the wall is located.)
Fadrttr Narne Fac ft U# (If pp/eollilR)
Sbeet Addms!
Zonston-'SaleM _ Nr, 27101
city or Town Sate tip Gods
AMF!C- Joe DAathecanA . _ -
Conted +ferns
PZ7.5-r1fleddl Rd
MaMV Address
Knny1jillw iN 379-42
City or Town Sub Zip Gods
(ags qFjg Re 11671-6774
Area cede PAons narrrew
a. WELL DETAILS:
e. TOTAL Dmit: 70 ft
b DOES WELL REPLACE EXISTING WELL? YESO NO IV
c. WATER LEVEL Heiow Top of CaslrrC AMi—FT.
(Use '*' If Above Top o1 Cawrg)
ATOP OF CXMG IS 0 F7 Above Lane Surface'
.,p ofcaatnp twMinated at<or below land surtsoa may nqu rs
a varhence in socordante with taA NCAC tC p1 i8-
: s, YIELD {gprn). METHOD OF TEST_
IL I]ISINFECTIOW Type - Amount
: 4} WATER ZONES {depth;
Top_ _
9ollom Top
Bottom
Top„
Soft m_ Top
So >nm
Top__
_ Gomm Top
Bottom
ThlekneaW
:7. CASINO:
Depth DteWM*W
Vft4hi Material
Top--0--
SoCL^_5r FL_j.2E__
SC 80 C EVS�
TOP 0 Bodomq�_ FL_tW _-
Top Batto PL
8 GROUT: Depth 1644iterW httthod
TaP_4— Bottorn5Z5- Ft. • POdWnd Tramis
Top_,_ T• BOltont �L
Top eoltora_FL__
1ti 3cREITN; Dose Dlernottr slotStm Motorist
TCp—a, Softrt-69-, F1 -12 m. Q_n In CFNQ
TCy 1W 65Botlom 4'F7o t l L25 In. �L in. , GPNC
'fop acaom Ft _ _ _in, in.
10. SANWORAVE L PACK:
Depth SLns A1sEartal
Too f*5LI_WWm&�)_ Ft..j#l_ _$Olaf&.
Top Bo.�cm70 F:._#1, ,Sillca
Top BAI!Om F L
II - DRILL ING LOG
Tap Bottom FOnratnn DeuiVfen
0 70 sandalsil s/dayaw/ rock
1
�J
_ 1
1
12, REMAM&
30165 sand seal from 52-5-54' and 64-70'
100 HMMIF CERr"17NT no vertu fhtti6 tZ7NBT1t11CTE4arAOWRDFW.i WITH
VW MCAQK, VtU CCaratRUCTKI1r WAla]OM AW TWAT A COPY OF THa
11EClJat TO l qMM
[�RTF*D WELL CONTRAR L7ATE
PRINTED NAME OF P ERSON CONSTRUCT I NG THE WELL
Formc M•tb
Rev- 20

NON�r ESIDENTM wL1. Cowguc Cr M McuRn
North Ca IJU Department of Envinownent and Nalunnl Reaourees- Division of w%w [malty
WILL CONTRACTOR CER1[F1CATION q 2675
1. WELL CONTRACTOR:
Robert Mr
Wal Contractor (WhaduaQ Name
$ggdaoco Inc. _
WalI Caniracbor Company Nana
�j88 Na YAM Dr,
Shtiet Add Ices
Cry or Town slate no Code
03 W-2180 --
Ama cods Phona number
2. WELL INFORMAT10W
WELL CON STRVCTK]Y PER MlWyoQ499Dg8
0111ER ASSOCIATED aERM. ITt(M sopio")
327E WELL iod{TePglosay7 DLW-40S & QWW-40❑
3. WELL USE (Clwa Of* Box) Monhorinp 17 Munldp*UOi Gc LI
n4us74tCommwds w Aoriv,"I F- Recovery❑ U¢aet.ond
Lrrlpallonfy Other E3 (bat uwj _
GATE DFULLE012-110-11
4. WELL LOCATION:
2000 LoW§(Y St.
(sa.el No, Number*, Ccrerr w*, &AK*wWm Lot No Pei �
crrr:.Winston-Salem CouNrr Fowth
TOPOGRAPHIC 1 iAND SETTING (c F*& appopdata eu )
0 5lope o vday I# tat .j Rklge ❑ OC+er
36' 5' 30-2300"
80' 12' 47.1s00"
LaCtAMongitude source: VOPS Ljropographlo map
flotation of wN must be shown ao a t1SGS topo mAo andad&:~io
Moo km if Ad usiry OPS,;
6. FACIL2TY (Na" of one buaInaas where Im wall is located.)
Fnanal FJekt Prnriuct% OM M17
Fmeaty Name FaGity Ird (If OPP Icstrla]
„2rM t nwa 5t-
Skoot Add raw
MnSton,9akm _ NC 27101
CRy or rvwn Stall ZIP Code
AMEC, - -Ine Deatheranp„ ,
Contact Nam
Malkinq AMman
Knnr►ri,lle rill, 37932
City or Town SUM ap Code
( ga5 �#671-6774
Ama CDdB Phone number
S. WELL DETAILS:
■- TOTAL DEPTK 70 ft
b. DOES WELL REPLACE EXISTING Y1ELL7 YESU No C(
c- WATER LEVEL Below Top of Ca34V 7 49 F`.
(Uae ••• If Wove Top at CaOV)
C TOP Of GASH 18 _ _ FT. Above Ladd Swrata'
`rop of caw Q tefftrwled aNnr below L" Krfaoa may rsqu'.re
a vorfonce In accordencewith 15A NCAC 2C .'0118
R YIELD {apm). _— - MMCD OF TEST_
R DISINFECTIOW Type Amount _
F WATER Z0#" (depM):
Top BIUIIILTap Sdnem
Top Sdw L,— Top Botlbrn
Top botlom Top_ 8oftm
Thicksaasl
1 CAMIO: Depth DWW*O ar W@42M kaekarial
TopesBcaorn 56--FL 1.25" ^UR _.QPy.Cr_
Top 0 Bollorr.6_FL I-2E SC 80 CPVC
Top Bottom F't
S. GROUT: oeplh kAatanlal method
: Top-0-- 3dtbm f§L-- FL 296WK! Trernie —
Top _ &YIom FL
Top Bvrtam Ft.
f. acpteeN: Depth Dkurwtor Mo sho Mabrlal
Top. NA— Bottom 60 FIL- j,ULrL 0.01 In C RVC
Top4*-65eowm. j+F70 FL_12Lin. 51.�1L in.
CP-VC
Top Boft FL—kn. kt.
IL SANDrORAVEL PAM''
Depth Stagy Malarial
TopAAt;_q_13*"_M_ 1:1.91
Top Bol:oro Fl.
11 MILLING LOG
Tot) Botlom �ofmsilon Cesolpftn
0, 70 sand2l3i151C ays W/ 20malock
1 _
1
12 ItEMA1WJk
30/65 sand seal from 53-54' and 64-70'
100 FFAFQr CEMFYTM%T TW %WLL *M COMI LIMM IRACO&MAMIX YfCM
• "A f,17Na1711,G71.7M 6'rAa . A+a7 TTIAT AC+bPr OF"JTFLi [�
86A E OF CERTIFIE0 W L CONTRACTOR DATE
f? W Miller _
: PRINTED NAME OF PERSON CONST1RUCTING THE WELL
Fan GW-lb
Rev. 2M

11L v
1. WELL CONTRACTOR:
pert Miler �...—._.
wtliI Contractm (ktdNitle ■I) Nwe
5aedacco inc. -
Well Contrectar COrnparry Natna- -
sass Nr?�Sh6eld Dr.
8tmot Addrtaats
fad mill
zip coo
� or Town - -- -- Stela
t3 54$ Z1k0_ _
Area coda Ptmiv rtumt:ar
2. WELL INFORUATION:
WELL COftrRI1CT ON PErwrr!
O1-HER ASSOCIATED PERMr r" wo"bbj
SITIc WELL ID p(Iraq�i�ls) D�fW.�i _4�.
3- WELL USE {Check One B6* L*wftdPg h h+lwrtiaVWftbk ❑
Induatriou0ommen7lal 0 AgrWbral 0 R00wW 7 W$N ffpn d
MAga;ionEl DSt'er ❑ (List Vw)
PATE DRILLED 1 9-0&11
♦ WELL LOCATK314:
ZQ44 -�Ipwqu St.
{BYret Nrne rrumton- Carsnu 8uWvWo , Lot ►to., Pw t 2%iCe
GRY: Wnston jPiam--{7ULwTT Fom! dh
r❑.'QORAPHK: .AND6CTrNf3: [ahalsapprgw"boq
j8 ope uVaNey k iat []"a robw
36' 5' 30.5500'
80` 12' 47.9400"
Lfi*A1*rlprft46 eoL" `"'5 f lropo qr hlc top
(k,nelrnn a! wyo nwa bo mo*n or a (),gaS two mop arrdlfi "do;
"a ANM R nor O&V OAS)
a. FACILITY [dame of tie btl k eaa wham m wril k loretpd.J
1 1 41 ►1 -- --- -
f-odlily Name Fac&y 106 (itappilcabiey
Vifinr%ton
City or Town r State zip CO&
Conglct Name
0725 Ccx d IL Rd
Maling Addnm
[spy a Town 61ga VP Cob
uffl 1i :fiffik671--6.Z24
Area cb4e Plwne rumbw
N-WFLL Di?TAIL8'
I. TOTAL DSPTI+k 70 ft—
b. L>OES WELL REPLACE EXISTING WELL? YC3 r- moo(
c. WATER LEVEL Befow Ivp ofCwlg..52 wFr
(Uaa'4' 1 Above Top of CoAng)
NON ARES 1.4L„muLcoNmu(—noN RxcoRD
t+Ianit Carolina i]rpytrnoN oT L'nriroament and Halwal Rtanu: ws- I]fWsit+K of W afar Qunlily
WELL CONTRACtOR CILWIFICAMON 0 167S
d. TOP OF CASWO IB -[j_ FT Above Land &A*%cn'
'rcpd C41SN krrntktated wor 4viaw land arlrfece &nay Mq&$
e tnrlancw h wcaordanae wO 1 SA klCAC 2C .011 fl.
A 1yXLDWP"* METHOD OFTEST-
%f. DI&NFECTION: Typo Amownt
¢ %KT&R ZONES (depthy:
Top Rotlorn
Top_
_ Wsom
Tap 9Oltum_
Tcp
-8O[Iom
Top Bottom
Top
—solom__-_._.__ T
Tt�laknew
r. CASING: Depot
01--now
t IMaterlal
Topes nowin-2_-___
RAM—
�vft5
_sar_c�Q CM�
Top— -- BottornI&— Ft 1.2b" _
_5C 80 ..QPVC .
Top Bat
FL
A. GROUT: Depth
k5bitw'a
kwod
: TOP-0 Boliom 5.' Ft-p4[wl4.
Nmig—
Top RoMrn
Ft -
-Top__ Top__ _ Bo5xn__
_ FL ___
0. sCREEN: Depth DINnobr slot Sire Material
TOP- — 8nnnrn-0—FL%25 tn- _Qat IR Geyr,
Top-&__ enwm m Ff. 1.251n. J)IL in CPVC
Top_ ^ _ Bottom-- _ FL,- -_ _ln.-_-_ In.
BAND+GRAVEL PACK
Dog% st>1a molartal
Top_5A____BMI-M PL-#I-____
Top-65_oatkrn 70 Ft. #1 1_
Top_ Morn F 1.
it. DMUM LOG
Top flAbnr r-omvaton Deecrloon
30/65 sand seal from 53-54' and 50-65'
1001 POWCOMFY YIMT 11MVOUWM SIN AOMMINrRM1MTII
IMMytGaC.11MLLt7piiTla M" RT1Mi0VIK AM MHO AOWYaFrM
fougm I tta!li-W TU 1 %LLOM M r f
&tMAMME OF CEITM-17D WMI Cow- DATE
PRINTFO NMC OF PERRsON CONSTRUCTING TXE WELL
RaY. 2M

rM �
��
1. WELL CONTRACTOR:
RobsdMiMr
wall Con"clor onco ciLw) blame
Saedacco Inc.
Welt Conb *r Comp" 'Ianre
9088 Northfield Dr.
Street Addream
City or Town State Z P Code
su 548-2180
Area co" Phfine number
2- WELL INFORMATION:
'NE tL CCNNSIRUCTON PERM(Ttt WI 400098
GTH£R ASSOCIATED P£RA1TTe{raapwaltay
SITE WFLL inPerapWMsWI0LlW-425 & QLIYV92D
3. WELL USE (Chad One Box) MonNorhp ❑ Mudgpa4Pt h k 0
IndustrlaMornnwdet ❑ AgrIcutN• M ❑ Recovery n b#kdw td
140"drto Other L3 (datum)
RATE DRILLED
4, WELL LOCATIC*
2004 Lgmvy St.
(Stoat Name- Nuw6erw Cworrw . Svbd%deW. LM Me, YaroY, rip Coda)
crrv: Winston-Salem couHTT Forsyth
TOPOGRAPHIC ! LAN❑ SET M40: {d1aeY epprciprlMa tosQ
r151ape 7Vofy Wl"I'ial ORidge t}Olher
36' 5' 30-5600"
80' 12. 47.7800•
La6l KWcngkxk sounss: UOPS Qropnraph!t map
,Roakian of w M rtrnre be anown on a :15'35 Napo rap arpafteche-j ro
Mla tofm Ynot usft GPS)
S. FACILITY (Naas of ft 4uslnans wftere the wap is Iocaled.j
Fnr®f%r Flakt PrcLducts _T amMY
Faculty Name Fadlity Of (if aMAcable)
20M01nwr of St
Snet Address
�6 jn--gtn[LSalem N-C �71fl1
City or Town `,ate Zip Code
AMFI,- AM Deallberaf1P
Contra NMne
0725j oedill Rd- -
Mating Address
KnOYH111A 7 N 37q,39
City yr Taws Slats Nip Code
(86s -so&,w +671-6774
Arcs code Phone number
fi. VEIL DETAILS:
a. TOTAL DEPTH: 71
b. 00CS WELL FM PLACE EJUSTINO WEiL7 YES 0 HO W
WATE R LPVEL Brine Top c(CaskV 51 _fi ____Fr.
(Usa't' It Above Top of Casing)
NQN RESIDENTIAL W1.GL CONKI-RUMOIN RVWORD
NORh CL-0iinl Depanmal of EnAronlnent and Natuml Resoumn- MyWost of Wow Quality
WELL CONTRACTOR CERTIFICA-flioN M 2675
d. TOP OF CASINO ill _ FT Above land SwUm'
"Top of caahp ter" nosed @Vcr below land s rkoo nsey require
a vadar+ce in eacordarm with 15A NCAC 2C 0118.
r YIEid (gprn) _ F�rMD OF TEST ---
= f. DISINFECTION: Type Amptmt
p. WATER ZONES (depth):
Top- ..- Sodom , Top ____ 800tom_— _ -
Top- —•- SOMM Top- 80,11M
• Too Bot1 - Top i+wbm
TMICkrlaeal
T. CASINO: Depth Olarfsstor wolght N*WMI
Topes_ 8oCOM 5 - - FL jjj!" - SC 80 CPYQ
Top- Bottom 66 FLyZC-- Q CpVC
Top BoNorn Ft,
S. UROUT: Depth IIgb11M IrlalrkOd
Top_Q eollorn 53 T-- FL Po111n3 Ie --
TOP_- __-- "om Pt.—
Top Bosoms Ft
!. SCRMW D"M 171swomor Slotalas YafsAaI
Topes_ aogo<n_61 Ft _Jain 4_Li] In. ,QM _
Too- 6_ 80111on-Z.L- Ft _12L,5_in. _QSL in. CF_VQ
TOP - noMonl-_ _ _ Fl In- In.
10. SAHO10RAVE L PACK:
Depth like Material
Top 5A.S dattom.�.1,5 _. Fi• � S$im _
Top-E�Botlom 71 FL#� 5dK:a
Top_T,Batmm Ft
11. OFULLiNO LOCI
Top Botsorn Formallor Oeawpoon
71
1
1
!
1
1 _
1
1
�� RIeMAI�Ks:
30165 sand seal from 53.7-54.8' and 61.5-65'
100 HEWOY C EATVY T)AT THe WCLL WASGON MXTEO IN AOCAlICMMIMtN
• taA W-AC M'eaLL C OWRU6WMSTANCAROe.ANOTIMT ACMV OF n"
:=TOT)& NF'-I-A�ME0.
MzFL / ►4 ►/
9KMTURE of C£FMFIE0 WILL CONTRACTOR
PRPEFED KAIYIE OF PERSON CONSTRUCTOiG THE WELL
...r..., i.tieYr-s. - .t^�1s>tr- •r•+:'±ti.ill:l:ri'vi Form OW-tb
• � M'A!s'. ►'R1 �7• ^_• �R��l F.0614M..__...- -`. ��"Y (.1. �."__—�.-_... .�j' Rev. 249

a� s�
i, W6LL CONTRACTOR:
-Michael_- 1
Weli Contra= (individual) Name
. Saedamo Inc.
Well Contactor Comp any Name
9088-Northfield Dr.
Street Addraaa
--Forl Mill �29715
City or Town state uq Coda
i 0 j ,' 48-2184
Am code Ptem number
2. WELL INFORMATION —
WELL CONSTRUCTk]N FERMIT/,W-IQ'rY.V098 -
❑TNER ASSOC I AT ED PE RM ITR(r apObabio)
ame WELL it) "aws=b* QM-43S & DLIW-43D
b. WELL USE (Gherk On* "Monsorttg ❑ IrlunldpagPuWk:Cl
InduW'*LC amrnerc'sl ❑ Agdcu aural C Rawveryr❑ Irodtond
rrigevorl7 Oftw U (ile: L")
nATE DRILLED�1-1
4. WELL LOCATION.
2409 Gowery 5t.
(StaaiName. Nmvbv% Comm kway, SubdMalo7, WANo. ftak apCob)
crry Winston-Salem . WLwTY 2 yth.
TOPMRAPHC 1 LAKD SETTING- (crack apprnphf boo
810" nValey WIVIat r]Ridpa
36' 5' 301400"
80' 12' 45.0500"
L211weAonokIide souks: 9rPs C7lopop+aphk map
(k caatm of vml must be &Wwn on n USGS lvpo map andeftashad to
►rtla lbtm lYnotusing GPSj
S- FACILITY (,As me of"busiress when Ow well Is located.)
F_=gr Flak Prodilris oaf) ❑ail
radrtty Name Fad Illy 08 (11 s 0coble)
20M I QWAry St_
5trset Addms&
Winrftn-galpm NC 271 al
City a Town stale Zip Cads
AMFC - .jrPA DAathprana
Contact Name
9725 Condi11 fed -
Mailing Addrasa
KnantiiiP TN_— _IZ232'
Ctty or Town Stela Zip Code
( am s4#671-6774
Aron coda Phone mntbfw
6. WELL DETAIL5:
L TOTAL DEPTH: If) It
b. DQF8 WELL REPLACE EXISTING WELL? YES Q NO d
c. WATER LEVEL Below To a1 Casing: !M FT.
(Use'►' II Above Tap of Casing)
NoN R ESIDENTm WELL CONSTRU ON MCORD
North Carolina flepaitr Rnt of F-Ironmmf and Natural Rcaources- Dfv4ion of Water Quality
"'YM, CONTRACTOR CERTIF'ICATI N N 3351
d. TOA OF CABM IS-Q FT. Abovs Lard &mace'
^op of 0191 4 tormirWad allay below land cartage may -KA's
a varlance In eratordoroewt*f SSA NCAC 2C 011S.
: a. YIELD (Ppnl:_
METHOD OF TEST
L DISINFECTION Typr
Amount
y WATER ZONES (doph):
= Top_ Botlom—
Top
BottPm___-
TAA -__ Bottum_
Top
so=tom
Top Bottom
Top
Bo!lorn_-____•__ -
Thlckerast
7. CASINO: Wpth
Dlarneor
Walyltt Material
too 0 %ottom 55 Ft 1 2Je" _ -5QN
Top-Q- BOaam 85 --FL 1,25.'_ SO
Top Bottom FL
d- GROUT Oeplh IYlalnrlal Method
Topes_ Bottom 53 FL PQrtleltd TCam)e
Top w Bottom F!
Top Bottom fL
f. 8CR EEK- Depth Dismetar Slot Seta Matb tal
Top 55 Bottom sa FL 1.25 in. 0.41 In CP11C
Top fi5 - Badem j0 _ Ft.-j, in. 4_d1 In.. GEV(;�—
Top %. UL rn _ —_ Ft _—kt In
10. SANMRAVEL PACK -
Depth Star SRrlaraal
foe 54 _ socarn 61.5 Ft #1
Tog B4 F3ottam�Q_ Ft.,�,
Toff_ ___—tjottom Ft
11 DRILUW- LOG
Top Bottom Formabon 00-yr tpdon
1
1
1
12,REMARKS:
30165 sand seal from 53-54' and 61.5-64'
i oo r-4w-ar Ctxlirr T*T TMS VftL V06COM7RUCTEO N AODCACO)" VATF
• teA r+cx: x, vousr r tiTAar6a11ea, AM0 r a► Doer aF r>,�a
RLS+�R9 t• L
= $IG F OF TWELL COHTRAt;� D TE
P W-ED NgME Of PERSON C.-A&STRUCTING THE WELL
Form GW • I b
Rev Zt;ty

0 It
N0NRESLQENMLWFLL CONSTRUCTION RECORD
North Carolina Departrwrit of rinvitonment and Natural Rosourm- Division of Wa w Quality
�4 WELL CONTRACTOR CRRTIRICATION p 2675
1. WELL CONTRACTOR:
Mill r
Wei Conhlletor (IndWlOusl),Name
Sagdam Inc. --
Well Conlractw Company Name
Street Address -
- -fort Mill — - �C 29715
Clay or Town State lip Code
(803 a 548-21 ao _
Area code Phone number
P. WELL INFORMATION:
WELL CONSTRUCTION PERMITi100400098
OTHER ASSOCIATED PEIRMITC"spoicabie]
SITE WELL 1D #Qf rvplkable)
3. WELL USE (Check One ilox) Mooloring ❑ MuniopeVPubiic ❑
InduslrlaVCommercIW p Agricultural ❑ Recovery ❑ InJecdon
In'90ono Other ❑ (11at use)
DATE DRILLED 92aWwW 02101I 1 Z
4. WELL LOCATION:
20�O %Weill Sty
(Strait Herne. Nurrbwa. Cormnanity. Sut>dhullen. Lot No.. PwoK ZipCode)
crryWnstQn-Salem COUNTY 9LJYtli _
TOPOGRAPHIC r LAND SE fTING {thick rppropAstebwq
[)Slope ❑ Valley flat D Ridge pOftr
36' 5' 30.6400"
80' 12' 45,6000'
Lataudellangllude source: BPS FJFopographic map
(iocadon of we# must oe shown on a USDS rope map mode Mxhad to
this kxm N not using GPS)
S. FACILITY;Name of tha busy iexs where the well is located ]
Pnrrnpr F1aktProdurts 4170 0017
Fadifty Name Fatuity IDo (if epp:"ble)
2400 1 nwerrr St_
S+fed Address
1Ntnsttnn-Salem- NC 27101
City of Town state tip coda
AMU! - Jne DAathpranp
Conlad Name
Mooing Address
Knimil►e T>tiL,.�3=
City or Town shale x0 CpdS
( am Tfiamsf671-6774
Area code Phone number
6. WELL DETAILS:
■. TOTAL DEPTH: 71) ft
-1L DOES WELL REPLACE EXISTING WELL? YES ❑ NO W
e. WATER LEVEL Below Top of Casing: 48.5 FT
(Use'** H Above Top of Casing]
0. TOP OF QUING IS .-]aFT, Above and Surface'
'Top of caning terminww Wor oolow land awfsoe tray mequlra
e variance in acco-daarm wtr T5A NCAG ZC .0118.
e. Y111710 (gpm); MET1400 OF TEST
f. OWNFECTION: Type Amount
g- WATER TONES (depth)'
Top
Bottom
fvp
Bottom
Top
Bottom
Top
Bottom
Top-
Bottom
Top
Bottom_ .-
ThIckneW
7. CASINO:
Oepth
Diameter
Weight Material
Top 0 Bottom s^ Ft.125"_ _ss$u Sc�y
Top-0-- sottom-L�­ Ft.1-25- Sc $0 GPVC
Top Bottom Ft-
8 GROUT OWh Material Melhod
Top 0-- Bottom 53 FL Portland Tren se
Top Bottom Ft.
Top Bottom Ft.
9. SCREENDepth 13tamafar Slot Size Mat"I
Top­5�— Bottom 26Q Ft iI In. d_6t In. QPVC -
Top_§;t___ 9aNOM_L Ft._ 1.25_In. 0"01 In. CPVQ
Top Bottom Ft. m, in _
10. 8ANDfOIiAVEL PACK:
Depth Size Material
:lop_ - _-9ottom_fiQ_Ft #1_ 5111ca
Top 64 . _8o"—ZQ—FI #1— Slllca
Top— - --Bottom FL
11 DRILLING LOG
Top Bottom Formation DescAMIon
�/ 70
r
t- M 41 1TO • C. t y •
: 41 REMARKS:
i 30/65 sand seal from 53-54' and 60-64'
100 WMEaY COLT WY TIMT TfN %F/,L WAe 00N$TI111LTE6 IN ACCOROANCE try"
zNA comsTROC'noR cTAg6Nt8a, Ah+h T7MTA COPY OF TM
PDTHOE:RTURE OF CERTIFIED W CONTRA OR GATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW1b
Rev.20

0 It
N RESIDENTM WELL CONSTRUCUION RECORD
North Caml Ina Dcparm)em of Envirrmmtnt and Natuml Rmurm- Division of Wn1er Qualify
WELL CONTRACTOR CERTIFICATION is 2675
T. WELL CONTRACTOR:
$4b-SrLMille[
WON Contractor (Indtvlduel) Name
WON Contractor Company Name
90d Northfield Ur.
Sheet Address
297i
City 3f Town SIeIa zp Code
(803 1 W-2180
Area code Phor-A number
2. WELL INFORMATION:
WELL CONSTRUCTION PERVITs W10490098 _ -
OTHER ASSOCIATED FERMI T#(if opokabe)
srrE WELL ID sc{ aopl+datfa) DLIW-45S & DLIW-450
3, WELL USE (Chaok One Box) MoNloMg ❑ K%MIdpaVPubllG0
IrldustrlallComnwdal ❑ Ag4wNural ❑ RecoveryC Injection jlilt'
Irrigatlonp Ofher ❑ (eat a*)
DATE DRILLER22-ft-111-021011T 2
4. WELL LOCATION:
($treat Nunn, NumMxa, CGrMYundy, Sut+d ASW Lot No., Pew!. Zip Code)
CITY: Winston-Sft!IM CQLNTY orwth
TOPCGRAPHrC 1 LANO $kTT114G: (chat* fi Qvb04a max)
❑S" ❑VeNay JI(F1al oRxlge 00ths(
36* 5' 30,6700"
80' 12' 45-4200"
LaBtudsAongftWo source: �XFS OTopographlemep
llocakv? of *0 muaf be shop" cn a t1SGS repo map andatreched to
thie form if not ua1ng GPSJ
5. FACILrTY (Name o( the business where 06 well Is IoC,atad.}
Facility Name F"Ity ID&#f sppli oW
2000_1 nwAry 5t_ — — - -
Street Address
Winstan-Salpm NC 2710t
City or Town Stele 4 Coda
AMFCI - .IOP r1patlf'iegania
Contact Name
725 ,.nodlll Rd
MailingAddress
Knoxville IN 3Z=
City or Town Stale 2104101116
( sas -sse.&&*+671-6774
Area code Phone number
b. WELL DETAILS:
a. TOTAL DEPTH,. 70 ft
b 00113 WELL REPLACE EXISTING WELL? YES ❑ Na Gf•
c. WATER LEVEL Baiow Tap of Ca$hV: 48_6 T.
(IJ&a'*' If Above Top of CasrV)
d. TOP OF CASING 13 _Q FT. A6pve Land Surface'
'Top df calling I*FWnttlad Mr below lend surface 'nay Mqut*
a valiance In acoordsnos W!!h 1SA NCAC 2C .011S.
e. YIELD (ppm)7 _ METNOD OF TEST
f. DISINFECTION!
g. WATER TONER (depth)
Top Bottom Top i3oftann
Toe Bottom Top __ .. Bcltom
Top Bottom Top &]Worn
Thlcknseel
7. CASINO Depth Diameter Weight MoftrtsI
Top_0 Doeom 56 FI- 12Y' SC 8Q CPVC
Top_Q_----- Bottom 66 F1.,.,25'-- 5C 80 CPV
Top Batlarr FI.
0. GROUT: Depth motanal Method
Tapes_ Bottoms_ Ft Pcdaw Tremie
Top Bottom FS.
Top Bottom Fl
9. SCREEN: Depth Dlenwor Blvl Wn 118NAe1
Tops_ Bdflom_p_ Ft. 1.25 In- 441 q. QBVCi
Top 65 BoBam_ZQ,_ F!_tJJrn Q.Q'j In CPyC
Top Bottom FT. I n- In.
70. SAND(URAVEL PACK?
Depth SI:a matarkal
Top 0 Bottom 6Q Ft. #1 SAmea
Top 64 Bottom 70 Ft. #1_ silica
Top_ Botto-nFt-
11. DRILLING LOG
Top Baliom Formation Dasc7r4on
-4 - !JQ
r
1
12. REMARKS:
- $its with fina gmin-%, s-ani;!s
30165 sand seal from 53-54' and 60-64'
t 00 t*REBV C F FY THAr TW9 MLL YrM CONS' Rkr-Tt V IN ACCORDAW.Z NA'"
14A W-AC K, 0T ucTION srAHOAR06, kN3 THAr A COPY OF 'H%
REp AD Y(] [
SIG q-ATUITE OF CERTIFIED WELL CONTRACTOR DATE
Robaft Miller _
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Fom+ GW-t h
Rey. 2%

�V q�
g�
3
1. WELL CONTRACTOR:
Bobert Millgr
Well Contraetot [InclMduaq Name
Saedaco Inc.
We Contracla Company Name
Northfield
Sheet Addrasa
Fort_Mit _ SC 29715-
City ofTowr S1916 Zip Code
M3 1 548-2180 _.
Area cods Phone number
2. WELL INFOR10ATION:
WELL CONSTRUCTION PERMITS__ 0
OTHER ASSOCIATEp FERMI-Cd a"kAble)
SITE WELI- in fail appnwNe] QL[W 46S & ❑LIW-46❑
7. WELL USE (Check One Dox) Monite:lrtq ❑ MIrIIcIpaVPuble Lt
InduMrisuCommerva1 0 AgrlcuRural ❑ RecoveryC I*Won id
Ir *Iioono Q&arEl (let use)
DATE DRILLED QM3-12
4. WELL LOCATION:
2909 ry t.
{Steal Nam. NumbeM Coornurft Sub%!P&lort Lot No. PAN, 21p Ccde}
ctTr: 1Mnston-66lem CCVNTY Forsyth
TOPOGRAPHG 1 LAND SETTING: (chs* appraprlaie box}
❑s" pvavay elal cRldge C4iher
360 5' 30.7000"
80" 12' 45,1900"
Lalltuderlonpituda source: WPS QopoWaphlc map
(locaWn of well must be shown on a USGS top map andelleched to
this form It not uafnp GPM
6. FACILrfY (Name of the buslnass where tree wen Is Iocatad j
Forrrinr Flake Rrciducts DO,0017
FaCiVy Name Fedlty +fill N applubley
SueelAddress
WiO,stnn salf1m NC 97101
Ctiy or Taw„ State ZIP code
AMFC ..Ina ❑tsafhprane
Contact Name
A722; Cnnr hl EIS - —
Making Address
Kn� nYViup_ IN _ 37432
City or Town State Zlp Code
(sss 671-6774
Ams coda Pltane nuanbw
S. WELL DETAILS:
a. TOTAL DEPTH: 70 ft
b. DOES WELL REPLACE EXISTING WELL? YCS ❑ NO {�
c. WATER LEVEL Below Top of Cashg:_48.7 _ _ FT.
it)se'*' If Above Top a Ca")
NoN RESLUA IAL wimi xONSTRUCTION RECORD
North Carollne Departmonl of Favironment and Natural Resouroe5• Division of Water Quality
WELL CON RACIi'OR CERTIFICATION # 2675
= d. TOP OF CASLNG IS FT. Above Land Surface'
'Top of Casing lermInalod aVOr below land surfooe may require
a vsrtanoe In aocorviance wig 15A NCAC 2C .0118.
a. YIELD lgpml: METHOD OF TEST
f- DISINFECTION: Type Amount
g- WATER ZONES {dept)]-.
Top Bottom Top— - Bollan
l Top Sottorr Top bottom
Too Balton Top 8a@orls
Thlsknessl
7. CASING. Depth Dilllladq Weight Matarlal
Tope Bottom_ r' Ft-1-29' Sc 80 _ CPVC
Top 0 Bottom e — R 425" 5C 8Q QPVC
Top Bottom FIL
: 8. GROLrr: Depth Matertal Mothod
' Taa Q _ HcWm_53 FI. P6Rland Tremre
Top Rellcm Fl,
Top Sotlorn Fl.
S. SCREEN: Depth otamKe► slot Slay 1lalufal
Top 55 8oltom_ 0 FI. U +n. -Ml in CP11C
TopS5 eataml0 Ft.-1>-In. 4.01 In. CPVC
:Top-- -.— Sottoml FL in- In..
fo. SANDIGRAVEL PACK:
Depth $Ise Natorlal
Top 54 Botto%o - Ft.. #1 ska
Top_64_Mo'h. Zd Ft- #1 51IiC 3
Top Bgltorn_ Ft
: 1 I. DRILLING LOG
Top Bottom Fomfadon Daserptior.
0- 170
1
!
12 REMARKS:
30165 sand seal from 53-54' and 6D-64'
I rx7?tEl wr CFAI Y TFNT THE Wr1LVM SCOHaTia/C= of Appg1� Vffh
• 166 WAC X VW.J.GOCH STlfirll OM AM TVAT A COPY OF TH A
AtCriR6 TO E WELI
pF CERTIFIED WELL CONTRACTOR � DATE
PRINTIED NAME OF PERSON CONSTRUC7TNG THE WELL
FormGW I
Rev.2M9

•
s~ •
1. WELL CONTRACTOR:
_Ro *grt Miller _
Well Con"cw (tndMduaf) Name
in
Welf Contrecior Company Name
9088 Nr�rt kld ❑r. _ _^
Streat Address
F,tartMIL_ -_ SC, 29715
City or Town Pima Zip Code
(8_) _W-2180__
Area code Phone number
1 WELL INFORMATION.
WELL CONSTRUCTION PER6Arre WI04OOO98
OTHER ASSOCIATED PERMITI( #Wp ,sbe}
SITE WELL ID $(ruppi�) DLIW47S & DI.IW470
3. WELL USE (Check Coo Box) Mvltoring ❑ Mun'dpaVPublFcC]
tndwetrIcYCnmrnerdaI C1 Agrfcu st 0 Recovery ❑ Injacaon d
inl"GonO Other U (list use)
OATLr 1 mu-Eo R-93-424,O2102/12
4. WELL LOCATION:
2000-LoWg0f St.
(Street Nerve. Numbers, Corwnunty, Sub&,Alorl LN Ns,-, Pomok Ap Code)
CITY: Winston-Salem 0MINITyForsyth
TOPOGRAPHIC r LAND SETTING' (olheO apm wom rue)
08140 ❑valley VFW ❑Ridge ❑Other
W 5' 30.7600"
80' 12' 44-8700"
Latdudellongltude source: UV�PS 1.3roaograph c msp
potation o4 w*N must be shown on a IISGS lopo map andarrachedto
Mrs ANM if rid uWag GPS)
S. FACIUTY (Name of Ve business where the well Is Ilxated1
— Fnrmer Flattl Fwducts
0000017
Fadllty Name
21340 1 5t
Fadry 100 (if appilcable)
nwely
Sirtrel Address
jMnsion-
-1C— '22101
CRy or Town
Slate ZIP Cede
AMFC. -Ina DeathprAne
--
Contact Name
9721S Cnndill Rd -
Making Addfeas
TN 3=
Knn5nrille
City or Town
Sime ap cob
(m ffA+671-6774
Aries Code Phone dumber
e. WELL DETAILS;
a. TOTAL DEPTH:-70_Ft
b. DOES WELL REPLACE EXISTING WELL? YES C} NO U/
c. WATER LEVEL Bslow Top of Csslhg. 419 2� FT.
iUse'+' if Above Top of Casing)
NON RESIDENTIAL W ELL CON91RUCTION RECORD
NOtth Care) ins Dvpartincat of Environ mcnt end Natural Rmumcs• Divisior, of WatcT Quality
WXLL COM'RACCUR CERTIFICATION # 2675
d. TOP OF CASING IS _a FT Abovs lane 5udeca'
`Top of Casing Isrn*Wed suer below tared surface may requm
a varlarco In aCwwQanCa wrath 1 SA NCAC 2C .011 S.
e. YIELD {gprn)
METHOIII OF TEST
1. DiSINFEC71❑N: Type
Amount
y. WATER IONES (deptn):
Top_ -Bottom—_
Toy
9otw
Top Bottom
Top
Bottom
Top Bonom
Top
. Bottom
Thtakn"at
7, CASING- Depth
Dleirls"T
Weight Material
Top 0 Bottoms Ft 1 25"
Top. 0 Boilom—Ok— Ft_1-26
Top 80llem Ft
---
S. GROUT! Depth Mato+al Method
Topes Bottom 6,L_ Ft Porband ).redo
Top Bottorn Ft
Top Sotlom­ _ Ft.
9. SCREEN: Depth Otsmster 31013ho Malisrlal
Top 55 90MM_6D_ FL_12&1n. _2&L In. QPVC
Top -K_ Borlan 70 Ft 1�25 in D_4L In MC
Top Bottom FL Ir1- In.
10. SAN010RAVEL PACXt
Depth 8111a ma"rtal
Top 54 BatWrn-N Ft _91 Silica
TopJL4—Soltam_Zg_ Ft #1_
: Top Bottom Ft
1'. DRILL INO LOO
Top Bottom F�rmaton OesctlpIon
0 1.70
1
_ 1
1
1
1
-Sifts with FOR Dr$lred sari
12- REMARKS:
30/65 sand seal from 53-54' and 60-64'
: 1001,11m8Y amlY T Trig VMZi WAS CONBTRUCrODIN ACQ OC MM WrH
• tall NCAC iC sTAWAROe. APO THAT A 00" OF T"
' O O r The O%*,R
SIG OF CERTIFIED WEVL CONTRACT DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Farm GW-Ib
Rev. 2K18

NONRESIDENTM WELL CONSTRUCTION R c� OR
North Carotins Deparowt of Envtranment and Natural Resourm- Division of Water Quit ity
WELL CONTRACTOR CERTIFICATION # 3351
1, WELL CONTRACTOR
WOO COMM du (krdivldusII Hama
5aedacco Inc_
Well Contfacwr Company Name
9488 iV� Jhfreld Dr_
5bcat Add re as
City or Town $late Zip Code
8r 03 y W-21QQ
Area rode Phone number
I. WELL INFORMATION.
WELL CONSTRUCTION PERMIT& WI0400098
OTHER ASSOC 1ATEp 1)ERMrTe(a apprcatw)
SITE WELL IO a(M wykat#al QLIW48S 6 QLIW46D.
3- WELL USE (Ctrec* On* lion) Mon+toring❑ Municipal/PubaC[]
1ndus4lel/Cornrm mial ❑ Agriwiftrral ❑ Recovery ❑ Injecbm 6(
I00340.ni 1 Dear❑ (satuaal
DATE DRILLFD QJ-03-17 -
4. WELL LOCATION:
lwO t.
{Bleat Name. Nix owv. Cauvrwty, 5ubdviakwk Lot No. Pa cel. Ilp Coda]
CITY: Winsto-Salem COUNTY FmAft
TOPOGRAPHIC f LAN0 SETTING- (check apprapnata b"
G5100 ❑VANY OFIM QR1doe 000e►
36° 5' 30.5400"
80° 1 Z' 45.5900'
Lantudationgitude source- J3PS Dropographrc mep
00cadon of we# must be drown on a LISGS iopo map undotIvO)ed to
this form Of not usfnq GPS)
S. FACILITY {Name of IM bV6IneaS where 1ho WON Is Iocalod j
Porma,c Plata PmducL% (110010017.
FadMy Name F&CYRy IDS (If apokcable)
Street Addren
1NRS nn-Sa-4etn NG _--27101
City or Town Slab zfp Coda
AMEC - joe Deatherane
Conled Nana
2725 randiN Rd
Malting Address
_-KrInyy4l1ft . _ _ TN 37932
City Or "Town am" Zip co"
L&5Si "r1�.4*671-6774
Aran code Phone number
6, WELL DETAILS:
a. TOTAL DEPTH: 70_5 ft
b. DOES WELL REPLACE EIIISTINO WELL? YES NO Iv
c. WATER LEVEL B6ow Top of Caarng 48.1 FT.
,Use +' f Above Top of Ceaing)
d- TOP OF CA81110 IS �}- _ _ i� FT. Above Lam Surlao6'
'Top of cat ing IarMkw*d allor below land Wow may rsgrlre
a v1danco In aaoordanos with 1 SA NCAC iC .01 18
a. YIELD (gpm):._ _ METHOD OF TEST
1. DISINFECTION Type Amount
p- WATER ZONES (d,�pt^,j
Tap Bottom- _ _ Top Bodom
Top f3cttom Top Beaorn
Top Bottom Top Bottom
Thkknasal
T. CASINO: Depth ckwaafar V"N1 akiwd
Top&- _ Bottom 55.5 Ft-13Z— Sc 84 ^
Top_Q—--9 otom-QUL FL 1258
Top Bottom FL
8, GROUT: Depth Material Mallbed
Top 0_ Bcftn 53.5 FL POrH and iismlA
Top Bo11611r^ Ft
Top Bottom F1.
IL SCRESN: Do* Oiamater Slot Size Ild"W
Top 55 5-- Bottom_U& Fl._1,2in. _,Q,¢1. in. CM
rop_65,5 t3otlom. Ta_5 ft_12 b.01 In. GEnM
Top Ba tom Ft In. In.
10. SMOPGRAVEL PACK:
(Depth Stu mdorm
Top 54_6 Do%= W.5 FI 01 rM'C$
Top 64.5 Bottum 70.5 FI _#1 -516 ;a
Top Bottom Fl
11. DRILLING LOG
Top Bottom farna!Icn Des-.11r, or;
0- - -17� Silts Martin fide araired sanos
1
17. REMARK&
30165 sand seal from 53-54' and 60-64'
I DO NEMEm' CER7IF7 T►MT ilea WFLt WAS 0ON,UMCM0 N ACtlOAUMCE 0114
ISA WAC ¢C ML ODMrrAVC7" STANDkgDk ANDTIIAT ACO►/ CF flea
• I r +� O T =EK
SIGNATURE OF CERTIF1Eo WELL CONTRAC"TOR GATE _
PRINTED NAAlE OF PERSON CONSTRUCTING THE WELL
Pone GW-1 b
Rev. 2a