WI0300373_DEEMED FILES_20180414

D~
WELL CONSTRUCTION RECORD
Tbis form can bo UHd for single, or IDlllriple =II•
i w nc I t 1 ~ r e on rac or n orlJUI aon:
Michael T. Stanforth, P.E.
Well Coolractor Name
2525
NC Wdl Con!ractor Certification Number
Excel Civil & Environmental Associates, PLLC
Company Name
2. Well Construdion PermiU: NA w J,,c ;o03 i_
Li1t al/ applicable well permlU (i.e. Co11111)', Siatt, florlonce, lnj,cl/o,,, tic.) 3
3. WtlJ Use (check well uar):
Water Supply Well:
□Agricultural □Municipal/Public
DGeolherrnal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□l1Ti11.a.tion
Noa.Water Supply Well:
□Monitoring IZIRecove,y
Injection Well:
□Aquifer Rci:harge □Groundwater Remediation
□Aquifer Storage alld Recoveiy □Salinity Barrier
□Aquifer Test DStormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal <H eatini!/Coolimi: Return) □Other /ex olain under #21 Remades )
4. Date Wtll(I) Completed: 3/2D lo 415118 well ID# SVE 1 thru 7
!!a. Well Location:
Sam's Mart No. 56
Paciticy/Owner Name l'acilicy ID# (ifapplicable)
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physical Admwss, City, and Zip
Mecklenburg
Cowrty Pan:cl Jdenlification No. (PIN)
6. b (are) lhe well(s): loPermanrnt or □Temporary
7. Is this a rep.air to an eil11i11g well: □Yes or l!lNo
If 1Jrls IS a npolr, fill oui Imo..,,, well comrr11ction infannalian and trplat111h, """"" of /Ii,
repair umkr N2 I r,llfQ,h ••ct/on or on the back of lhb /Orm.
8. Number of wells coastr11cted: _7,.......,,..----,.....,..----
For multiple tnjectton or non-waltr rupply wills ONLY wUh the salflt ~anstructlon , Y"" can
sulnnll 01t1 fann.
I For In1cmal u,e ONLY :
t,f, WATMZONES
lillUM TO DUCRIP'llDN
ft. n.
n. ft.
lS. O1!TEll CASING""-lllldlkand wtllsl OR LINER nr a-.mllulllel
l'ltOM I TO I DIAMETER I ffllCKNl'.SS I MAffRIAL
n. n. in.
16. INNER CASING Oil TIJBING lnodluaAI dmal.:,;;:,;;;,
raoM TO !IIAlll!TEII ffllCJCNESs MATERIAL
0 ft. 10 fl. 2 in.
ft. n. In.
17 ........ gu,
FllDM TO DIAMETER SLOTSIZI!: 'llllCXNESS MATEIUAL
10 ft. 20 ft. 2 In.
ft. fl, la.
18.0llOITr
FROM TO MATERLU EMPIA.CIMENT MtTHOD A AMOUNT
0 ft. 6 ff. Cement
6 ft, 8 ft. Bentonite
n. n.
UI. SANDfGJlAv.L PACK nt a --K•al,lal
fROM TO MATIRL\L l!:Ml'LAC.l:MIENTMEntOb
8 fl, 20 n. medium quartz
n. fl,
20. DIULLIN'G LOO (llltaclladdllloul -D ll111r-··-·'
fllO,'A TO Dt;SCIIIPTWN l<0lot .. ..,_,..._ ,oll'nuk ,. __ •rala •-.,,,1
0 JI. 1 It. Asphalt/stone
1 n. 8 n. Dark brown sandy clay
6 ft, 20 ft, Reel sandy clay
ft. ft.
ft. ft.
ft. fl. ___ ....
-.•--· ,. .... -.
fl, fl. ~< t:. l rr~ ', V r· ., ·"""" ;.,,r li'-r .. .n i ' ?i .. -~ .. ~.
.U, llllMAllKS
Ar'I< l 8 ZUl o
·•"-~•I ~ :.J Ii.,,'.
4/J .,,/;I
Dale '
By signing 1hls fann, I he ljj, IMI 11w irel/(s) i,as (were) co,utn,cled In accordaHCt
wilh /SA NCAC 0lC .0100 or /JA NCAC 01C .0200 Well Cons1111e1/on Slandtmis and that a
copy ofthlJ record htJI heenpl"o••«lad lo 1M w~/1 awner.
23. Sile dlagnm or addlllonal w,11 details:
You may use the baek of this page to provide additional well site details or well
construction details. You may also attach additional pages ifnei:esmy.
SUBMITIALINSTUCTI0NS
'.I. Total well depth below land surface: _2_0c--c-::-::-:-:---:-:-:::--:-c=-----'ft.) 24a. For All Wtlls: Submit this form within 30 days of completion of well For mu/1;p1, N•elb li1t all <kpths If different (uomple• ]@200 • ond 2@100') construction to tne following:
10. Stadt watu level below top of casing: _n_o_n_e ________ (f't.)
/f H'lller /e.,/ ir above casing, use "·• "
It. Borehole dl.,neter: 4 (la.)
12. Well construction method: _A_,u......;;.g_e_r ___________ _
(i .e. auger, 1otary, cable, direa push. elc.)
FOR WATER SUPPLY WELLS ONLY:
Division of Water Re$Olltces, Information Proceasinc Unit,
1617 MaU Service C,ntn, R1l,ich, NC 276519-1617
24b. For Ipjcclion Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of ~ompletion of well
construction to the following:
Division or Water Resources, Undu<gro1md lnjeclto11 Control Program,
1636 Mall Service Center, Raleigh, NC 276519-1636
13■• Yidd (gpm) _______ Method of tut:________ 24c. For W11ter Su pply & Injection Wells:
Also submit one copy of this fonn within 30 days of completion of
13b. Dislnrection type: Amount: well construction to the county health department of the county where L:.::=.:===::..:~::...::========-...::==-==========.J constructed .
l'onnOW•I North Carolina Depallmont ofEnvironmenl and Naturel Resource., -Division of Wller R~sourc~ ReVised August 20 t 3
WELL CONSTRUCTION RECORD
This form caibe used fife rWale rirmolt=pt. weti.
t. Weil Contractor Information:
Michael T. Stanforth, P.E,
Wen Connector Navin
2525
NC Well Contractor Certification Number
Excel Civil & Environmental Associates, PUG
Company Name
2. Well Construction Permit if: NA , N.' J) 3003
Line aft appllraiie ur1 parrremlr (Le. Corertry, Stater, Allittltee4 httac(aa[ ek J
3. Weil Use (check well nee):
Water Supply Well:
°Agricultural
DGcothetrnal (Hcaring/Coolirrg Supply)
❑1ndtictriatiCtammerc ial
©Irrigation
Non -Water Supply Well:
L1Morritoriot,
O Municipa1/Pubiic
DREsidential Water Supply (single)
OResideitiat Water Supply (shared)
°Recovery
Injection Well:
❑ Aquifer Recharge
o Aquifer Siorage and Recovery
Aquifer Tea
O xperimentai Technology
°Geothermal (Closed Loop)
❑Geothermal (lieatinWCoolirrii, Return(
1. Bate Well(s) Completed: 4/2/18
h. Weil Loertion:
Sarn's Mart No, 56
°Groundwater Relnecliatitur
❑Salinity Barrier
❑ SLormwater Drainage
❑ Subsidence Control
OTrecer
ClO1heqexnlain under 021 Remarks_
Well IDli MW-9
Facility/Owner Name Facility MO (if eppluaLiel
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physical Address. City. end Zip
Mecklenburg
Courtly Parcel Identification No. (P1W
Sb. Latitude and Lougltude in degreealminafesJsetonds or decimal degrees:
(ifwell field. one 1etflooK is sufficient)
35.32039 - 80.95269
6. la (are) the well[(): rOPerminent or °Temporary
7. fa this a repair to an existing well: OYes or DNo
If Ibis is a repair, flit! ore known weal cwurrucriorr rnfornmarinn and explorer th' »mare aJ'rhe
repair grader a1! mnm'kt xecrion or oar dee back edits foots,
8. Number of wells constructed:
For nodeiple enlecfmn w "Mr- water.tnppfy wclrS ONLY wnh the ramie masrrpcHon, your can
!ohm n one form.
9. Total well depth below tend surface: 30
(fl.)
Fur molrrpk went lrsl on depths rfdi frrenl (example- 3(0,700' curd 2§1 Del
16. Static water level below lop of ea iiigt 23 (ft.)
If weer level is above cnarng, mlrp "= "
1. Borehole diameter: (in.)
12. Well construction mrthed: Auger
(Leauger, rosary. rabic, direct pUsb etc ]
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method or test:
13b, Disinfection type: Amount:
for 0W-i
For internal Uso ONLY
448921
14. WArER ZON
FROM
TO r7ICI I 'TION
23 n.
30 rt.
ft
ft.
r13c OUTER CAJTRG (for mMILmed wd14LOR 1dtIER OE/ HO
FROM
TO
OMMLTIR
THICrooss _1 maxima
R.
rt_
in.
16. INNfl
CARING OR TUPJNG
igeotheraaael
eed-leep)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 R,
15 it
2 to
n.
n.
ET. SCR!.SNt
t'RU61
-re
DIAMETER
SLOT SIRE
Tirt(KNWS4
r MATERIAL
15 R,
30 rt-
2 irk
J
fi.
rt.
to.
In. CRo
FROM
TO
MATERIAL
€M LACESENT Mrfio_p dt AMOUNT
0 It.
11 IL
Cement
11 It
13 rt.
Bentonite
R.
R
19. sA1tiDJGRAv
, PACK (I1 RPFE,sbk1
FROM
TO
MATERIAL
FM FLACEML1T METHOD
13 n.
30
rnedlurn quartz
fi,
ft.
20. DRILLING
LOG (.teach addistesal skew If sesew arT1
rxnnt
TO
hesnun' ION(crier.6aednen,i IIIT•th rya, 'rain RH,M.)
0 ft
1 'r•
Asphalt/atone
1 IT.
8 IL
bark brown sandy clay
8 n•
28 ft•
Red sandy clay
28 n-
30 n•
Light grey sandy clay
rt.
it
R.
tL
`1
ft.rt
',cal.
ZI. REMARKS j Q
irInt vAini tfY'_ ;
22 Certifrratlon:
Signature ofcertified Welt .rZISR• r
6y rtgning this J1n i. J
with 7S.4 NCAC OJC .0
corgi that she Wrli(r) 1+ar (were) sow irucled to liccaHOGrnCe
yr 15A NCAC 02C.0200 YYelf Corlslrrrcnrrre Slreridardr and Ail a
18
copy of do's record has Been prorated la he well urrerre.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site dctaila or well
construction details. You may also enach additional pages if necessary.
SUBMITTAL 1NSTUCTIONS
21a. For MI Wail'. Submit this form within 39 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Msi1 Service Center, RIleigb, NC 27699.1617
24h. Foy 1nisctlou ►Yet t ONLY: In addition to sending the form to the address in
24a above, also submit a Copy of ihis form within 30 days of completion of well
construction to the. following:
Division of Water Resources, Underground Injection Control Program,
1636 Mall Service ('enter, Raleigh, NC 27699-4636
2-1e. For Water sap)* & Ire jtct1ou Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Nonh Carolina Deparmunl of E+w ironraent end Naima) Resources - Divisiea0( Water Resouteea Revisei August T02+

WELL CONSTRUCTION RECORD
This foment' be used for Single re rmilliFic wdi1
I. Well Contractor Information:
Michael T. Stanforth, P.E. (1e41) g53- pg°1°
Welt Corriracsw Nanra
2525
NC Well Coat/estar Certification Nelda
Excel Civil & Environmental Associates, PLLC
tompanyNrne
2. Well Coostracelon Permit $: NA 1-0 3 G C]
use all appilarkweH per wsta h.e. Cnunry. Stare. Variance. IejernaA err,)
3, Well ilea (check well use):
Water Supply Well:
❑Agricultural
CGeotherrnal (Heating/Cooling Supply)
❑ indusirialtComrnercial
❑Ifrigsslion
Non -Water Supply We11:
❑Monitoring
injection Well:
© Aquifer Recharge
°Aquifer Storage and Recovery
❑Aquifer Test
❑ExperimentaI Technology
❑Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Retuml
4. Date Weflla) Completed: 3/19/18
5a. Well Location:
Sam's Mart No. 56
❑ManicipaVPublto
❑Rcsidential Water Supply (single)
❑Residential Water Supply (shared)
Q Recovery
laGroundwater Rem edlotion
❑Salinity Barrier
OStormwater Drainage
°Subsidence Control
❑Tracer
pother (explain under #21 Remarks)
Well ID#
AS-1
Faaitity/Owner Name Facility WO (ifapplieabla)
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physical Address, City. and Zip
Mecklenburg
For kkterrnl Usc ONLY:
448
14. WATER ZONES
PROM
TO
23 a•
34 0.
ft.
MESCR1PTigt4
is, irAfING
nix AMA-errd welrtOR LINER [1f asp LAID)
7ItrCKNr3S MATERIAL
TO
0.
R.
DIAMETER
16.1104ER C'A N ORTLi5ING (tes alciaaad•lpop)
TRIMNESS
TROIA
0
MATERIAL
0
R
31
2
IL
17 scup
FROM
31 k'
TO
34 tr,
AMMETER SLATSrut
2
[m
TRIMMER
MAIRRIAL
R,
R
Is
Il. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METEORA AMOUNT
0
27 R,
Cement
27
TT,
29 IL
Bentonite
R
19. SANIUGYAYEZL PACK lf.pplJc W,
FROM
70
MATERIAL
LMPLACFM NT ME7HOEI
29 a-
34
rt.
medium quartz
R
R.
ilr. ORILU % LOG tamed' adiLNsaal Roth RisrecemAry)
FROM
IF,
1
IL
TO
T R,
8
R
Drsourrz r1 { pkr, hard.rm, r.R'rwrr rya. erela yari Lies
AsphaWstone
Dark brown sandy clay
8
Ile.
28
h
Rod sandy clay
28 A.
it.
ft.
34 a.
a
R
Light grey sandy day
iL REMARIc6
14 gob
County Puce! Ideaifiaaiion No (FM
5h. Latitude and Longitude iu degrees/minutes/seconds or decimal degrees:
Orwell Field. one larl]aeg is wtilcienI)
35.32039 N - 80.95269
6. fa (are) I15ewef(a): ®Permanent or °Temporary
7. 1a this A repair fo nn existing well: ❑Yes or Me
1jehls es n repotr, fl/4 rwr hraw+t +Eel! canserucuan R jnrmatlen and explofir the nature of the
Popo*, wider 1!2) remoras realm crop the bock of this fatal
8. Number dwells conatrarted: • -t
For malirple r jerrren or nett water urn* wens ONLlrwith the some rwnstrYNlon, }mie ht
ithmis one force
9. Total well depth below land surface: 34
For infrittole swells !act all depths sfdrurrnr (example-
10. Static water level below Tap of casing:
!fa�krlerelrsabece rasing, We +"
11. Borehole diameter: 4 (ier.)
22. Certification:
Sigrwture of Certi!(e d s': ell COnliaetOr
!r4ii�'
3•]at4
8y sigriing this farm. 1 hereby randy that rho weirs) was (were) rarisfrursed to acre/7k re
Will 154 NCAC 02C .0100 or 1 SA NCAC 02C .020r1 Weil Consveerooe SYardards pad fhpl
ii a
copy of rids retard has been prperded to rho It turner.
23. Site diagram or additional welldetalls:
You may use the hack of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
1 iITAL INSTUCTIO S
9 �(t, 24a. For Ali Wellt: Submit this form within 30
, construction to the following:
.7
tit
ric
12. Well construction method: Auger
ti4s. auger. rotary. cable. dour frikA, ere,)
days of completion of well
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
NOV 204aecti4b. For [Outran Weill ONLY: In addition to sending the form to the address in
a above. also submit a copy of this Corm within 30 days of completion of well
1Mareae Q„ construction to the following:
Ftegb+ral Operations SOCtion Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center. Raleigh, NC 27699-I636
24c. Far Water Soppl+ & Iu1ectioo Welts:
Also submit one copy of this forni within 30 days orcompietion of
well construction to the county health department of the county where
constructed.
FOR WATER SUPPLY WELLS ONLY:
13a. Yield tgpit) Method of teat:
13b: Disinfection type: Amount: _
DIAMETER
Form GW.t
North Carolina Dena/mans of Environment
and Nat urn I Resources - Division o C Wirer R rsaurves
Revised August 2013

WELL CONSTRUCTION RECORD
This fortis can be uted free single or multiple walks
I. Well Contractor information:
Michael T. Stanforth, P.E.
Welt CanrreelorNarne
2525
NC Wall Connector ten iBestial Numbn
Excel Civil & Environmental Associates, PLUG
Company Name
2. Well Cons1rustian Permit Ile NA
Use all applkaM+k well perorate (t.e Cooney. Stalle. Varwmcr• 1nlrcttwr, elc.l
3. Weil U c (check wen one):
Water Supply Well:
❑Agricultural
❑Geothermal (Hearing/Cooling Supply}
R I ndustrial/Con merc is I
°Irrigation
1Voo-Water Supply Well:
OMonilanng
injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifdr Test
❑Experimental Technology
E Geothermal(Closed Loop)
°Geothermal (Heating/CoolRctum,
4. Date Welke Completed: 3120118
Si. Well Location:
Sam's Mart No. 56
OMunicipal/Public
ClResidentia.1 Water Supply (single)
o Residential Water Supply (shared)
f]Recovery
OGroundwaler Remediation
❑ Salinity Barrier
UStormwiter Urdinage
nSuhsidencc Control
o Tracer
Clothes (explain udder N2l Remarks)
Well Ind AS-2
FacilitylOwner Hama Yeti' ry IDI (if applicabta )
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physics] Addict. City. end Zip
Mecklenburg
County Parcel ldentilium on No. (PINT
Sb. Latitude and Longitude in degrerilminutsslaseonds or duitnsl degrees:
Orwell Held, Mt leulooe is sufficient)
35.32039 N—80.95269
For Internal Use ONLY:
448993
14. WATER Z0141111
MGM
23
n.
To
33 R.
DZSCEIPTIOI
I1t. O1TTER CASING (Or mu111rearrd wait) OR 1.INeat fu apprar61s1
PROM DIAMETER
R ft
TRIC1CMlM J MATERIAL
tit i'.%MR CARING ORIVa1N410141 t11Wdeaa4 toe
PROM TO RIAMSFER TRICIQOef3 MATERIAL
0 30 2 tw
ft,
fL
n.
PROM
30 ft.
TO
33 IL
81e41 $JZ TNLCKNLSE
MATERIAL
A.
le.
ILL GROUT
rRoa!
v
iL
TO t MATERIAL
26
R,
Cement
EMPlACEMENTMETROD & AMMOLN
26
n.
28 +.
Bentanite
It.
b.
14, BAND/GRAVEL PACK tif l eeaMe}
FROM
TO
MATERIAL
EMPLACEMENT PALTKOD
28 fr.
33
R
medium quartz
n.
20. rantLL1N4: LAG (stitch nifitkmai dead Ifwereu+v7l
PROM
0
1
ft.
R
To
1
ft
8 IL
8
28
0E3C11 FFT1ON •R eler, harilum. egYrerk i r.ixam ran 400
Asphaltlstone
Dark brown sandy clay
Red sandy day
28 It
R
33
IL
Light grey sandy clay
O.
ft.
21. RimiARNic
22. Certification:
w
6. Is (art) Mbewea(s): oFermanent or °Temporary
7. Is this a repair to ore existing well: t IYes or ONa
Il this is a repofr. Jill out erwwn waif eartttrttrrloe Informaliwa anderpfain the Neither yrthe
watt raider e21 rem wkr YEdiop or OM the bacll ofthls rprm.
S. Number of write constructed:
For mnleiple infection ar 170rr-1•10ee7 rrhpply went ONLY with the rare! rae.+rretedos, you ran
suborn oar farm
9. TotsI well depth below land surface: 33
For multiple wells list all depth: o'clo erect text etple- 20200'aid max)
10. Static water level below top of casing: 23
If water /emir abort rasmg, psi "+ "
I1. Borehole diameter: 4 (in)
12. Well construction method: Auger
(l.r. auger, misty. cabte. direct push. ctc.1
%Signenue of Cams e1 antiwar
(ft.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpta) _
I3b. Disinfection type: _
Method of test:
spittioFaller!► arm: "
ay signing rhls fort, t Prey ceetlA that the wall(:) was )1rere) erourraeered fir tereord tree
with 15A NCAC 02C.0100or IJA NCAC 4TC.020a Wall Corzrrruclrwv Stmxdardr and that a
cagy of oral record has ternleraeliedta rife ILO pwrwr,
23. Site diagram or additional well details:
You may use alto back of this page to provide additional wrtl site details or well
construction details. You may also attach additional pages if Accessory.
SUBMITTAL MST UCT1O S
24a, ForAll Wells: Submit this fort within 30 days of completion of wen
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mali Service Center, Raleigh, NC 27699.1617
241x For jnILcllva Weill ONLY: in addition to sending the !form to the address in
24a above. also submit a ccoy of this form within 30 days of completion of well
construction to the following-
Divleioa of Water Resources, Underground Injectloe Control Program,
1636 Mail Service Center, Raleigh, MC 17699-1636
24c. For Water Supp1Z& 1njs 1ki. Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW- l
Noah Carolina Du'sroncnr of Earuonment And Neturei Resources — ilivifies oPOP wet Resources
Rreisrd August 2013

WELL CONSTRUCTION RECORD
This farts ran be used fbr airrgla or multiple wens
I. Well Contractor Information:
Michael T. Stanforth, P.E.
Well Coratech r Name
2525
HC Welt Camino/srCertification Number
Excel Civil 8: Environmental Associates, PLLC
Company Name
2. Well Continuity'. If: NA
rne
Lin all applicable well parents (+.r. County, Smte, Yarioiwe, lnjecrlrav, arc/
3. Well Use (cheek well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commerc ial
Dlrrigation
Non•Watcr Supply Well:
°Monitoring
❑Munictool/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
ORecovo
Injection Well:
❑ Aquifer Recharge
DAquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Creo[htr•mal tHeating/Cooling Retum1
4. Date Welf(s) Completed: 3a'20118
5a. Wel Emotion:
Sam's Mart No, 56
Fad6ty/Ow=Name
OGroutuhuatcr Remodialion
❑Salinity Barrier
❑Sto=tmwtcr Drainage
❑Subsidence Control
❑Tmser
DOlher [explain under 821 Remarks)
Well am AS-3
Facility R]b (if applicable)
2932 Mt. Hotly Huntersville Rd, Charlotte, 28214
Physical McNeal, City, oriel Zip
Mecklenburg
For Internal Use ONLY:
l4 WATIA ZONES
FROM TO
23 rr, 35
nfSCRIPTIOR
ft,
R
lA OUTER CASING the mubYsmed welki OR LLNTR u *optical'
OLAAferaa I TIiloiiS ct *MLR
PROM
TO
h.
si
16. fl Nf.R CASING ORY_:NG tarn al ttgLd-rood,
i PROM
' TO
1=A ET=
THICKNESS
btAT'IRMAL
0 n.
32 ft'
2 lu.
-
It. f
R.
In.
+
FROM
TO
DLta OTICR
SLOT SEER
TRIMNESS
MATTRIAL
32 R
35 R.
2 is~
rt.
R.
b►
it GROUT
FROM
0
rO
28
MATERIAL TEMPSACIMIN, Ffi,'n ODA asus.rirr
Cement
28
IL
11..
30
1G
Hentonite
Ti0 SAIONC-RAV IL PACK
nom
TO
MAT taut
EMPLACERIO TMil11O0
30 e.
35 fc
me&urn quartz
R,
Z0. DRILLING LOG omen Me[elmnt thteletroseaaw )
FROM
0
1
1t.
8
rp
1
a
ft.
RESClurrlOh (use. hxdr., oirfesektrpr rosin e.ue. vit.i
Asphaltisbone
Dark brown sandy clay
28 1r.
Red sandy clay
28 it
IL
35
n.
Light grey sandy clay
ft.
fr.
rt.
R
r`�
31.11It11tARK1S
ikPR1t�
VTO
County Parcel tdenti(ecation Na iPINI
5b. Latitude sad Longitude in 4egreeseminuteereronds or decimal degrees:
{ifwell Odd, one Iarllong is Aoffscienej
35.32039
N — 80.95269
6. L (art) fha well(s): IZIPermaaent or °Temporary
w
7. le this a repair to an existing well: ❑Yes or En No
If this is a 'guar, frtl air brown well contraction In fornmrron andexploin she rroture of the
repair under s21 remarks tecoaa or an the Dark 4( this farm
8. Number ofwella constructed: 1
For mainnpfo injection or tem-r ater,suppiy wells ONLY with the saes, mnsfraettas. jest can
submit one fines.
9. Total well depth below land surface: 35 (rt.)
For multiple weds pit all depth: if rfrfirrrm (example- 3 r(200' and 2 Jie MO
10. Static water level below top orrasing: 23
[f+wter levet tr about easing, tin "
1 I, Borehole diameter: 4 (in.)
12. Well construction method: Auger
fie. auger, rotary. cable, dint push etc.}
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gyro) _ Method of test
Lab. Disinfection type: _ Amount:.
32. Certiticalian:
. tgnem+e afCerti ed Wonenetor
Dat,
Hy wiping fhia first. I ' - y cerit6P dons the we(e) xas (here) constructed in accordanrs
with ►3 t NCAC a2r.0700 ar ISA NCAC 02('.0240 Well t,'nrvtn,erirw She'dords and that a
copy<finis record has been provided fa she well owner.
23. Silt diagram or additlortal well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if accessary.
SUBMITTAL INSTUCTIONS
24a. For Ali War Submit this form within 30 days of completion of well
construction to the foiiowting:
Division of Water Resources, Information Processing Unit,
1617 NUB Service Center, Raleigh, NC 27699-1617
24b. For Infection %VQi ONLY: In oddilion to sending the corm to the address in
24a above, also submit a copy of this form within 30 days of cornplelion of well
construction to the following:
Division of Water Resources, Underground [q(ectIon Control Program,
1636 Moil Service Center, Raleigh, NC 27699-1636
24c, For Water Sippiy 4r Ia)ectlea Wdts:
Mao submit one copy of this form within 30 days of completion of
well construction to the county health department of she county where
constructed.
Foam Cl W t
North Carotins Department ofliwiranniem end Natural Resources —Division of Water Resources Revitcd August Nil

WELL CONSTRUCTION UECQ »
Thu Farm can be used for Jingle pr multiple weir
I. Well Contractor Information;
Michael T, Stanforth, P.E.
Wa{1 CondrxI w Namc
2525
NC Welt Cowsl clef Ceni eentioa Number
Excel Civil & Environmental Associates, PLLC
Company Name
2, Well Comiruction Permit IS;NA
for off applicable well permits jLe. County. Stare. Irrxlarrce, hyeetroa ere.)
3. Well Use (rbeck well use):
Water Supply Well:
DAgsicultural
L]Geothe rural (Heating/Cool I ng Supply)
O l ]dust riot ICommexc is l
I] LrrigMion
Non -Water Supply Well:
©Monitoring
0Mun;cipal(Public
°Bes:dential Water Supply (single)
OResidentiai Water Supply [shared)
U Retwvel y
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
CI Aquifer Test
ElExperimental TapbriotOgy
❑Gcothermal(Closed Loap)
°Cieothernsal (Heating+Coniing Return)
4. Date Wril(s) Completed: 3j j i
8
Ss. Well Location:
Sam's Mart No. 56
@Groundwater Reined lotion
❑ Salinity Barrier
❑ Storrewatcr Drainage
LSubsidence Control
OTracer
°Other (plain under 921 RemaricsL
Well WI AS-4
Faciffly/Owner Name F'Icthty l68 (it'applkable)
2932 Mt. Holly Hurltersviile Rd, Charlotte, 28214
rhyeical AdAreri, City. and Zip
Mecklenburg
County
Parcel ldeolificasian No. (PIN)
Sb. Latitude Ind Longitude in degreeslminules/seemidi or decimal degrees:
(if wail Bald, one lavboeg is s,iIGcient)
35.32039 - 80.95289 ►v
6. Is (are) the well(!): @Permanent or ETempurary
7. Is this a repair to an existing well: ❑Yes or L]No
(/OhiJ u a repair, fiI/ oW known well construcrW r rfrforrnalwo awe reploin the rmlure of the
repair Larder 01 remark] section or on the back of this farm.
R. Number (dwells constructed:
For multiple lit/maim or lean-Lraier strpply wells 0144, P with die some cutLsrrnNion. you ear
rubnorone form
For Intern!) Use ONLY
.1489n9
11, WAnn ZO1Yris
YRO1
TO
DESCRIPTION
23 Ft.
36 A.
1).
ft.
IL Durex cASlrtc fifer
motel -cored wear) OR LINER (If e,ele)
FROM
i'0
r DIAMETER
T THICKNE,CS
MAMMAL
R.
n.
in
16, INNER CASING OR Tho1n
iteolb test} died --Loup}
FROM TO
n1AMCrTR
TI]IC)CNF$S
MATERIAL
0 "' 33 R.
2 ta.
rt. rt.
to
17. SCREEN
i FROM
TO
D1AME7111
SLOTIEEJ
TII!CI(N S
- MATERIAL
33
r36 n.
2 le.
n.
a.
to
11. GROUT
PROM
TO
MATERIAL
rArre.ACIMiiNT amigo p & MOLT T
Q rt,
29 n,
Cet-nent
29 0-
A.
31 ff•
rBentonite
A.
19. SAND/cItAV$L
PACK 4f derail;Lte1
IRON
TO
MATERiAl.
t{AIPLACCMINFRIrn lot
31 h'
,
36 e.
medium quartz
rt,
A.
2a1. RR/LUNG
LOG fatsaelaadUnowat glee la If me caw,.)
FROM '
Pc.
DISCRITTIO2j. trio. hat In ear, anima r, ae, [rah aids see. ]
D rt.
1 it
Asphalt/stone
1 it
8 a
Dark brown sandy day
B r'-
28 et'
Red sandy day
28 h•
36 rt.
Light grey sandy clay
n.
O.
A.
A.
}fr'1 E;—•_ Y
2t. REMARKS 'l4 1 F
✓
Ini0ft:'1:iit?'l ::
22. Certification:
! Signature of Cali red W j� • actor
9. ToAPI well depth below hand sorrow36 (D )
For multiple wells fist WI deprh,r Ifdrferrm (exae,plc• r@12o0' cared I(41017)
10, Static water level below top of casing: 23 (n.)
ff wafer level Is above rasing, use
11. Borehole diameter: 4
12. Well construction method: Auger
tr.e Luger, !bury, cable, dincl push, etc )
MR WATER SUPPLY WELLS ONLY;
13a. Yield (gpmi Method of test:
13h. Disinfection type: Amount:
#1/4EL
Dale
Hy steering dLG form, cerl45 slur the weflhi Nos ?here) rnnseracud to accordorkr
++Mir ISA NCAC 07(' .0Il , or ISA NCAC 02C.0180 Well f.onserur io, Sloodani3 end rhrn n
copy aphis record Fins &es on:odedm the cell miner.
23. Site diagram or addltioaal well details:
You may use the back of this page to provide additional nei! site details or well
cmratruction details. You may also attach additional pages if necessary.
Wit mi TAL DISTUCFIOONS
24a. ror All Wei: Submit this form within 30 days of completion of web
construction to the following:
Division or Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27659.1617
24b. For Injection Welk ONLY: In addition to sending the form to the address in
244labove, also submit a copy of this farm within 30 days of completion of well
constriction to the following.
Division Pr Water Reraurres, Underground injection Control Program,
1636 Moil $ervite Center, Raleigh, NC 27699.1636
24c. For Water Supply & injection Wells:
Also submit one copy of this form within 30 cloys of completion of
well construction to the county health department of the county where
constructed.
Fowl GW.I
North Carolina Department e F ERYLTORMtni end
Nature' Resuorcw - Divular. of WeterResoureei Revised August 2013

WELL CONSTRUCTION RECORD
This formGan be wed Rs singe or multiple wells
!, Well Contractor Information:
Michael T. $tanforth, P.E.
Well Conlraotur titan
2525
NC Well Coma for Certif ealinn Number
Excel Civil & Environmental Associates, PLLC
Company Name
2, Well Construction Permit 0: NA
List all app0eabla Drell pennies (t.e. Cow SmMr, Parlance, ftyeeitan, reed
3. Well Use (check well use):
Water Supply Well:
f]Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ hrulustriallCommercial
_Qlmgation
Non -Wafer Supply Weft:
❑Matritosing
fMunicipaVPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimenta 1 'Technology
f3Geothertnal(Closed Loop)
❑Geothermal (14eatingiCoolinn Return)
Groundwater Remcdiation
°Salinity Barrier
❑Slormwat€r Drainage
❑Subsidence Control
°Tracer
❑(Other (explain under 921 Remarks)
Far Irdenial the ONLY:
44891.0
!A. WATER ZONES
1IOM
TD
DESCRIPTION
23 n-
32 R.
1,.
ft.
1L eons CASINO i for males -eared wed) OR LINER
—TO—TO
moM
ft.
k.
DMAMATER
io.
tI[ap
T
THICKNESSTHICKNESSMATMAT
IiRIAI.
T6. INNER CASING OR TUBING ineothermnl Blot ra-loop)
FROM
0
tT.
74
29 ft'
DIAMLTSR
2 In.
TH1C1CrlFF6
MATERIAL
ffi
1L
in.
17. SCREEN
FROM
TO
DIAMETER
lo.
29 fL
32 n•
2
SLOTSIZE
1TKCENE. S 1 MAMMAL
ir.
It.
Ia.
!S GROUT
FROM
TO
MATEPML
EMPUCEMrNr MirROD i AMOUNT
0
If.
25
Cement
25 n.
27 R.
Bentonite
n.
n.
19. SAND/GRAVEL PACKIRapplicable)
FROM TO MATERIAL
EMPLACEMENT METHOD
27 D-
32
ft.
medium quartz
R
1a. DRtLLSING LAG faeraeh addldapd theme U arecrs+ar al
FROM
a
4. Dale Well(*) Completed: 3/21/18
Se. Well Location:
Sam's Mart No. 56
FecilirylOwncr Name
well stall AS-5
Facility ION (i Capp) is s61e)
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physkal Addreat. City, and Zip
Mecklenburg
County Parcel Identification No. (PIN)
5h. Latitude and I oogitude in degrees/minutes/seconds or decimal degrees:
Or well field, one Shin ong is suinicited)
35.32039
N - 80.95289
6. Is (are) thewell(s): Ir7Permanent or ❑Temporsry
W
7, Is this a repair to an existing well: ClYea or PINo
1jlhlr is a repair, frf out k7001411 well MISRurttan Itrfornratio i and explain rh a +insure of the
repair under b21 rermrlk sea ion LW on the backaphis form
8. Number of wells constructed: 1
Par ?make!' lafaritan ar Harr -rater supply welia ONLY NM the same cenriewrrian. you can
submit one from.
9. T6talwell depth below hand surface: 32 (It.)
Formaulltple rdI lire all depths ifd/Jferenl (example- 13,700'and WOO')
10. Static water level below top of rasing: 23 (ft)
!f water level is °hove caring. wie "- "
I I. Borehole diameter: 4 (in.)
12. Well construction method: Auger
(i.e. auger. rolnay, sable, direct push, ctc
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ Method or lest
13b. Disinfection type: Amount:
Form GW.I
1
TO
k.
ti.
nES4_TIiPT I0 (,H.r, he.ensn, sal rtrek qr., into lire, tar.)
Asphalt/stone
Ira
8
R.
Dark brown sandy clay
8
28
R.
Red sandy clay
28 n.
32
rt
Light grey sandy clay
It.
ft.
1l.
a.
21, REMARKS
FL
9.
APR 18i G
22. Certification:
Signature ofCtnified W i mtrrctor
Intprolguein
Dare
By steams rhix firm. 1 r nay read, that she uYN(') Hits (titre) cooslrucled In accordance
with I3A NCAC 02C.01B° or 134 NCAC 02C.0200 WeG Corulruc1iwr Standards and flat a
ropy of Ws record has been provided ro the well owner.
23. Slit diagram or additional well details:
You may use the back of this page to provide additional well site details or welt
construction details. You may also attach additional pages if necessary.
SUBMITTAL 1NSTUCTIONS
24s. For MI Weli.t: Submit this form within 30 days of completion of well
construction to the following'
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raheigb, NC 27699-1617
24b. For Injection Wells ONLY! In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of Hal}
construction to the following
Division of Water Resources, Underground Injection Control Program,
1636 hhoii5erviee Canter, Rahrigh, NC 27699-I636
24r. For Water Supply & Fnjection Wells;
Also submit one copy of this fonn within 30 days of completion of
will construction to the county health department of the county where
constructed.
North Carolina Department of Env irmmnene and Naval Reuateces - Division of Water Rtaoutcca Revised August 2013

WELL CONSTRUCTION RECORD
This form can be used for singly oi multiply volt;
I. Well Contractor Information:
Michael T. Stanforth, P.E.
Wolf Contrncier Nam
2525
N?C Well Contractor Celli fi:elion Number
Excel Civil & Environmental Associates, PLLC
Company Name
2. Well Construction Pcrtoilt: NA
tat elf applicable meipermirs (1 e. Cow*.. Starr. Yammer. lnjrc Mon. err.)
}_ Well the (cheek well use):
Water Supply Wetl:
❑Agricultural
OGeothermal(Heating/Cooling Supply)
I7lnd ust vial/Commercial
❑Irrigation
°Municipal/Public
DRcsidcntial Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑ Monitoring 0 Recovery
lajeetiaa Weil:
❑Aquifer Recharge
[Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
0Geotherma!(Closed Loop)
COcothemial (Neatinglennling Return)
OGrowtdwater Ratnedintion
DSalinify Barrier
USiormvrater Drainagc
flSubsidence Control
❑Tracer
DOthet [explain under tat Remarks)
4. Date Well{s) Completed: 3I28I1 $ Welt MN AS-6
Si. Well Location:
Sam's Mart No. 56
FacilisylOwnex Name Faclliry ION (ifapplirxelej
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
P hysitaI Address, City, end Zip
Mecklenburg
County Ponce! idontifcation No. INN,
5b. Latitude and Longitude in degreralauutiles/seconds or decimal degrees:
(if well field, wit FWhmg Is suitdeo°
35.32039 N - 80.95269
6. Is {arc) the well(a): CdPermaueat or L JTemporary
For internal L'6e ONLY
14. WATER WNF.s
FROM
To
23 n.
36
ft
DESCRIPTION
fr.
15.OLITER CABLYG (Far xamilLeatrd wei4) OR LINER (Hap}lirabiej
FROM TO t1IAMCf6it THICKNESS 1 MATERIAL
n. It.
in.
y
16. INKIER CARING URT'(l*1N &FEW dmKe-Iwq}
FROM ' -ro I/ AMM:R TR[EINEZS
0
rr.
rt.
33
2
MATERIAI
in
17. �4{ liE EN
FRO%1 TO SLAT BALE
33
36 fl la
T[1ICI{NFSS
MATLRIA
rt.
is
1d. GROUT
FROM j TO
0
fe.
29
f<.
MATEMAt.
Cement
EMPLACEMENT Melillo I) mMOtneT
29
ft.
fe.
31
R,
ft.
Bentonite
19. SANUFGRAVRL PACK(11typpHeabltj
FROM TO PL4TLMAAL
31
36
medium quartz
EmPtAcissrerTmertiolf
fL
1o, oar LUNG LOG boa& addle slat na a if seaenear&
FROM
0
n
fi.
m
8
fL
ft
DESCAZPnCIY trnio;_ Iardaer, rrdtrroyh IMF tnla 42010e-
8
fc
28
AsphaWstone
Dark brown sandy clay
Red sandy clay
28 fe'
ft
36
n.
Light grey sandy clay
ft
ft
tf.
21. kEMA*XS
22. Certification:
�
7. Es this a repair to an existing welt: ❑Yes or k�No
(I MO Is a rapulr, Jxf opt knotnz self eniatracno1 isfortl+ar(an and crplar r fhr NOW* of the
repaer ander l21 remarks sec/ram or an the back of tars farnr.
S. Humber of sells constructed:
Far urullfpfr rnjrcfenn or aaR-water iapply wells ONLY 'WA the SAWN rnasrredtax, SJ Carr
sutrmm, ff one for
9. Total well depth below land surface: 36 [R.)
For wudfip(e wells lit, Rif depths ifa6g'erenf (raeyde- 3@200' orrd 2®160')
10. Static water level below for of casing; 23 (ft,)
(f woler level fs °boor cretirg, use
11. Borehole diameter: 4 {in.)
method:12, Well construction method: Auger
tr.e. auger, twiny. cubit. duce[ push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13s. Yield (gpm) Method of teat:
13b. Dislnfechon type; - - Amount:
.RE \ t
EL -
.Dh7rfa31 ^`l r . ,
/
SigtunueofCert1Fied We1 tractor Oste
fi'y afgrrfrfg Otis fonii,, 1 Mcy.i1s'crrlify dot eke wilds} was (here) eaiunrarnd in occordunce
wall 13A NCAC 02C.0100 or 1.14 NCAC' 02C.0200 Weft Caaaracann Siividards and dun a
ropy of &Is recantlots been ircwldad to dtr well owner
23. SIN diagram or additional well details:
You nosy use the back of this page to provide additional well site details of we])
construction details. You may also attach additional pages if necessary
Sl1EMHITTA L JKSTUCTIONS
24a. Fnr AI) Weft Submit this form within 30 days of completion of well
construction 10 the following
Division of Water Resources, Information Processing Untt,
1617 Me It Service Center, Raleigh, NC 27699-1617
24b. forJniection WeNF ONLY: 1n addition to sending the form to the address in
24a above. also submits copy of this form within 30 days of completion of well
construction to the followmg:
Division of Water Resources, Underground injection Control Program,
1636 Mail Service Center, Raleigh, (lC27699-I636
24r. For Water Supply 6 Injection Wells:
Also submit one copy of this form wilhin 30 days of completion of
well construction to the county health depatlment of the county where
cnns[ructed.
t Gyro 13W. i
North Cerolrnn Depaiineru of Eurironmonl and Naiwral Resources - Division Wiser Rexsutees Rcvesed Aug4,I2 I1

WELL CONSTRUCTION RECORD
This form can be turd for siegk a multiple wells
1. Well Contractor Informsnon:
Michael T. Stanforth, P.E.
W ell Camrector Name
2525
NC Well Couvactor CertiSearewa Number
Excel Civil & Environmental Associates, PLLC
Company Nara
t. Well Construction Permit litNA
1.01 oft applicable well pinnies (t e. Coswiyt, Stare, Varicose, helecrian. ere)
3. Well Use (checkweil tut):
Walter Supply Well:
['Agricultural
❑Geaihemsal (Heating/Cooling Supply)
°Industrial/Commercial
❑ Irriignlion
OMunicipal/Public
❑Residential Water Supply (single)
tJResidential Water Supply (shared)
Non -Water Supply Well:
o Mon Loring °Recovery
Injection Well:
DAquifcr Recharge
❑Aquifer Storage and Recovery
❑ Aquirer Test
RExperimental Technology
°Geothermal (Closed Loop)
o Geothermal QNeating?Cooting Raumj
BiGraundwater Remediation
❑Salinity Barrier
❑Storm water Drainage
❑Subsidence Control
o Tracer
❑ Other (explain under #2 t /tornados
4. pate Wallin) Completed: 312811$ Wen UM AS-7
5a. Wen Loudon:
Sams Mart No. 56
Fecitiiy/Owen Nmnc Facility IDI (iIapplicable)
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physical Address. City. and Zip
Mecklenburg
County
For Istansal (*ONLY:
44 89 01
I4 WA'l'Bttamiss
vitom
II1630OPr nH
TO
23 35 d.
h.
1S.OlTl'R3t CASING fear soda -eased wear OR LINElilfir a�krahla)
b1AMSTER �j THICIOOM
MOM
ir.
R.
TO
a.
in.
IIMIES1AL
16. °EMII t CASING °STORING rse$lberanl deaed4ostO
ntoM TO
0 e' , 33 R.
DIAMSrmR
2 La.
TRICIO1FAS
M.ATCRGL
n.
ia.
37. SCREEN
FROM
32 14
TO
35 rr.
UMA1HCTER
2 la
nun gtza
MICKNESE
MAMMAL
R
IR
`OS GRO7rT
■ROM
0
tl.
28 re.
fi.
TO
28 It
30
11
MATWAL aMPIACIAtttr[ML-TROD / AMOUHC
Cement
Berlt4nite
19. SAI1DA3StAYEd. PACK[N.ppncsble)
FROM TO 6tATERIAL
SMFLAcrairrfr unarm
35
f.
tt
medium quartz
aROM TO f78SCR1P 1001 [chan iruinrf r, rik'rsdr hs4 Merl daf,efe l
Q s. 1 a. Asphalt/stone
1
8 a.
8 f
28
Dark brown sandy clay
Red sandy day
28 fl.
>k
35
ft.
0.
Light grey sandy day
re.
R.
t3
tr
' L
IL. REMARKS
-Ain IRZ1
Fast! Identification No. (PIN)
5b, latitude and Longitude In degrees/minutes/moods or decimal degrees:
(if wslt fcad. oak iat/loog is sufficient)
35.32039 N - 80.95269
6. In (are) the well(s): UlPermascist or ❑Temporary
W
7. Is this a repair to an existing wei1: CYea or FIND
!Phis is a report, y9N out blown self coosirfaa-rran frifiumoiran and explain the riahrn.. of the
re parr reader 411 rrrrmrks sedan* or au the back of AA form.
8. Number of wear constructed: 1
Fvr mwlirple overman or nun.wrier pop* with ONLY with tea raw cemsrrvtMea, yam can
rrifrarrr aria
9. Total well depth below fund surface: 35 ([t.)
For ourlrode wells fist ofldepths i/Jffirsni (example- 32200' wed igloo)
14. Static water Level below top *teasing: 23 (f1.)
if Inter Wei is oboe rasing, use "- "
[I. Borehole diameter: a (in)
12. Well construction method: Auger
as. auger, rotary, cable, direct push otc.1
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (spin) Method oft.*
13b. Disinfection type: Amatsaf:
22. Certification:
Signe= arcedlned j . tractor
19i1tet sr
DIP t .
' fL=
tins[
By signing this fom rely cm* Aar the e..il) was /a<rrc) COILS tracr rn ucconiauce
whir 13A NCAC 02C.0100 v ISA NC4C 02C.02L10 Well Conrduetrpn &melon& and nice a
copy ofthis res+orrlhas been provided ro the well nwir¢r.
23. Siu diagram or additional well details:
You may use the back of this page to provide additional well site detaila or wall
construction dktails. You may also attach additional pages if ncce530ry.
SUBMITTAL INSTUCrIONS
24s. For Ali Wear Submit this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b. F I Irgectiou Wells ONLY: In addition In sending the forgo to the address in
24a above, also submit a copy of this form within 30 days of completion of well
conutrltcl iorl to the following:
Division of Water Resourres, Underground lnjertiotl Control Program.
1636 Mail Service Center, Raleigh, NC 27699-1636
24e, For Water Sappy & Injection Wellit
Also submit one copy of this form within 30 days of completion of
well construction to the county health department or the county where
constructed.
30 R.
ft.
74! DRILLING WO fatueh addlrimas sows if stresses')
Form OW.1 North Carolina Dccestmcnr of Environmcnr and Natural Rtaontcec - Di vision Wafer Resources
Revised August 21:i13

WELL CONSTRUCTION RECORD
This form can be used far tingle or nxlupie well'
I. Weil Contractor lnlelrmIllhrl:
Michael T. Stanforth, P.E.
Well Contractor Nema
2525
NC Weil Corttoelcr Certi5eatsOn Nlrrobes
Excel Civil & Environmental Associates, PLLC
Company Name
2. Well Construction Permit q: NA
1.1rt ali applicable well permla Ca soy, Stale. Variance, Iryeeileg etc.)
3. Weil Use (check well use):
Water Supply Well:
[Agricultural
° Geothermal (Head nglCooi i ng Supply)
❑ Industr ill (Commercial
D1rrigalion
Nutt -Water Supply Well;
❑Monitoring
❑ Municipal/Publ is
°Residential Water supply (single)
❑Rcsrdential Water Supply (Shared)
°Recovery
Injection Welt
❑Aquifee Recharge
°Aquifer Storage and Recovery
❑Aquifer Tess
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal IHeatinglCooling Return)
frIGtvuladwatcr Renrediation
❑Salinity Ranier
❑Stormwater ()manage
❑Subsidence Control
o Tracer
❑ Other (cxpIai# under #2f Remarks!
4. Dare Wen(s1 Completed: 3/29/18 Wetl Ins AS-8
Sa. Well Location:
Sam's Mart No. 58
raeiiityft wxrName Facility 1Dd (ifeppliceble)
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
t'hysic8l Address, City, and Lip
Mecklenburg
C41Mty Parcel iJcntiftcslion No. (PIN)
Sb. Latitude and Longitude in degrees)minutealseconds nr decimal degrees:
(ifwetl field one 'alma is sufficient)
35.32039 N - 80_95269
6. Is (are) the wilts): °Permanent or ❑Temporary
1. Is this a repair to an existing well: °Yes or EINo
($:hires a repair. I ll or+r kno+m well eonsirrrcrran informorfan nod expect, the manure of the
repair under ell remarks rattler or on the back of this farm.
a. Number of wells constructed: 1
F r eianiple 1 jedlon OF tsea•water srpplly well. ONLY with the same emestrarrlarr. you can
a donne one farrrr.
9.Iotai well depth below laud .surface: 35
For mufilple welt Ifsl all depth If d+,jfcrcrn (eramp(r- 3r G00' mod 26000')
111. Static water level below lop of casing: 23 (fr.)
if wirier revellsabove cosrrrg, rise
11. Borehole diameter: 4
12. Well construction method; Auger
(i.e auger, rentry, noble. direct pushy etc.}
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpnl) Method of teat:
13h. Disinfection type: Amount
For Crow' Use ONLY
1485n9
t4. WATER TONES
FROM
TO
Discs:moll
23 n•
35 1t-
ff.
ft.
1S OUTER CASING tibr auld-weed wens OR LINER (if ipll��c1µ�-ahie)
rat7M
1O
o,AMAr!a
] TiCicaS$
n.
rt.
LrihvntiWL
ad, IN IRR CASING OR Timm
(gerribeemai
eland -loop]
FROM
TO
DIAMETER
THICKNESS
MATERIAL.
0 s,r,
33 n.
2 id
t1.
O.
in.
17.
N
FROM
TO
DIAMETER
ELOragr
TTOCEMESS 1 MA7rRUAE.
32 n•
35 n•
2 la,
11.
ft.
I.
ld. GROUT
FROM
Stu
MAIYnIAI.
EMPLACEMENT Mrrp(Op & ASI2L,Yr
0
28 n,
Cement
28 n'
30 It
Bentonite
rt.
fr.
14. sANDAGRAvrL.
PACk
((a//lleablel
PROM
TV/
MATIDUAI,
EMFLACfMINTM81ETO0
30 R•
35 R
medium quartz
fr.
9.
20. DRILLING
TOG fogfoga addibl 'kith If a.eammi)
TRoM
To
nt$(YIPTtnV y Nor_ h.rd.en, pi. Ihv.k rypnjnln Liu, erg.
0 n.
1 n,
Asphalt/stone
1 rt.
8 °'
Dark brown sandy clay
8 fL
28 f,_
Red sandy clay
28 R•
ft_
35 n-
Light grey sandy clay
ft.
2i. REMARKS eliljj�
A?R $ B
:-.:, pt'"wry
22. Certification:
Signature °fetetitled SS etl (j+fn+jector
8y rfRrling this farm. I Acreby crrl[fy :Aar rAe well(t) kiln (were) conrrrlrrlad rn areardatrce
with 13A NCAC 02C .0109 or 114 NCAC 07C.0200 Well Cansrrachow SYmrrrartts and llwi r
ropy ofihrr record has been provided is the well aurae.
23. Site diagram or additional well details:
You may use the back of this page to provide additional wail site details or well
construction details. You may also attach additional pages if necessary.
SUBMIfAL INSTUC1 IONS
24a.',or All Weill: Submit this for within 10 days of completion of well
construction to the hollowing'
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-16 l7
7Ab, gor 1alectioa WeI11 ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of this form within 3(1 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program.
1636 Mail Service Center, Raleigh, NC 27699.1636
24e. For Water Supply & 1 jectioa Wells:
Also submit one copy of this form within 30 days of completion of
ut it construction to the county health department of the county where
onstructed.
Form OW-1,
North C+6clma Oepsttrneof of Environment and Nature!. Resources - I]ivisms of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
cif form co, to Bud f. r+ulc n nwtrtylr wens
1. Well Contractor Iiatbrraatton:
Michael T. Stanforth, P.E.
well Camtractas Nurse
2525
NC Wet Contsactot Cenirscati n Number
Excel Civil & Environmental Associates, PLLC
Company Name
2. Well Construction Permit P: NA
Lfsr aff gap' beetle aellpajrmfie j!. e- Como Siam. Variance. lnjecIon, etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
°Geothermal (lieeting/Cooling Supply)
❑ IndustriWVCommrrnia1
c°lrrigation
Non -Water Supply Weft:
❑Monitoring
OMunicipel/Pubiic
❑Resiidential Water Supply (single)
l°Residential Water Supply (shared)
ORocovery
Injection Web
°Aquifer Recharge
RAqui for Storage and Recovery
❑Aquifer Teat
0lixperimental Technology
❑Geohermal (Closed Loop)
❑Geothermal iHeatinidCoolirig Return)
4. Date Well(a) Completed: 415118
52. Well Location:
Sams Mart No. 56
ZGroundwater Rcmediation
❑Salinity Sorrier
OStormwater Drainage
°Subsidence Control
°Tracer
❑Other (explain under #23 Remarks)
Well 111M AS-9
facriiryffAwner Now Facility IDN (if applicable)
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physical Address. City. and Zip
Mecklenburg
For lnte real Use ONLY:
.;4$9(15
1e. WATER ZONY8
FROM TO
23 IL 35
11.
_ DESCRIPTION
m
D.
ill. OUrzaCASING ]far mdN-eased sib) OR LINER (Dap
PROM
TO
ft.
DIAMETER
I& INNER CASING GEMMING Realkrreral eleeed-ta0P1
PROM
TO
DIAMETER
?tbucTrrrr�
MATERIM
0
rt.
33
2
in
It
ff.
in.
17. SC &EN
FLOM
iG
TO
35 B.
OLIMRTFR
2 �.
SLOT SIZE
TItICn7VESS
MATERIAL
R
rt.
IL GROVE
FROM
TO
MATERIAL -1 imeLmtitaiserrearIDOA&AMOUNT
0
ft.
28
ft.
28
ft.
30 n•
Bento ide
ff.
ft.
IR SAND/GRAVE. PACK id asmmuTrlal
PROM
TO
MATERIAL
EMPLACE:MOW aIE7ltUn
30
ft.
35
i.
medium quartz
lr.
ft
3A DRILLING LOG faced addivaaat aisles if W.see:ry}
PROM
0
1
TO Df-S C 111 PTI akirek faith r, fairea, wirer& opt, wale are, roc
1
ft. 8 ft,8 c' 28 fi•
Asphalt/stone
Darin brown sandy day
Red sandy clay
28 h- 35 n•
Tr.
Light grey sandy clay
it,
ft.
0.
e.
t.:.:
R.ECR.ai 1.
211. RBMARI=S
APR I. g
Comity Parcel IdUbifcatianNo. (PIN}
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well held, ore tetlltng is sal&cieet)
35.32039 - 80.95269
6. Is (arc) the well(s): Werrnanae' or °Temporary
7. Is this a repair to An existing well: °Yes or ®No
ffrhu u a repow,IPS art knower will caterrnrrceior Mth fbrawrfon and erpfaio e aware oldiewi repair der 021 remarks section or an the bark of rho form.
8, Number of wells cwish-tatted:
For mntrlpfe fnfecuon ear nyip on-woiersary write ONLY with the some construction. yam COP
submir one loan
9. Total well depth below load surface: 35 (toFor m ufryrre wells Ilse all &puler if dffarent (esanipte- i®200' old 2®100)
Stage wrier level below top of casing: 23
ffweer revel rsabove cmftwg, use
It. Borehole diameter: 4 (in.)
12. Well construction method: Auger
(Le, auger, Miry. cable. direct mob, ete.l
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ _ Method of test:
13b. Disinfection type: Amount:
22. Cerlilkalion:
Sipahlte of Certified IVd1 r car Pi'
By living this farm, I art* rhea the imel(r) mgf vrsi caurrrrursed rn occomanrr,
with ESA NCAC 02C.0100or ISA )CCAC t7X'.0210 Well Cotufrucrrwr Stmrdwds and Mot
• (Ndr record has beenprorkkd to the ants owner,
23. Site diagram or additional well details:
You may use the back ofthis page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL 1NSTLUCTIONS
24a. ForAll Well[: Submit this form within 10 days of complelion of well
construction to the following
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 276994617
24b. For Iuiertlon Wells ONLY: In addition to sending the form to the address in
24aabove. also submit a copy of this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Progra of.1636 Mall5errice Center, Rakich, NC 27699-1636
24c. For Water Supply & [election Wells:
Also submit one copy of this form within 30 days of completion of
well coestructiorr to the county health department of the county where
constructed.
leirailel
TIOCIOIESS MATERIAL
Form OW-1
North Cerolrrw Department of Environ relent and Natural Resources Dive = of Weer Restuaes Revised A

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor information:
Michael T. Stanforth, P.E.
Well Conlraclor Name
2525
r+C We11 Conrreclm Ccrti Oration Number
Excel Civil & Environmental Associates, PLLC
For Internet Use ONLY.
14. WATER ZONES
d1489fl6
THOM
23 IL
TO
32
DESCRIPTION
A.
IS. OUTER CASINO dor mold -eased walla) OR LINER of apptieab()
MOM
TO
DIAN, ET 18R
THICKNESS
MATERIAL
n.
in.
Company Namc
2. Well Construction Permit 4:NA
tilt all applreable melt pernras (Le ['onnh•, Pate, Parlance. lnlrerrsm, etc,)
3, Wtlr Use (check well arse):
16. INN!R CASING OR T M:NG (teothrrmd eloted•luap]
PROM
TO
DIAMETER
THICKNESS
MATERIAL.
0
29
ft.
2
to.
ft.
In.
17. SCREEN
'Water Supply Well:
°Agricultural
°Geothermal (licating/Cooling Supply)
CI Industrial/Commercial
❑lrrigatian
Non -Water Supply Well:
❑Monitoring
0Municipal/Public
°Residential Water Supply (single)
❑Residential Water Supply (shared)
°Recovery
Infection Well:
EJAquifer Recharge
°Aquifer Storage and Recovery
DAqui fer Test
°Experimental TechnoIogy
D Geothermal (Closed Loop)
°Geothermal:HeatingCoolin» Rctum)
4. Dale r►'eI s) Completed: 4/5/18
Sa, Well Location:
Sam's Mart No. 56
Fa cilityfOwner Harare
93Graundwatcr Remediatian
DSalinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
°Other (explain under %21 Remarks]
Well IDN AS-10
Facility IDa cif applicable)
2932 Mt. Holly Huntersville Rd, Charlotte, 28214
Physical Address, City, and Zip
Mecklenburg
County Pared Identilicalion No (PIN)
5b. Latitude lad Longitude in degrees/minutes/seconds or decimal degrees:
(dwelt 611d. OM latilong is suff:ienl)
35.32039 N - 80.95269
6. la (are) thr ive!I(s): 0Permaaeni or °Temporary
W
7. Is Ibis a repair ID ltn existing +veil: ❑Yens or EiNo
If this is n repair fill our known well conaruction Information areal expfaor Ihr a,00eer older
repair raider n remarks 31,010,711, W1 flee hack of Mrs forme.
S. Number of wells constructed: 1
1=or nratdpie ]tyection pr etorr-starer supply wells ONLY with the soaze conserrcnkas )Vie CON
subNtll ore fora.
9. Total well depth bylaw land surface: 32
For arxlrlpte II'rlls lost an depths If Verret' (example- If2200' and 7 er 1411'j
(n•1
I0. Static wester level helow top of casing: 23 (Ft.)
melee level is Doreen twang. use
11. Borehole diameter: 4 fin.)
12. Well construction method: Auger
c. auger, coney, cable, direct push. etc.]
FOR WATER SUPPLY WELLS ONLY:
13n.1'leld (glum) Method of test:
I3b. Disinfection type_
Amount:
FROM TO
DIAMETER SLOT SIZE
THICKNESS
MATERIAL
29 rt.
32 le,
2
In,
fr-
n,
ia,
IE. GROUT
FROM TO
0 R' 25
MATERIAL EMPLACEMENT NICt710DA AMQ11YT
n' Cement
25
ft.
27
fl.
Bentonite
ft.
R.
19. SA1fa/GRAVEL PACK lI1 pplkaSkj
FROM TO
MATERIAL { E.MPLACEM ENTMETIIOD
27
fl.
32
medium quartz
n.
lr.
TO. DRILLING 1.O4: Winch additional deers If Dec i* y}
TO atsciurTI01 (Ecru r, hsrdnrm selVraek eytr, train sin, etc)
FROM
0
8
n.
R.
ft.
't
8
28
b.
Asphalt/stone
Dark brown sandy clay
Red sandy clay
28 n,
32
Light grey sandy clay
fe,
ft.
rt,
21. RE'MlRK&
22, CertiBcatiou:
rxaR > f; Nib
n1Ofr�i:'1-_�:
4-// 4//1
anatureofCertified Well - me for Date
Ay signing i!oi farm. 1 he t cerlljy that the Irell(s) unl (were) constructed rn accordance
rrilh 15.? WA(' 02C . 01 fl0 or 13,1 NCeC 0N- .0200 Well i'errrstrrrrliorl Standards trod shoe a
copy of !Ins record has hasp protded fa the well owner.
23. Site diagram or additions) well dtlaiis:
You may use the back of this page to provide additional well site details of well
construction details. You may also attach additional pages if necessary.
SUSMiTI'AL INSTUC IONS
24a. For AIL % Vella: Submit this form within 30 drays of completion of %veil
Con slruction to the following:
Division orW ier Resources, Information Processing Unit,
1617 Snail Seti•icc Center, Raleigh, NC 21699•1617
24b. For Iniectioh Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion at s vII
C0n5truCtinn to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Semite Center, Raleigh, NC 27699-1636
24c. For Water Supple & injection Wells:
Also submit one copy of this foal within 30 days of completion of
well construction to the county health department of the county where
constructed
Forth OW -I
North Carolina Dcpenmenr of Environment and Natural Resourtes - Division of M'ater Rtsourccs Rmsed August 20I3

Permit Number WI0300373
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Sam's Mart#56
Location Address
2932 Mt Holly-Huntersville Rd
Charlotte
Owner
Owner Name
Sam's Mart LLC
Dates/Events
NC
Orig Issue
2/26/2018
App Received
2/16/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28214
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
3/2/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Adnan Jazairi
President Vice
7935 Council Pl
Matthews
Region
Mooresville
County
Mecklenburg
NC 28105500
Issue
2/26/2018
Effective
2/26/2018
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
North Carolina Department of Environmental Quality -Division of Water Resources
NOTIFICATION OF INTENT {NOi) TO CONSTRUCT OR OPERA TE INJECTION WELLS
Tlte followil1g are "permitted by rule" and do not require a11 individual permit 111/ie11 com·tructed in accorda11ce
with tlle rules of 15A NCAC 02C .0200. Tltis form slla/1 be submitted at least 2 WEEKS prior to i11iectio11.
AQUIFER TEST WELLS (ISA NCAC02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifet hydraulic characteristics.
IN SITU REMEDIATION C 15A NCAC 02c ,022S) or TRACER WELLS (15A NCAC 02C .0229):
I) Passive In jection Systems -fn-well delivery systems to diffuse injectatits into the subsu rface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replace01ent of each sock used in ORC systems).
2) Sn1all-Scale In jection O perations -Injection wells located 1,vithin a land surface area not to exceed J(),000
square feet for the purpose of soil or groundwater remediation or tracer tests. An in(fividual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests ~ Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remed iation strategy i(1 order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot tes.t on any separate groundwater contaminant plume.
4) Air In jection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Prim Clearly or Type h1/orm11tio11. Illegible S"bmlttals Will Be Ret11r11ed As /1tcompiete.
DATE: 2-/ 2G , 20_/fs PERMIT NO. NJ. O &oo :~l 3 (to be filled in by DWR)
~CEtVE:01Ncop,,
A.
~OIOWR
WELL TYPE TO nE CONSTRUCTED OR OPERATED FEB 1·6 ZOl
(I) X Air Injection Well. ..................................... Complete se ~ns B throug~ F, K, N
. Re · aterouat~·
(2) __ Aquifer Test Well. ...................................... Comple ffi~ri-011:!rclb &R I h_ F, K, N
01)
(3) ___ Passive Injection System ............................... Complete sections B through F, H-N
(4)
(5)
(6)
___ Small-Scale Injection Operation ...................... Complete sections B through N
___ Pilot Test.. ............................................... Complete sections B through N
___ Tracer Inj ection Well.. ................................. Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER(S) -State name of Business/Agency , and Name and Title of person delegated authority to
sign on behalf of the business or agency :
Name(s): __ _,,,S=a,_,_m,_,'s,c..M:.:.=a=rt"-. ='n=c _,_. _________ A'-'=d=na=n=J=a=za=i,..,ri ,_. C=O=· -=O=-------------
Mailing Address: __ __,_79""3,,_,5'-C=o::e.cu:::.:1.:.:1c""'il_,_P_,_la=c=e-'-. =Su=i=te"--'2=-=0e.o0=----------------____ _
City: Matthews State: .J:,K;_ Zip Code: 281 05 County: Mecklenburg
Day Tele No .: ___ _.7=0_,_4 -=5=-67,_-=-84"""2""'4 ___ _ Cell No .: _________ _
EMAIL Address: _______ -,-_____ _ Fax No.:
Deemed Pe1111it1ed GW Remed iation NOi Rev . 8-28 -2 017 Pa ge I
D. PROPERTY OWNER(S) (if different than wel l owner)
Name and Title: ___ S:.:a:::.m.:..:.e::::....::;as:e....:..:w..::ce.:..:.ll ""°'oc..:..w,.__,_'n"""e_,_r _____________________ _
Company Name _______________________________ _
Mailing Address:--------------------------------
City: _____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ____________ _ Cell No.: ________ _
EMAIL Address: _____________ _ Fax No .: __________ _
E. PROJECT CONT ACT (Typically Environmental Engineering Firm)
Name and Title: Mike Stanforth , Principal En gineer
Company Name ---=E,__,_xc=e'--'-l--=C'--'-iv-'--'i'-'--1 =&=---=E,_,_nv-'---'i'-'--'ro=1=1m=e=n=t=al'--'A--=-s=s=o=c=ia=te=s'--------------------
Mailing Address : ----=6=2=5_,_l---'--'IL=m=t=sm_,_,_a=t_,_1 C=o=ur'""t _____________________ _
City: Gastonia State: NC Zip Code:28054 County:-'G=a=s=to=n'-----------
Day Tele No.: 704 853 -0800 Cell No.:. ___________ _
EMAIL Address: ___ rn~st=a~nfi~o_rt~h_._(r;-1Je~x~c~e~le-'n=g~r.c_o_m __ _ Fax No.: 704 853-3949
F. PHYSICAL LOCATION OF WELL SITE
(I) raci lity Name & Address: _,_('""fo""'rn""'1""e"""rl__,S=a=n~1 '=s~M=a=r~t _,_N=o'-'--. =5=6 ________________ _
2932 Mt. Hollv-Huntersville Road
City: __ __,C=h=a=rl=o_,_,tt=e _________ County: Mecklenbur Zip Code: 28214
(2) Geographic Coordinates : Latitude**: ___ 0 ____ " or J.i___0 .320106 ____ _
Longitude**: 0 "or ~0 .952395
Reference Datum: _______ ~Accuracy : _______ _
Method of Collection : _________________ _
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAI' WITH PROPERTY
BOUNDARIES MAY BC SUBMITTED IN LIEU Of GEOGRAPHIC COORDINATES .
G. TREATMENT AREA
Land surface area of contaminant plume: _______ square feet
Land surface area of inj, we! I network: square feet(~ I 0,000 ft 2 for smal I-scale injections)
Percent of contaminant plume area to be treated: (must be~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(I) Contaminant plume rnap(s) with isoconccntration lines that show the hofizontal extent of th e
contaminant pl ume in soil and groundwater, existing and proposed monitoring wells. and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contam inant plume in soil and groundwater, changes in lithology. existing and
proposed moni toring wells, and existing and proposed injection wells .
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
Deemed Pennilled GW Remediat ion NOi Rev, 8-28-2017 Pa ge 2
I.
J.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, a:nd goals of the proposed injection activity. This should include the rate, volume, and
duration of injection over time. ·
APPROVED INJECTANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Hea/Jh, Department of Heallh and Hum(.m
Services can be injected. Approved injectants can be found online at htt ://de .nc . ov/about/divisions/ ater-
resources/water-re sources-permits/wastewater-branch/gro und-water-protection/ ground-water -ap roved-in· ectants
All other substances must be reviewed by the DHHS prior to ZL~e. Contact the VIC Program for more info
(919-807-6496).
lnjectant: _______________________________ _
Volumeofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with Other iajectants: ___________________ _
lnjectant: --------------------------------
Volume ofinjectant: ___________________________ _
Concentration at point ofinjecfion: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
Iltjectant: --------------------------------
Volume ofinjectant: _______________________ _
Concentration at point of injection :
Percent if in a mixture with other in_jectants: ___________________ _
K. WELL CONSTRUCTION DATA
(I) Number of injection wells : 10 Proposed O Existing (provide G W -Is)
(2) For Proposed wells or Existing wells not having GW-1 s, pmvide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the saine construction details. Well construction details shall include the
following (indicate if construction is proposed or as-builO:
(a) Well type as pennanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Deemed Pcm1itted GW Remediation NOi Re\. 8-28-.WI? Page 3
it. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to he used to determine
if violations of groundwater quality standards specified in Subchapter 02 L result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "t hereby certify, under penalty of lava, that I ant familiar with the information submitted in
this document and all attachments thereto and that, based on any inquiry ref those individuals immediately
responsible, for obtaining said information, I believe that the information is true, accurate and complete. 1 cant
aware that there are significant penalties, including the possibility offines and imprisonment, for .submitting
,false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the infection ss'e11
and all related appurtenances irr accordance with the 1 SA NCAC 02C 0200 Rules."
Signature gfifpplicant
ilewr i
Print or Type Full Name slat Title
PROPERTY OWNER (if the property is not owned by the permit applicant):
"As owner of the property on which the infection well(s) are to he constructed and operated. 1 hereby consent
to allow the applicant to construct each injection well as outlined irr this application and agree that it shall he
the responsibility of the applicant to ensure that the injection wellN conforaar to the Well Construction
Standards (I SA NC .- C 02C , d2d0).
"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 an land shall be deemed to vest ownership in the land owner, in
the absence of contrary agreement in writing.
Signature* of Property Owner (if different From applicant) Print or Type Full Name a�nct, Title
*An access agreement between Me applicant and property owner +uray be submitted in lieu of a signature on this form.
Please send this NOI electronically to Shristi.Shresthaf ncdenrkov AND one hard copy to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted CiW Rcinediatimr NOI R. )1-28-2017 Page: 4

NC Weil Contractor information
Michael T. Stantorth. P.E.
Certification W 2525
Pramsurc Gauge -..
From Sp
Mower
1" SCAB° PYL
or 1- SOSE
Lowelo Frau!
reed, - 28' Oa_
Bor1100ile, Plug
BlY Pia
,F%uve Control Valve
Sand 30. - DCA.
18. 1B" ).
1.lonivele Cover
2* PVC Solid
BiB Casirq
•' ••:cos 32' BOL
7 2- PVC 0.020. SCB140
*Pi Scree,
32' - 334 ROL
SPARGE WELL DETAIL
crmicm. - rosy
lel MOO
Okramila Coro.
1B'• le
IVA / Leclifog
klanhola
Potplacw.I.1 i;raocrp
Motel% (Wing
SC44&) PVC cr
, I" Flom PVC
tiog Sur/m.7
MANHOLE DETAIL
(TYPICAL - MS)
illark-rooshed m
3,000 FM? C:O.C.ipt.,
Pmear. Caug.,
(Prim:wary - 3.7 p•B
Roo CBrilroi Valve
50444 PC 90'
3.6BB poi Ccncrsto
(ammo 1a1/41 and
SioBod le onan)
Excel
Civi ek EnvironmentalAssociates. PLLC
......1r., ffit PO Clyni r. r. atta/.1. ,..-.4..41 hthAteovu an-earas
I PREPARED FOR I SAM'S A SAR r /Az:
FORMEN}S.404S AS 4RT MA. IM
.29)2 lir NOLLV-)UATERSVIELE R.D. minorrE, Ar
NW' TITLE!
I11.110.1W71' NO.: DRAW,: SY
/ 2.17621. CUP
I
SPARGE WELL DEZIIL
NOI TO CONSTRUCT OR ORERAre INJECTIOX WELLS
SCALK:
NI' M1V211118

North Carolina Department of Environmental Quality -Division of Water Resources
NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This fo rm shall be submitted at least 2 WEEKS prior to in iection.
AQUIFER TEST WELLS (1 5A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (1 5A NCAC 02C .0225 ) or TRACER WELLS (15A NCAC 02C .0229 ):
1) Passive In jection S ystems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small-Scale In jection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air In jection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: _____ _, 20 PERMIT NO. _________ (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
B.
(1)
(2)
(3)
(4)
(5)
(6)
=X~ __ .Air Injection Well ...................................... Complete sections B through F, K, N
___ Aquifer Test Well ....................................... Complete sections B through F, K, N
___ Passive Injection System ............................... Complete sections B through F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B through N
___ .Pilot Test. ................................................ Complete sections R~' · ~l f!i · /NCOEQ/DWR
___ Tracer Injection Well ................................... Complete sections B through N
FEB 2 0 L018
STATUS OF WELL OWNER: Business/Organization Water Quality ~1;;y1onal
Operations
C. WELL OWNER(S) -State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalfof the business or agency:
Name(s ): ----=S=am==---'=--s =M=art==-, -=ln=c=. ------------=--A=d=n=an=--=--Jaz=ru.=·r=i ---'C"--'O=--O=-----------
Mailing Address: ------'-7-"-9""'35a......:C""o""'un=c=i=-l P=-l=a=ce=·--=S~u=it-=-e -=2-=-00"'--------------------
City: Matthews State: NC Zip Code:28105 County: Mecklenburg
Day Tele No.: 704 567-8424 Cell No.: _________ _
EMAIL Address: _____________ _ FaxNo.: ___________ _
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page 1
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: -------'S=a=m=e-=---=as"-----'-'w'---=e=ll'---'o'-'w__,_,n=e=r-----------------------
Company Name ---------------------------------
Mailing Address: ________________________________ _
City: _____________ State: __ Zip Code: _______ County: _____ _
DayTeleNo.: ___________ _ Cell No.: __________ _
EMAIL Address: _____________ _ FaxNo.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ------'M"'-=ik=e~St=an=fo=rt=h=·~P~r=in=c-=-ip=a=l =E=n=g=in=e~er~-----------------
Company Name ---=E=x~ce=l~C~i~v=il----'&~E=n~v=ir~o=n=m=e=n=ta=l =A=s~so~c=i=at~e~s _______________ _
Mailing Address: --~6~2~5_H_un~t~sm~an_C_o_u_rt ______________________ _
City: Gastonia State: NC Zip Code:28054 County:_G~as~to~n _____ _
Day Tele No.: 704 853-0800 Cell No .: __________ _
EMAIL Address: mstanforth@excelen!!r.com Fax No.: ___ 7:....:0:c....:4_,8=5-=3---=-3=9---=4=-9----
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ~(fi=o=rm=er~l---=S=a=m~•~s ~M=art~N~o.----'5----'6~----------------
2932 Mt. Holl y-Huntersville Road
City: ___ C_,h=ar~l~o=tt~e ________ County: Mecklenburg Zip Code: ~28~2=1_4 __ _
(2) Geographic Coordinates: Latitude**: ___
0
____ "or&__0 .3~2~0~1~0~6 ____ _
Longitude**: 0 "or ~0 ._95_2_3_9_5 ____ _
Reference Datum : ________ .Accuracy: ________ _
Method of Collection: _________________ _
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: AF ACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COO RD INA TES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ square feet
Land surface area of inj. well network: square feet (:S 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be :S 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
Deemed Permitted GW Remediation NOI Rev . 8-28-2017 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and
duration of injection over time.
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http ://de g .nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/e.r ound-water-protection/ground-water-a pproved-in jectants .
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info
(919-807-6496).
Injectant: ----------------------------------
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
Injectant: ----------------------------------
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
lnjectant:
Volume of injectant: _____________________________ _
Concentration at point of injection:
Percent if in a mixture with other injectants: ____________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: ___ l _O __ Proposed. __ --=O'--__ Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page 3
L. SCHEDULES— Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certi, under penalty of law, that I am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately
responsible for obtaining said information, I believe that the information is true, accurate and complete. I am
aware that there are significant penalties, including the passibility ref', fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well
and all related appurtenances in accordance with the 1 SA NCAC 02C 0200 Rules."
Signature Ipplicant
iferfar ftr't -S ,wp#114--
Print or Type Full Name and Title
PROPERTY OWNERsif the property is not owned by the permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent
to allow the applicant to construct each injection well as outlined in this application and agree that it shall be
the responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction
Standards (15,4 NCAC 02C 0200j. "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A
well is real property and its construction on land shall be deemed to vest ownership in the land owner, in
the absence of contrary agreement in writing.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form,
Please send this NOI electronically to Shristi.Shrestlta n nctlenr.Eov AND one hard copy to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOT Rev. 8-28-2017 Page 4

NC Well Contractor Information
Iulic.hoel T. Stanforth. P.E.
Certification # 2525
Pressure Gauge
1' SCH8t1 PVC
er e' HOSE
Concrete phut
Grade - 28' BGL
Banlonlle Plug
28' - 3l]' ea
Flow Control Volvo
TB' x 18' x 1U'
IRpnhals Cnrrr
mow
Sand 30' - 35' BGL
'4' PVC SON
z- S2H4G *I1 Cashlg
• Grade - 32' 6Ct
- 2' PVC 0.020- SCH40
Weil screen
32. - 35' BGL
SPARGE WELL DETAIL
(TYPICAL - NTS)
18' x 18' a 18'
Water Tight / Locelny
Moral ale
wry Head
1� Verl Min COW 1
r Reuloc*ment Suriacina to
valcn Erm ing Sorrowing
1' SC.6O PVC or
1' Moe* PVC
-Existing Sxioca
MANHOLE DETAIL
(TYPICAL - NTS)
CLein-weened AFC or
3,000 Pe Concrete
[Preece 0 pelj
noir Ca*d W rd
2' SC140 PVC W Elbe*
30OD est Concrete
(Broom Flnleh end
Sloped le gran)
Excel
Crory & Environment JIAssociates, PLLC
RJ NuranbN COUNT, v4s WJtf NC2l4N !*CANE t rim 3s%.Ar
PREPA RED FOR : SAM S MART INC
(FORMER) SAM'S MART No. 56
2932 NIT. HOLLY HUNTERSi7LLE RD. CHARLOTTE. NC
MAP TITLE : AIR SPARGE WELL DETALr.
NO1 TO CONSTRUCTOR OPERATE INJECTION WELLS
PROJECT NO. :
28171126
DRAWN sY:
CUD
SCALE: DATE:
]YTS 211T12MS

Monitoring Well Construction and Liquid Level Data
Sam's Mart 56
WELL DATE WELL
NUMBER INSTALLED DEPTH (ft)
MW-1 7/15/08 30
MW-2 8/6/08 30
MW-3 8/6/08 30
MW-4R 8/3/17 27
MW-4 8/11/08 30
MW-5 12/27/17 29
MW-6 12/27/17 30
MW-7 12/27/17 30
NOTES:
Data provided in feet unless otherwise noted
Liquid levels for collected January 3, 2018
Liquid levels collected January 3, 2018
2932 Mt. Holly-Huntersville Road
Charlotte, North Carolina
ExcelNo.2017028
SCREEN TOP OF Depth to
INTERVAL (ft) CASING (ft) Product (ft)
10-30 740.00
15-30 739.34 --
15-30 740.37 -
12 -27 740.34 23.59
15-30 739.90
14-29 741.74 --
15-30 740.82 --
15-30 741.04 --
Depth to Free Product
Water (ft) Thickness (ft)
ABANDONED
21.90 --
23.29 --
24.89 1.30
ABANDONED
24.05 --
23.77 --
23.99 --
Water Table
Elevation (ft)
717.44
717.08
715.78
717.69
717.05
717.05
Concrete
MW-7
1/3/18
173
24.263
< 36.7
Mt. HOLLY-HUNTERSVILLE ROAD
SAM'S MART 56
MW-6
1/3/18
7.750
83.890
<184
MW-3
9/20/17
15,800
81,990
33.3
UST Basin
Concrete Surface
MW-2
7/5/17
65.8
73.48 J
❑.367
1
1
11
1
I
r
1
l
II
LEGEND
- — Property Line (Approximate)
Approximate UST Locations
Dispenser Pump Locations
Monitor Well Location
Estimated extent of Benzene at GCLs
in groundwater
IQi
Constituents Shown:
NOTES
Well ID
Date Sampled
Benzene
BTEX
MTBE
Map not exact for sampling location
references only
Map adapted from aerial photograph
of Mecklenburg County GIS
Structure locations are approximate
UST Underground Storage Tank
BDL - Below Detection Limit
Data shown in ug/L
Samples collected 7/5/2017, 9/20/2017 & 1/3/2018
BTEX - Summary of Benzene, Toluene,
Ethylbenzene and Xylenes
MTBE - Methyl Tert Butyl Ether
Line dashed where inferred
Excel
civil c LnvronmentalAssociates, PLLC
615 HUNTSM4NCOURT, GASTOM,1, NC18054 PHONE: P0d) d5348e0
PREPARED FOR : SAM'S MART, INC
SAM'S MART NO. 36
2932 ML HOLLY-HUNTERSVILLE ROAD, CHARLOTTE, NC
MAP TITLE :
GROUNDWATER CONSTITUENTS MAP
NOI TO CONSTRUCT OR OPERATE INJECTION WELLS
PROJECT NO. :
2017028
DRAWN BY :
ACL
SCALE:
1" = 25'
DATE:
111212D18

Mt. HOLLY-HUNTERSVILLE ROAD
Asphalt
Concrete Surface
`cool
LEGEND
Property Line (Approximate)
Roadway Centerline (Approximate)
Approximate UST Locations
Dispenser Pump Locations
Monitor Well Location
0;Proposed Air Sparge Well Location
NOTES
Map not exact for sampling location
references only
Map adapted from aerial photograph
of Mecklenburg County GIS
Structure locations are approximate
UST - Underground Storage Tank
Excel
Civil & Environmental Associates, PLL C
625 HUNTSMAN COURT. CASmNIA, NC2665d PHONE : [phone]
PREPARED FOR : SAM'S MART, INC.
SAMSMART NO. 56
2932 Mi. HOLLY-HUNIERSVILLE ROAD, CHARLOTTE, NC
MAP TITLE :
PROJECT NO.:
2017028
PROPOSED AIR SPARGE WELL LOCATIONS
NOI TO CONSTRUCT OR OPERATE INJECTION WELLS
DRAWN RV :
CBD
SCALE:
1"=25'
DATE:
3/1/2018