WI0400384_DEEMED FILES_20161001

Rogers, Michael
From:
Sent:
To:
Subject:
Permit number WI0400384
Chad Northington <[e-mail]>
Tuesday, November 01, 2016 5:09 PM
Rogers, Michael
RE: Request for Expanded SOW under Existing Conditional Approval UIC permit no.
WI0400384 -Winston Salem PlumeStop p·roject
From: Rogers, Michael [mailto:[e-mail]]
Sent: Friday, October 28, 2016 10:07 AM
To: Chad Northington <[e-mail]>
Subject: FW: Request for Expanded SOW under Existing Conditional Approval -Winston Salem PlumeStop Project
What was the permit number for this site? Please put in the subject line.
From: Rogers, Michael
Sent: Friday, October 28, 2016 10:06 AM
To: 'Chad Northington' <CNorthin gton @Re genesis.com>
Subject: RE: Request for Expanded SOW under Existing Conditional Approval -Winston Salem PlumeStop Project
Acknowledged you are doing further remediation at this site, which had previous permission by DHHS to use PlumeStop.
From: Chad Northington 1·mailto:CN0rthington @ Re genesis.com]
Sent: Friday, October 28, 2016 9:25 AM
To: Rogers, Michael <michael.rog ers @ncdenr.gov>
Subject: Request for Expanded SOW under Existing Conditional Approval -Winston Salem PlumeStop Project
Mr. Rogers,
Pursuant to our discussion on 10/20/16, please accept this as notification that REGENESIS intends to conduct an
expanded scope of work under the existing Conditional UIC Approval already in place for the Industrial Drive Winston
Salem project. We are currently in the process of gathering additional data for development of the full-scale
approach. Your acknowledgement of this conditional approval for further work at this site is requested.
Should you have any questions or require additional information, please do not hesitate to contact me at the number
below. Your assistance with this matter is greatly appreciated.
Respectfully,
Chad Northington
REGE NESIS
Chad D. Northington, PE I REGENESIS
Southeast District Technical Manager
C: 864.884 .4346
www.regenesis .com
1
This Email is confidential. If you ore not the addressee or an authorized recipient of this message, any distribution, copying,
publication, or use of this information for any purpose is prohibited. If you have received this Email in error, please notify the sender
immediately by Email and delete this message.
2
Rogers, Michael
From: Chad Northington <CNorthington©Regenesis.com>
Sent: Tuesday, November 01, 2016 5:09 PM
To: Rogers, Michael
Subject: RE: Request for Expanded SOW under Existing Conditional Approval UIC permit no.
WI0400384 - Winston Salem PlumeStop Project
Permit number W10400384
From: Rogers, Michael [mailto:michael.rogers@ncdenr-govj
Sent: Friday, October 28, 2016 10:07 AM
To: Chad Northington <[e-mail]>
Subject: FW: Request for Expanded SOW under Existing Conditional Approval - Winston Salem PlumeStop Project
What was the permit number for this site? Please put in the subject line.
From: Rogers, Michael
Sent: Friday, October 28, 2016 10:06 AM
To: 'Chad Northington' <CNorthinFton,a.Re enesis.com>
Subject: RE: Request for Expanded SOW under Existing Conditional Approval - Winston Salem PlumeStop Project
Acknowledged you are doing further remediation at this site, which had previous permission by DHHS to use PlumeStop.
Frorn: Chad Northington imailto:CNorthin tono.Recenesis.corrsj
Sent: Friday, October 28, 2016 9:25 AM
To: Rogers, Michael rmichael.roKers; = ncdenr.00v>
Subject: Request for Expanded SOW under Existing Conditional Approval - Winston Salem PlumeStop Project
Mr. Rogers,
Pursuant to our discussion on 10/20/16, please accept this as notification that REGENESIS intends to conduct an
expanded scopeof work under the existing Conditional UIC Approval already in place for the industrial Drive Winston
Salem project. We are currently in the process of gathering additional data for development of the full-scale
approach. Your acknowledgement of this conditional approval for further work at this site is requested_
Should you have any questions or require additional information, please do not hesitate to contact me at the number
below. Your assistance with this matter is greatly appreciated.
Respectfully,
Chad Northington
REGENESIS
Chad D. Northington, PE' REGENESIS
Southeast District Technical Manager
C: 864.884.4346
www.regenesis.com
I

This Email is confidential. If you are not the addressee or an authorized recipient of this message, any distribution, copying,
publication, or use of this information for any purpose is prohibited. If you have received this Email in error, please notify the sender
immediately by Email and delete this message.
2
WELL CONSTRUCTION RECORD
For Internet Use ONLY:
This form can he used For single Or multiple wells
1. Well Contractor lnforntation:
Joshua Ellingworth
Well Contractor Name
3544
NC Well Contractor Certification Number
Parratt-Wolff, Inc.
Company Nam=
2. Well Construction Permit k:
List all applicable well permits (le. County; Slate. Variative, lnjectlon. arc)
3. Well Use (check well use]:
Water Supply Well:
DAgricultural
❑Geothl:rrnal (Heating/Cotrling Supply)
❑Industrial/Cammercial
❑irri intiOn
Non -Water Supply Well:
ElMonitoring
❑ MlmicipalPPublic
U Residential Water Supply (single)
❑ Residential Water Supply (shared)
©Recovery
Injection Well:
Aquifer Recharge
tJAquifcr Storage and Recovery
DAquifcr Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Coolity Return)
179Grotmdwater Remcdiation
CDSahnity Harrier
DStormwater Drainage
USubsidcncc Control
ID Tracer
❑Other (explain under #21 Remarks)
14. WATER ZONES
FROM
TO
DESCRIPTION
40.5 ft
6
R.
fL
ft
1S. OUTER CASING tier teadti•caeed aria) OR LINER [if appiicahlei_
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft
fl.
in.
16.INNF,R CASING OR Trfs1NY: (geothermal dfaedluoll!
FROM
35.5 a'
TO
0
ft.
DIAM R
2 Ter
T ICENESS
Sch 80
MATERIAL
PVC
rL
rL
is
17. SCREEN
PROM
10
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40.5 f`
35.0 ft.
2
in.
0.010
Sch 80
PVC
ft.
ff.
ia.
IIL MOM'
PROM
33 $.
TO
0
fL
MATERIAL
PortlandlBent
EMPLACEMENT Mn OD & AMOUNT
Tremie Pipe. 64 Gallons
ft.
ft.
It
15t SAND/GR*VE4. PACK or Apr iicahtr)
FROM
TO
MATERIAL
EMPLACEMENT MlTROD
40.5 n•
33
ft.
#1 sand
Gravity
ft.
ft:
Zt1,.DRILLING LOG {efurb additimtrl abort if neweaan-I
FROM
10
DEsi-R ' IIION (rnln(. INASJne.e. .ml.rnel. e.J.r %rain n2r, etc.'
fL
IL
No Sampling
4. Date Well(a) Completed: 1/27/15
5a. Well Location:
RUS-Cintas
Well D M INJ-1
Facility/Owner Name Fadlity IU# (if applicable)
3775 Industrial Ave Winston-Salem NC
Physical Address, City, and Zip
Forsyth
County Farrel 1denti5wtionNo. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. Certification:
(ifwe) field, one Iattinng is xafficicnt)
36.14884 N 80.241673
40.5 fl•
f4
Auger Refusal
rt.
n.
fc
tL
ft.
R
fl.
ft,
21. REMARKS
6. Is lore) the well(s): It7Permanent or OTemporary
7. Is this a repair to at existing well: ❑Yes or JNo
phis is a rrpc r, fell oat known well coturrucrlon information and erpI 15 the nature ofthe
repair under #21 remarks section or an the back of this form.
$.Number of wells constructed: 1
Far multiple infective Or non-wafersupply wells ONLr with the same ewnstelictiolr, ynw cm,
submit rare jornl.
9. Total well depth below land surface: 41 (ft.)
For multiple x'rlls list all depths if di,(ferenr (example-. 3@200' and 2 100'l
to. Static water level below top of casing: 6
/1 xntrr level Is above ragtag. we "4"
11. Borehole diameter: g,( Lin.)
12. Well construction method: Hollow Stem Auger
(Le. auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type; Amount:
Signature of Certified Well Contractor
?r37/A_
Date
ay signing this farm, 1 hereby e.rtif t rhal the wall(s) WEEK (Were) consrntcted 1n accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Wall Corutrwrtion Standards and that a
copy of this ree'arrf haw been provided in the well owner_
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details_ You may also attach additional pages if necessary.
SUBMITTAL JNSTUCT1ONS
24a. For AR Welt: 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, Raleigh, NC 27699-1617
24b, For luiection 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 well
construction to the following:
Dis•islon of WaterResonrces, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Witter Suppit• & Injection Wells:
Also submit one copy of this font within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-I
North Carnlinn Depamnent of Environment on
d Natural Resources - Division of Water Resources Revised August 2013

WELL CONSTRUCTION RECORD
This fo rm can b e used for s ingle or multiple well s
1. Well Contractor Information:
Joshua Ellingworth RECEIVED/DENR/DV\
Well Contractor Name
3544 F ~B ' O 201J
NC Well Contractor Certification Number
Parratt-Wolff, Inc. Water Quality Region~ ,,.. ____ .;,..,..., ~,.,-+inn
Compavy Name
2. Well Construction Permit#:
Lis t all applicable well pen nits (i.e. Co unty , State, Varian ce. Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
DGeothennal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irri g ation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aqui fer Recharge Ill Groundwater Remediation
□Aquifer Storage and Recovety □Salinity Barrier
□Aquifer Test □ Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothennal (Closed Loop) □Tracer
□Geothennal (Heating/Cooling Return) □Other (explain under #21 Remarks)
4. Date Well(s) Completed: 1/26/15 Well ID# INJ-2
Sa. Well Location:
RUS-Cintas
Facility/Owner Name Facility ID# (if applicable)
3775 Industrial Ave Winston-Salem NC
Physical Address, City, and Zip
Forsyth
Cowity Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifweU field, one lat/long is sufficient)
36.14884 N 80.241673 ------------
6. Is (are) the well(s): @Permanent or □Temporary
7. Is this a repair to an existing well: DY es or li'.JNo
If this is a repair,fi/1 out known well constructfon ieformatio11 and explain the nature oft/Je
repair under #21 remarks section or 011 the back of this form.
8. Number of wells constructed: _1 __________ _
For multiple injection or non~water .s.upp{v wells ONLY with the same construction, you can
submit one form.
9. Total well depth below land surface: _3_9_.5 __________ (ft.)
For multiple wells list all depths if different (example-3@200 • and 2@100')
10. Static water level below top of casing : _6 ___________ (ft.)
Jf V.'Clter level is above casing, use "+"
11. Borehole diameter: 8" (in.)
12. Well construction method: Hollow Stem Auger
(i .e. auger, rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _______ Method of test: _______ _
13b. Disinfection type: Amount:
I For Internal Use ONLY :
14. WATER ZONES
moM TO DESCRIPTION
39.5 ft. 6 ft.
ft. ft.
15. OUTER CASING 1for muld-cased wellsJ OR LINEll (if a r,vlicable)
moM I TO I DIAMETER TIIICKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING IPeothermal closed-loon\
moM TO DIAMETER TIIICKNESS MATERIAL
34 .5 ft. 0 ft. 2 In. Sch 80 PVC
ft. ft. in.
17. SCREEN
moM TO DIAMETER SLOT SIZE TIIICKNESS MATERIAL
39.5 ft. 34.5 ft. 2 In. 0.010 Sch 80 PVC
ft. ft. In.
IS.GROUT
moM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
32.5 ft. 0 ft. Portland/Bent Tremie Pipe, 64 Gallons
ft. ft.
ft. ft.
19,. SAND/GRAVEL PACK lif 11 n..licable •
FROM TO MATERIAL EMPLACEMENT METHOD
39.5 ft. 32.5 ft. #1 sand Gravity
ft. ft.
20. DlULLING LOG l■nnh addlrion.1 1 shcou ifnrcesst1n)
m o M TO DES CRIPTI ON lcolor, hardness, .soiVrock 1vne.. 111r2in size ttc.)
ft. ft. No Sampling
39.5 ft. ft. Auger Refusal
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
11.REMARKS
22. Certification:
~~,J:1rzllt Date
_,/'
~-~-/j
By signing this form, I hereby certify that th e wel/(s) was (were) consrmcred in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Constmction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this fonn within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For In jection Wells ONLY: In addition to sending the fonn to the address in
24a above, also submit a copy of this form \\~thin 30 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
24c. For Water Su pplv & In jection Wells:
Also submit one copy of this fonn within 30 days of completion of
well construction to the county health department of the county where
constructed.
FormGW-1 · North Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 2013
WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells .
1. Well Contractor Information: v
Joshua Ellingworth
Well Contractor Name
3544
VEDIDENR/ WR
f EB
NC Well Contractor Certification Number riJater Quality Reg~onal
Ooer:::itil"'n~ $(:"ct:nn Parratt-Wolff, Inc.
Company Name
2. Well Construction Permit#:
List all applicable well permits (i.e. County, State, Variance, Jnjectio11, etc.)
3. Well Use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irriii.ation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge IZJGroundwater Remediation
□Aquifer Storage and Recovery D Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal (Heatinl!!Cooling Return) □Other (exDlain under #21 Remarks)
4. Date Well(s) Completed: 1/26/15 Well ID# INJ-3
Sa. Well Location:
RUS-Cintas
Facility/Owner Name Facility ID# (if applicable)
3775 Industrial Ave Winston-Salem NC
Physical Address, City, and Zip
Forsyth
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
I For Internal Use ONLY:
14. WATER ZONES
FROM TO DFSCRIPTJON
38 ft. 6 ft.
ft. ft.
15. OUTER CASING tfor multi-cased wells l OR LINER tif annlicable)
FROM I TO DIAMETER TIHCKNESS MATERIAL
ft. ft. in.
16. INNER CASING OR TUBING t<>eotbermal closed-l01>nl
FROM TO DIAMETER IBICKNESS MATERIAL
33 ft. 0 ft. 2 in. Sch 80 PVC
ft. ft. in.
17.SCREEJI(
FROM TO DIAMETER SLOT SIZE IBICKNFSS MATERIAL
38 ft. 33 ft. 2 in. 0.010 Sch 80 PVC
ft. ft. in.
18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
31 ft. 0 ft. Portland/Bent Tremie Pipe, 64 Gallons
ft. ft.
ft. ft.
19. SAND/GRAVEL PACK (if ••fnlicablel
FROM TO MATERIAL EMPLACEMENT MEIBOD
38 ft. 31 ft. #1 sand Gravity
ft. ft.
IO. DRTLUNG L.(IG Canub addliinnal.•h=t.i Ir n,<1U11...,1
rnoM TO DESCRIPTION tcolor, hardness, soil/rock l\'De, !.rain size, etc,)
ft. ft. No Sampling
38 ft. ft. Auger Refusal
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
21.REMARKS
22. Certification: (if well field, one lat/long is sufficient)
N 80.241673 ------------36.14884 VI~~..--?':/ '.53 7/A ,;z -::1.-/ <
6. Is (are) the well(s): IZIPermanent or □Temporary
7. ls this a repair to an existing well: □Yes or IZJNo
If this is a repair,fi/1 out known well construction information and explai11 the 11ature of the
repair under #21 remarks section or on the back of this form.
8. Nnmber of wells constructed: _1 __________ _
For multiple injection or non-water su.pp{v wells ONLY ~'ith the same construction, you can
submit one form.
9. Total well depth below land surface: 38 (ft.)
For multiple wells list all depths if different (example-3@200' and 2@100')
10. Static water level below top of casing: _6 ___________ (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8" (in.)
12. Well construction method: Hollow Stem Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ______ _ Method of test: ________ _
13b. Disinfection type: ______ _ Amount: ________ _
Signature of Certified Well Contractor Date
By signing this Jonn, I hereby certify that tire well(s) was (were) cons~1tcted in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Constn,ction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: 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, Raleigh, 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 well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Su pplv & In jectio~ 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.
FonnGW-1 N01th Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 2013
Permit Number WI0400384
Program Category
Deemed Ground Water
Permit Type
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
thomas .slusser
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former RUS Winston Salem Facility
Location Address
3760 And 3775 Industrial Dr
Winston Salem
Owner
Owner Name
Cintas Corporation
Dates/Events
NC
Orig Issue
1/15/2015
App Received
1/13/2015
Re g ulated Activities
Groundwater remediation
Outfall
Waterbody Name
27105
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
4/14/2015
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Perm it Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Steve Pucke
Issue
1/15/2015
Effective
1/15/2015
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbas i n
A:COM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
tel [phone]
fax [phone]
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are ''permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This form shall be submitted at least 2 weeks prior to iniection.
AQUIFER TEST WELLS 0 5A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (ISA NCAC 02c .0225) or TRACER WELLS 0 5A NCAC 02C .0229):
1) Passive lniection Sy stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale Injection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the pwpose 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 pwpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: January 12 , 2015_ PERMIT NO. WXo'; fJ() .rB' it (to be filled in b~D Wll.L
Rt:CEIVED/DENR/DWR
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B-F, K
--~Aquifer Test Well. ...................................... Complete sections B~F, K,
___ .Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
=X,____.Pilot Test ........................ , ........................ Complete sections B-N
___ Tracer Injection Well. .................................. Complete sections B-N
B. STATUS OF WELL OWNER: Business/Organization
/3
JA!·~~ 2015
ter Quality Regional
oeratkv,~ C::a,-tion
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: Cintas Corp oration (Cintas Contact: Jim Buckman)
Mailing Address: 27 Whitney Drive
City: Milford State: OH Zip Code: ---"45=1,,_,5""0'--__ County: _____ _
UICI In Situ Remed. Notification (Revised 11/19/2013) Page 2
AECOM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
Day Tele No.: (513 ) 965-4932
tel [phone]
fax [phone]
EMAIL Address: __ ~b=u=c=km=an=i .... ® ... c=in=t=as=·=co=m~---
Cell No.: (513 ) 659-3896
Fax No.: (513 ) 701-2629
D. PROPERTY OWNER (if different than well owner)
Name: Tom Thompson
Mailing Address: Champion Industries In corp orated, 9765 Champion Blvd.
City: Winston-Salem State:~ Zip Code: 27105 County :=F~o=rs_yth~---
Day Tele No.: 336-661-1556 Cell No.: =33~6~-6=5~5~-64~4_3~-----
EMAIL Address : [e-mail] Fax No.: N~A~---------
E. PROJECT CONTACT -Person who can answer technical questions about the proposed injection project.
Name: Chris Brownfield
Mailing Address: 701 Co rp orate Center Dr. ___________________ _
City: Raleigh State: NC Zip Code: 27607 County:,_W'--'---=ak=e,...__ __ _
Day Tele No.: 919-239-7133 Cell No.:,~9...,1=9--=-2=-=1-=-5--=2'--'-40=9'--------
EMAIL Address: Christo [e-mail] Fax No.: 919-854-6259
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 3760 and 3775 Industrial Drive
_______________________ County:.~F~o=rs=--yth~------
City: Winston-Salem State: NC Zip Code: ~2~71~0=5 _____ _
(2) Geographic Coordinates: Latitude**: ___ 0 ____ " or 36 °. 148970 ~~~~---
Longitude**: ___ 0
__ __" or _~-8~0~0
• 241629
Reference Datum: North American 1983 Accuracy: 99.9999
Method of Collection: internet website (www.itcouchmap .com)
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: 490,200 square feet
Land surface area ofinj. well network:_~l=0=0~0~ ___ square feet ts 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 0.2% (must be :=:: 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
UIC/Jn Situ Remed. Notification (Revised 11/19/2013) Page3
AECOM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
tel [phone]
fax [phone]
(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.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a briefnarrative regarding the
purpose, scope, and goals of the proposed injection activity.
In accordance with the Remedial Action Plan for the Site, the purpose of the proposed pilot-scale injection
activities will be to evaluate the performance of Plume Stop™ Bioremediation Complex (Regenesis, San
Clemente, California) to arrest plume migration toward monitoring wells MW-10 and MW-1 Os and ultimately
to mitigate discharge of the plume to the nearby Class C surface water body. A previously-submitted UIC
notification (WI0400367) detailed small-scale groundwater injection activities upgradient (enhanced reductive
dechlorination, in-situ chemical reduction) and downgradient (aerobic barrier) of the proposed PlumeStop™
pilot test area. The proposed pilot scale activities will involve the injection of PlumeStop™ into the saprolite
zone of the surficial aquifer via 6 direct-push (DPT) points and into the partially weathered rock {PWR) zone
of the surficial aquifer via 3 permanent injection wells. Three separate intervals will be targeted for injections:
shallow saprolite (9-24 ft bgs). deep saprolite (25-35 ft bgs), and PWR (36-41 ft bgs): with a total target
volume of approximately 8,325 gallons. Plumestop injections will be performed at a distance of at least 60
feet from the unnamed tributary of Leak Fork as a contingency measure to ensure the release ofinjectate into
the water body will not occur. Supporting calculations. previously reviewed by NCDENR. are provided in
Appendix A. The pilot test activities may be expanded into other areas of the groundwater plume or
supplemented with additional injection activities in the future. Expansion of the proposed injection program or
supplemental injection activities may require additional UIC notifications or UIC permit applications.
J. IN.JECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/weblwq/apsl'lW.,pro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more irifo (919-807-6496).
Injectant: Plumestop™. Aqueous Suspension
Volume ofinjectant: Upto 10,000
Concentration at point of injection: Approximately 60 to 150 g/L (0.4 to 1.0 g/L active ingredient)
Percent if in a mixture with other injectants: N=-=A=--------------------
Injectant: Hydrogen Release Compound HR.C® (Glycerol tripolylactate and Glycerol)
Volume ofinjectant: 0 to 100 gallons
Concentration at point of injection: Aru,roximately 1,000 to 1,500 g/L
Percent ifin a mixture with other injectants: Approximately 0.5 to 1.0 % by volume in Plumestop™
Suspension
' UIC/Jn Situ Remed. Notification (Revised 11/19/2013) Page4
AECOM
January 12, 2015
AECOM
701 Corporate Center Crave, Suite 475
Raleigh. North Carolina 27607
Mr. Thomas Slusser
North Carolina Department of Environment and Natural Resources
Division of Water Quality, Aquifer Protection Section
Underground Injection Control Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Subject: Notification of Intent to Construct or Operate Injection Wells
Cintas
Former RUS Winston Salem Facility
Site #NONC00002431
Dear Mr_ Slusser:
tei 919.854.6200
fax [phone]
RECE1VED/DENR/DWR
t3
Water Quality Revon al
On behalf of Cintas Corporation, AECOM North Carolina, Inc., is submitting one copy of the above
referenced document for the former RUS Facility located in Winston-Salem, North Carolina (NCDENR Site
ID #NONCDI0002431). Please contact Chris Brownfield at [phone] if you have any questions.
Yours Sincerely.
William Bremen, P.E„ RSM
Project Manager
Registered Site Manager
Christopher S. Brownfield, P.E
Project Engineer
U1C//n Situ Rcmed. Notification (Revised 111 t 912013)
Page 1

AECOM
AECOM tel [phone]
791 Corporate Center Drive, Suite 475 fax [phone]
Raleigh, North Carolina 27607
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: 9 Proposed 0 Existing
(2) 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:
(a) well type as permanent, direct -push, or subsurface distribution system (infltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
(c) weIl contractor name and certification number
Proposed injection well construction details are summarized in the attached tables.
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The proposed pilot injection activities are schedule for implementation over approximately 4 to/ days irI
January, February. or March 20 ] 5 (dependent on weather). The infections willbe completed ng later than
December. 2015. Injection well and monitoring well installation will precede the iniectiort work by rip Irk
than 48 hours and is currcnti., planned for late January. 2015.
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 021, result from the injection activity.
Existing wells MW 10, MW 10sand PMW-2, and new monitoring wells PMW-3, TPMW-4 and TPMW-5, will
be the primary monitoring points for injection performance. Surface water and porewater samples will be the
primary locations for monitoring Subchapter 02L compliance, These wells and the surface water and
porewater sample Locations are shown on the attached Figure 3. Table 2 (also attached) provides additional
details about the proposed analvtes. manitorinee points, and monitoring schedule.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby cert, under penalty of law, that I am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately
responsible for obtaining said information, I believe that the information is true, accurate and complete. I am
aware that there are significant penalties, including the possibility of fines and irnprisonment, 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 15A NCAC 02C 0200 Rules." •
A s AcEkir Fe it- CAI tsraP S . F3Ra tuF��trti
5ignatu pp#cant
[AEro0 Gi wr .S Cve$otzp.t-+or.l
Print or Type Full lame
CT[C/Zn Situ Reined, Notification (Revisor' t 1/t912013) Page 5

A:COM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
PROPERTY OWNER (if the pro perty is not owned by the pennit ayplicant):
tel [phone]
fax [phone]
"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 lryection 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 (J 5A NCAC 02C . 0200). "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A
well is real property and its construction on land shall be deemed to vest ownership in the land owner, in
the absence of contrary agreement in writing.
SEE ATTACHED ENCROACHMENT AGREEMENT
Signature* of Property Owner (if different from applicant) Print or Type Full Name
* An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Submit one copy of the completed notification package to:
UIC/In Situ Remed. Notification (Revised 11/19/2013)
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page6
AECOM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
Injection Zone Maps
UICI In Situ Remed. Notification (Revised 11/19/2013)
tel [phone]
fax [phone]
Page?
m
z
z
ci
Designer. E.S.S.
Underground Injection Control Notification
Cintas - Former RUS Facility
3775 Industrial Drive, Winston-Salem, NC
Project No.: 60272437 Date. 01/12/15
SITE LOCATION MAP
AXOM
Figure: 1

m
z
,
a
a
Project Management initials
I IIC'N s oR nR
a
2
z
U
z
a
1-
1-
-z
•- z
a]
--N
cr
a
a
a
4z
nV
ctti
E
Legend
--_--X -X
• MW.03
• RI-GW20
o SPIN-13
ED MP-2
MW-12d
ART-1
•J
e9 PMW-2
*MH1Q
CaD
LJ
i
lk
Cintas Property Boundary
Adjacent Property Boundary
Fence
Stream ( Surveyed )
Stream (Unsurveyed )
Type II Groundwater Monitoring Well
Groundwater OPT Sampling Location
Sediment Pore Water Sample Location
Groundwater Monitoring Point (Piezometer)
Type III Groundwater Monitoring Well
Existing Wells, Proposed pH Adjustment and
Carbon Substrate Injection Locations (Phase I)
Performance Monitoring Weil Location
(Existing Well)
Soil Boring (Existing)
Proposed ZVI Injection Location (Phase II)
Proposed ORC Injection Location (Phase II)
Proposed Saprolite PlumestopT"" Injection
Location (Phase III)
Proposed PWR Plumestop-rm Injection
Location (Phase III)
Proposed Temporary Performance
Monitoring Well
Proposed Surface Water Sample Location
Area Utilities
Overhead Electric Line
Fiber Optic Line
Gas Line
Sanitary Sewer Line
Storm Water Ditch
Storm Water Piping
( Buried )
Storm Water Drop Inlet
Water Line
Buried Utility Line (Unknown Type)
Note-
1. The location and screened interval for
proposed injection points will be
field -determined and may be different than
what is shown.
2. Area of ORC injections was calculated as
follows: 115 ft length (8 foot spacing on
center between points) x 5 ft width
3. All injections locations to be field located to
avoid focal interferences.
PAVEMENT AREA 1
(CITY OF WINSTON-SALEM)
PAVEMENT AREA 2
(CHAMPION INDUSTRIES)
MH14
1
j MH03
PMW-3
/1®®/
TPMw-4 ��'
1
MHa2
TPMW-5
MW10 0
o e e e ij Mwi o> r
d MW10s
0
a■
■
t
SW-06
OSPW-06
I 0
Ri-GW19
MI-l10
►• •
►
1
c�s
1 Tie
►
i
\ SPW-05
SW:05 ►
►
■
SW-04'
ca
Rip -Rap for tarrn
Water Discha
SPW-04
" !ART-1
MP-1
MHD5
1
MH15
s PMW-1
PMW-2
MHQ4
•
MWD2d
ART-2
MH06
PROPOSED
ZERO-VALENT IRON
INJECTIONS
PROPOSED PLLJMESTOPTM
PILOT INJECTIONS
PROPOSED AEROBIC
BARRIER INJECTIONS
15
0
30
1 "=30'

ANSI 8 11" x 17"
V
n
<3
——<0.03— —
r1
LJ
Legend
19 MW-03
0 RI-GW2O
0 SPW-13
MP-2
MW-12d
0) ART-1
SPW-12
Cintas Property Boundary
Fence
Stream ( Surveyed )
Stream ( Unsurveyed )
Type II Groundwater Monitoring Well
Groundwater CPT Sampling Location
Sediment Pore Water Sample Location
Groundwater Monitoring Point (Piezometer)
Type III Groundwater Monitoring Well
Existing Wells, Proposed pH Adjustment and
Carbon Substrate Injection Locations (Phase I)
Boundary of POE a1 pg1L in Shallow
G roundwater
Boundary of PCE <1 pgJL in
Intermediate Groundwater
Boundary of TCE c3 pg/L in Shallow
Groundwater
.<3. Boundary of TCE a3 pg/L in
Intermediate Groundwater
Boundary of cis-1,2-DCE <70 pg1L In
Shallow Groundwater
Boundary of Vinyl Chloride <0.03 pg1L in
Shallow Groundwater ( Dashed because
Notes:
1. Gradients are based on 12 July 2012
gauging event reported in the Remedial
Investigation Report and are approximate.
2. The location and screened interval for
proposed injection points will be
field -determined and may be different than
what is shown.
35
0
1 "=70'
0-•00".-
70 400
MW1 5
MW15j W15d
FzI-G �7O MWOBd
VMW78
c't
SPW-07
RI•kw200
MVW7s
MWO7d
NNW MW7Omani
Od.
M Ca
PW-c 4
{�o
9 DPT-GW\
V
sPw 02 •
0 RI-GW1S
MWU2
MWO2d
1
RI-GW09
0 RI-GW15
PROPOSED
ZERO-VALENT IRON
JINJECTIONS
PROPOSED PLUMESTOPTM
PILOT INJECTIONS
j'-
PROPOSED AEROBIC
BARRIER INJECTIONS
MW09S
M�
1
1
1
co
Z
0
2 U
�0
re J
Z
1-0
vw
_Z W
La
a-
z 0
n0.
V
2
t_—
0
00 0
Z u�
w -
o
z
C to
L
a�o
o
di
te CI
€ m
c
0
oti�Z
�to
iSin w
0MIi

Project Management InitlBfs
MW12s
i MW12s(R) MW12
MW12d
Legend
▪ Cintas Property Boundary
—%-x— Fence
— — Stream { Surveyed )
Stream { Unsurveyed )
Type it Groundwater Monitoring Well
Type III Groundwater Monitoring Well
Existing Weil, Proposed pH Adjustment and
Carbon Substrate Injection Location {Phase I)
Groundwater DPT Sampling Location
Pore Water Sample location
Sail Boring Location
Background Soil Boring Location
Groundwater Monitoring Point (Piezometer)
• MW03
MW12d
ART-3
9 RI-GW20
Q SPW-Q5
RI(1)-SB21
• RI(1)-BG01
® MP-2
At t A' Cross Section Location
Ciao
000
000
Proposed Zero-Valent Iron Injections
Proposed Aerobic Barrier Injections
Proposed Plumestop'"' Pilot Injections
Note:
1. The location and screened interval for
proposed injection points will be
field -determined and may be different than
what is shown.
RI(1)-SB21
L_
Rj (1)-BGO1
RI-GW12
R4-GW11 MWO1d
MW17
MW18
MWO8s MWO8d
MWO8
MW11
MW15
MW15s ..; MW15d
0
co
.65
MWO4d
M WQ4
1
�I
•i
I MP-2
�I]
ART-1
r t
MWO2d
aRT-2
MWO3 • 1 i l PROPOSED
ART-.ZERO-VALENT IRON
PMVV-1 INJECTIONS
M W02
MP-1
�PMW-2
PROPOSED PLLIMESTOPTM
PILOT INJECTIONS
MW1Od MW10
a•ee -. J
MW1 os_
SPW-Q
RI-GW191
RI- GW20 g,,AL
PROPOSED AEROBIC
BARRIER INJECTIONS
MWO9
CROSS SECTION LOCATION MAP

ANSI 911°x 17"
Pro;ec' Nanagem
940 —
930 —
920 --
910-
900 —
890 —
880 --
870
866 —
850 —
840 —
830 —
820
810 —
800 —
790
S) UTAvuESt
(869.38)4-
c1
' 1
(869.05)
(868.58)
780 —
Legend
2 of 13 ZVI injections
shown (See Note 1 & 2)
Saprolite'Plumestop7M Injections.
(1 of 6 Saprolite Plumestop7°^ Injections.)
PWR Plumestap'm Injection
Well (1 of 3)
1 of 15 ORC injections
shown (See Note 3)
DRY
SAPROLITE
FWR
BR
J
c1
Groundwater Monitoring Well
Wen Screen
DPT Groundwater Sample
DPT Screen
LEAK m
FORK
•
iWR 4,210
• I
4.1
m
SAPROLITE
I--+— DPT Soil Baring
(87 •16)
{'NOI A A$1 )-940
PAVED PARKING LOT
PAVED PARKING LOT
I -
CC
(871.90)
■
3,160
12,300
3 (872.18)
a
(871.46) _ 981
Groundwater Potentiometric Elevation
( ft. msl) July 2012
❑ Groundwater Equipotential Surface
( ff. msl j ( Dashed Where Inferred
r
General Direction of Vertical
Hydraulic Flow Gradients at
Multi -Depth Well Clusters
0,09
cc
(77.1.6)
•
:MAMMA
or
SEE
NOTE
1
-20,900
FWR
do
duo1
PCE Concentration (ug1L) in
987 Groundwater ( Dates Vary
100 —
PCE Isoconcentration in
Micrograms per Liter (ugfL
( Dashed Where Inferred )
,. — Line of Lithologic Contact
( Dashed Where Inferred )
(878.65)!
ddo
d 4-
7
CINTAS BUILDING
[�7
SAPROLITE'
(879.31)
78.3
IIII Asphalt 1 Concrete Paving
1
PRE
BR
(894.74)
DRY
Saprolite ( includes residuum
and local fill material )
PWR
2.6
1.511.8
m
Cr-
1
DRY
(831.14) <1
.1MASSJVE BEDROCK
/I —
{FAT A�1} RLVGPRACTURES
Partially Weathered Rock (PWR )
Bedrock (Biotite Gneiss and Schist )
ER
VERTICAL 'SCALE : '1'" = 20`
HORIZONTAL SCALE : 1" = 80'
VERTICAL EXAGGERATION : 4x
Abbreviations
— 930
— 920
— 910
-- 900
— 890
— 880
— 870
= 860
— 850
— 840
— 830
— 820
— 810
800
— 790
780
DPT Direct Push Technology
ft. msl Feet mean sea level
PCE Perch laroethene ( Tetrachloroethene )
ZVI Zero Valent Iron
Notes:
1. Depth of PWR and bedrock between wells ART-2 and ART-3 is
estimated from direct push boring DPT-GW14 (ENSR, 2008) that
encountered probe refusal at depth of 59 ft. bls.
2. Injection interval will be 10 f!. up from OPT refusal (i.e. PWR)
3. The location and screened interval for proposed injection paints will be
field -determined and may be different than what is shown.
CROSS SECTION A -A`

ANSI B 11' x 1i
rT
a
Project Management Initials•
( NORTHHINEST )
900 —
590 —
880
870 —
860 —
850 —
840 —
830 -
820
810 —
800 —
790 —
to
780 —
-
PAVED PARKING LOT
(871.46)
987
13 of 15 ORC injections
shown (See Note) 1
STORMWATER PIPE
2
( SOUTHEAST )
- 900
• — 890
— 880
— 870
— 860
— 850
— 840
— 830
— 820
— 810
— 800
790
— 780
VERTICAL SCALE : 1" = 20'
HORIZONTAL SCALE : 1" = 80'
VERTICAL EXAGGERATION . 4x
Legend
I-01— DPT Groundwater Sample
Groundwater Monitoring Well
Well Screen
DPT Screen
DPT Sod Boring
Groundwater Potentiometnc Elevation
(ft. msl) July 2012
Groundwater Equipotential Surface
(ft. msl) ( Dashed Where Inferred)
Der PCE Concentration (ug1L ) in
Groundwater ( Dates Vary)
10a — —
$APROZJTE
FWR
BR
PCE Isoconcentration in
Micrograms per Liter (ug/L )
( Dashed Where Inferred)
General Direction of Vertical
Hydraulic Flow Gradients at
Multi -Depth Well Clusters
Line of Litholagic Contact
(Dashed Where Inferred)
Asphalt /Concrete Paving
Saprolite (includes residuum and
local fill material )
Partially Weathered Rock (PWR (
Bedrock (Biotite Gneiss and Schist )
Abbreviations
DPT Direct Push Technology
ft. msl Feet mean sea level
PCE Perchlomethene ( Telrach:oroethene )
Note:
1. The location and screened interval for proposed
injection points will be field -determined and may be
different than what is shown.
CROSS SECTION ION B-B
N
w
[t3
0

AECOM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
Well Construction Data and Monitoring Plan
UIC/Jn Situ Remed. Notification (Revised 11/19/2013)
tel [phone]
fax [phone]
Page8
Table 1
Proposed Pilot Study Injection Well Construction
Former RUS Facility
Winston-Salem, North Carolina
Well No. lnJectate Injection Type Diameter Total Depth interval Well Status I I I
Well I I Screened I
PWR1-PWR3
Notes
feet bis-feel below land surface
PS-Plumestop™
PS Injection well
(inches) (feet bis) (feet bis)
2 50 45-50
•DPT points will be installed with a direct push rig and will be abandoned following Injection activities. Injection wells will be installed by Parrat-
Wolff, Inc. under the supervision of Tod Muench {Certification# 4223) or other North Carolina Cerifled Well Contractor.
The location and screened interval for proposed Injection points will be field-determined and may be different than what is shown.
Proposed
Title 2
ABM S:ude Montr:prIna Plan
Former RL5 Fa1lIly
Wfn:t1n-SNP, Nerrh Corotlg1
an.0.0tlReiulrSminls
Wt•I IP
t1'443 RAWiII MWW1C5 SYS-1 ARI-1 AP,T•? ART Fly RY 1 PSiV7•1 JY+1W3 TlPAW-e irl.A*5 pupa 5N4.75 SPW{15 SWile :w7.
VW1g?ps,[ [moo, a.
1121
P.J11InIt1
Minns
9.Ifat•
uxsolwd tree rend Miasmas
Xydlegeil
LtFihanr
Flagons.
When.
Mep%haYc Ands
M4rphfat AaaaunctlGnar &Mai
�ffiap
FJe Panmetera
6round%aser NvYatiun
X
x
a
•
■
•
r
x
■
Nan-
MAW. Prgpn.ed Peneem.PCe agantrottre W!P
SW - Woeoee4NyF1Pe wsrrnmpk MOWS iiscotad adjacem m pore-muttmexple wddanJ
SPW - P+apoxed pare Wafer luaple !xi bon
1parph'al gluey. al15115 G1Apehxi1W01141 4Jµ and Ce'w1111111,31,.
runnlrnal C.rnr Mity;i{= CENSUS MaL.V A Red4tll1r, 2c1A Redllctaocc. V.nyl t lotldt Redustise
e. Inca:lrn wI.I he umtaed hefere PQng1SW211nitryans and app•wdmrtey S mon* 3lronchs. filnonths, and 22 Months.Ret Plolnettop Wectlons
f hcailen will 6e ..,pled enoehetp x and.PPn,dgate1yllslas suing>he peefemu:hoe mM1Wllij period.
Flak! pararpercrs W[Iud. dhatiaeda./%en, 2N, csld.pon nxlsSelarl sat.n1L1, apes,r mndyrtlNtr, tepperaryrr, and 1U1WOW
Mdklon al mnr herYlywIlsnld eru}U., may be added h•.ed w+M.e need Le sp0ratt Liss 'Islamise* 41 tnjari1n43ar SupWpo-rdit 1 Puente,

AECOM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
Supporting Calculations
UICl/n Situ Remed. Notification (Revised 11/19/2013)
tel [phone]
fax [phone]
Page9
A:COM
November 25, 2014
Mr. Thomas Slusser
AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
North Carolina Department of Environment and Natural Resources
Division of Water Quality, Aquifer Protection Section
Underground Injection Control Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Subject: Use of Plumestop™ for Groundwater Remediation
Cintas Corporation
Former RUS Winston-Salem Facility
Site #NONCD0002431
Dear Mr. Slusser:
tel [phone]
fax [phone]
On .behalf of Cintas Corporation (Cintas) AECOM North Carolina, Inc. (AECOM) is submitting
preliminary calculations and arguments to support ongoing discussion related to the proposed
pilot application of the sorptive product Plumestop™ (Regenesis, San Clemente, California) for
groundwater remediation at the former RUS facility in Winston-Salem, North Carolina (the Site).
These calculations and arguments are presented at the request the North Carolina Department
of Natural Resources (NCDENR) following an initial meeting on October 9, 2014 in which you
expressed interest in technical justifications for proposed placement of the product near the
unnamed tributary of Leak Fork at the Site.
AECOM has prepared these calculations using input from Regenesis related to the following
key tenants that govern its fate and transport:
• Plumestop™ is a colloidal suspension of activated carbon particles and a supporting
polymer in water.
• Suspensions of Plumestop TM in water are stable predominantly because of electrostatic
repulsion between suspended particles that is facilitated by the supporting polymer,
which modifies the surface charge of the activated carbon particles and increases
repulsion between particles.
• Co-deposition of the activated carbon particles and the supporting polymer has been
observed in the presence of soluble divalent cations and sorptive mineral surfaces, such
as those that are common in silts and clays.
AECOM
AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
tel [phone]
fax [phone]
Using these key tenants, AECOM prepared one calculation based on laboratory data and one
calculation based on field data to evaluate the likely transport distance of Plumestop™.
Su pp ortin g Calculation 1
AECOM estimated the composition of divalent cations that may be present on the soil exchange
complex and calculated the volume of soil required to interact with the proposed amount of
Plumestop™ based on a critical cation:Plumestop™ ratio that was suggested by Regenesis.
Based on the manufacturer's experience, the critical cation:Plumestop™ ratio has resulted in
flocculation of Plumestop TM product in laboratory microcosms. Using the pH of nearby wells
MW-10 and MW-10s as a guide, and assuming a relatively low cation exchange capacity of
approximately 1 O centimoles per kilogram, AECOM estimated that approximately 15 feet of
downgradient transport should be allowed to provide opportunities for Plumestop TM to interact
with exchangeable, divalent cations resulting in deposition. This calculation includes a 50%
factor-of-safety and does not account for other electrostatic interactions between Plumestop™
and soil surfaces, which are likely very important processes for governing its fate and transport
and may reduce the required downgradient travel distance.
Su pp ortin g Calculation 2
Data collected by Regenesis during beta testing of the Plumestop TM product indicate that more
than 99 percent of suspended Plumestop TM was removed from groundwater approximately 60
days after injections. These data were collected from a monitoring well centrally located within
a Plumestop™ injection grid based on 5-feet centers, and in an aquifer where plug-flow flushing
cannot account for a significant portion of observed concentration reductions. AECOM used
these data to estimate a maximum transport distance over 60 days of saturated, advective flow
using Darcy's Law. An estimated radius of influence (ROI) associated with injection under
pressure was assumed based on design inputs from Regenesis, and used as the upgradient
reference point from which transport associated with saturated flow conditions originates.
Applying this logic, a maximum transport distance of 21 feet from the point of injection is
estimated for the Plumestop™. The calculations are provided as Calculation 2 in the
attachment to this letter.
Supporting Argument 1
These calculations suggest that approximately 25 feet of offset should be allowed to facilitate
Plumestop TM deposition at the Site. Although AECOM offers these two calculations in good
faith based on reasonable assumptions, we would like to reiterate that actual inputs are not
known, and that the density of sites available for interaction with Plumestop TM along a tortuous
flow path is difficult to model analytically. As an additional measure, AECOM has already
permitted and plans to install a barrier of ORC® (also manufactured and marketed by
Regenesis) between the proposed Plumestop™ injection barrier and the unnamed tributary.
ORC® includes slow-release forms of magnesium, and the manufacturer's bench testing
AECOM
AECOM tel [phone]
701 Corporate Center Drive, Suite 475 fax 919.854,8259
Raleigh, North Carolina 27607
indicates that it is effective at flocculating PlumestopTM. AECOM's performance monitoring plan
for the proposed PlumestopTM injections will also include monitoring of the unnamed tributary for
total organic carbon, turbidity, and visible signs of PlumestopTm. if observed, point discharges of
PlumestopTM could be mitigated with targeted follow up injections of ORe, ORC-A°, or other
flocculating salt.
Supporting Argument 2
AECOM is currently working to propose a PlumestopTM injection location that balances the
Division's concerns over initial use of the product in the vicinity of the unnamed tributary of Leak
Fork with progress towards project milestones that are stipulated in the Remedial Action Plan
for the Site. These project milestones are derived from the Administrative Agreement between
the State of North Carolina and Cintas Corporation for voluntary remedial action, and include a
requirement to achieve remediation of surface water impacts in October, 2017, Therefore
placement of PlumestopTM within an estimated one-year travel distance (about 40 feet) would
facilitate timely evaluation of the effectiveness, and would leave a minimal amount of time for
scale -up of contingent remedies in the event that adequate performance is not observed.
AECOM considers this approach to be optimal considering that PCE-impacted groundwater is
likely discharging to the unnamed tributary at present, and the proposed PlumestopTM material
is relatively benign both in comparison to the regulated constituents and to other viable in -situ
remediation products that could be used to address them.
AECOM requests the opportunity to review and discuss these calculations and arguments
following your review. Please contact Chris Brownfield at [phone] if you have any
questions.
Yours Sincerely,
William Bremen, P.E., RSM
Project Manager
Registered Site Manager
Christopher S. Brownfield, P.E.
Project Engineer
Attachments: Supporting Calculation 1, Supporting Calculation 2

Suppertleg Calculation 1
in order to predict the plumestop transport distance, the CEC of sells w19 be used to calculate the soils capacfty to destabilise the COliold- This t Icual%iln Maluates whether or not the CEC of
the soils is adequate to destabilise all of the Injected Aumettep before it reaches the tributary.
Calculation Assumptions
Description
Value
Units
Soil bulk density
1.45
filar'
Porosity
03
unitiess
CEC
10
crnol/kg
Base Saturation"
0.1
tinniest
JCar4SpylCaiMgotiNar
115
unittess
Design infection Radius
b
k
Design inioction thickness
26
ft
Plumestop conceheration° _ _
1000
mgjL
Manipulated Variables
Discriptfon
Value
units
Predkted transport distance of Plumestop
9 9
ft
Recommended offset %stance
14.9
Pc
Calculated Variables
Description
Volume of soil available to react with Plumestop`
Volume of soil available to react with Plumestop
Mass of son available to react with PIumesttpd
Available Divalent Base Eq. in total soli mats`
Total Mass of active ingredient injected'
Patio of CSC to PI umestops
Vak,e
6,006
227
318,705
164,392
44,396,093
0.00370
Unita
fie
input Val ucs
Calculated Values
Manipulate 'Predicted transport
oaten ea of plum estop" to change
Patio of CEC to Plumestop until
"PASS" is achieved.
Pass
Pons
' One Sateraflon refers to the number of bask satltre that are nerd on the soil media nip (GEC sitesi In comparison to the total number of alter. (Gi-Mg)/IG.Mg+Ne f] refers to the'auv of divalent base
cease so motto- and dl-talent base cations.
I Conservative assumptfon of in situ concentration of plumesee0 cave Ingredient obtained from Aegenesfs
' Cakufatfon is equlratent to the vnlune of a rya rider, where radius is the transport distance of oturnestoe and the hele9t b the design Infection thkkr cis.
"'Mato Is the product of rd ume of toll and sof! bulk dtrtRy
r Ave a able divalent hese equivalents is the product of We soil Milos pyallableta react, the CEe, the 6dsc faturytlpry aqd the f09 t1en 91 dlteleoe haws that won p!!ac the base aatatatIen.
'Mate al Plunsesu 0active ingredient Is the product of Plumes -top Concentration and the ln9ftu injection volume iCh prosily PI a the 1njerhon radius squared a the ihjf•OMO MIAMOLSJ.
cfsased on laboratory data coif acted by amen ads, 0.75 mg Cat+ Is required to des -teethe 1 ens of cake Plumes -top Jrgradient.
0.75mg of Cal+ converted to tmofc f o.75 me Ca2+-M4t1078 mglmol Ce2t).41 gn81/0.31 me) • 2 charge= 00 137 cruel- PAS$= ratio

Supporting Calculation 2
Description
Based on data collected during research and development of the Plumestop product, Plumestop Is expected to become completely destabilized
(flocculated and deposited) in the aquifer 60 days after injection. Assuming no additional transport of Plumestop will occur after day 60, the total
transport distance can be calculated by combining the initial transport distance associated with pressure injection (ROI) and the transport distance
associated with GO days of saturated fluid flow (Darcy's Law).
Description
Value
Units
Porosity
0.3
unttless
Hydraulic conductivity
15
ft/day
Hydraulic gradient
0.02
ft/ft
PlumAtop Lunt, mefl
MW-6 Data
txa
tqq At day 60 foliowing injection, 99%
of the Plumestop concentration is
removed as verified by UV Spec
L.
30 60 90 120 150 155 210 240 210 300
DaVs Post Ptu0161t5p ApppcaGon
Total distance Plumestop will travel cm 50 days from inlecttpn
Anticipated ROI
8 ft
Anticipated transport
distance at day 60 (from
edge of ROI)
6.00 ft
Total travel distance
from in] paint
14.00 ft
50% Contingency
21.00 ft
Q —AK-
Input Va iues
Calculated Values

AS'COM
MSDS Forms
AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
UICI In Situ Remed. Notification (Revised 11/19/2013)
tel [phone]
fax [phone]
Page 10
Hydrogen Release Compound (HRe)
MATERIAL SAFETY DATA SHEET (MSDS)
Last Revised: March 23, 2012
Section 1 - Material Identification
Supplier:
REGENESIS
1011 Calle Sombra
San Clemente, CA 92673
Phone: [phone]
Fax: [phone]
E-mail: Wow reEenesis.cor
Chemical Name:
Chemical Family:
Trade Name:
Product Use:
Propanoic acid, 2-[2-[2-(2-hydroxy-l-oxopropoxy)-1-
oxopropoxyJ-l-oxopropoxyl-1,2,3-propanetriyl ester
Organic Chemical
Hydrogen Release Compound® (HRO
Glycerol tripolylactate and Glycerol
Used to remediate contaminated soil and groundwater
(environmental applications)
Section 2 — Chemical Identification
CAS# Chemical
201167-72-8 Glycerol Tripolylactate
56-81-5 Glycerol
50-21-5 Lactic Acid
Section 3 - Physical Data
Melting Point: Not Available (NA)
Boiling Point: Not Determined (ND)
Flash Point: ND
Density: 1.3 glcc

Regenesis -HRC MSDS
Solubility:
Appearance:
Odor:
Vapor Pressure:
Extinguishing Media:
Section 3 -Physical Data ( cont)
Acetone and DMSO
Viscous amber gel/liquid
Not detectable
None
Section 4 -Fire and Explosion Hazard Data
Use Water Spray, Carbon Dioxide, Dry Chemical Powder or
Appropriate Foam.
Water may be used to keep exposed containers cool.
For large quantities involved in a fire, one should wear full protective clothing and a
NIOSH approved self contained breathing apparatus with full face piece operated in the
pressure demand or positive pressure mode as for a situation where lack of oxygen and
excess heat are present.
Section 5 -Toxicological Information
Acute Effects:
RTECS#:
Irritation data:
J :\Operations\MSDS\HRC MSDS
May be harmful by inhalation, ingestion, or skin absorption.
May cause irritation. To the best of our knowledge, the
chemical, physical, and toxicological properties of the glycerol
tripolylactate have not been investigated. Listed below are the
toxicological information for glycerol and lactic acid.
MA8050000
Glycerol
SKN-RBT 500 MG/24H MLD
85JCAE-,207,1986
EYE-RBT 126 MG MLD
EYE-RBT 500 MG/24H MLD
SKN-RBT 5MG/24H SEV
EYE-RBT 750 UG SEV
Page2
BIOFX* 9-4/1970
85JCAE-,207,1986
85JCAE -,656,86
AJOP AA 29,13~3,46
Regenesis -HRC MSDS
Section 5 -Toxicological Information ( cont)
Toxicity data:
Target Organ data:
RTECS#:
ORL-MUS LD50:4090 MG/KG
FRZKAP (6),56,1977
SCU-RBT LD50:100 MG/KG
ORL-RAT LD50:12600 MG/KG
IHL-
RATLC50:>570MG/M3/1HBIO
FX*9-4/1970 IPR-RAT LD50:
4420MG/KG
IVN-RAT LD50: 5566 MG/KG
IPR-MUS LD50: 8700 MG/KG
SCU-MUS LD50: 91 MG/KG
IVN-MUS LD50: 4250 MG/KG
ORL-RBT LD50: 27 GM/KG
SKN-RBT LD50:>10GM/KG
IVN-RBT LD50: 53 GM/KG
ORL-GPG LD50: 7750 MG/KG
ORL-RAT LD50:3543 MG/KG
SKN-RBT LD50:>2 GM/KG
ORL-MUS LD50: 4875 MG/KG
ORL-GPG LD50: 1810 MG/KG
ORL-QAL LD50: >2250
MG/KG
NIIRDN 6,215,1982
FEPRA7 4,142,1945
RCOCB8 56,125,1987
ARZNAD 26,1581,1976
ARZNAD 26,1579,1978
NIIRDN 6,215,1982
JAPMA8 39,583,1950
DMDJAP 31,276,1959
BIOFX* 9-4/1970
NIIRDN 6,215,1982
FMCHA2-,C252,91
FMCHA2-,C252,91
FAONAU 40,144,67
JIHTAB 23,259,41
FMCHA2-,C252.91
JIHTAB 23,259,1941
Behavioral (headache), gastrointestinal (nausea or vomiting),
Paternal effects (spermatogenesis, testes, epididymis, sperm
duct), effects of fertility (male fertility index, post-
implantation mortality).
OD2800000
Lactic acid
Only selected registry of toxic effects of chemical substances {RTECS) data is presented
here. See actual entry in RTECS for complete information on lactic acid and glycerol.
J :\Operations\MSDS\HRC MSDS Page 3
Regenesis -HRC MSDS
Section 6 -Health Hazard Data
Handling: Avoid continued contact with skin. Avoid contact with eyes.
In any case of any exposure which elicits a response, a physician should be consulted
immediately.
First Aid Procedures
Inhalation:
Ingestion:
Skin Contact:
Eye contact:
Conditions to Avoid:
Hazardous
Polymerization:
Further Information:
Remove to fresh air. If not breathing give artificial
respiration. In case of labored breathing give oxygen. Call a
physician.
No effects expected. Do not give anything to an unconscious
person. Call a physician immediately.
Flush with plenty of water. Contaminated clothing may be
washed or dry cleaned normally.
Wash eyes with plenty of water for at least 15 minutes lifting
both upper and lower lids. Call a physician.
Section 7 -Reactivity Data
Strong oxidizing agents, bases and acids
None known
Hydrolyses in water to form Lactic Acid and Glycerol.
Section 8 -Spill, Leak or Accident Procedures
After Spillage or
Leakage:
Disposal:
Neutralization is not required. This material may be burned
in a chemical incinerator equipped with an afterburner and
scrubber.
Laws and regulations for disposal vary widely by locality.
Observe all applicable regulations and laws. This material,
may be disposed of in solid waste. Material is readily
degradable and hydrolyses in several hours.
No requirement for a reportable quantity (CERCLA) of a spill is known.
J:\Operations\MSDS\HRC MSDS Page4
Regenesis -HRC MSDS
Section 9 -Special Protection or Handling
Should be stored in plastic lined, steel, plastic, glass, aluminum, stainless steel, or
reinforced fiberglass containers.
Protective Gloves:
Eyes:
Ventilation:
Storage:
Vinyl or Rubber
Splash Goggles or Full Face Shield
Area should have approved means of washing eyes.
General exhaust.
Store in cool, dry, ventilated area. Protect from incompatible
materials.
Section 10-Other Information
This material will degrade in the environment by hydrolysis to lactic acid and glycerol.
Materials containing reactive chemicals should be used only by personnel with
appropriate chemical training.
The information contained in this document is the best available to the supplier as of the·
time of writing. Some possible hazards have been determined by analogy to similar
classes of material. No separate tests have been performed on the toxicity of this material.
The items in this document are subject to change and clarification as more information
becomes available.
J :\Operations\MSDS\HRC MSDS Page5
c) ccc
Canada Colors and Chemicals Limited
152 Kennedy Road South
Brampton, Ontario
Canada
L6W 3G4
General inquiry Number: [phone]
Material Safety Data Sheet
Attached

last Revised: July, 1 2014
PlumeStop™
1111s product b d-d by
can.da Colon •d Clwmlall Umltad
G.,ml loqulry: .ltllSl as-im
2A-r Emefsalcy: (416)444-llll
a:c, Produ<ICode : 758021
ecx:ProduclNmo: PLUMESTOP
Material Safety Data Sheet (MSDS)
Section 1 -Supplier Information and Material Identification
Supplier:
REGENESIS
1011 Calle Sombra
San Clemente, CA 92673
Telephone: [phone]
Fax: [phone]
E-mail: [e-mail]
Chemical Description:
Trade Name:
Product Use:
An aqueous mixture of activated carbon and other food grade additives
PlumeStop™
Used to remediate contaminated soil and groundwater (environmental
applications)
Section 2 -Chemical Information/Other Designations
CAS No.
7440-44-0
7732-18-5
Form:
Color:
Odor:
Melting Point:
Boiling Point:
Flammability/Flash Point:
Vapor Pressure:
Bulk Density:
Solubility:
Viscosity:
pH {1% solution)
Chemical Weight %
Colloidal activated carbon ~2.5 µm
Water
Proprietary additives
Section 3 -Physical Data
Aqueous suspension
Black
Odorless
0°C
NA
NA
NA
NA
NA
NA
8-10
<25
> 75
~2
Decomposition Temperature: NA
CCC
PlumeStop™ MSDS
Stability:
Conditions to
Avoid/Incompatibility:
Possibility of Hazardous
Reactions:
Hazardous Decomposition
Products:
TSCA Inventory:
OSHA Hazards:
Section 4 -Reactivity Data
Stable under recommended storage conditions.
Avoid contact with alkali metals and strong oxidizing
agents.
Hazardous polymerization will not occur.
Hazardous decomposition products formed under fire conditions.
Carbon oxides.
Section 5 -Regulations
Listed (activated carbon)
Not regulated
CERCLA Reportable Quantity: NA
Canadian Domestic Substance Listed (activated carbon)
List:
WHMIS Classification:
SARA 302 Components:
SARA 313 Components:
Listed (activated carbon)
No chemicals in this material are subject to the reporting requirements
of SARA Title Ill, Section 302.
This material does not contain any chemical components with known
CAS numbers that exceed the threshold reporting limits established by
SARA Title Ill, Section 313.
Section 6 -Protective Measures, Storage and Handling
Technical Protective Measures
Storage:
Handling:
Keep container tightly closed in the original container. Do not allow
product to freeze.
As with any chemical product, use good laboratory/workplace
procedures. Avoid contact with skin and eyes. Wash thoroughly after
handling this product.
Personal Protective Equipment (PPE)
Exposure Limits
Engineering Controls:
Respiratory Controls:
Eye Protection:
Contains no substances with occupational exposure limit values.
Local exhaust ventilation is recommended.
Not required for routine handling. A NIOSH approved respirator should
be used if handling dust that results in the event that water evaporates
from product.
Wear chemical safety goggles. A full face shield may be worn in lieu of
safety goggles.
Page 2 of 4
PlumeStop™ MSDS
Section 6 -Protective Measures, Storage and Handling, continued
Hand Protection: Wear chemical resistant gloves (neoprene, rubber or PVC). Dispose of
used gloves in accordance with good laboratory practices. Wash and dry
hands after handling.
Skin Protection: Try to avoid skin contact with this product. Chemical resistant gloves
and protective clothing should be worn during use.
Protection Against Fire &
Explosion:
Potential Health Effects
Inhalation:
Eye Contact:
Skin Contact:
Ingestion:
After Spillage/Leakage:
Extinguishing Media:
Eye Contact:
Inhalation:
Ingestion:
Skin Contact:
Cleanup Methods:
Oral LOSO:
Dermal LOSO:
Carcinosenicity:
Product is non-explosive and non-flammable. In the unlikely event that
all water is evaporated, residual dust is flammable.
Section 7 -Hazards Identification
Not applicable.
May cause eye irritation.
May cause skin irritation.
May be harmful if swallowed.
Section 8 -Measures in Case of Accidents and Fire
Contain spill with absorbent material. Vacuum or sweep into suitable,
closed container for disposal. Do not return spilled or contaminated
material to the inventory.
Water, alcohol-resistant foam, dry chemical or carbon dioxide.
Rinse thoroughly with plenty of water for at least 15 minutes and
consult a physician.
If affected, move person to fresh air. Get medical attention if symptoms
occur.
Rinse mouth with water. Get medical aid if symptoms occur.
Wash off with soap and water to remove the activated carbon.
Section 9 -Accidental Release Measures
Contain spill with absorbent material. Vacuum or sweep into suitable,
closed container for disposal.
Section 10 -Information on Toxicology
No data available.
No data available.
No component of this product is identified as a probable, possible or
confirmed human carcinogen by IARC, ACGIH, NTP, OSHA or CA Prop 65.
Page 3of 4
PlumeStop™ MSDS
No data available.
Waste Treatment:
Package (Pail) Treatment:
D.O.T. Shipping Name:
IMDG,IATA
NFPA Rating:
Section 11-Information on Ecology
Section 12 -Disposal Considerations
Dispose of in an approved waste facility operated by an authorized
contractor in compliance with local regulations.
The empty and clean containers are to be recycled or disposed of in
conformity with local regulations.
Section 13 -Shipping/Transport Information
Not dangerous goods.
Not dangerous goods
Section 14 -Other Information
Health-a Flammability-a
Section 15 -Further Information
Reactivity Hazards - 0
The information contained in this document is the best available to the supplier at the time of writing, but
is provided without warranty of any kind. Some possible hazards have been determined by analogy to
similar classes of material. The items in this document are subject to change and clarification as more
information become available. This document is intended only as a guide to the appropriate precautionary
handling of the material by a properly trained person. Individuals receiving this information must exercise
their independent judgment in determining its appropriateness for a particular purpose.
Page 4of4
A:COM
Agent Agreement
AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
UIC/Jn Situ Remed. Notification (Revised 11/19/2013)
tel [phone]
fax [phone]
Page 11
September 27, 2011
To Whom It May Concern:
Cintas Corporation hereby authorizes AECOM to act as its Agent in the securing of
regulatory permits for installation and maintenance of wells used for environmental
monitoring and remediation purposes. This Agent authorization allows AECOM to sign
well permit applications on behalf of Cintas, to the extent that such Agent designee is
allowed by State policies and laws. The Agent assignment is further established in the
current Master Services Agreement contract between Cintas and AECOM.
If you have any questions, please contact me at 513-701-2821.
Sincerely,
James A. Buckman
Director,
Chemical and Environmental Engineering
Cintas Corporation 6800 Cintas Blvd F.O. Mason, OH 43040 Office S 13.701-2821

AS'COM AECOM
701 Corporate Center Drive, Suite 475
Raleigh, North Carolina 27607
Access/Encroachment Agreement
UICI In Situ Remed. Notification (Revised 11/19/2013)
tel [phone]
fax [phone]
Page 12
ROUTE Industrial Drive
CITY OF WINSTON-SALEM
-AND-
CINTAS Corporation
PROJECT Installation of
Temporary Sampling
Wells
RIGHT OF WAY
STATE OF NOR.TI-I CAROLINA
COUNTY OF Forsyth
ENCROACHMENT AGREEMENT
PRIMARY AND SECONDARY HIGHWAYS
THIS AGREEMENT, made and entered into this the ~day of November, 2014, by and between the City of
Winston-Salem, party of the first part; and ..:C~IN'-'-"T=A=-=S,_C=orpoez_,,c:.,ra=t=-=io""n,__ _______ _,p arty of the second part,
WITNES SETH:
THAT WHEREAS, the party of the second part desires to encroach on the right of way of a public road
being designated as Industrial Drive . with temporary wells for groundwater sam pling. These sam ples will be
used to detect the possible s pread of chemical contaminates in the water table around 3775 Industrial Drive , the
previous site of a rental uniform laundering facili ty owned bv CINTAS Corporation. AECOM, the environmental
contractor. has contacted the business alon g Industrial Drive to inform them of the proposed work within the
ri ght-of-way. The installation of the monitorin g wells will be performed on the weekend or durin g hours of the
da y that will have the least amount of impact on traffic to and from the businesses in the 3700 block oflndustrial
Drive.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and
the party of the first part in the exercise of authority conferred upon it by statute, is willing to permit the
encroachment within the limits of the right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the
second part the right and privilege to make this encroachment as shown on attached plan sheet(s), specifications
and special provisions which are made a part hereofupon the following conditions, to wit:
That the installation, operation , and maintenance of the above-described facility will be accomplished in accordance with the
City's then-cUITent policies and procedures for accommodating such improvements on street rights-of-way . Information as to these
policies and procedures may be obtained from the Streets and Public Works Departments .
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe
and proper condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper
maintenance thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways and
structures necessary due to the installation and existence of the facilities of the party of the second part, and if at any time the party of
the first part shall require the removal of or changes in the location of the said facilities, that the said party of the second part binds
himself, his successors and assigns, to promptly remove or alter the said facilities in order to conform to the said requirement, without
any cost to the party of the first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs, signal
ligbts, flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform Traffic Control
Devices for Streets and Hi ghwavs and Amendments or Supplements thereto. Information as to the above rules and regulations may be
obtained from the City Engineer of the party of the first part.
That the party of the second part hereby agrees to indemoify and save harmless the party of the first part from all damages and
claims for damage that may arise by reason of the installation and maintenance of this encroachment.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of
the City Engineer of the party of the first part. Toe party of the second part agrees to exercise eve:ry reasonable precaution during
construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There sball be compliance with applicable rules and regulations
of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and with ordinances
and regulations of party of the first part relating to pollution preventions and control. When any installation or maintenance operation
disturbs the ground surface and the existing ground cover, the party of the second part agrees to remove and replace the sod or otherwise
reestablish the grass cover to meet the satisfaction of the City Engineer of the party of the first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary by
the City Engineer of the party of the first part.
That the party of the second part agrees to have available at the construction site, at all times during construction, a copy of this
agreement showing evidence of approval by the party of the first part. The party of the first part reserves the right to stop all work unless
evidence of approval can be shown.
Provided the work contained in this agreement is being performed on a completed highway open to traffic; the party of the
second part agrees to give written notice to the City Engineer of the party of the frrst part when all work contained herein has been
completed. Unless specifically requested by the party of the first part, written notice of completion of work on highway projects under
construction will not be required.
That in the case of noncompliance with the tarns of this agreement by the party of the second part, the patty of the first pan
reserves the right to slop all work until the facility has been brought into compliance or removed from the right .of -way at no east to the
party of the first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein
is not begun within one (1) year from the date ofauthtunuation by the party of the first pert unless written waiver is mural by the party
of the second pan from the party of the first pan.
IN WITNESS WHEREOF, oath (Stile parties to this agreement has eau he same to be exec ed in
the day and year first above written.
ATTEST:
.41,Azt -6),(
ATTEST:
ottlintieiO4,
1 ().''-%4 - `� Pl st"of NANCY
: NOTARY P
STATE 0 ' 0 FtP ° m , rector o Chemical and
—_ Comm. E X p HS* onmental Engineering
• }
a:: May 03, 2019
r r ' Recorded in
EsTRuc ir-Ns drir,i••• so��o�t•�`4 Clefmont County
af
When the applicant is a/ca raft n, this agreement must have the corporate seal; and be attested by the corporation secretary.
In the space provided is this agreement for execution, the name of the corporation shall be typed above tine name and title of
all persons signing She agreement should be typed directly below their signature.
CITY OF . r ON-SALEM
sy iyi ''
Gregory M. Tunier
Assistant City Manager
CINCS (;brporatioa
( SEAL)
This agreement must be accompanied in the form of an attachment, by pions or drawings showing the following applicable
information;
I. All roadways and ramps
2. Right of way linos and where applicable, the control of access tines
3. Location of the existing and/or proposed encroachment
4. Length, size and type ofence:reament
5. Method of installation
6. Dimensions showing the distance from the encroachment to edge of pavement, shoulders, structures, etc-
7 . Location by highway survey station number. if station number cannot be obtained, location should be shown by distance
from some idendlablc point such as a bridge, road, intersection, etc.
8. Drainage srntctt res or bridges if affected by encroachment (show vertical and horizontal dimensions from encroachment
to nearest part of am -lure)
9. Method of attachment to drainage structures or bridges
IC. Manhole Design
1 I. On endexgruund tailities, the depth of bury under all traveled lanes, shoulders, ditches, sidewalks, etc.
12. Length, size and type of encasement where required.
13. On underground crossings, notation as to method of crossing - boring and Sacking open cur. etc.
14_ Location of vents.
GENERAL REOU1REMENTS
1. Any attachment to a bridge or other drainage structure must be approved by the Engineering Division prior to submission
of encroachment agreement to the City Engineer.
2. All crossings should be as near as possible normal to the centerline of the highway.
3. Minimum vertical clearances of overhead wires and cables above all roadways must conform to clearances scr out in the
National Electric Safety Code.
4. Encasements shall execs d from ditch line to ditch line in cut sections and 5' beyond toe of slopes in MI sections.
5. Ali vents should be extended to the right-of-way line or as otherwise required by the Department.
5. All pipe encascn sit as to material and strength shall meet the standards and specifications of the Department_
7. Any special provisions or specifications as to the performance ofthe work or the method of construction that may be
required by the Department must be shown on a separate sheet attached to encrtranhment agreement provided that
such information cannot be shown on plans or drawings.
8. The City Eegineer sltorrld be given notice by the applicant prior to scum/ starring of in ailatton included in this
apemen
g Work will not begin until a written permit has boon obtained from the Ciiy Engineering Division.