WI0400523_PERMIT_20191108

Permit Number WI0400523
SCANNED
Central Files: APS SWP _
11/8/2019
Permit Tracking Slip
Program Category Status Project Type
Ground Water Active New Project
Permit Type
Injection In situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Facility Name
Former Salem Uniform Site
Location Address
4015 N Cherry St
Winston Salem
Owner
Major/Minor Region
Minor Winston-Salem
County
Forsyth
Facility Contact Affiliation
NC 27105 Bethany Donovan
27 Whitney Dr
Milford
OH 45150
Owner Name Owner Type
Cintas Corporation Non -Government
Owner Affiliation
Stephen Koehler
27 Whitney Dr
Dates/Events Milford
OH 45150
Orig Issue
11/8/2019
App Received Draft Initiated
Scheduled
Issuance Public Notice Issue Effective Expiration
7/26/2019 11/8/2019 11/8/2019 10/31/2024
Regulated Activities Requested /Received Events
Groundwater remediation
Outfall
RO staff report requested
RO staff report received
7/30/19
10/28/19
Waterbody Name Streamindex Number Current Class Subbasin

Central Files: APS _ SWP _
11/5/2019
Permit Number WI0400523 Permit Tracking Slip
Program Category
Ground Water
Permit Type
Status Project Type
In review New Project
Version Permit Classification
Injection In situ Groundwater Remediation Well Individual
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Permit Contact Affiliation
Facility Name
Fortner Salem Uniform Site
Location Address
4015 N Cherry St
Winston Salem
Owner
Major/Minor Region
Minor Winston-Salem
County
Forsyth
Facility Contact Affiliation
NC 27105 Bethany Donovan
27 Whitney Dr
Milford
OH 45150
Owner Name
Cintas Corporation
Dates/Events
Owner Type
Non -Government
Owner Affiliation
Stephen Koehler
27 Whitney Dr
Milford
OH 45150
Orig Issue App Received Draft Initiated
7/26/2019
Scheduled
Issuance Public Notice Issue Effective Expiration
Regulated Activities Requested /Received Events
Groundwater remediation
Outfall
RO staff report requested
RO staff report received
7/30/19
10/28/19
Waterbody Name Streamlndex Number Current Class Subbasin

ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Director
Stephen Koehler
27 Whitney Drive
Milford OH 45150
NORTH CAROLINA
Environmental Quality
November 8, 2019
Re: Issuance of Injection Permit WI0400523
Former Salem Uniform Site
Forsyth County, NC
Dear Mr. Koehler:
In accordance with the permit application received on July 26, 2019, we are forwarding permit number
WI0400523. This permit is to inject ABC Ole, ZVI, Enviroblend- 93, RTB-1, High Fructose Com Syrup,
Sodium Bicarbonate to remediate groundwater contaminated with Tetrachloroethene at the Former
Salem Uniform Site located at 4015 N. Cherry Street, Winston Salem, Forsyth County, NC 27105.
This permit shall be effective from November 8, 2019 until October 31;2024 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.1, the proposed monitoring plan as submitted in application
from July 26, 2019 shall be followed.
• 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. Just indicate in the comments section on the form the total number of well
points. These forms are available on the Division of Water resource's website at
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11636 Mail Service Center I Raleigh, North Carolina 27699-1636
919.707.9000

http://deq.nc.g ov/about/divisions/water-resources/water-resources-I, ermits/wastewater-
branch/ground-water-protection/ground-water-reporting-forms
> Injection Event Record
> Well Construction Record (GW-1)
> Well Abandonment Record (GW-30)
In order to continue uninterrupted legal use adds 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,
Shristi Shrestha
Underground Injection Control (UIC) - Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
cc: Lon Snider — Jim Gonsiewski, WQROS — Winston Salem Regional Office
Central Office File, WI0400523
Matthew Allen, AECOM Technical Services of North Carolina, 1600 Perimeter Park Drive,
Suite 400, Morrisville NC 27560

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENTAL QUALITY
RALEIGH, NORTH CAROLINA
PERMIT FOR THE USE OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87; Article 21, Chapter 143; and other
applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
Former Salem Uniform Site
FOR THE CONSTRUCTION AND OPERATION OF 141 (One hundred and forty-one) IN
SITU REMEDIATION / TRACER INJECTION WELLS, defined in Title 15A North Carolina
Administrative Code 2C .0209(5)(b)(viii), to inject the following additives (either individually or
in combination): ABC Ole, Zero Valent Iron, Enviroblend- 93, RTB-1, High Fructose Corn Syrup,
Sodium Bicarbonate to remediate groundwater contaminated with Tetrachloroethene. These
injection wells/points will be located at the Former Salem Uniform Site, located at 4015 N. Cherry
Street, Winston Salem, Forsyth County, NC 27105, and will be operated in accordance with the
permit application submitted July 26, 2019, and in conformity with the specifications and
supporting data submitted, all of which are filed with the Department of Environmental Quality
and are considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the Water
Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an injection
well shall be in compliance with Title 15A North Carolina Administrative Code 02C .0100 and
.0200, and any other Laws, Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from November 8, 2019 until October 31, 2024.
Permit issued this the 8th day of November 2019.
For Linda Culpepper, Director
Division of Water Resources
By Authority of the Environmental Management Commission.
Permit No. WI400523 PAGE 1 OF 7
ver. 5-21-2019 UIC-51/5T

PART I — PERMIT GENERAL CONDITIONS
1. The Permittee shall comply with all conditions of this permit and with the standards and criteria
specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C .0200).
Noncompliance with conditions of this permit constitutes a violation of the North Carolina
Well Construction Act and is grounds for enforcement action as provided for in N.C.G.S. 87-
94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data [15A
NCAC 02C .0211(k)].
3. This permit is valid only for construction or operation of the number of injection wells
described in the application and other supporting data. Construction of additional injection
wells must be approved in advance by the Division of Water Resources (DWR) [15A NCAC
.0211(a)].
4. This permit is not transferable without prior notice and approval. In the event there is a desire
for the facility to change ownership, or there is a name change of the Permittee, a formal permit
amendment request and any supporting materials must be submitted at least 30 days prior to
the date of the change [15A NCAC 02C .0211(o)].
5. The issuance of this permit shall not relieve the Permittee of the responsibility of complying
with any and all statutes, rules, regulations, or ordinances that may be imposed by other local,
state, and federal agencies having jurisdiction. Furthermore, the issuance of this permit does
not imply that all regulatory requirements have been met [15A NCAC 02C .0203].
PART II - WELL CONSTRUCTION GENERAL CONDITIONS
1. Each injection well shall not hydraulically connect separate aquifers [15A NCAC 02C
.0211(b)].
2. Multi -screened wells shall not hydraulically connect different aquifers or zones having
differences in water quality that would result in a degradation of any aquifer or zone [15A
NCAC 02C .0225(h)(17)].
3. Each injection well shall be constructed in such a manner that water from land surface cannot
migrate into the gravel pack or well screen [15A NCAC 02C .0225(h)(4)].
4. Bentonite grout shall not be used to seal any water -bearing zone with a chloride concentration
equal to or greater than 1,500 milligrams per liter. In areas where elevated chloride levels are
known to exist or are probable, such as coastal areas, chloride levels shall be verified in the
field to determine existing conditions. [15A NCAC .0225(h)(8)].
5. Each injection well shall be secured to reasonably insure against unauthorized access and use.
Each well shall be permanently labeled with a warning that it is for injection purposes and the
entrance to each well shall be secured with a locking cap as defined in G.S. 87-85(16) [15A
NCAC 02C .0225(h)(23)].
Permit No. WI400523 PAGE 2 OF 7
ver. 5-21-2019 UIC-5I/5T

6. Each injection well sha.. oe afforded reasonable protection against damage during construction
and use [15A NCAC 02C .0225(j)(3)].
7. Each permanent injection well shall have a permanently affixed identification plate [15A
NCAC .0225(h)(20)].
8. A copy of the completed Well Construction Record (Form GW-1) shall be submitted as
described in Part VI.3 of this permit (the original document goes to the address indicated on
the form).
PART III - WELL CONSTRUCTION SPECIAL CONDITIONS
1. At least forty-eight (48) hours prior to constructing or operating each injection well, the
Permittee shall notify the Underground Injection Control (UIC) Central Office staff, telephone
number 919-807-6406, and the Winston Salem Regional Office staff, telephone number 336-
776-9800 [15A NCAC 02C .0219(d)(1)].
PART IV - OPERATION AND USE CONDITIONS
1. The Permittee shall be required to comply with the terms and conditions of this permit even
if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C
.0211(i)].
2. The issuance of this permit shall not relieve the Permittee of the responsibility for damages
to surface water or groundwater resulting from the operation of this facility [15A NCAC 02C
.0206].
3. The injection facility shall be properly maintained and operated at all times to achieve
compliance with the conditions of this permit and the rules of 15A NCAC 02C .0200, even
if compliance requires a reduction or elimination of the permitted activity [15A NCAC 02C
.0211(i)].
4. In the event that the facility fails to perform satisfactorily resulting in the creation of nuisance
conditions, failure of the injection zone to adequately assimilate the injected fluid, or
daylighting, the Permittee shall take immediate corrective actions including, but not limited
to, repairs, modifications, or abandonment of the injection facility. The Permitee shall report
non-compliance according to Part VI.7 of this permit [15A NCAC 02C .0206].
PART V - INSPECTIONS [15A NCAC 02C .0211(j)]
1. Any duly authorized officer, employee, or representative of the Division of Water Resources
(DWR) may, upon presentation of credentials, enter and inspect any property, premises, or
place on or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained under
the terms and conditions of this permit, and may obtain samples of groundwater, surface water,
or injection fluids.
Permit No. WI400523 PAGE 3 OF 7
ver. 5-21-2019 UIC-5U5T

2. DWR representatives shall have reasonable access for purposes of inspection, observation, and
sampling associated with injection and any related facilities as provided for in N.C.G.S. 87-
90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated with
the injection facility activities.
PART VI - MONITORING AND REPORTING REQUIREMENTS
1. The proposed monitoring plan shall be followed. Any additional monitoring, including
groundwater, surface water, or soil sampling, deemed necessary to ensure surface water and
groundwater protection may be established and an acceptable sampling reporting schedule
shall be followed [15A NCAC 02C .0225(k)].
2. An Annual Report with all historical monitoring results shall be submitted in bound hard copy
format with attached CD or flash drive to the AFOGPB Central Office, and Winston Salem
Regional Office starting from date permit is issued. Monitoring reports shall include, a
summary of injection activities and monitoring results, analytical data presented in a
spreadsheet distinguishing between pre -injection and post injection data, and an update on the
status and location of monitoring and injection wells. Well locations may be given in a table
with the name and geographic coordinates or shown on an updated version of the site map
[15A NCAC 02C .0225(1)].
3. Records of well construction, repair, or abandonment shall be submitted within 30 days of
completion of such activities [15A NCAC 02C .0225(1)].
4. An Injection Event Record shall be submitted within 30 days of each injection event [15A
NCAC 02C .0225(1)].
5. The Permittee shall submit a Final Project Evaluation (FPE) within 9 months after completing
all injection -related activity associated with this permit or produce an interim evaluation to be
submitted with a renewal application for this permit. Both the final project evaluation and
interim evaluation shall contain historical monitoring data and updated contaminant plume and
potentiometric surface maps. PLEASE NOTE: Inj ectants and related reaction byproducts must
attenuate to pre-ini ection concentrations or groundwater standards specified in rule 15A NCAC
02L .0202, whichever is greater, in order for this permit to be closed. Otherwise, corrective
action as described in Part VII may be required [15A NCAC 02C .0225(1)].
6. All monitoring results, forms, and reports required in this Part shall be submitted to:
UIC Program
NC Division of Water Resources and
1636 Mail Service Center
Raleigh, NC 27699-1636
Water Quality Regional Operations Section
DWR Winston Salem Regional Office
450 Hanes Mill Road, Suite 300
Winston-Salem, NC 27105
7. The Permittee shall report any monitoring or other information that indicates noncompliance
with a specific permit condition, that a contaminant may cause a violation of applicable
groundwater quality standards, or that a malfunction of the injection system may cause the
injected fluids to migrate outside the approved injection zone or area. As specified in rule 15A
Permit No. WI400523 PAGE 4 OF 7
ver. 5-21-2019 UIC-5I/5T

NCAC 02C .0211(p), ;._dicompliance notification shall be as foci.., ws:
(A) Oral notification shall be given within 24 hours of the occurrence, or first knowledge
of the occurrence, to the Winston Salem Regional Office, telephone number 336-776-
9800.
(B) Written notification shall be made within five days of the occurrence and submitted
to the addresses in Item #6 above.
(C) The written notification shall contain a description of the noncompliance and its
cause; the period of noncompliance, including dates and times; if the noncompliance
has not been corrected, the anticipated time it is expected to continue; and any steps
taken or planned to reduce, eliminate, and prevent reoccurrence of the
noncompliance.
PART VII - CORRECTIVE ACTION [15A NCAC 02C .0206]
1. Any injection well not constructed or operated in accordance with this permit, or the criteria
and standards specified in 15A NCAC 02C .0200, shall be subject to corrective action as
provided under rule 15A NCAC 02C .0206.
2. The following corrective actions shall apply to elevated concentrations of inj ectants or reaction
byproducts resulting from the permitted injection activity:
(A) Continued monitoring until concentrations return to pre -injection values or meet the
standards specified in 15A NCAC 02L .0202, whichever are greater. The frequency,
duration, and location of monitoring shall be appropriate for site specific conditions and
potential receptors.
(B)
Groundwater quality parameters that do not attenuate as described in 2(A) above may
warrant a corrective action plan as provided under rule 15A NCAC 02C .0206, depending
on the type, concentration, and distribution of the groundwater quality standards being
exceeded.
PART VIII - PERMIT RENEWAL [15A NCAC 02C .0211(h)]
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the
Permittee should submit an application to renew the permit 120 days prior to its expiration date.
PART IX - CHANGE OF WELL STATUS [15A NCAC 02C .0240]
1. The Permittee shall provide written notification within 15 days of any change of status of an
injection well. Such a change would include the discontinued use of a well for injection. If a
well is taken completely out of service temporarily, the Permittee must install a sanitary seal.
If a well is not to be used for any purpose that well must be permanently abandoned according
to 15A NCAC 2C .0240, Well Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any purpose,
the Permittee shall abandon that injection well in accordance with the procedures specified in
15A NCAC 2C .0240, including but not limited to the following:
Permit No. WI400523 PAGE 5 OF 7
ver. 5-21-2019 UIC-5I/5T

(A) All casing and screen materials may be removed prior to initiation of abandonment
procedures if such removal will not cause or contribute to contamination of the ground
waters.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom
from obstructions that may interfere with sealing operations.
(C) The well shall be thoroughly disinfected, prior to sealing, if WQROS staff determines
that failure to do so could lead to the contamination of an underground source of
drinking water.
(D) Drilled wells shall be completely filled with cement grout or bentonite grout, which
shall be introduced into the well through a pipe which extends to the bottom of the well
and is raised as the well is filled.
(E) In the case of gravel -packed wells in which the casing and screens have not been
removed, neat -cement, or bentonite grout shall be injected into the well completely
filling it from the bottom of the casing to the top.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has been
created, each well shall be abandoned in such a manner that will prevent the movement
of fluids into or between underground sources of drinking water and in accordance with
the terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0225(1) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2)(G) shall be submitted to:
UIC Program
DEQ - Division of Water Resources
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X — WORKER PRECAUTIONS DURING APPLICATION [15A NCAC 02C
.0225(a)]
1. Some effects reported to be associated with the product proposed to be used are as follows:
eye, skin, nose, throat, and lung irritation. If the product is 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 proper personal protective equipment should be used. The
application process should be reviewed by an industrial hygienist to ensure that the most
appropriate personal protective equipment is used.
2. Persons working with these products should wear goggles or a face shield, gloves, and
protective clothing. Face and body protection should be used for anticipated splashes or
sprays.
Permit No. WI400523 PAGE 6 OF 7
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3. Eating, drinking, smok:1ig, handling contact lenses, and applying cosmetics should not be
permitted in the application area during or immediately following application.
4. Safety controls should be in place to ensure that the check valve and the pressure delivery
systems are working properly.
5. The Material Safety Data Sheets should be followed to prevent incompatible or adverse
reactions and injuries.
Permit No. W1400523 PAGE 7 OF 7
ver. 5-21-2019 UIC-5I/5T

DIVISION OF WATER RESOURCES
WQROS
MEMORANDUM y�
TO: FILE / Rick Bolich( /�j�
FROM: Shristi Shrestha 5 ,�5 -
RE:
November 4, 2019
Issuance of permit to inject (Permit #WI0400523)
Former Salem Uniform Facility
Forsyth County
I recommend that Permit Number WI0400523 be issued to the above to inject the following additive(s) to remediate
groundwater (GW) contaminated with Tetrachloroethene: ABC Ole, Zero Valent Iron, Enviroblend 93, RTB-1, High
Fructose Corn Syrup, Sodium Bicarbonate.
SITE DESCRIPTION: The site was used as industrial uniform cleaning and laundry service from 1967 to 1986. Data collected
during previous investigations suggest that surface releaseor spills occurred close to former building. (Ref page 2).
HYDROGEOLOGIC DESCRIPTION: The Winston-Salem areas is located in western portion of Piedmont Physiographic
Province of North Carolina. Geologically, the site is located in the Milton Belt litho -tectonic province of North Carolina.
Saprolite and Partially Weathered Rock act as a storage reservoir for groundwater that feeds the underlying fractured
bedrock hydrostatigraphic unit. Onsite groundwater is encountered at 13 to 33 feet bgs and water table surface is found
primarily in Saprolite hydrostratigraphic unit. Potentiometric data has shown that flow in both units is towards South -
Southeast and discharges into the closest surface water body to the Site; an unnamed tributary of Silas Creek. Hydraulic
conductivity values derived from slug tests varied from 1.26 ft/day at MW-1(s) to 4.1 ft/day at MW-7(s). (Refer to pages 5-
7).
EXTENT OF CONTAMINATION: The groundwater contamination plume(s) are large and vary in shape and size. Refer to
Figures 3 & 4.
PROPOSED INJECTION: Previous injections were completed at this site as deemed permitted projects. Based upon good
results of the pilot test. the Permittee is proposing a full-scale injection project requiring a permit. Injections will take place
via DPT point's at 131 locations within the source area. It is proposed to inject 103,850 pounds of dilute ABC Ole, 103,850
pounds of ZVI and 10,385 pounds of Magnesium oxide.
Also, two downgradient PWR barriers will be created by injection into permanent wells. A series of five permanent injection
wells (IW-3 to 7), IW-1 and seven injection wells (IW8 to 14) will be created in two different locations. In these barriers
dilute High Fructose Com Syrup and Sodium Bicarbonate will be injected. Apart from this bio augmentation to increase the
natural population of the anaerobic bacteria will be done too. According to the attached spreadsheet used for calculating
plume displacement, the potential for plume displacement is very low.
HOW IT WORDS: ABC -Ole will create anaerobic conditions and provide electron for dehalorespiring bacteria. ZVI will
rapidly reduce chlorinated solvents upon contact through abiotic process. Magnesium oxide will be used to buffer the
groundwater pH. High Fructose Com Syrup is also being used to provide an electron donor for the dehalorespiring bacteria
and Sodium Bicarbonate is used as a buffer.
MONITORING: A baseline monitoring well sampling is planned before the injection. All the monitoring wells and detailed
sampling plan is listed on Table 4 &5.
EPIDEMIOLOGY: The DHHS has approved the injectant(s).
REGIONAL OFFICE COMMENTS:
The Winston-Salem Regional Office recommends permit issuance.

5I Calculations Worksheet
Applicant/Facility: (i -rti S C&o 0-h. 'J E- fale'vvi (,%-te`' WL. 5.14
Permit No. WI 04 D 0 5 2 3
Date: It/5/ 2©t9
Reviewer: SkS
Depth to groundwater (GW): /3- 33 f . BLS
GW flow direction: SefriAtli
MWs installed in same aquifer as injection? y (Y or N); Inj zone: 17- - 108 5 MW zone: 1 r - a D 5 s-
v'
Nearest water supply well:
Groundwater Flow Rate
Iva.
HC X gradient(FT?) = flow rate/DAY(?) X 365 = FT/YR
SY or porosity (-.30)
[FYI- 60 min. X 24 hrs X 365 days = 525,600]
Calculations for Potential Contaminate Plume Displacement
36, 4'0 Lt. o
47142 (n) X r2 X
!i-59 2va
space
height = 01- 59 i 2 0 0
CF
Reported: (° 2 6 — 4• Ifc.ts /4
CF x 6.3 SY or porosity (i.e. -.30) ='3 9 , ? 0 CF of available void
3, 2 3 , 44L44.8
CF of available void space X 7.48 gallons = gallons of water in void sp
128,6ro
CESteg gallons of injectant = 3.9 2.. % of fluid displaced by injectant (move decimal)
gallons of water in void space
3, 2 9-4, 41-44
Potential displacement of plume by injection: t -w
Injection Volume and Pumping Rate Per Well Per Day
/ 3Q / 0 5 total amt. of injectant //4 / number of wells / 90 number of days of injection event =
amount of injectant per well per day (average gallons per day)
S:UIC/Applications and forms/ 5I Calculations worksheet version 9/10/10