WI0400395_DEEMED FILES_20160523

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Resources
Permit N umber_Wl_o_4o_o3_ss ____ _
1. Permit Information
Quality Oil Company, LLC
Permittee
Former Coliseum Shell Service
Facility Name
3009 University Pkwy, Winston-Salem
Facility Address
2. Injection Contractor Information
Terraquest Environmental Consultants , P .C.
Injection Contractor I Company Name
Street Address 100 E. Ruffin St
Mebane NC 27302
City State Zip Code
~ 563-9091
Area code -Phone number
3. Well Information
Number of wells used for injection _6 ___ _
Well names MW4, 13, RW5, 15, 16, 17
Were any new wells installed during this injection
event?
D Yes Iii No
lf yes , please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells -------
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
D Yes Iii No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells -------
Please include a copy of the GW-30 for each well
abandoned.
4. lnjectant Information
Oxygen BioChem
lnjectant Type
Concentration =solubility=7 weight %
If the injectant is diluted please indicate the source
dilution fluid. distilled water ------------
Total Volume Injected 1.2 gallons
Volume Injected per well 0.2 gallon/well
5. Injection History
Injection date(s) 5/1 1 f 16 ------------
Injection number (e.g. 3 of 5) 11 Of 20
Is this the last injection at this site?
D Yes Iii No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
Olgllaly' signed by Ryan D. Kerin5 tD-1--ON : cn•Ryan D. Kerins, o, ou, email-."dkerins@terraqutstpc .cc;tm,
c1aUS
Olt.:2016.05.2315:al0:17-04'00'
SIGNATURE OF INJECTION CONTRACTOR
Ryan D. Kerins Rr-.c:::: ,-~
DATE
PRINT NAME OF PERSON PERFORMING THE INJECTION M!'f ;2.3 2ot(y
Submit the original of this form to the Division of Water Resources within 30 days of injection. WaterQuaut~orm UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 RegionalOperationsf ~ig~/2013
c
January 18, 2016
03gY TERRAcluest
ENVIRONMENTAL CONSULTANTS. P.C.
Shristi Shrestha
DWR-UIC Program
1636 Mail Service Center.
Raleigh, NC 27699-1636
Re: Injection Event Record
Coliseum Shell -Quality Oil Company, LLC
NCDMW-UST Incident No. 15260
Terraquest Project No. 01195
UIC No. WI0400395
Dear Ms. Shrestha:
RECEIVED1NCDEQ/DWR
JAN 212016
Web*. Quality
FitgiOnai ,as
On behalf of Quality Oil Company, LLC, Terraquest Environmental Consultants, P.C. hereby
submits the enclosed Injection Event Record for the Coliseum Shell facility located in Winston-
Salem, Forsyth County, North Carolina.
Sincerely,
TERRAQUEST ENVIRONMENTAL CONSULTANTS, P.C.
Ryan D. Kerins
Project Manager
Enclosure
100 E. Ruffin Street • Mebane, North Carolina 27302
Telephone [phone] • Facsimile [phone]
www.terraquestpc.com

1.
2.
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Resources
Permit Number_w_10_4o_o3_9s ____ _
Permit ln(ormation
Quality Oil Company, LLC
Permittee
Former Coliseum Shell Service
Facility Name
3009 University Pkwy, Winston-Salem
Facility Address
Injection Contractor Information
Terraquest Environmental Consultants, P.C.
Injection Contractor/ Company Name
Street Address 1 00 E. Ruffin St
4.
Mebane NC 2lJ~1NcoeOJ1 ll" R
City State Zip Code
< 919) 563-9091 JAN 112.0 B
Area code -Phone number Water Quality
Were any wells abandoned during this injection
event?
D Yes Iii No
If yes, please provide the following information:
Number of Monitoring Wells ------
Number of Injection Wells ______ _
Please include a copy of the GW-30/or each well
abandoned.
lnjectant Information
Oxygen BioChem
Injectant Type
Concentration =solubility=? weight %
If the injectant is diluted please indicate the source
dilution fluid. distilled water ------------
Total Volume Injected 6 gallons
3. Well Information
• I operations SE ctlon 1 11
Regiona Volume Injected per well ga On
Number of wells used for injection _6 ___ _
Well names RW5, 12, 13, 14, 16, 17
Were any new wells installed during this injection
event?
0 Yes [j] o
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
5. Injection History
Injection date(s) 1 f 18/16 ------------
Injection number ( e.g. 3 of 5) 1 Q Of 20
Is this the last injection at this site?
D Yes Iii No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
ST AND ARDS LAID OUT IN THE PERMIT.
t-x,./4 Digitally algned by Ryan D. Kerins
DN: cn..Jlyan D. Kerim, o, ou, emalt,,[e-mail],
,-us
0ate:201e.01.H11a:11:21-05'oo'
SIGNATURE OF INJECTION CONTRACTOR DATE
Ryan D. Kerins
PRINT NAME OF PERSON PERFORMJNG THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 8/5/2013
rs v p 4-0035
INJECTION EVENT RECORD
RECEIVEDIDENRIDWR
OCT 1 5 2015
North Carolina Depai intent of Environment and Natural Resources — Division of Water Resources
Permit Number WI 3S Water Quality Regional
eratiofta Sinn
1. Permit information
Quality Oil Company, LLC
Permittee
Former Coliseum Shell Service
Facility Name
3009 University Pkwy, Winston-Salem
Facility Address
2. Injection Contractor Lnformation
Terraquest Environmental Consultants, P.C.
Injection Contractor / Company Name
Street Address 100 E. Ruffin St
Mebane NC 27302
City State Zip Code
[phone]
Area code— Phone number
3. Wen Information
Number of wells used for injection 9
Well names MW4,13,RW1,5,12,13,14,15,17
Were any new wells installed during this injection
event?
❑ Yes 0 No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored . ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-J form for each
well installed.
Were any wells abandoned during this injection
event?
❑ Yes N
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Oxygen BioChem
Inj ectant Type
Concentration =solubility=7 weight %
If the injectant is diluted please indicate the source
dilution fluid. dlstiited water
Total Volume Injected 9 gallons
Volume Injected per well 1 gallon
5 Injection History
Injection date(s) 10'8/ 15
Injection number (e.g. 3 of 5) 9 of 20
Is this the last injection at this site?
El Yes ID No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
64
OWwo,. vow b/ It. O. !SEAM
u+m.apnwwe.o.w•ninri•er i
w. Ow.m,sicm,rsr.s. -0a11r
SIGNATURE OF INJECTION CONTRACTOR DATE
Ryan D. Kerins
PRINT NAME OF PERSON PERFORMING I'HE INJECTION
Submit the original of this farm to the Division of Water Resources within 30 days of injection.
Attu: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699- I 636, Phone No. 919-807-6464
Form HIC-IER
Rev. 8/5/2013

~ ' ,
~~ogers, Michael
From:
Sent:
To:
Subject:
Attachments:
Ryan Kerins <[e-mail]>
Tuesday, September 01, 2015 10:39 AM
Rogers, Michael
WI0400395 Event Record Submittal
lnjectionEventRecord 8of20 8-24-15.pdf
Please see attached. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.~091
From: Rogers, Michael [mailto:[e-mail]]
Sent: Thursday, July 30, 2015 5:00 PM
To: Ryan Kerins <[e-mail]>
Cc: Moore, Thomas <[e-mail]>
Subject: RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
OK, thanks. Just a reminder, this supplemental work under the permit is OK as long as it remains a 'Passive Injection'
type.
From: Ryan Kerins [mailto:rdkerins @terra q uestpc.com]
Sent: Thursday, July 30, 2015 3:48 PM
To: Rogers, Michael
Cc: Moore, Thomas
Subject: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thanks for the phone message yesterday. Following our addition of OBC to the permitted well at this site, MW4, the
MTBE concentration dropped from 45,500 ug/L to 14,300 ug/L. We'd like to do some more of that across the site.
I'd like to add OBC to the following wells at Coliseum Shell: MW1, MW3, MW10, MW14, RW1, RW4, RW10, RW15,
RW19, RW20, and PZ1.
I've included well construction records that I have, soil borings and a well construction table for the others.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.ro gers @ncdenr.gov]
Sent: Thursday, June 18, 2015 2:59 PM
To: Ryan Kerins <rdkerins @terra o uest pc.com>
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please follow up with hard copy. Thanks.
1
From: Ryan Kerins [mailto:rdkerins@terrag uestpc.com]
Sent: Tuesday, June 16, 2015 9:58 AM
To: Rogers, Michael
Subject: FW: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
Please see attached.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563 .9091
From: Ryan Kerins [mailto:rdkerins @terraq uestpc.com]
Sent: Thursday, June 04, 2015 5:08 PM
To: 'Rogers, Michael'
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please see attached.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.rogers @ncdenr.g ov]
Sent: Thursday, April 23, 2015 2:22 PM
To: Ryan Kerins; 'bsnover@qocnc .com' (bsnover @q ocnc.com)
Cc: Basinger, Corey; Knight, Sherri
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015) is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies
of the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form . These forms can be found on
our website at http://portal.n cdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g ., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.rogers @ncdenr.mv. send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
2
this email. You may if you wish, scan and send back as attachments in re p ly to this email. as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE : Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Ryan Kerins [mailto:rdkerins@terra questpc.com]
Sent: Thursday, April 23, 2015 10:00 AM
To: Rogers, Michael
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
I do not have the GW-1 form. I've pieced together the following from old field notes:
The well was drilled on January 25 -26, 1996 by Mike Ransier of American Drilling. Mr. Ransiers driller's license number is
2501.
Construction follows:
Outer casing: 0-40 feet below ground level (BGL) 6"-diameter PVC
Inner casing: 0-45 feet BGL 2"-diameter PVC casing with another 5 feet of 2"-diameter PVC screen with a 0.010" slot size
for a total well depth of 50 feet BGL.
Inner: Grout 0-38' BGL, bentonite 38-43', sand 43-50'.
Manager: Kenneth Basch
Ryan Kerins , Project Manager, Site's ORC (phys/chem Grade I)
Thanks,
Ryan Kerins
Terraquest Environmental Consultants, P.C.
From: Rogers, Michael f mailto :m ichael.ro gers (a)ncdenr.g ov]
Sent: Wednesday, April 22, 2015 4 :23 PM
To: Ryan Kerins
Subject: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Ryan-
3
We received the NOi for the above project. Thanks .
• Do you have the GW-1 for the MW-4. If not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
• And finally, your title.
Thanks
From: Ryan Kerins [mailto:rdkerins ©terrag uestpc.com]
Sent: Wednesday, April 22, 2015 9:02 AM
To: Rogers, Michael
Subject: UIC Notice submittal
Please find the attached Notification of Intent. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919 .563 .9091
4
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Resources
Permit Number w10400395
1. Permit Information
Quality Oil Company, LLC
Permittee
Former Coliseum Shell Service
Facility Name
3009 University Pkwy, Winston-Salem
Facility Address
2. Injection Contractor Information
Terraquest Environmental Consultants, P.C.
Injection Contractor I Company Name
Street Address 100 E. Ruffin St
Mebane NC 27302
City State Zip Code
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection 13
PZ1 ,MW3,4,RW1 ,4,5,12, 13, 14, 16, 17, 19,20
Well names -------------
Were any new wells installed during this injection
event?
D Yes Ii] No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
--------
Were any wells abandoned during this injection
event?
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number ofinjection Wells _______ _
Please include a copy of the GW-30for each well
abandoned.
4. Injectant Information
Oxygen BioChem
Injectant Type
C t t . =solubility=? wei.ght % oncen ra 10n -----------
If the injectant is diluted please indicate the source
dilution fluid. municipal water ------------
Total Volume Injected 1 o.5 gallons
1/2 gallon in PZ1 ,MW3,4,RW1 ,RW5
Volume Injected per well _______ _
1 gallon in RW4,12,13,14,16,17,19,20
5. Injection History
Injection date(s) B/31 f 15
------------
Injection number ( e.g. 3 of 5) B Of 20
Is this the last injection at this site?
D Yes [j] No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
(b./4 Oigi1allysignl:dbyRyim0.Kerins
ON: Gfl"Ryan D. Kerins, o, oo. e111ail=rdkt,[e-mail],
.·c=US
SIGNATURE OF INJECTION CONTRACTOR DATE
Ryan D. Kerins
PRlNT NAME OF PERSON PERFORMJNG THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UTC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UTC-1ER
Rev. 8/5/2013
INJECTION EVENT RECORD
RECEIVEDIDENRIDWR
AUG 2 7 2015
North Carolina Department of Environment and Natural Resources -Division of Wat, , -, u I t R .
Permit Numberw104003ss Oo,:\rat.· Y8 eg_,ona!
r----------------------
1. Permit Information
Quality Oil Company, LLC
Permittee
Former Coliseum Shell Service
Facility Name
3009 University Pkwy, Winston-Salem
Facility Address
2 . Injection Contractor Information
Terraquest Environmental Consultants, P.C.
Injection Contractor/ Company Name
Street Address 1 00 E. Ruffin St
Mebane NC 27302
City State Zip Code
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection _2 ___ _
Well names PZ 1' RW20
Were any new wells installed during this injection
event?
D Yes Ii] No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells ______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
, ... ,_ .,ons ectron
Were any wells abandoned during this injection
event?
0 Yes [j] o
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells ______ _
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Oxygen BioChem
Injectant Type
Concentration =solubility=? weight %
If the injectant is diluted please indicate the source
dilution fluid. municipal water -----------
Tot al Volume Injected 2 gallons
Volume Injected per well 1 gallon
5. Injection History
Injection date(s) __ B_f 2_4_f_1_5 _____ _
Injection number (e.g. 3 of5) 7 of 20
Is this the last injection at this site?
D Yes [j] No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
t~-J. Dlgblly llgned by Ryan 0, Kel'ffl
DN :cn•Ryari D. Kerin,, o, 01.1. emai""[e-mail], ..us
0.119:2015.08.2500:31:41 -G4'00'
SIGNATURE OF INJECTION CONTRACTOR DATE
Ryan D. Kerins
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 , Phone No. 919-807-6464
Form UIC-IER
Rev. 8/5/2013
0~,Michael
From:
Sent:
Ryan Kerins <[e-mail]>
Monday, August 31, 2015 8:53 AM
To: Rogers, Michael
Subject:
Attachments:
RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
20150830205009154.pdf
Michael:
We have turned off our onsite treatment syst j m and will be adding OBC to wells that were previously actively
pumping. Well construction records for RW 1,~W12, RW13, RW14, RW16, and RW17 are attached. This serves to
update our Notice of Intent for passive injection of OBC into those wells.
Thanks!
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563 .90 91
From: Rogers, Michael [mailto:[e-mail]]
Sent: Thursday, July 30, 2015 5:00 PM
To: Ryan Kerins <[e-mail]>
Cc: Moore, Thomas <[e-mail]>
Subject: RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE : UIC Notice submittal
OK, thanks. Just a reminder, this supplemental work under the permit is OK as long as it remains a 'Passive Injection'
type.
From: Ryan Kerins [mailto:rdkerins (Q terra q uestpc.com]
Sent: Thursday, July 30, 2015 3:48 PM
To: Rogers, Michael
Cc: Moore, Thomas
Subject: WI0400395 RE: WI0400395 NO! Former Coliseum Shell RE: UIC Notice submittal
Thanks for the phone message yesterday. Following our addition of OBC to the permitted well at this site, MW4, the
MTBE concentration dropped from 45,500 ug/L to 14,300 ug/L. We'd like to do some more of that across the site.
I'd like to add OBC to the following wells at Coliseum Shell: MWl, MW3, MWl0, MW14, RW1, RW4, RW10, RWlS,
RW19, RW20, and PZ1.
I've included well construction records that I have, soil borings and a well construction table for the others.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.rogers @ncdenr.g ov]
Sent: Thursday, June 18, 2015 2:59 PM
1
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Well Contractor [lndividualj'Name
TerraQuest Environmental Cons.
Well Contractor Company Name
STREET ADDRESS 100 E. Ruffin St.
Mebane NC
27302
City or Town State Zip Code
( 919 J. 563 - 9091
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ir applicable) RW5
STATE WELL PERMIT .Qrapplicable) NA
DWQ or OTHER PERMIT #(if applicable) NA
WELL USE (Check Applicable Box) Monitoring 0 Municipa IPublic Cl
Industrial/Commercial ❑ Agricultural 0 Recovery ID Injection ❑
irrigation° Other 0 (list use)
DATE DRILLED 9/14110
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: Winston-Salem
COUNTY Forsyth
3009 University Pkwy
(Street Name. Numbers, Community, Subdnision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley °Flat ❑ Rtdge ❑ Other
(check appropriate box)
LATITUDE j_ 07` 50" N
LONGITUDE 80 15' 45" W
May be in degrees:
minutes, seconds or
in tic decimal format
Latitude/longitude source: 0GPS °Topographic reap
pc-of/on of well mus( be shown on a USGS lopo map end
allachad to this form if not using GPS)
4. FACILITY- Is the name of the business whale the earl Is located.
FACILITY ID #(1f applicable) 0-020021
NAME OF FACILITY Coliseum Shell
STREET ADDRESS 3009 University Pkwy.
Winston-Salem NC
City or Town State
27102
Zip Code
CONTACT PERSON Danny Stroud
MAILING ADDRESS P.O. Box 2736
Winston-Salem NC 27102
City or Town Stale Zip Code
( 336 ). 867 - 5309
Area code - Phone number
5. WELL DETAILS:
e. TOTAL DEPTH: 44
b, DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use "+' If Above Top of Casing)
YES [7 NO n
FT.
d. TOP OF CASING IS 0.0' F. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
From NA To NA
From, NA To NA
From NA To NA
6. CASING:
From NA To NA
From
From NA To NA
Thickness/
Depth Diameter Weight Material
From 0 To i4 Ft. 2 inch Sch. 40 PVC
NA To NA
Frorn To Ft.
From To Ft
7. GROUT: Depth Material Method
From 10 To 12 R. Bentonite Pour
From 0 To 10 FI. Portland Cement Pour
From To Ft.
9, SCREEN: Depth Diameter Slot Site Material
Ft, 2 in, .010 in. PVC
From 14 To 44
From To Ft. in. _ _ In.
From To Ft. in. In.
9. SAND/GRAVEL PACK:
Depth Sire Material
From 12 To 44 Ft caarsa sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 1 ASPHALT
1 14
14 44
11. REMARKS:
SILTY
SAPROLITE
I DO HERE CERTIFY /HAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC " C. W ' L CONSTRUCTIONs/AWARDS, AND THAT A COPY OF THIS
RECORD CS 6PROVIDED TO THE WELL OWNER.
SIGNATURE 'TlFIED WELL CONTRACTOR DATE
PRIN1rD NAME PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mall Service Center Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-lb
Rev. 7105

i. WELL CONTRACTOR:
Vick Perry
NON RESIDENTLAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
Well Contractor (tndividual) Name
TerraOuest Environmental Cons.
Well Contractor Company Name
100 E Ruffin St.
Street Address
Mebane
City or Town
(919 ) 563-9091
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PERMIT#(tF applicable) NA
SITE WELL tO #(stapplicable) RW 12
3. WELL USE (Check One Box) Monitoring d Municipal/Public❑
IndustriaL+Commercial 0 Agricultural 1D Recovery 0 Injection 111
Irrigationl] Other ❑ (llstuse)
DATE DRILLED 10-8-1 Q
4, WELL LOCATION:
3009 University Pkwv
NC 27302
State 7ip Code
(Street Name, Numbers. Community, SubdMslnn, Lot No., Parcel, Zip Code)
CITY: Winston Salem COUNTY Porsvth
TOPOGRAPHIC ( LAND SETTING; (check appropriate box)
❑Slope ❑Valley QFlat DR1dge L ICther
LATITUDE 36 7 } 5o.otxxl • DMS OR
LONGITUDE 79 15 ' 45.0000 " DMS OR
Latitudef[ongltude source: EPPS l rapographic map
(location of well must ha shown on a USGS Topo map endatfached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Da
DO
Co lseum S.hf'!{ [1-02002i
racility Name Facility 1D4 (if applicable)
Street Address
-Gre!?nshrirn N{ : 27102
City or Town
❑anrlV Stroud
Contact Name
P C3_ 130x 27361
Mailing Address
Winston Salem
City or Town
(3 _15 867-5309
Stake Zip Code
NC 27102
Slate Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_(}' y!
b. DOES WELL REPLACE EXISTING WELL? YES ID NO Ly
E. WATER LEVEL Below Top of Casing: FT.
(Use `+" If Above Top of Casing)
d. TOP OF CASING IS 110 FT. Above Land Surface`
'Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C ,t0118.
D. YIELD] (gpm): NA METHOD OF TEST NA
L DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
Top_NA A Boilom�� Tap NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Haltom 10 Ft. flinch sch 40 PVI
Top Bottom Ft.
Top 8oltom. Ft.
8. GROUT: Depth Material Method
Top 2 _ Bottom 6 Ft. Portland Pour
Top 6 Bottom 8 Ft. Bentonite Pour
Top Bottom Ft._
9. SCREEN: Depth Diameter Slot Size Material
Top I0 Bottom 40 FL 41riClirt. .010 in. PVC _
Top Bottom Ft. in. in.
Top Bottom Ft In. in.
10. SANDIGRAVEL PACK
Depth Size Material
Top 8 Bottom 40 Ft..eo irse ._Sand
Top _ Bottom Ft.
Top Bottom Ft.
DRILLING LOG
Top Bottom Formation Description
0 ! 40' Silly Clay
1
/
1
1
1
1
1
1
12. REMARKS:
I DO HE
15A N
RECO
9irCERIFT THAT -THIS WELL WAS CONSTRUCTED IN ACCORDANCE 'OATH
, WELL CANSTRUCTID4 STANDARDS, AND T AT A COPY OF THLS
REt:N A3 t}VIDEO TO THE WELL OWNER,
SIGNATURE O). CERTIFIED WELL CONTRACTOR
D
PRI 'TED NNA E (IF PERSON CONSTRUCTING THE WEt I.
Submit within 30 days of completion to! Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
TE
Form GW-lt,
Rev. 7100

Facility Name
3000 F Market St
street Address
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironment and Natural Resources- Division ofWater Quality
WELL CONTRACTOR CERTIFICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Welt Contractor (Individual) Name
TerraQuest Environmental Cons.
Well Contractor Company Name
100 E Ruffin St.
Street Address
Mebane
NC 27302
City or Town State Zip Code
(919 ) 563-9091
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PRMIT#(ifapplicable) NA
SITE WELL ID#(IfapplIcable) RW13
3. WELL USE (Check One Box) Monitoring Ne'Municipal/Public ❑
IndustrialiCommerclal ❑ Agric.atti rat ri Recovery El Injection ❑
IrrigatlonD Other C] (Fist use)
DATE DRILLED 10-6-10
4. WELL LOCATION:
3009 University Pkwv
(Street Name, Numbers, Community, Subdivision, Lot No., Parcet, Zip Cade)
CITY: Winston Salem COUNTY Forsyth
TOPOGRAPHIC / LAND SETTING_ (cheek appropriate box)
©51ope ❑Valley ❑Flat oRidge ❑Other
LATITUDE 36 •7 ' 50.0000 " DAM OR
LONGITUDE 79 ° 15 ' 45•0000 " DMS OR
Latltude1ongltude source: ❑GPS ViTopographIc map
(location of well must be shown on a USGS tope map artdatiached to
this form if not using GFS)
5. FACILITY (Name of the business where the welt is located.)
DO
DID
Colisetlrrl Shell 0-029f21
Facility ID# (if applicabley
Gre.ensbrro Ni : 27102
7
City or Town Stale Zip Code
Danny Stroud
Contact Name
PS3Jam( 2736
Mailing Address
Winston Salem
City or Town
NO 27107
State Zip Code
i 336fi 8675309
Area code Phone number
6, WELL DETAILS:
a. TOTAL DEPTH:_ l
b. DOES WELL REPLACE EXISTING WELL? YES a NO
c_ WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d, TOP OF CASING IS 0.0 FT. Above Land Surface'
"Top or casing terminated etfor below land surface may require
a variance In accordance with 1$A NCAC 2C .0118.
e. YIELD (gpm): NA METHOD OF TEST N/
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top_ NA Bottom NA _
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 13 . FL 4ioCh sch 1 40 PVC
Top Bottom Ft.
Top Bottom FI.
8. GROUT: Depth Material Method
Tapes_ Bottom 9 Ft. Portland Pgur
Top 9 Bottom 11 Ft. Berltonite Pour
Top Bottom
9. SCREEN: Depth Diameter Slot Size Material
Top 15 Bottom 43 Ft. 41nchn. .010 in. PVC
Top_ Bottom Ft. in. In.
Top Bottom FL In. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 11 Bottom 43 Ft coarse Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
D 143'
1
I
1
l
f
1
12. REMARKS:
Formation Description
Silty Clav
[ Do HERE
1SA NCgC
REOOR0+
r CERTIFY THAT THIS WELL WAS caoNSTRLICTEO It+tACCORDANCE WIT[ I
- LL CONSTRUCTION STANDMOS. AND 'MAT A COPY OF THIS
nS - EN PRO . t D TO THE WELL OWNER.
V
SIGNATURE er ERTIFIED WELL CONTRACTOR
R�
R D NAME
1)TE
P i OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water quality - Information ,Processing,
1617 Mall Service Center, Raleigh, NC.27699-161, Phone : (9T9) 807-630Q
Form GWib
Rev. 2/0g

NON ONRESJDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Enviromnent and Natural Resotuces- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Well Contractor (Indniduai) Name
TerraQuest Environmental Cons.
Well Contractor Company Name
100 E Ruffin St.
Street Address
Mebane NC 27302
City or Town State Zip Code
(919 563-9091
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PERMIT#(if appfi able) NA
SITE WELL 1D#{ifappiicabfe) RW14 _
1. WELL US (Check One Box) Monitoring at Municipal/Public [j
IndtrsirialICommercfal G Agricultural C7 Recovery L7 Injection D
Irrigation❑ Other ❑ (list use)
DATE DRILLED 10-6-10
4. WELL LOCATION:
3009 University Pkwv
(Street Name, Numbers, Corrmunfry, Subdivision, Lot No., Parcel, Zip Code)
CITY: Winston Salem COUNTY Forsyth
TOPOGRAPHIC f LAND SETTING' (check appropriate box)
1JSIope r7Valley (it Flat ❑fudge °Other
LATITUDE 36
LONGITUDE 79
• 7 50.0000 • DMs OR
• 15 + 45.0000 • DM5 oR
DD
DO
LatitudeltongItude source: E13PS 1i1"opographlc map
(locatiarr of well must be shown on e iJSGS topo map andattached to
this form if not using GPS)
6. FACILITY (Name of the business where the well 1s located.)
Cniisetirn She!! - 20_021
Fadllty Name Faculty li3# (it applicable)
3000 F Market St
Street Address
Greenshsjn NC 27102
City or Town State Zip Code
Danny Stroud
Canted Warne
PD Box2J30
Malting Address
Winston Sale rn
City or Town
NC: 27102
State Zip Cade
c 336 3 67-5309
Area code Phone number
8. WELL DETAILS:
a. TOTAL DEPTH: 45'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 1
C. WATER LEVEL Below Top of Casing: _ _ _ Fit
(Else "+' if Above 1 op of Casing)
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated atior below land surface may require
a variance In accordance with 15A NCAC 20 .0118.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA_
g. WATER ZONES (depth):
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom_NA
Top NA Bolton} NA Top NA Bottom NA
Thickness!
7. CASING: Depth Diameter We2ght Material
Top 0 Bottom 15 Ft. 4inch soh 40 PVC
Top Bottom Et.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 2 Bottom 11 Ft. Portland Pour
Top 11 Bottom 13 Ft, Bentonite loDiir __
Top Bottom Ft.
9. SCREEN: Depth Diamot0r Slot Size Material
Top 15 Bottom 45 FL 4inci1n. .010 In. FC
Top Boltom Ft. In. In_
Top Bottom Ft. in. in.
10, SAND/GRAVEL PACK:
Depth Size Material
Top_ 13 Bottom 45 Ft. coarse Sand
Top Bolcom Ft.
Top Bottom FL
11. DRILLING LOG
Top Bottom Formation DescrlptiOn
0 / 45' clak
1
1
1
1
1
12. REMARKS:
DO HE
1.N
RECOR
©YAentire THAT THIS WELL WAS CONSTRUCTED }IV ACCORDANCE W#Tli.
Fi L CONSTRICTION STANDARDS, AND THAT A COPY OF THUS
SEEN PRO Y My y To THE WELL OWNER.
SIGNATUf OFERTIFIED WELL CONTRACTOR DATE
G +
PRINTED NAM OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing.
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2f09

•flit �'
1. WELL CONTRACTOR:
Nick Perm
NON _RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rcsourtes- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
Well Contractor (Individual) Name
TerraQuest Environmental Cons.
Welt Contractor Company Name
100 E Ruffin St.
Street Address
Mebane
City or Town
[phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERM1Tt# NA
NC 27302
State Zip Code
OTHERASSOCtATED PERM1T#(# applicable) NA
SITE WELL ID #iaepplible) RW16
3. WELL USE (Check One Box) Monitoring 6/MunicrpallPubiic 0
Industrial/Commercial 0 Agricultural 0 Recovery p Injection 0
lrrtgationp Other 0 (fist use)
DATE DRILLED 10-6-10
4. WELL LOCATION:
3009 University Pkwv
(Street Name, Numbers, Carnmunliy, Subdivision, Lot Mx, Parcel, Zip Coda)
CITY: Winston Salem couNTY Forsyth
TOPOGRAPHIC 1 LAND SETTING: (checis appropriate box)
DSiope L1Valtey °Flat EIRIdge ❑Other
LATITUDE 35 ° 7 50.0000 DMS OR
LONGITUDE 79 ° 15 45.0E706 ° DMS OR
DD
DD
Latitude/longitude source: [PPS Topographic map
(location of well Must be shown on a USGS logo map andattached to
This form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
Coliset tm Shell 0-070021
Facility Name Facility ID# (if applicable)
'loon F MRticet,St
Street Address
G;reenshorn NC 2 J07
City or Town State Zip Code
17annv Sf rot rrl
Contact Name
P.Q. Box 7736
Mailing Address
Winton Salem
City or Town
r 336. R67-5309
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 43'
N n 77107
Stale Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES a NO a
c. WATER LEVEL Below Top of Casing: FT.
(Use "+" If Above Top of -Casing)
d. TOP OF CASING IS 0 0 FT_Above Land Surface"
`Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
Top NA Bottomij
Top NA Bottom NA
Top NA Bottom NA
Top NA Bottom NA
Top NA Bottom NA
Top NA Bottom NA
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 13 Ft. 4irtGh $ t) 40 PVC
Top
Top
Bottom Ft
Bottom Ft
8. GROUT: Depth Material Method
Tod 2 Bottom 9 Ft. Portland Pour
Top 9 Bottom 11 Fi. Bentonite Pour
Top Bottom FL
9. SCREEN: Depth Diameter Slot Size Material
Top 13 Bottom 43 Ft. 4indin. .010 in. PVC
Top Bottom Ft. In. In.
Top Bottom F!, in. in.
10, SANDIGRAVEL PACK:
Depth
Top 11. Bottom 43
Top
Top
Size
Ft. COBrse
Bottom Ft. _
Bottom FL
11. DRILLING LOG
Top Bottom
i7 ! 43'
1
I
1
1
1
1
12. REMARKS:
Material
Sand
Formation Description
Silty Ciao
IDOIiERERYC
1SA NCAII' 2C, v1E!
RECORD 1AS! EN
t
r{FY THAT THIS WELL WAS CONSTRUCTED IN ACC0ROANCE WTH
CONSTRUCTION STANDAR US, AND THAT ACOPY OF THIS
OVj7E D TO THE WELL OWNER.
SIG NATURE OF CERT1F1ED WELL CONTRACTOR - a E
_____Yakk•rir'l
PRIFED NAME OFF PERSON CONSTRUCTING THE WELL
Submit within 30 clays ofcompletion to: Division of Water Quality - Information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/0S

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Caroiina Department of Enviromnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION tl 3329
1. WELL CONTRACTOR:
Nick Perry
Weft Contractor (Individuai) Name
TerraQuest Environmental Cons.
Wei Contractor Company Name
100 E Ruffin St.
Street Address
Mebane NC 27302
City or Town State Zip Code
(919 ) 563-9091
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* NA
OTHER ASSOCIATED PERMFT#(if applicable) NA
StTE WELL ID #td eppiirable) RW17
3. WELL USE (Check One Sox) Monitoring i( Municipal/Pubic L7
IndustriallCommercial ❑ Agricultural ❑ Recoveryp Injection
Irrigalion[T Other[] (list use)
DATE DRILLED 10-6-10
4. WELL LOCATION:
3009 University Pkwv
(Street Name, Numbers. Community, Subdivision, Lot Nu., Parm!, Zip Code)
CITY: Winston Salem
TOPOGRAPHIC f LAND SETTING:
0Slope EJValley F]F1at uRidge
LATITUDE 36 ° 7 ' so.ovaa
COUNTY Forsyth
(check appropriate box)
D Other
• DINS Oft
LONGITUDE 79 ° 15 • "aao . 1]tv1S OR
Latitude/longitude source: D3PS Vtropographic map
(location of well must be shown on a USGS lopo wrap andattached to
this form i(no! using CPS)
6. FACILITY (Name of the business where the well 1s located,)
❑D
DD
Coliseum Shell 0-020fl21
Facility Name Facility ID# (if applicable)
3000 F Market St
Street Address
Greensboro NC271 07
Ctty or Town
Danny_ Stroud
Contact Name
P 0 Rnx 273E
Mailing Address
Winston s s3Le.m
City or Town
t. ab 867-5309
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 45'
State Zip Cade
NC% 271122
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES u NO LY
c. WATER LEVEL Betaw Top of Casing. FT.
;Use "4- if Above Top of Cesirtgl
d. TOP OF CASING IS 0 0 FT. Above Land Surface`
'Top of casing terminated atlor below land surface may require
a variance In accordance with i5A NCAC 2C .0118,
a. YIELD (gpm): NA METHOD OF TEST NA
f_ DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Boltom NA
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 15_ Fl, 4inch sch 40 PVC
Top _ Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 2 E3otlam 11 Ft. Po - rand �<aC_ _
Top 11 Bottom 13 Ft. aentoplte Pow`
Top Bottom_ Fl.
9. SCREEN: Depth Diameter Slot Size Material
Top 15 Bottom 45 Ft. 4IDGhn. L010 in. _PVC
Top Bodoni _ f Ft. in. In.
Fop Bottom Ft. In. In.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 13 Bottom 45 Ft. coarse Sand
Top Bottom__ Ft._
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formellon Description
0 1 45T Silty_ C1av
1
_ 1
12. REMARKS:
100
15A
RE
Y CERTIFY THAT THIS Wirt WAS CONSTRUCTED IN ACEORCAT;CE WI1 H
C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
c BEEN P'",OVIDFD TO THE WELL OWNER.
S GNATU
CERTIFIED WELL CONTRACTOR D TE
PRENTAAME QF RsoN CONSTRUCTJNG THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone] -
Form GW 1 b
Rev. 2/09

Table 1 MONITORING WEU CONSTRUCTION INFORMATION
Date: 7 /24/15 Incident Name: Coliseum Shell Service Incident No. 15260 Facility ID No: 0·020021
Depth to
Date Water Water from
Level Wall Cosing Depth (ft. Screened Interval (x Bottom of Wall TopofCesfng Top of Casing Free Produ ct Groundwater
Well ID Date Installed Measured 8G51 toy ft. SGS} !ft .BGSl Elevation (ft.I (ft.) Thickness (ft.) Elevation (ft.) Comments
MWl 9/12/1995 7/13/2015 11 11-33 33 959.266 28AO 0 930.87 Type II well
MW2 9/12/1995 7/13/2015 15 15-35 35 960.000 30.90 0 929.10 Type II well
MW3 9/12/1995 15 15-35 35 959.193 Type II well
MW4 1/25-26/96 7/13/2015 OC:40 I IC:45 45-50 so 959.586 29.02 0 930.57 Type Ill well
MWS 1/25/1996 7/13/2015 20 20-35 35 959A05 27.71 0 931.69 Type II well
MW6 1/25/1996 7/13/2015 20 20-35 35 957.466 25.10 0 932.37 Type II well
MW7 1/25/1996 7/13/2015 15 15-30 30 960.246 DRY DRY DRY Type II well
MW8 1/25/1996 7/13/2015 15 15-30 30 957A74 27.50 0 929.97 Type II well
MW9 1/25/1996 7/13/2015 15 15-30 30 954.147 2338 0 930.77 Type llwell
MWlO 5/6/1999 7/13/2015 20 20-30 30 960.733 DRY DRY DRY Type II well
MWll 5/6/1999 7/13/2015 20 20-35 35 964.503 DRY DRY DRY Type II well
MW13 7/8/1999 7/13/2015 10 10-30 30 960.097 DRY DRY DRY Type II well
MW14 7/8/1999 7/13/2015 10 10-30 30 961.950 29.48 0 932.47 Type II well
MWlS 7/9/1999 7/13/2015 10 10-30 30 962.022 DRY DRY DRY Type II well
MW16' 7/9/1999 7/13/2015 10 10-30 30 959.541 Small amount of water/free product trapped in Type II well
well.
MW17 10/13/1999 7/13/2015 10 10-30 30 964.225 DRY DRY DRY Type II well
MW18 10/13/1999 7/13/2015 10 10-30 30 962.198 DRY DRY DRY Type II well
MW19 10/12/1999 7/13/2015 10 10-30 30 958.039 27.30 0 930.74 Type II well
MW20 10/28/2008 7/13/2015 20 20-40 40 963.725 30.14 0 933.58 Type llwell
MW21 10/28/2008 7/13/2015 20 20-40 40 961.512 28.90 0 932.61 Type II well
MW22 10/29/2008 7/13/2015 20 20-40 40 963.903 32.35 0 931.55 Type II well
MW23 10/29/2008 7/13/2015 20 20-40 40 963.825 32.48 0 931.34 Type II well
PZl 3/26/2001 7/13/2015 10 10-35 35 959.266 29.00 0 930.27 Type II well
RWl [EWl) 3/26/2001 10 10-45 45 959.568 Type II well
RW2 10/28/2008 7/13/2015 20 20-45 45 963.739 31.31 0 932A3 4 in. Type II well
RW3 10/29/2008 19 19-44 44 963.856 4 In. Type II well
RW4 9/13/2010 13 13-43 43 959.060 4 in. Type II well
RWS 9/14/2010 14 14-44 44 959.230 2 in. Type II well
RW6 9/15/2010 15 15-45 45 963.320 4 In. Type II well
RW7 9/16/2010 14 14-44 44 959.870 4 in. Type II well
RW8 9/16/2010 15 15-45 45 960.620 4 in. Type II well
RW9 9/16/2010 15 15-45 45 961.040 4 in. Type II well
RWl0 9/16/2010 7 7-37 37 960.550 4 in. Type II well
RWll 10/6/2010 15 15-45 45 959.080 4 in. Type II well
RW12 10/6/2010 10 10-40 40 957.930 4 in. Type II well
RW13 10/6/2010 13 13-43 43 958.620 4 In. Type II well
RW14 10/6/2010 15 15-45 45 959.280 4 in.' Type II well
RW15 10/6/2010 15 15-45 45 959.060 4 In. Type II well
RW16 10/6/2010 13 13-43 43 960.010 4 in. Type II well
RW17 10/6/2010 -15 15-45 45 960.760 4 in. Type II well
RW18 10/7/2010 12 12-42 42 959.270 4 in. Type II well
RW19 10/7/2010 10 10-40 40 958.720 4 in. Type II well
RW20 10/7/2010 12 12-42 42 959.510 4 in. Type II well
All 9/14/2010 15 15-30 30 959.320 1 in. Type II Well
Al2 9/14/2010 15 15-30 30 959.460 1 In. Type II Well
Al3 9/14/2010 15 15-30 30 959.640 1 In. Type II Well
Al4 9/14/2010 ' 15 15-30 30 959.630 1 in. Type II Well
AIS 6/23/2010 15 15-30 30 960.560 1 In. Type II Well
Al6 6/23/2010 -15 15-30 30 958.690 1 in. Type II Well
Al7 6/23/2010 15 15-30 30 960.360 1 in. Type II Well
Al8 6/23/2010 -15 15-30 30 960.210 1 in. Type II Well
Al9 9/14/2010 15 15-30 30 963.180 1 in. Type II Well
AllO 6/23/2010 15 15-30 30 961.700 1 in. Type II Well
Notes:
1. All units In feet.
2. MW4 ls a Type Ill monitoring well used fer vertical delineation.
3. · Not Measured.
4. OC = outer casing, IC= Inner casing
5. Groundwiilltu elevation measurements for wells with product were corrected using the following equation:
(top of casing -depth to water) + (free product thJckness >e 0.729) Note: 0.729 is speciftc to gasoline.
6. • • MW12 has been paved over.
7. "= Monitoring well MW16 had small amount of water and free product trapped in the bottom of the monitoring well.
8. NA= Not Applicable.
Ro gers, Michael
From:
Sent:
Ryan Kerins <[e-mail]>
Monday, August 31, 2015 8:53 AM
To: Rogers, Michael
Subject:
Attachments:
RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE : UIC Notice submittal
20150830205009154.pdf
Michael:
We have turned off our onsite treatment system and will be adding OBC to wells that were previously actively
pumping. Well construction records for RW5, RW12, RW13, RW14, RW16, and RW17 are attached. This serves to
update our Notice of Intent for passive injection of OBC into those wells.
Thanks!
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919 .563.9091
From: Rogers, Michael [mailto:[e-mail]]
Sent: Thursday, July 30, 2015 5:00 PM
To: Ryan Kerins <[e-mail]>
Cc: Moore, Thomas <[e-mail]>
Subject: RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
OK, thanks . Just a reminder, this supplemental work under the permit is OK as long as it remains a 'Passive Injection'
type .
From: Ryan Kerins (mailto:rdkerins @terra q uestpc.com]
Sent: Thursday, July 30, 2015 3:48 PM
To: Rogers, Michael
Cc: Moore, Thomas
Subject: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thanks for the phone message yesterday. Following our addition of OBC to the permitted well at this site, MW4, the
MTBE concentration dropped from 45,500 ug/L to 14,300 ug/L. We'd like to do some more of that across the site .
I'd like to add OBC to the following wells at Coliseum Shell: MWl, MW3, MW10, MW14, RWl, RW4, RW10, RWlS,
RW19, RW20, and PZl.
I've included well construction records that I have, soil borings and a well construction table for the others.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563 .9091
From: Rogers, Michael j mailto:m ichael.ro [e-mail]]
Sent: Thursday, June 18, 2015 2:59 PM
1
To: Ryan Kerins <rdkerins @terraquestpc.com>
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please follow up with hard copy. Thanks .
From: Ryan Kerins [mailto:rdkerins@terrag uestpc.com]
Sent: Tuesday, June 16, 2015 9:58 AM
To: Rogers, Michael
Subject: FW: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
Please see attached.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Ryan Kerins fmailto :rdkerins @terra q uest pc.com)
Sent: Thursday, June 04, 2015 5:08 PM
To: 'Rogers, Michael'
Subject: RE: W10400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please see attached .
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St , Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.ro gers @ncdenr.gov]
Sent: Thursday, April 23, 2015 2:22 PM
To: Ryan Kerins; '[e-mail]' (bsnover @q ocnc.com)
Cc: Basinger, Corey; Knight, Sherri
Subject: RE: WI0400395 NOi Former Coliseum Shell RE : UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015) is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies
of the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE : Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
2
You can scan and send these forms directly to me at michael.ro gers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e ., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re ply to this email. as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hyd rogeologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE : Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Ryan Kerins [mailto:rdkerins @terra guestpc.com]
Sent: Thursday, April 23, 2015 10:00 AM
To: Rogers, Michael
Subject: RE: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
I do not have the GW-1 form . I've pieced together the following from old field notes:
The well was drilled on January 25-26, 1996 by Mike Ransier of American Drilling . M r. Ransiers driller's license number is
2501 .
Construction follows:
Outer casing: 0-40 feet below ground level (BGL) 6"-diameter PVC
Inner casing : 0-45 feet BGL 2" -diameter PVC casing with another 5 feet of 2"-diameter PVC screen with a 0 .010" slot size
for a total well depth of 50 feet BGL .
Inner: Grout 0-38' BGL, bentonite 38-43', sand 43-50'.
Manager: Kenneth Basch
Ryan Kerins, Project Manager, Site 's ORC (phys/chem Grade I)
Thank s,
Ryan Kerins
Terraquest Environmental Consultant s, P.C.
3
From: Rogers, Michael fmailto:michael.rogers @ncdenr.gov]
Sent: Wednesday, April 22, 2015 4:23 PM
To: Ryan Kerins
Subject: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Ryan-
We received the NOi for the above project. Thanks .
• Do you have the GW-1 for the MW-4. If not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
• And finally, your title.
Thanks
From: Ryan Kerins fm ailto:rdkerins(ci)terra g uest oc.com]
Sent: Wednesday, April 22, 2015 9:02 AM
To: Rogers, Michael
Subject: UIC Notice submittal
Please find the attached Notification of Intent. Thank you.
Ryan Kerins
Terraquest Environmental Corisultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919 .563 .9091
4
(
Ro gers, Michael
From:
Sent:
To:
Ryan Kerins <[e-mail]>
Tuesday, August 25, 2015 9:33 AM
Rogers, Michael
Subject:
Attachments:
RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
7of20-8-24-15-lnjectionEventRecord-20130805.pdf
Please see attached. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:[e-mail]]
Sent: Thursday, July 30, 2015 5:00 PM
To: Ryan Kerins <[e-mail]>
Cc: Moore, Thomas <[e-mail]>
Subject: RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
OK, thanks. Just a reminder, this supplemental work under the permit is OK as long as it remains a 'Passive Injection'
type.
From: Ryan Kerins [mailto: rdkerins @terraquestpc.com]
Sent: Thursday, July 30, 2015 3:48 PM
To: Rogers, Michael
Cc: Moore, Thomas
Subject: WI0400395 RE: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
Thanks for the phone message yesterday. Following our addition of OBC to the permitted well at this site, MW4, the
MTBE concentration dropped from 45,500 ug/L to 14,300 ug/L. We'd like to do some more of that across the site.
I'd like to add OBC to the following wells at Coliseum Shell: MWl, MW3, MWlO, MW14, RWl, RW4, RWlO, RW15,
RW19, RW20, and PZl.
I've included well construction records that I have, soil borings and a well construction table for the others.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.ro gers @ncdenr.gov]
Sent: Thursday, June 18, 2015 2:59 PM
To: Ryan Kerins <rdkerins @terra q uest pc.com>
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please follow up with hard copy. Thanks.
1
From: Ryan Kerins [mailto:rdkerins@terrag uestpc.com]
Sent: Tuesday, June 16, 2015 9:58 AM
To: Rogers, Michael
Subject: FW: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
Please see attached.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Ryan Kerins [mailto:rdkerins @terra q uest pc.com]
Sent: Thursday, June 04, 2015 5:08 PM
To: 'Rogers, Michael'
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please see attached.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.rogers @ncdenr.gov]
Sent: Thursday, April 23, 2015 2:22 PM
To: Ryan Kerins; '[e-mail]' (bsnover @q ocnc.com)
Cc: Basinger, Corey; Knight, Sherri
Subject: RE: WI0400395 NOi Former Coliseum Shell RE-: UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015) is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies
of the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms {GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http ://portal.ncdenr.org/web /w q/ap s/gw p ro /re porting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells {e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.ro gers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
2
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Resources
Permit Number w10400395
1. Permit Information
Quality Oil Company, LLC
Permittee
Former Coliseum Shell Service
Facility Name
3009 University Pkwy, Winston-Salem
Facility Address
2. Injection Contractor Information
Terraquest Environmental Consultants, P.C.
Injection Contractor/ Company Name
Street Address 100 E. Ruffin St
Mebane NC 27302
City State Zip Code
c 919) 563.:.9091
Area code -Phone number
3. Well Information
Number of wells used for injection _2 ___ _
Well names PZ 1 ' RW 2 0
Were any new wells installed during this injection
event?
D Yes ~ No
If yes, pJease provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-lformfor each
well installed.
--------
Were any wells abandoned during this injection
event?
D Yes Ii] No
If yes, please provide the following information:
Number of Monitoring Wells -------
Number oflnjection Wells _______ _
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Oxygen BioChem
Injectant Type
C tr t . =solubility=? weight % oncen a 10n ___________ _
If the injectant is diluted please indicate the source
dilution fluid. municipal water ------------
Tot al Volume Injected 2 gaHons
Volume Injected per well -2.__ga_ll _o_n ___ _
5 . Injection History
Injection date(s)_B_f _2_4_f _1 _5 ______ _
Injection number (e.g. 3 of 5) 7 of 20
Is this the last injection at this site?
D Yes Ii] No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
(o/4 Digitelly signed by Ry"n D. Kfffins
ON: o,=R!(ao D. Kerins, o. ou, email=rdkefin5@1erraqu,.stpc.oom,
~us
Dai,,; 2015_0!3_25{)&:31:41 --04'00'
SIGNATURE OF INJECTION CONTRACTOR DATE
Ryan D. Kerins
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-I 636, Phone No. 919-807-6464
Fonn UIC-IER
Rev. 8/5/2013
Ro gers, Michael
From:
Sent:
To:
Ryan Kerins <[e-mail]>
Tuesday, August 04, 2015 10:47 AM
Rogers, Michael
Subject:
Attachments:
RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
20150803224417613.pdf
Please see attached, thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.ro gers @ncdenr.gov]
Sent: Thursday, April 23, 2015 2:22 PM
To: Ryan Kerins <rdkerins @terra q uest pc.com>; '[e-mail]' (bsnover @q ocnc.com) <[e-mail]>
Cc: Basinger, Corey <[e-mail]>; Knight, Sherri <sherri.knig ht @ncdenr.gov>
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015) is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies
of the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1} and abandonment forms (GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.ro gers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re ply to this email, as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hyd rogeologist
NCDENR-DWR
1
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Permit Number WI 011 OD 34
1. Permit Information
Pexrniittee 1 _
Yu l e-! 64 5-€,L4
Facility Name
36 act U i t ve rsf'Y tilAsh
Facility Address
2, Injection Contractor Information
� s� �ro.tuemsL[ r4 .1s,-g.0
Injection Contractor / Company Name
Street Address 100 COT' 5' .
MelVe e Z irov
City State Zip Code
(ctlq ) 5 5 -D169-1
Area code— Rhone number
3, Well Information
Number of wells used for injection it
Well names M ' 3i elf, ' '� w#3
Were any new wells installed during this injection
event?
❑ Yes No
Ifyes, please provide the following information:
Number of Monitoring Wells — —
Number of injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ DrilIed ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify) —
Please include a copy of the GWW-.1 fords for each
well installed.
Were any wells abandoned during this injection
event?
D Yes ia No
Ifyes, pleaso provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include a copy of the GI'30 for each well
abandoned.
4. Injectaut Information
K tooc
Tnjectant�pe
Concentration = 50LL �'t J c k4-
If the injectant is diluted peas : indicate the source
dilation fluid. cd's ,((€ jtt•;
Volume Injected per well LOKI'
5. Injection HistoryI�—
Injectioanumber Injection date(s) $ (3
(e.g. 3 of 5) 1-44 20
Total Volume Injected
Is this the last inlet at this site?
❑ Yes J No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY ,' OWLEDGE AND THAT THE
INJECT SN WAS PERFORMED WITII N THE
STANI ARDS LA OUT IN THE PERMIT.
11_5—
SIGNAIE OF NI .TION CONTRACTOk DATE
PRINT NAME of PERSON FERFORAIllia THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 dap of injection.
Attn: []IC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, PhoneNo. 919-807-6464
Form UIC-TER
Rev, 815I2013

—..,EDI"VR INJECTION EVENT RECORD
RAC
North Carolina Department of Environment and Natural Resources —Division of Water Resources
Permit Number L t'
kipn
1 Perrnit Information
Quo. 4'41 d.-( CepvTj 4ec
Permittee
grrkte,-£ f leu wt Ste, ((
Facility Name
34 d G(n fro-1,Ctl�� f (Oof- $ (e eA^
Facility Address
2. Injection Contractor Information
re, �F t urrdrtiwca��-+�- l
Injection Contractor / Company Name
Street Address (bd C e it
fl�t� 1Jt� Z3dZ
City
State Zip Code
1011
Area code -Phone number
3. Well Information
Number of wells used for injection
Well names M UVLI
Were any new wells installed during this injection
event?
❑Yes 0No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed
Were any wells abandoned during this injection
event?
❑ Yes ®,No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please inchrde a copy of the GW-30 for each well
abandoned.
4. Iujeetant Information
0 ?e-y f;d24 C Li"
Injectant Tv is
Concentration = 504-1s11'41 = 4 r...er t `'a
If the injectant is diluted plesind#cate th9 source
dilution fl 'd -f `f d 6�-
ur . c 5 i 4vch. r
Total Volume Injected
Volume Injected per well
5. injection History
Injection date(s)
Injection number (e.g. 3 of 5)
t p} r110
i(s-/15--
q orEc>
Is this the last injeetio at this site?
❑ Yes [t No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTIO WAS PERFORMED WITHIN THE
STAND AFV S LAIDUT IN THE PERMIT.
4b6/13---
SIGNA7 U E DF INIECF ION CONTRACTOR DATE
(-IAA) `;? realms
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attu; UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 9I9-807-6464
Forrn U1C-IER
Rev. 8/5/2013

.. ..
Rogers, Mich-.iel
From: Rogers, Michael
Sent:
To:
Thursday, July 30, 2015 5:00 PM
'Ryan Kerins'
Cc: Moore, Thomas
Subject: RE: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
OK, thanks. Just a reminder, this supplemental work under the permit is OK as long as it remains a 'Passive Injection'
type.
From: Ryan Kerins [mailto:[e-mail]]
Sent: Thursday, July 30, :2015 3:48 PM
To: Rogers, Michael
Cc: Moore, Thomas
Subject: WI0400395 RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thanks for the phone message yesterday. Following our addition of OBC to the permitted well at this site, MW4, the
MTBE concentration dropped from 45,500 ug/L to 14,300 ug/L. We'd like to do some more of that across the site.
f1d like to add OBC to the following wells at Coliseum Shell: MWl, MW3, MWlO, MW14, RWl, RW4, RWlO, RW15,
RWl~, RW20, nd PZl.
I've included well construction records that I have, soil borings and a well construction table for the others.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.rogers @ncdenr.gov]
Sent: Thursday, June 18, 2015 2:59 PM
To: Ryan Kerins <rdkerins@terra quest p c.com>
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please follow up with hard copy. Thanks.
From: Ryan Kerins [mailto:rdkerins @terra questpc.com]
Sent: Tuesday, June 16, 2015 9:58 AM
To: Rogers, Michael
Subject: FW: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please see attached.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Ryan Kerins (mailto:rdkerins@terra q uest pc.com]
Sent: Thursday, June 04, 2015 5:08 PM
1
To: 'Rogers, Michael'
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Please see attached.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael [mailto:michael.rogers @ncdenr.gov]
Sent: Thursday, April 23, 2015 2:22 PM
To: Ryan Kerins; '[e-mail]' (bsnover @q ocnc.com)
Cc: Basinger, Corey; Knight, Sherri
•
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015) is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies
of the GW-1s and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.rogers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re p ly to this email, as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http ://po rta I. ncde n r .o rg/we b/wq/ a ps/gw pro/ repo rti ng-fo rm s
2
NOTE : Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Ryan Kerins [mailto:rdkerins@terrag uestpc.com]
Sent: Thursday, April 23, 2015 10:00 AM
To: Rogers, Michael
Subject: RE: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
I do not have the GW-1 form. I've pieced together the following from old field notes:
The well was drilled on January 25-26, 1996 by Mike Ransier of American Drilling. Mr. Ransiers driller's license number is
2501.
Construction follows:
Outer casing: 0-40 feet below ground level (BGL) 6"-diameter PVC
Inner casing: 0-45 feet BGL 2"-diameter PVC casing with another 5 feet of 2"-diameter PVC screen with a 0.010" slot size
for a total well depth of 50 feet BGL.
Inner: Grout 0-38' BGL, bentonite 38-43', sand 43-50'.
Manager: Kenneth Basch
Ryan Kerins, Project Manager, Site's ORC (phys/chem Grade I}
Thanks,
Ryan Kerins
Terraquest Environmental Consultants, P.C.
From: Rogers, Michael (mailto:michael.ro gers @ncdenr.gov]
Sent: Wednesday, April 22, 2015 4:23 PM
To: Ryan Kerins
Subject: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Ryan-
We received the NOi for the above project. Thanks.
• Do you have the GW-1 for the-MW-4. If not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
• And finally, your title.
Thanks
From: Ryan Kerins [mailto:rdkerins @terra g uest pc.com]
Sent: Wednesday, April 22, 2015 9:02 AM
3
To: Rogers, Michael
Subject: UIC Notice submittal
Please find the attached Notification of Intent. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
4
Table l MONITORING WELL CONSTRUCTION INFORMATION
Date: 7 /24/15 Incident Name: Coliseum Shell Service Incident No. 15260 Facility ID No: 0-020021
Oepthto
DateW.ater Waterftem
t,,vel -IC.sing Depth {ft. Scre,med Interval (x Bottom of Well TopofCasmg "ropofCa,mg RreeProrll.lOl Groundwate,
Woll ID Ua te-=ln,bl~ Mg~~~ !,GS) •ovft.~ {ft.ll@Sl Sm•r!lcm !ft.I (11.l Thk:kn,s; (ft..) Ell!vatlon I ft.) Comffl@J"ltS,
MWl 9/12/1995 7/13/2015 11 11-33 33 959.266 28.40 0 930.87 Type II well
MW2 9/12/1995 7/13/2015 15 15-35 35 960.000 30.90 0 929.10 Type llwell
MW3 9/12/1995 15 15-35 35 959.193 Type llwell
MW4 1/25-26/96 7/13/2015 ·OC:40 I IC:45 45-50 50 959.586 29.02 0 930.57 Type Ill well
MW5 1/25/1996 7/13/2015 20 20-35 35 959.405 27.71 0 931.69 Type II well
MW6 1/25/1996 7/13/2015 20 20-35 35 957.466 25.10 0 932.37 Type II well
MW7 1/25/1996 7/13/2015 15 15-30 30 960.246 DRY DRY DRY Type II well
MW8 1/25/1996 7/13/2015 15 15-30 30 957.474 27.50 0 929.97 Type II well
MW9 1/25/1996 7/13/2015 15 15-30 30 954.147 23.38 0 930.77 Type II well
MWlO 5/6/1999 7/13/2015 20 20-30 30 960.733 DRY DRY DRY Type llwell
MWll 5/6/1999 7/13/2015 20 20-35 35 964.503 DRY DRY DRY Type If well
MW13 7/8/1999 7/13/2015 10 10-30 30 960.097 DRY DRY DRY Type II well
MW14 7/8/1999 7/13/2015 10 10-30 30 961.950 29.48 0 932.47 Type II well
MW15 7/9/1999 7/13/2015 10 10-30 30 962.022 DRY DRY DRY Type llwell
MW16• 7/9/1999 7/13/2015 10 10-30 30 959.541 Small amount of water/free product trapped in Type II well
well.
MW17 10/13/1999 7/13/2015 10 10-30 30 964.225 DRY DRY DRY Type II well
MW18 10/13/1999 7/13/2015 10 10-30 30 962.198 DRY DRY DRY Type II well
MW19 10/12/1999 7/13/2015 10 10-30 30 958.039 27.30 0 930.74 Type II well
MW20 10/28/2008 7/13/2015 20 20-40 40 963.725 30.14 0 933.58 Type II well
MW21 10/28/2008 7/13/2015 20 20-40 40 961.512 28.90 0 932.61 Type ll well
MW22 10/29/2008 7/13/2015 20 20-40 40 963.903 32.35 0 931.55 Type II well
MW23 10/29/2008 7/13/2015 20 20-40 40 963.825 32.48 0 931.34 Type II well
PZl 3/26/2001 7/13/2015 10 10-35 35 959.266 29.00 0 930.27 Type II well
RWl (EWl) 3/26/2001 10 10-45 45 959.568 Type II well
RW2 10/28/2008 7/13/2015 20 20-45 45 963.739 31.31 0 932.43 4 in. Type II well
RW3 10/29/2008 19 19-44 44 963.856 -4 in. Type II well
RW4 9/13/2010 13 13-43 43 959.060 . 4 in. Type II well
RW5 9/14/2010 14 14-44 44 959.230 2 in. Type II well
RW6 9/15/2010" 15 15-45 45 963.320 4 in. Type II well
RW7 9/16/2010 14 14-44 44 959.870 4 in. Type II well
RW8 9/16/2010 15 15-45 45 960.620 4 in. Type II well
RW9 9/16/2010 15 15-45 45 961.040 4 in. Type II well
RWlO 9/16/2010 7 7-37 37 960.550 . 4 in. Type II well
RW11 10/6/2010 15 15-45 45 959.080 4 in. Type II well
RW12 10/6/2010 10 10-40 40 957.930 4 in. Type ll well
RW13 10/6/2010 13 13-43 43 958.620 4 in. Type ll well
RW14 10/6/2010 15 15-45 45 959.280 4 in. Type II well
RW15 10/6/2010 15 15-45 45 959.060 4 in. Type II well
RW16 10/6/2010 13 13-43 43 960.010 4 in. Type ti well
RW17 10/6/2010 15 15-45 45 960.760 4 in. Type II well
RW18 10/7/2010 12 12-42 42 959.270 4 in. Type ll well
RW19 10/7/2010 10 10-40 40 958.720 4 in. Type II well
RW20 10/7/2010 12 12-42 42 959.510 4 in. Type II well
All 9/14/2010 15 15-30 30 959.320 1 in. Type JI Well
Al2 9/14/2010 15 15-30 30 959.460 1 in. Type II Well
Al3 9/14/2010 15 15-30 30 959.640 1 in. Type II Well
Al4 9/14/2010 15 15-30 30 959.630 1 in. Type II Well
AIS 6/23/2010 15 15-30 30 960.560 1 in. Type II Well
Al6 6/23/2010 15 15-30 30 958.690 l in . Tyoe II Well
Al7 6/23/2010 15 15-30 30 960.360 1 in. Type II Well
Al8 6/23/2010 15 15-30 30 960.210 1 in. Type II Well
A19 9/14/2010 15 15-30 30 963.180 1 in. Type II Well
AllO 6/23/2010 15 15-30 30 961.700 1 in. Type II Well
9-19 NA r
Notes:
1. AU units in feet.
2. MW4 is a Type Ill monitoring well used for vertical delineation.
3. -Not Measured.
4. OC = outer casing, IC= inner casing
5. Groundwater elevation measurements for wells with product were corrected using the following equation:
{top ofcasing-depth to water)+ (free productthickness x 0.729) Note: 0.729 is specific to gasoline.
6. • = MW12 has been paved over.
7. "= Monitoring well MW16 had small amount of water and free product trapped in the bottom of the monitoring well.
8. NA= Not Applicable.
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Nature( Resources -Division of Water Quality
WELL, CONTRACTOR CERTIFICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Well Contractor (€ndMduaf) Name
TerraOuast Environmental Cons.
Well Contractor Company Narne
STREET ADDRESS 100 E. Ruffin St,
Mebane NC
27302
City or Town State
[ 919 J. 553 - 9091
Zip Coda
Area code- Phone number
2. WELL INFORMATION:
SITE WELL 1D Cif appiicable) RW4
STATE WELL PERMIT#0r applicable) NA
❑WQ or OTHER PERMIT #(if applicable) NA
WELL USE (Check Applicable Box) Monitoring 0 MunlcipalfPubiic
industrial/Commercial 17 Agricultural a Recovery0 injection 0
irrigation? Other ❑ (list use)
DATE DRILLED 9/13/10
TIME COMPLETED AM 0 PM ❑
3. WELL LOCATION:
CITY: Winston-Salem
3009 University Pkwy
COUNTY Forsyth
(Street Name. Numbers, Community, SubdiHsion, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑crape ❑Valley 0Flat °Ridge ❑ Other
(check appropriate box)
LATITUDE 35 07' 50" N
LONGITUDE 60 15' 45' W
May be. in degrees,
rniRnte.e, seconds or
in s decimai format
Latitude/longitude source: 0GPS riTopographic neap
poralion of well must be shown an a USGS tape map end
attached to this kind not using GPS)
4. FACILITY- is the name o! the ixisiness where (Yid well Is faceted.
FACILITY ID #(If applicable) 0-420021
NAME OF FACILITY Coliseum Shell
STREET ADDRESS 3009 University Pinny,
Winston-Salem
City or Tow
NG
State
CONTACT PERSON Danny Stroud
27102
Zip Code
MAILING ADDRESS P.O. Box 2736
Winston-Salem NC
City or Town State
336 )- 867 - 5309
Area code - Phone number
5, WELL DETAILS:
a, TOTAL DEPTH: 43
b. DOES WELL REPLACE EXISTING WELL?
27102
zip Code
YES fl ND ❑
c. WATER LEVEL Below Top of Casing: FT.
(Use "+' if Above Top of Casing)
d. TOP OF CASING IS 0.01 FT. Above Land Surface'
'Top of casing terminated attar below land surface may require
a variance In accordance with 15A NCAO 2C .01153.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
From NA To NA
From NA To NA
From NA To NA From NA To NA
Frorn NA To NA From NA To NA
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To 13 Ft. 4 inch Sch. 40 PVC
From To Ft.
From To Ft.
7, GROUT: Depth Material Method
From 9 To 11 FL Bentonite Pour
From 0 To 9 Ft Pori#and Cement Pour
From To Ft.
8, SCREEN: Depth Diameter Slot Size Materiel
From 13 To 43 Ft. 4 In. -010 in, PVC
From To Fiin. in.
From To Ft. in. In.
9, SAND/GRAVEL PACK:
Depth Size Material
From 11 To 43 Ft coarse sand
From To Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0 1 ASPHALT
1 14
14 43
11, REMARKS;
SILTY
SAPROLITE
DO HEREBY
MA MAC. 2
RECORD I -LA
LRrIFY THAT THIS WELL WAS CONSTRUCTED IN. ACCORDANCE WITH
WEL CONSTRUCTION STANDARDS, AND -n-im A COPY OF THIS
BEE PROVIDED TO THE WELL OWNER.
L
SIGNATURE RTIFIED WELL CONTRACTOR p E
AfM:Perri
PRINTED NAME (IF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-4517 Phone No. [phone] ext 568.
Form GW-lb
Rev, 7/05

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Well Contractor (Individual) Name
TerraQuest Environmental Cores.
Well Contractor Company Name
100 E Ruffin St,
Street Address
Mebane NC 27302
City or Town Slate Zip Code
(919 ) 563-9091
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PERMfT#(ilapplicable) NA
SITE WELL in #{sf appiicadlej RW20
3. WELL USE (Check One Box) Monitoring it Municipal/Public 0
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 0
irrigalion0 Other 0 (list use)
DATE DRILLED 10-7-10
4. WELL LOCATION:
3009 University Pkwv
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, tip Coda)
cir': Winston Salem - COUNTY Forsyth
TOPOGRAPHIC I LAND SETTING: (check epp oprfate box)�
❑Slope ❑Valley ©Flat L1I1dge ❑Other_
LATITUDE 36 .7 ' 50.0000 • OMS OR
DO
LONGITUDE 78 " 45 ' 4511000 ' DMS OR ❑>7
Latitude/longitudo source: ILDPS OTopographtc map
[location of wsli must be shown on a USGS tops) map ant/attached to
this form if not using GPS)
6. FACILITY (Name of the business where the wail Is located.)
Cnlisellrrt Shell 0-020071
Facility Name Facility ID# (if applicable)
3000 F Market St
Street Address
reenRhorn NI: 7710?
City or Town Stale Zip Code
Danny StrolIft
Contact Name
PO.Roy 7716
Mailing Address
Winston Salem NC 271 0?
City or Town State Zip Coda
ulafz$ 867-5309
Area code Phone number
6. WELL DETAILS:
a. TOTAL. DEPTH:-_42'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO g/
c. WATER LEVEL Below Top of Casing: FT.
(Use '+` if Above Top of Casing)
d. TOP OF CASING IS 0.0 FT, Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
Top NA BottomJA____ Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 10 Ft. 4inoh
Top Bottom Ft.
Top Bottom Ft.
sch 40 PVC
8. GROUT: Depth Material Method
Top 2 Bottom 8 Ft, Portland _Pour
Top 8 Bottom 10 Ft. t3entorilte Pour
Top - Bottom FL
9. SCREEN: Depth Diameter Slot Sire Material
Top 12 Bottom 42 A. 4111chn. ..010 in. PVC
Top Bottom Ft. In. in,
Top Bottom Ft. In. in.
10. SAND/GRAVEL PACK:
Depth Sire Material
Top 10 Bottom 42 Ft. coarse Sand
Top - Bottom FL
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 1 42' Siltv Clav
f
i
I
1
i
[
12. REMARKS:
IDO HERS
ISA NCA
RECORD
YCERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WItH
C, WELL CONSTRUCTION STANDARDS. AND T HAT A COPY OF THIS
EN PR MCt D TO THE WELL OWNER
�/
SIGNATURF(OF CERTIFIED WELL CONTRACTOR DATE
A/Y-C Per`
PRINTED NAME O PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division o€Water .Quality - Information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161, Phone : {919} 807-6300
Form GW-lb
Rev. 2/09

.[ ■ ON RESIDENTIAL WELL CONSTRUCTTON RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION fi 3329
1. WELL CONTRACTOR:
Nick Perry
Weil Contractor (Individual) Name
TerraQuest Environmental Cons.
Welt Contractor Company Name
100 E Ruffin St
Street Address
Mebane NC 27302
City or Town State Zip Code
(919 ) 563-9091
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NA
OTHER ASSOCIATED PERMIT"#{if applicable) NA
SITE WELL ID ##f apptirable) RW 19
3. WELL USE (Check One Box) Monitoring (V'MunicfpeI/Pubiic❑
Industrial/Commercial D Agricultural D Recovery ❑ Injection f11
IrrigationO Other 0 (list use)
DATE DRILLED I 0-7-10
4. WELL LOCATION:
3009 University Pkwv
(Street Name, Numbers. Community, Subdivision. Lot No., Parcel, zip Code)
CITY; Winston Salem COUNTY Forsyth
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge r]Other
LATITUDE 36 • 7 ' 50.0000 " i]MS OR AD
LONGITUDE 79 a 1s ' 15.0000 • ❑Ms OR Df7
Latitude/longltude source: ❑CPS Wiopograph1cmap
(location of well must be shown on a JSGS tapo mep andettached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
Coliseum Shell 0-020071
Facility Name Facility IDS (if applicable)
:300n F Market St
Street Address
Greensboro NC 27107
City or Town Slate Zip Code
Danr wStrntlrt
Contact Name
P ❑. Box 7736
Matting Address
�C1f-i.nstorL Saje�t NC 27'102
Cttyor Town State Zfp Code
[ 336.6 867-5309
Area code Phone number
6. WELL DETAILS;
a. TOTAL DEPTH: 40'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO q%
c. WATER LEVEL Below Top of Casing: FT_
(Use +' if Above Top of Casing)
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top encasing terminated alter below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD 4gpmj: NA METHOD OF TEST NA
1. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
Top NA Bottom NA Top NA Bottom NA _!
Top _ NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 10 Et. 4-rich sch 40 PVC
Top
Top
Bottom 1=t.
Bottom Ft
8. GROUT; Depth Material Method
Top 2 Bottom 4 Ft. Portland PQur
Top 4 Bottom 6 Ft. BentOtlite Pour
Top Bottom Ft.
S. SCREEN: Depth Diameter' Slot Size Material
Top 1O Bottom 40 Ft. 4inc11n. , ,010 in. PVC
Top _ Bottom Ft. In.
Top _ Bottom Ft. In.
10. SAND/GRAVEL PACK:
Depth
Top 8 Bottom 40
Top Bottom
Top Bottom
In.
In.
Size Material
Ft. coarse Sand
Ft.
FL
it DRILLING LOG
Top Bottom
_0_, 40'
1
1
1
1
12. REMARKS;
Formation Description
SiltY
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED rN ACCORDANCE WITH
tbA NCACLL CONSTRUCTION Si -AWARDS, AND THAT A COPY OF pi S
RECORD 144E B EN pROVIDED TO THE WELL OWNER.
i1et°
SIGNATURE ERTIFIED WELL CONTRAc; fOR DATE
PRINNDuNArME OF PERSON CONSTRUCTING THE WELL
Submit within 30;days of completion to: Division of Water Quality information Processing,
1617 Mali Service Center, Raleigh, NC 27699-161,:Phone : (919) 8Q.7-S300. :.
Form GW-1h
Rev. 2109

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Welt Contractor (lndividuai) Name
TerraQuest Environmental Cons.
Well Contractor Company Name
100 E Ruffin St.
Street Address
Mebane NC 27302
City or Town State Zip Code
(919 ) 563-9091
Area code Phone number
2. WELL. INFORMATION:
WELL CONSTRUCTION PERMIT4 NA
OTHER ASSOCIATED PERMIT#(if applicable) NA
SITE WELL ID Ofe applicable} RW15
3. WELL USE (Check One Box) Monitoring Ir Munieipal/PublIc ❑
Industrial/Commercial a Agricultural ❑ Recovery ❑ injection 0
irrigation0 Other Q (list use)
DATE DRILLED 10-6-10
4. WELL LOCATION:
3009 University Pkwv
(Street Name, Numbers, Community, Subdivision, Lot No., Aaresl, Zip Cwde)
CITY: Winston Salem cou wry Forsyth
TOPOGRAPHIC! LANs SETTING: (eheelc appropriate box)
❑slope [Valley 0Ftat 0Ridge pother
1.ATITUDE 36 ° 7 ' &Loam DMS OR CD
LONGITUDE 79 0 15 ' 45.0000 • DMS DR DO
Lalitudeliongitude source: E"uPS 2fropographlc map
(location ortvefl must be shown on a USGS topo map andattached to
this form if not i+sing GPS)
6. FACILITY (Name of the business where the well is located_)
Coliseum Sbek ¢D20071
Facility Name Facility ID# (if applicable)
3000 F Market St
Street Address
Greensboro NC 27102
City or Town State Zip Code
Danny Stroi td
Contact Name
P O Box 7736
Mailing Address
Winsfrn. Salem NC 27102
City or Town State Zip Dodo
L33il $67-5 09
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH:_45' _
4. DOES WELL REPLACE EXISTING WELL? YES O NO�
c, WATER LEVEL. 6efow Top of Casing: FT.
(Use "+' If Above Top of Casing)
d. TOP OF CASING IS 0 0 FT. Above Land Stsrfece'
'Top of casing terminated aVor below and surface may require
a variance in accordance with T6A NCAC 2C ,0118.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
WATER ZONES (depth):
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Top NA Bottom NA Top NA Bottom NA
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 15 Ft. flinch Sit 40 PVC
Tap _ Bottom Ft
Top Bottom FL
8. GROUT: Depth Material
Top_ 2 Bottom 11 Ft, Portland PQ1Jr
Top 11 Bottom 13 r-t Bent❑nite Pour
Top Bottom Ft,
Method
9. SCREEN: Depth Diameter Slot Size Material
Top 15 Bottom 45 Ft. 4inchn. .0113 In. PVC
Top - Bottom Ft. In. In.
Top Bottom Ft. in. In,
10. SAND/GRAVEL PACK:
Depth Size Material
Top 13 Bottom _5 Ft. coarse Sand
Top Bottom EL
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 45? Silty Clay
1
1
1
1
1
1
I
1
12. REMARKS:
I DO HERE
15ANCAC
REGO
CERTIFY THAT THIS WELL WAS CQNSTRtJC1 ED IhIACCORDANCE ' 1TH
, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
SEEN .hDEDTOII* WELL OWNER.
S GNATURF=TSF CERTIFIED WELL CONTRACTOR DATE
.rs �
PRINTED NAM£ of PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev_ 2/09

N ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carmine Deportment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Wetf Contractor (Individual) Name
TerraQuest Environmental Cons.
We Contractor Company Name
STREET ADDRESS 100 E. Ruffin St
Mebane NC
27302
City or Town State
( 919 ). 563 - 9091
Area code- Phone number
2, WELL INFORMATION:
SITE WELL ID #(ir applicable) RW 1 D
STATE WELL PERMIT#(if applicable) NA
Zip Code
DWQ of OTHER PERMIT Cif applicable) NA
WELL USE (Check Applicable Box) Monitoring 0 MunicIpal/Pubec ❑
InduslrtalVCOmmerclal ❑ Agricultural ❑ Recovery ❑ infection ❑
IrrtgalionO Other ❑ (Iisi use)
DATE DRILLED 9116/10
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
CITY: Winston-Salem COUNTY FarsYtll
3009 Unrverslty Pkwy
(Street Name. Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC ! LAND SETTING:
0Slope ❑Valley ❑Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 07' 50' N
LONGITUDE 80 15' 45" W
May ba in degrees,
minutes, seconds Of
it a decimal format
Latitudelfangitude source: ❑CPS ❑Topographic map
(location ofwelmust be shown on a USGS (opo map and
attached to this tam rf not using GPS)
4. FACILITY-rx a ngme ar she buaineas where the well Is (pca1 1.
FACILITY ID 1/(if applicable) 0-020021
NAME OF FACILITY Coliseum Shell
STREET ADDRESS 3009 University Pkwy.
Winston-Salem NC
27102
City orTovrn State
CONTACT PERSON Danny Stroud
Zip Code
MAILING ADDRESS P.O. Box 2736
Winston-Salem NC
City w Town State
f 336 )- 867 - 5309
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 37
b, DOES WELL REPLACE EXISTING WELL?
c, WATER LEVEL Below Top of Casing:
(Use "+" If Above Top of Casing)
27102
Zip Code
YES L7 NO❑
FT.
d. TOP OF CASING IS 0.0' FT. Above Land Surface*
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depth):
From NA To NA
From NA To NA
From NA To NA
From NA To NA
From NA To NA
From NA To NA
B. CASING: Thickness)
Depth Diameter Weight Material
From 0 To 7 Ft, 4 inch Sch. 40 PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 3 To 5
From 1] To 3 Ft. Portland Cement Pour
Ft Bentontfe Pour
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 7 To 37 Ft 4 In. .010 In, PVC
From To FL In. In.
From To FL In. in.
9. SAND/GRAVEL PACK;
Depth Size Material
From 5 To 37 Ft.Coarse sand
From To Ft.
From To FL
10. DRILLING LOG
From
0
1
14
To
1
14
37
11. REMARKS:
Formation Description
ASPHALT
SILTY
SAPROLITE
I DQ HERESY tFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W'TN
SSA N ABC 2C, LL CONSTRUCTION STANDARDS. AND THAT COPYOFTfi15
RECO DHAS EN ' PEDTO7}iEWELL OWNER.
S1GNATUR
CERTIFIED WELL CONTRACTOR ATE
PRINTED NAME (F PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. (919) T33-7016 ext 668.
Farm GW-lb
Rev. 7105

TERRAc
Etiwterimarrio. CflNsurrA T$. Pc.
c.
E
14
Blow
Counts
uest
Completion
BORING LOG/MONITORING WELL INSTALLATION DETAIL
Confrartpr- TprLaquPsr
flrill Mprhod__Soiid Stem Auger
Driller' NlrkPer y
OVM Depth Litholog
(ppm) Feet
Dare Stanad • qI t iLi [t
Dab, Finistubd• g/.13 11
agged by• araa Hayps
Description
Boring Number:.
RW4
5
•
10
15
20
25
30
40
__
• _ASPHALT
SILT (ML)
Mostly soft reddish brown silt. Trace moisture. No petroleum
odor.
SILT WITH CLAY (ML)
Mostly medium stiff gray brown silt with little very fine grained
sand. Trace moisture.
\vsimilar to 0.5 - 2 feet BGL.
L J
SILT (ML)
Mostly stiff to very stiff red tan brown silt. Trace mositure,
No petroleum odor
SAPROLITE with characteristics of silt
Mostly stiff red/white/tan/brownish silL No petroleum odor.
Trace moisture,
SAPROLITE with characteristics of silt
Mostly stiff red/orange/maroon/whitish silt_ Quartz flecked
throughout. Little manganese oxide. No petroleum odor.
Trace moisture.
- -�
//
',
as above but with color taNvrangelred. Some quartz pieces
Iup to 112" diameter. With tittle characteristic of clay.
similar to 15 -18 feet BGL. Relic textures noted. Trace mica 1
noted.
SAPROLITE characteristic of silt
Mostly stiff to medium stiff sift with some very fine grained
sand_ No petroleum odor. Trace mositure. Trace mica.
Drilling terminated at 43 ft BGL
Scale as shown: Hatch pattern denotes soil sample depth;
Solid denotes lab sample depth; Lithology hatch pattern legend is attached;
Well Construction
4" diameter Sch 40 PVC, .010" slotted screen
Sand: no. 2 sand; Grout: poured portland; Bentonite: poured pellets;
Manhole- flush 8" diameter steel;
NA - Not Applicable; BGL - Below Ground Level;
Site:
Mt View Gas House
3162 H127 SE
Hickory, NC 28602
Client:
Qualify Oil Company, LLC
P.O. Box 2736
Winston-Salem, IBC 27102
Project No.:
Page 1

MIRA,,_______sluest
I3onamaim CHAELEAtra,P.c
BORING LOG/MONITORING WELL INSTALLATION DETAIL
Cnntractnr• Ta esl
�
ate_Started• giijji❑
Baring Number:
[hill MafhtnrdfInllnw gIem Auger
flat& Finished' 4[1fiI1n
n
mill. Ni Fry
I nnged hy' Brad Hayes
RWI
M■ V
69
Blow
Counts
Completion
t7YiY!
(ppm)
Depth
Feet
Lithology
Description
" a
•
':
:
•:-#•
•'F:«'
.i
- �
_
:r ;
—
(•
_`ASPI-IALT
SILT (ML)
Mostly soft reddish brown silt. Trace moisture. No petroleum
odor.
SILTWITH CLAY (MO 7
MostlyIli
silt with little very finegrained
\ rY
-
5
—
10 —
medium stiff graybrown
f
sand. Trace moisture.
J
\ similar to 4.5 - 2 feet BGL. 1
SILT (ML)
Mostly stiff to very stiff red tan brown silt. Trace masiture.
No petroleum odor.
:'
•
_
•
•
SAPROLiTE with characteristics of silt
Mostly stiff red/white/tan/brownish sift- No petroleum odor.
Trace moisture.
_
;;
• F- z .: ;
< `'%� "`,
`• :
"`
`
s
—
`'- `
-• n
= -4--.H
i,• ;:.1
SAPROLITE with characteristics of silt
Mostly stiff red/orange/maroon/whitish silt. Quartz flecked
throughout. Little manganese oxide. No petroleum odor.
Trace moisture_
_
:�
as above but with color tart/orange/red. Some quartz pieces ,
up to 1/2" diameter. With lithe characteristic of clay.
similar to 15 - 18 feet 13GL. Relic textures noted. Trace mica—/'
SAPROLITE characteristic of silt
Mostly stiff to medium stiff silt with some very fine grained
sand- No petroleum odor. Trace masiture. Trace mica.
Drilling terminated at 37 ft BGL
20
—
—+`'
30 - aY'
- _L-f
35
1
• ' f .
.
' "'
0- '
-•' ~u�S_
.` -- -
:. ';
w,.
iF
-
-
_ -
Scale as shown; Hatch pattern denotes soil sample depth;
Solid denotes lab sample depth; Lithology hatch pattern legend is attached;
Well Construction
Site:
Mt View Gas House
3162 Hwy 127 SE
Hickory, NC 26662
Client:
4" diameter Sch. 40 PVC; .010" slotted screen
Sand: no. 2 sand; Grout: poured portland; 8entonite: poured pellets;
Manhole; flush 8" diameter steel;
NA - Not Applicable; BGL - Below Ground Level,
Quality Oil Company, LLC
P.O. Box 2736
Vlfinston-Salem, NC 27102
i
Project No.: ! Page 1

EJm o1wtxru Catsc USIS. PS.
a
E
m
Blow
Counts
uest
Completion
BORING LOGIMONITORING WELL INSTALLATION DETAIL
Cnntrartnr_ _Terra ryiiect
frill MPthnd'Hnllnw Slam AliaPr
Driller Nick Parry
OVM
(ppm)
Depth
Feet
Lithalog)
f]als3 startrrrL• 4i16fnn
Date Finisi+pst 4116.+1fl
1 ngrgpri hy• Rratl I.iayPa
Description
Boring Number:
RW1 0
— 40 —
— 45 —
50
— 55
60 —
— 65
— 70 —
75
Scale as shown; Hatch pattern denotes soil sample depth;
Solid denotes lab sample depth; Lithology hatch pattern legend is attached;
Well Construction
4" diameter Sch. 40 PVC; .010" slotted screen
Sand: no. 2 sand; Grout: poured portland; Bentonite: poured pellets;
Manhole: flush 8" diameter steel,
NA - Not Applicable, BGL - Below Ground Level;
Site:
Mt View Gas House
3162 Hwy 127 SE
Hickory, NC 28602
Client:
Quality Oil Company, LLC
P_C. Box 2736
Winston-Salem, NC 27102
Project No.:
Page 2

TRAc
uest
BORING LOG/MONITORING WELL INSTALLATION DETAIL
C.nntrar}tu 7Pf'aquesI naiP $iartpd• 7i1l '1n•
BoringinNumber:
RW15
■■■r 1
�
�ONSUTAIt6,r_ti
krill Mpthod7P •5nidSterrLA41r Date_EinishPR• 10/6/1r1
nriller Njr•kLPPrr 1 nugert by gn[dy W[ann
a
ra
Blow
Counts
Completion
OVM
(ppm)
Depth
Feet
Lithology
Description
H
:�
ASPHALT
• =
- .: :
NA
!
!•
NA
•
•::•,_
4.•.'..„
•-' .
— 5 —
{
LEAN CLAY ! SILT (CLIML)
—
{ .�;
,
—
.r' ./
Medium stiff, red, mostly clay, some silt, little sand, dry,
4: -
+t •_ • i •—
—::'
i //
grading to a saprolite with silty characteristics
• ..'.
4.
• .;!�'
— 10 —
.f
}
NA
.
NA
_
15
-/ /J.
—_
—
`-�'_
.=
SAPROLITE
NA
NA
n
Sepiolite with characteristics of
silt, remnant foliations-
_
20
°.
Boring Terminated at 45' BGL.
25
is •• -..
.�—•-
NA
NA
�:•
1—
-..
30
:
w•
—
— 35
, -
- - .
40
-
— 45
Scale as shown: Hatch pattern denotes soil sample depth;
Site:
Solid denotes lab sample depth; Lithology hatch pattern legend is attached;
Mt View Gas House
Well Construction
3162 liwy 127 SE
Hickory, NC 28602
4" diameter Sch. 40
PVC; .010" slotted screen
Client:
Sand: no. 2 sand: Grout: poured portland; Bentonite: poured pellets:
Quality Oil Company, LLC
Manhole: flush 8" diameter steel;
P.O. Box 2736
NA - Not Applicable; BGL - Below Ground Level;
WnstonSalem, NC 27102
Project No.:
Page
1

TIERRAfr,.,est
BeetnahmerruConsaumrs.P.C.
E
rn
Blow
Counts
Completion
BORING LOG/MONITORING WELL INSTALLATION DETAIL
Conirartnr Tin ca,at P St • //Ate Srtpr 1Qj711fl
Drill Meg:lad-Solid Sre•rn.,Ai•grq .1 Dare Finistipri,
rdIef Nirk PP r
OVM
(ppm)
Depth
Feet
Lithology
I nggpri by • Anctk., Wrenn
Description
Boring Number:
RW1 9
NA
NA
NA
NA
NA
NA
NA
NA
NA
15
20
35
40
ASPHALT
LEAN CLAY / SILT (CL/ML)
Medium stiff, red, mostly clay, some silt, little sand, dry,
grading into a saprolite
SAPROLITE
Saprolite with charactenstics of silt, rernnant foliations,
petroleum smell
Bonng Terminated at 40BGL
Scale as shown; Hatch pattern denotes so i sample depth;
Solid denotes lab sample depth; Lithology hatch pattern legend is attached:
Well Construction
4" diameter Sch. 40 PVC; .010" siotted screen
Sand: no. 2 sand; Grout: poured portland; Bentonite: poured pellets;
Manhole; flush 8" diameter steel:
NA - Not Applicable; BGL - Below Ground Level;
Blank sample depth denotes that no spoon could be collected
Site:
Mt View Gas House
3162 Hwy 127 SE
Hickory, NC 28602
Ctient:
Quality Oil Company, LLC
P.O. Box 2736
Winston-Salem, NC 27102
Project No.:
Page 1

inERRAC
---------'----'—
Eitmowenia
cs
a.
cowl/R.5,n.
nest
----_,-------
BORING LOG/MONITORING WELL INSTALLATION DETAIL
Ecintrartor Teriarinpst
natl.. startpiri. 1i1i7rtli
Boring Number:
RW20
Drill MpthrutSolid_Cipm ALIT=r
flat/. Finihprl- in+71'in
Driller Nick Pr.4.
hy- Any Wrpnn
Blow
Completion
OVM
Depth
Lithology
_Loggprt
Description
Is
Counts
(13Pm)
Feet
0
• -
. .1.
Ise • -
• .. :40 .
11---____
ASPHALT
*
—1'
NA
..... -
ii • .
• ....
W .-._.-
• •
.-.-,-
....
•= • -
• • •.•=•
_ •-•10 '
ii. • •
• -•:= •
NA
5 —/
- /-, / •
// . ,•••••
/ 7 ' • _.•
' . z
•
LEAN CLAY / SILT (ClilviL)
Medium stiff, red, mostly clay, some silt, little sand, dry,
grading into a saprolite
'IF • . •
., ..:••••
e -- .
4 -: ii..
'Il ' • -
. .--f-
• . -://
.
NA
-ik - - -
:t e.:.,'
NA
• /.•
.-......--.-.
NA
NA
_.1
15
:•:...•••:,.-.]. • ---
-•:.:_":1?.,...er
SAPROLITE
NA
.
.z: -..0_-., •
Saprolite with characteristics of silt, remnant foliations,
H
_-":7'f--°:'5e-'
petroleum smell,
20 --J-11;•••-,
Boring Terrninated at 42GGL.
-,..-,1,_•_:_:•-::-,::-..,-..,:
'•-"•-v (1- ,d e ,
NA
,NA
i.,•-t7:6•_1.4:
-7-r. '3"::.: - 'ell- •
,-,v;•:f-,::-_,
_ .
25
(..:,-!:.--•..5',.
5.._•:,.....:•.....,.
21.7h.;•-...:-
.,.
_
NA
•-,.
NA
--i--.k.j4X.I.'"•'2-L.
%:.:'.a.:7;:,1-',:•-1°•:.... f.:
30 -.,
4",•4';':-
:•,.;:.,:._:.,,,,,,:-,
-1!•:.
-
..-1.-:•-•,•7F: -.:F.-di:
:II% :t?t-:.;
35 --.,...,„
:- • ;;G:i., -- . .
- -.-
-
. 5: ,1[7. LI'
-
-' .
.•2•,•:„,
• ] -;:i,c-:LP.ter-.S: .
..
---•'•
r" • ..• - ' ` "4
-).-.'''... • - ''• •
- '' :Z.,
40
... — . -
- 1 ••.'?..•e.: ...
-- -iinc......•
.X.. ..... --‘g,
Scale as shown; Hatch pattern denotes soil sample depth;
Site:
Solid denotes lab sample depth, Lithology hatch pattern legend is attached;
Mt View Gas House
3162 Hwy 127 SE
Well Construction
Hickory, NC 28602
4'' diameter Sch. 40
PVC; 010' slotted screen
Client:
Sand: no. 2 sand; Grout: poured portland; Bentonite poured pellets;
Quality Oil Company, LLC
Manhole: flush 8" diameter steel;
P.O. Box 2736
NA- Not Applicable; BGL - Below Ground Level:
Winston-Salem, NC 27102
Blank sample depth denotes that no spoon could be collected
Project No.: Page
1

TERRAcuest
1
BORING LOGIMONITORING WELL INSTALLATION DETAIL
Cnnlractorr R e c. - STitic
Min Startarl• 4/FJ49
Boring Number:
•,Drift Malhnd • HniIw Siam Akkirr
hate Firu hod• c/FAci
DfinglHRI. RT> SAi
Tray Griffith
1 nd teg hy• _Inn*than ( rithbc
�r
MWI O
cD
coCounts
0,
Blow
_Driller.
OVMCompletion ppm
(ppmj
Depth
Feet
Lithology
Description
•
N/A
N/A
�+q'dJ k_i.'A 1-0',. •�i i• i'•it'.l'r••� it--i1-•1'-IV••$.••i... . 1.•i �'-p.•#•+M';M*•I!•1., ti_.';:;: •;::';
'i''I�:,ib. .47• . ••i•• i' .61' ;•:.'r..
, '�' : $'r�'�' �i'. r�': i'. . i'ii'r�P' �i'rIM': IV•i>b'r�'igl': �' _ _�; i'r�'r1'ri :ail ;'• __ .. . . ..... . ... ........ ... ..•. .....
`-
- -
x•
es _
•.: •--
• • ,
111
• a • , -
:f
NIA
1.---
N/A
-
—
— 5 —,
-
-
ASPHALT
, ,
' //
` ff
j rr
LEAN CLAY I SILT (CLIML)
Medium to very stiff, red, mostly clay, some silt. little sand,
dry
SAPROLITE
with the soil characteristics of a SILT (ML)
Medium stiffness, light red to tan in color, mostly silt, some
clay to little clay, little fine to coarse grained sand, mica
present, dry. Layers of manganese oxide present with few
weathered mica schist gravels mild petroleum smell. (No
spoons collected after 20' BGL)
SAPROLITE
Saprolite has characteristics of silt (ML)- Mostly silt, little
clay, some gravel, remnent foliation present, red, tan, white,
black lens. gravels -4-5 cm in diameter, very stiff rnagnese
layers, mottling present, sample saturated,
Boring Terminated at 30' BGL.
- -
-- -
20
i
1
-
- -
-•
-
-
25 T
30
•
r
Scale as shown: Hatch pattern denotes soil sample depth
Solid denotes lab sample depth; Lithology hatch pattern legend is attached;
Well Construction
Site:
Mt View Gas House
3162 Hwy 127 SE
Client: ClNC 2$662
Client:
2" diameter Sch. 40 PVC; .010" slotted screen
Sand_ no 2 sand: Grout_ poured portland; Bentonite: poured pellets
Finished with 8"-diameter metal bolt down manhole.
NA - Not Applicable; BGL - Below Ground Level
Blank sample depth denotes that no spoon could be collected
Quality Oil Company, LLC
P.O. Sox 2736
Winston Salem, NC 27102
Project No.:
Page 1

LEMO111100.1.r
E
Blow
Counts
uest
Completion
BORING LOG/MONITORING WELL INSTALLATION DETAIL
f:nnlrarthr•_Eps,- Sri Inc
nri1LM8plhrirt'HD1ltiv C?Pm A.inPl
.1:1ritlp,
OVM
(PPm)
Depth
Feet
Rnhart
Lithology
flat Started 71iSrgq
Date Finichprt' 'litlgq
nryJr•rt hy• lnhn tang
Description
Boring Number:
MW 9 4
N/A
NIA
:•
N/A
•
NIA
5
20
r fy
—:,•gir
25
30
ASPHALT
LEAN CLAY / SILT (CLIML)
Medium to very stiff, red, mostly clay, some silt, little sand,
dry grading into a saprolite
SAPROLITE
Saprolite with characteristics of silt, remnant fotiatians,
cuttings saturated at -•25 BGL.
Boring Terminated at 30' BGL.
Scale as shown; Hatch pattern denotes soi sample depth;
Solid denotes lab sample depth; Lithoiogy hatch pattern legend is attached;
Well Construction
2" diameter Sch. 40 PVC; .010" slotted screen
Sand: no. 2 sand; Grout: poured Portland; Bentonite: poured pellets
Finished with 8"{diameter metal bort down manhole.
NA - Not Applicable; BGL - Below Ground Level
Blank sample depth denotes that no spoon could be collected
Site:
Mt View Gas House
3162 Hwy 127 SE
Hickory, NC 28602
Client:
Quality Oil Company, LLC
P.O. Box 2736
Winston-Salem, NC 27102
Project No.:
Page 1
e

COLCOMM►C.
to
us
Blow
Counts
Completion
BORING LOG/MONITORING WELL INSTALLATION DETAIL
tj ntrartor- Ras -Sgi Ynr
Datr Startnrt• 71$i99
�tL1�aMnrt.Finilw Slam Arum _Etato Finish.e. ?! I9
Dri!IPl Pr hart 3 nr9ge:thy• John Lang
OVM
(PM)
Depth
Feet
Lithologj
Description
N/A
N/A
•
R '
11
NIA
5
10
15
N/A -
- 2D
- 25
30
Jam`. f!f
/!.
J�7
— '!:.
•
•
-�
ASPHALT
Boring Number:
MWI
LEAN CLAY / SILT (CLJML)
Medium to very stiff, red, mostly clay, some silt, little sand,
dry, grading into a saprolite
SAPRCLUTE
Saprolite with characteristics of silt, remnant foliations,
cuttings saturated, petroleum smell
Boring Terminated at 30' BGL.
Scale as shown; Hatch pattern denotes soi sample depth;
Solid denotes lab sample depth, Lithology hatch pattern legend is attached;
Welt Construction
2" diameter Bch- 40 PVC; .010" slotted screen
Sand: no. 2 sand; Grout: poured portland; Bentonite_ poured pellets
Finished with a' -diameter metal bolldown manhole_
NA - Not Applicable; BGL - Below Ground Level
Blank sample depth denotes that no spoon could be collected
Site:
Mt View Gas House
3162 Hwy 127 SE
Hickory, NC 28602
Client:
Quality Oil Company, LLG
P_Q- Box 2736
Winston-Salem, NC 27102
Project No.:
Pattie 1.

~gers, Michael
From:
Sent:
Ryan Kerins <[e-mail]>
Friday, May 08, 2015 2:57 PM
To: Rogers, Michael
Subject: Injection Event Record ....... RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice
submittal
Attachments: 20150509025109376. pdf
Please find the attached Injection Event Record.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael (mailto:michael.ro gers @ncdenr.gov]
Sent: Thursday, April 23, 2015 2:22 PM
To: Ryan Kerins; '[e-mail]' (bsnover @q ocnc.com)
Cc: Basinger, Corey; Knight, Sherri
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015) is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies
of the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form . These forms can be found on
our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.rogers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
this email. You may if you wish , scan and send back as attachments in reply to this email, as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hyd rogeologist
NCDENR-DWR
1
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Ryan Kerins [mailto:rdkerins @terraq uestpc.com]
Sent: Thursday, April 23, 2015 10:00 AM
To: Rogers, Michael
Subject: RE: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
I do not have the GW-1 form. I've pieced together the following from old field notes:
The well was drilled on January 25-26, 1996 by Mike Ransier of American Drilling. Mr. Ransiers driller's license number is
2501.
Construction follows:
Outer casing: 0-40 feet below ground level {BGL) 6"-diameter PVC
Inner casing: 0-45 feet BGL 2"-diameter PVC casing with another 5 feet of 2"-diameter PVC screen with a 0.010" slot size
for a total well depth of 50 feet BGL.
Inner: Grout 0-38' BGL, bentonite 38-43', sand 43-50'.
Manager: Kenneth Basch
Ryan Kerins, Project Manager, Site's ORC (phys/chem Grade I)
Thanks,
Ryan Kerins
Terraquest Environmental Consultants, P.C.
From: Rogers, Michael fmailto:michael.ro gers @ncdenr.gov]
Sent: Wednesday, April 22, 2015 4:23 PM
To: Ryan Kerins
Subject: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Ryan-
We received the NOi for the above project. Thanks.
• Do you have the GW-1 for the MW-4. If not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
2
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
PermitNumber_l0Y0a3`?r
1. Permit Information
%tc, / 4 ►:1/ 661 t/�Q I
Permittee it,
00er 6ije(au Rod (
(
Facility Name
Facility Address
2. Injection Contractor Information
Injection Contractor 1 Company Name
Street Address (Op G ��(6;3-
S'
City
AJG.
State
(Ctfrt ) ¶(23 -°Ibgi
Area code -- Phone number
3. Well Inform atlan
Number of wells used for injection
Wclt names
Zip Code
r
Were any new wells installed during this injection
event?
❑ Yes
14 No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection. Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify) _
Please include a copy of the GIV-1 form for each
well installed
S. Injection History
Injection dates)_
Were any wells abandoned during this injection
event?
❑ Yes 6- No
If yes, please provide the following information:
Number of Monitoring Wells __ —�
Number of Injection Welts-- _-- —
Please include a copy of the GW-30 for each well
abandoned.
4. Injectint Information(
Injectant £;'pc
%Concentxatian = Sa�L�` r ��. u.e i �,L``�" ffjj
1.7
If the injectant is diluted please indicate $he source
dilation fluid. ("A/ G fe-f"
Total Volume Injected
Volume Injected per well ! vsl(on
sJrllr
Injection number (e.g. 3 of 5 Z ?4
Is this the last injectiat this site?
❑ Yes fNo
l DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST G F MY KNOW :TOE AND THAT THE
INJECTIO WAS PE DRMED WITHIN THE
STANDA t S LAID DI i' IN THE PERMIT.
SIGMA )P INJECTICtrht CONTRACTOR ]ATE
rimid 4 ew'
PRINT NAME? OF PERSON PERFORMING THE INJECTION
Submit the original of this form. to the Division of Water Resources within 30 days ofinjection.
Atth: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1536, Phone No. 919-807-6464
Form UIC-IER
Rev. 81612OI3

0:::-rs, Michael
From:
Sent:
To:
Subject:
Attachments:
Event record attached.
Ryan Kerins
Ryan Kerins <[e-mail]>
Wednesday, April 29, 2015 1 :56 PM
Rogers, Michael
RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
20150430015043934.pdf
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
From: Rogers, Michael (mailto:michael.rogers @ncdenr.gov]
Sent: Thursday, April 23, 2015 2:22 PM
To: Ryan Kerins; '[e-mail]' (bsnover @g ocnc.com)
Cc: Basinger, Corey; Knight, Sherri
Subject: RE: W10400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015} is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1} and Abandonment Records (GW-30} when completed. Please provide copies
of the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wg/aps/gwpro/reoorting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER . The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.ro gers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re p ly to this email , as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. {NC & FL)
Hydrogeologist
NCDENR-DWR
1
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wg/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Ryan Kerins [mailto:rdkerins @terraa uestpc.com]
Sent: Thursday, April 23, 2015 10:00 AM
To: Rogers, Michael
Subject: RE: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
I do not have the GW-1 form. I've pieced together the following from old field notes:
The well was drilled on January 25-26, 1996 by Mike Ransier of American Drilling. Mr. Ransiers driller's license number is
2501.
Construction follows:
Outer casing: 0-40 feet below ground level (BGL) 6"-diameter PVC
Inner casing: 0-45 feet BGL 2"-diameter PVC casing with another 5 feet of 2"-diameter PVC screen with a 0.010" slot size
for a total well depth of 50 feet BGL.
Inner: Grout 0-38' BGL, bentonite 38-43', sand 43-50'.
Manager: Kenneth Basch
Ryan Kerins, Project Manager, Site's ORC (phys/chem Grade 1)
Thanks,
Ryan Kerins
Terraquest Environmental Consultants, P.C.
From: Rogers, Michael [mailto:michael.rogers @ncdenr.gov]
Sent: Wednesday, April 22, 2015 4:23 PM
To: Ryan Kerins
Subject: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Ryan-
We received the NOi for the above project. Thanks.
• Do you have the GW-1 for the MW-4. If not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
2
Pernnttee
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Permit Number w t a 1-t 61539 r
I. Permit Information
6?LAC4. (ill "1
c 1--•
C071-0-r Co1z stu„t - SLU
Facility Name
kePt uit•Z r.srLt 9L1 _ ,�C Rime
Facility Address
2. Injection Contractor Information r r
rL e�-ra��es Lem
Injection Contractor 1 Company Name
Street``rrAddress
City
Lk -
State
7,1 02.
Zip Code
0(1) 5 3— loa(
Area code — Phone number
3. Well information
Number of wells used for injection
Well names /V '
Were any new wells installed during this injection
event?
❑ Yes No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled D Direct -Push
[I Hand -Augured ❑ Other (specify)
Please include a copy o, f the GW-1 foram for each
well installed_
Wereany wells abandoned during this injection
event?
❑ Yes No
Ifyes, please provide the following information:
Number of Monitori ng Wells
Number of Injection Wells
Please include a copy of The Gil! 34 for each well
abandoned.
4. Injectant Information
O c Q, 4
In} �[1SG wl
'eciartt�y�e
Concentration
t'bG.ei�.•�a'a
If the injectant is dilutel SIas9 in�icate the source
dilution fluid. a w
Total Volume Injected
Volume Injected per well
5. Injection History
Injection date(s)
Injection number (e_g. 3 of 5)
of
Is this the last injection at this site?
❑ Yes 0. No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FO M IS CORRECT TO
THE BEST MY KNO DGE AND THAT THE
IN.IECTIOI WAS PER RMED WITHIN THE
STANDAI S Li4 D OUT THE PERMIT,
SIGNATURE O11tINJECTION (ONTRACTOR DATE
A OA r w111J re. Kv
PRIMP NAME OF PERSON PERFORMING TIE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: MC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-JER
Rev. 8/5/2013

Permit Number WI0400395
Program Category
Deemed Ground Water
Permit Type
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Coliseum Shell
Location Address
3009 University Pkwy
Winston Salem
Owner
Owner Name
Quality Oil Company LLC
Dates/Events
NC
Orig Issue
4/23/2015
App Received
4/22/2015
Re gulated Activities
Groundwater remediation
Outfall
Waterbody Name
27105
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
4/23/2015
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Forsyth
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Bradley Snover
PO Box2736
Winston Salem
Issue
4/23/2015
Effective
4/23/2015
NC 27102273
Expiration
Re quested./Received Events
Additional information requested
Additional information received
Streamlndex Number Current Class
4/22/15
4/23/15
Subbasin
Ro g ers, Michael
From: Rogers, Michael
Sent: Thursday, April 23, 2015 2:22 PM
To:
Cc:
'Ryan Kerins'; '[e-mail]' ([e-mail])
Basinger, Corey; Knight, Sherri
Subject: RE: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Former Coliseum
Shell Facility. This facility is located at 3009 University Parkway, Winston-Salem, Forsyth County, NC 27106. We
received your complete NOi on April 23, 2015.
For your information, a newer revised NOi (revised 3/2015) is available at our website.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies of
the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct push
or Geoprobe wells are considered wells and require construction (GW-1) and a.bandonment forms {GW-30}. If well
construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wg/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me atmichael.rogers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e ., WI0XXXXXX) that has been assigned to the injection activity at this site . This
notification has been given the deemed permit number WI0400395. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re ply to this email, as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hydro geologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://porta l.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Ryan Kerins [mailto:rdkerins@terra g uestpc.com]
Sent: Thursday, April 23, 2015 10:00 AM
1
To: Rogers, Michael
Subject: RE: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
I do not have the GW-1 form. I've pieced together the following from old field notes:
The well was drilled on January 25-26, 1996 by Mike Ransier of American Drilling. Mr. Ransiers driller's license number is
2501.
Construction follows:
Outer casing: 0-40 feet below ground level (BGL) 6"-diameter PVC
Inner casing: 0-45 feet BGL 2"-diameter PVC casing with another 5 feet of 2"-diameter PVC screen with a 0.010" slot size
for a total well depth of 50 feet BGL.
Inner: Grout 0-38' BGL, bentonite 38-43', sand 43-50'.
Manager: Kenneth Basch
Ryan Kerins, Project Manager, Site's ORC (phys/chem Grade I)
Thanks,
Ryan Kerins
Terraquest Environmental Consultants, P.C.
From: Rogers, Michael [mailto:michael.rogers @ncdenr.gov]
Sent: Wednesday, April 22, 2015 4:23 PM
To: Ryan Kerins
Subject: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Ryan-
We received the NOi for the above project. Thanks.
• Do you have the GW-1 for the MW-4. If not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
• And finally, your title.
Thanks
From: Ryan Kerins [mailto:rdkerins@terraq uest pc.com]
Sent: Wednesday, April 22, 2015 9:02 AM
To: Rogers, Michael
Subject: UIC Notice submittal
Please find the attached Notification of Intent. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
2
Ro ers, Michael
From: Ryan Kerins <rdkerins [e-mail]>
Sent: Thursday, April 23, 2015 10:00 AM
To: Rogers, Michael
Subject: RE: WI0400395 NOI Former Coliseum Shell RE: UIC Notice submittal
do not have the GW-1 form. I've pieced together the following from old field notes:
The well was drilled on January 25-26, 1996 by Mike Ransler of American Drilling. Mr. Ransiers driller's license number is
2501.
Construction follows:
Outer casing: 0-40 feet below ground level (BGL) 6"-diameter PVC
Inner casing: 0-45 feet BGL 2"-diameter PVC casing with another 5 feet of 2"-diameter PVC screen with a 0.010" slot size
for a total well depth of 50 feet BGL.
Inner: Grout 0-38' BGL, bentonite 38-43', sand 43-50'
Manager: Kenneth Basch
Ryan Kerins, Project Manager, Site's ORC (phys/them Grade I)
Thanks,
Ryan Kerins
Terraquest Environmental Consultants, P.C.
From: Rogers, Michael [mailto:michael.ro-ers@ncdenr,gov]
Sent: Wednesday, April 22, 2015 4:23 PM
To: Ryan Kerins
Subject: W10400395 NOI Former Coliseum Shell RE: UIC Notice submittal
Ryan -
We received the NOI for the above project. Thanks.
• Do you have the GW-1 for the MW-4. if not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
▪ And finally, your title.
Thanks
From: Ryan Kerins [maifta:rdkerinsiu terraquestac.carn]
Sent: Wednesday, April 22, 2015 9:02 AM
To: Rogers, Michael
Subject: UIC Notice submittal
1

Please find the attached Notification of Intent. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
2
Rogers, Michael
From: Rogers, Michael
Sent:
To:
Wednesday, April 22, 2015 4:23 PM
'Ryan Kerins'
Subject: WI0400395 NOi Former Coliseum Shell RE: UIC Notice submittal
Ryan-
We received the NOi for the above project. Thanks.
• Do you have the GW-1 for the MW-4. If not please provide additional well construction info-
grouts/depths/sand pack, diameter, well driller cert no., etc.
• Please confirm spelling for Manager.
• And finally, your title.
Thanks
From: Ryan Kerins [mailto:[e-mail]]
Sent: Wednesday, April 22, 2015 9:02 AM
To: Rogers, Michael
Subject: UIC Notice submittal
Please find the attached Notification of Intent. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Thursday, April 23, 2015 2 :09 PM
Basinger, Corey; Knight, Sherri
Subject:
Attachments:
WI0400395 NOi Former Coliseum Shell FW: UIC Notice submittal
In Situ Remediation Notification-20131119 ( 13). pdf
Please find attached a NOi for the above site. I am also sending a follow up email from Ryan Kerins w/well construction
info.
From: Ryan Kerins [mailto:rdkerins@terraq uestpc.com]
Sent: Wednesday, April 22, 2015 9:02 AM
To: Rogers, Michael
Subject: UIC Notice submittal
Please find the attached Notification of Intent. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
1
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 ISA NCAC 02C .0200. This form shall be submitted at least 2 weeks prior to iniection.
AQUIFER TEST WELLS U SA 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 (ISA NCAC 02C .0229):
1) Passive Injection Svstems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale Injection Operations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: March31 • 20 15 PERMITNO_iJ.'.t0'10D3; ~obefilledinbyDWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
(1)
(2)
(3)
(4)
(5)
(6)
=X~ ___ Air Injection Well ...................................... Complete sections B-F, K, N
___ Aquifer Test Well ....................................... Complete sections B-F, K, N
=X,___ __ .Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
___ Pilot Test. ................................................ Complete sections B-N
___ Tracer Injection Well ................................... Complete~DENR/DWR
STATUS OF WELL OWNER: Business/Organization APR 2 2 2015
C. WELL OWNER-State name of entity and name of person delegated authorit1'Y~-~,-~business
or agency:
Name: Quality Oil Companv. LLC -Bradlev Snover
Mailing Address: PO Box 2736
City: Winston-Salem State: NC Zip Code: 27102-2736 County: Forsyth
Day Tele No.: [phone] Cell No.: __________ _
EMAIL Address: __ ~b=s=no~v~e=r-(@,._g.,_o~cn=c~.c~o~m~_ Fax No.: --~(3_3_6~) ~72=1~-9~5~2~0 __ _
UIC/In Situ Remed. Notification (Revised 11/19/2013) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: --------"D=e=a=c=o=n-=B::..::l..:..vd:;•c..,H=o=l=d=in""'g:,.,:sc...::X~Ie...V,__ _________ _
Mailing Address: -----=-P-=O;...:B=-o=x-"----'----74--'---'7,_,7 _____________________ _
City: Winston-Salem State:~ Zip Code:.-'2~7-=1~0~9 ______ County: Forsyth
Day Tele No.: Cell No.: __________ _
EMAIL Address: _____________ _ FaxNo.: ___________ _
E. PROJECT CONTACT -Person who can answer technical questions about the proposed injection project.
Name: ------"""R"'"y'-"an==--<K=e=r=in=s"---------------------------
Mailing Address: --------=-l0=-0a...-=E-=R=uffi=1=n-=S=t ____________________ _
City: ------=-M=e~b=an=e~-----State: NC Zip Code: 27302 County: Alamance
Day Tele No.: ---"""9_._1-"-9-....::5=63:::....-~9=09"-'l'--_____ _ Cell No.: 919-906-0960
EMAIL Address: __ ----'r,.,.dk=er=i=ns=®=te=-=-rr.:..::a:a.::;q..,.u=e=st""p=c.=c=om==---Fax No.: 919-563-9095
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: --~3~00=9c--=U=n~iv~e=r=si""ty~P~ar=k~w=a'""y ______________ _
________________________ County: Forsyt h
City: Winston-Salem State: NC Zip Code: ---=2:....:..7..:..10=6"----------
(2) Geographic Coordinates: Latitude**: ___ 0 ______ " or 36.1306°
Longitude**: ___ 0 ______ " or -80.2625 °
Reference Datum: North American Datum of 1927 Accuracy: 1/2 of
a contour interval from actual elevation. and/or more than 1/40 of an inch (0.6 mm) horizontally from actual position
Method of Collection: USGS 7.5 minute to po-Rural Hall. NC
**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: _______ .square feet
Land surface area of inj. well network: square feet~ 10,000 ft2 for small-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.
(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.
UIC/In Situ Remed . Notification (Revised 11/19/2013) Page 2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity .
A dual-phase extraction (p um p and treat) s ystem has o perated at the site for several years to remove petroleum
contamination from a former UST leak from the soil and gr oundwater. This re quest is to a pprove injection of
Oxygen BioChem and to s parge air within gr oundwater monitoring well MW4
J. INJECT 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.orwweblwqlapslgwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program/or more info (919-807-6496).
lnjectant: Oxyg en BioChem
Volume of injectant: _________ _
Concentration at point of injection: The solubilitv is approximatelv 7 wei ght percent , so that is the
concentration.
Percent if in a mixture with other injectants: 100% (no other) __________ _
lnjectant: --------------------------------
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: _____ .Proposed 1 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 (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
( c) well contractor name and certification number
UIC/Jn Situ Remed. Notification (Revised 11/19/2013) Page3
L. SCHEDULES-Briefly describe the schedule for well construction and injection activities.
Wells already exist. lnjectjon will begjn ypon confinnation of receipt and io accordance wjth schedule ofUIC.
(typically two weeks following receipt of this Notice}
M. MONITORING PLAN -Describe below or in separate attachment a monitoring plan to be used to detennine
if violations of groundwater quality standards specified in Subcha pter 02L result from the injection activity.
Groundwater at this site is sampled, at a minimum, on a semi-annual basis under the NCDWM-UST approved
Correctjye Action Pian.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "/ hereby certify, under penalty of law, that I am familiar with the information submiued in this
document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I bellet.>e that the information is true, accurate and complete. I am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct, operate, maimain, repair, and if applicable, abandon the ir,iection well and
a/l~Z' in accordance with the /SA NCAC 02C 0200 R.,/e,. "
3/31/15 Ryan D. Kerins
Signature or Applicant Print or Type Full Name
PROPERTY OWNER (jf 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 conse111 to
allow the applicant lo constn1ct each injection well as outlined in this application and agree that ii shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Constn1ction Standards
(15 A 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.
{u&U,-J ftY°cl, X\v
'='y'· ~ -;;,
t1h1Ai"(k (.c;: bl N tcr'4:: J2~
Signature• of Property Owner (if dill'eren t 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:
UICI In Sit11 Rcmed Nolilication (Revised I 1/19,':!0IJ)
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Tab le 1 MONllORING WELL CONSTRU«;TION INFORMATION
Date: 2/6/15 Incident Name: Coliseum Shell Service Incident No. 15260 Facility ID No : 0--020021
Depth to
Date Water Water from
Level Wei Cosing Cepth (ft. SCreened Interval (x Bottom of Well Top of casing Top of casing Free Product Groundwater
Well ID Cate Installed Measured BGS) toy ft. BGS) (ft.BGS) Elevation (ft.) (ft.) Thickness (ft.) Elev•tion (11.) Comments
MWl 9/12/199S 1/21/201S 11 11-33 33 959.266 26.90 0 932.37 Type II well
MW2 9/12/1995 1/21/2015 15 15-35 35 960.000 27.75 0.01 932.25 Type llwell
MW3 9/12/199S 1/21/2015 15 15-35 35 959.193 Type llwell
MW4 1/25-26/96 1/21/2015 OC:40 I IC:45 45-50 50 959.586 29.93 0 929.66 Type Ill well
MW5 1/25/1996 1/21/2015 20 20-35 35 959.405 26.54 0 932 .86 Type llwell
MW6 1/25/1996 1/21/2015 20 20-35 35 957A66 24.35 0 933 .12 Type llwell
MW7 1/25/1996 1/21/2015 15 15-30 30 960.246 27.85 0 932.40 Type II well
MW8 1/25/1996 1/21/2015 15 15-30 30 957A74 2531 0 932 .16 Type II well
MW9 1/25/1996 1/21/2015 15 15-30 30 954.147 21.92 0 932.23 Type II well
MWlO 5/6/1999 1/21/2015 20 20-30 30 960.733 2831 0 932.42 Type II well
MWll 5/6/1999 1/21/2015 20 20-35 35 964.503 32.13 0 932.37 Type llwell
MW13 7/8/1999 1/21/2015 10 10-30 30 960.097 28.25 0 931.85 Type II well
MW14 7/8/1999 1/21/2015 10 10-30 30 961.950 DRY DRY DRY Type llwell
MW15 7/9/1999 1/21/2015 10 10-30 30 962.022 29.52 0 932.50 Type llwell
MW16 7/9/1999 1/21/2015 10 10-30 30 959.541 27.38 0 932.16 Type llwell
MW17 10/13/1999 1/21/2015 10 10-30 30 964.225 DRY DRY DRY Type II well
MWlB 10/13/1999 1/21/2015 10 10-30 30 962.198 DRY DRY DRY Type II well
MW19 10/12/1999 1/21/2015 10 10-30 30 958.039 25.96 0 932.08 Type llwell
MW20 10/28/2008 1/21/2015 20 20-40 40 963.725 29.92 0 933.80 Type II well
MW21 10/28/2008 1/21/2015 20 20-40 40 961 .512 28.44 0 933 .07 Type llwell
MW22 10/29/2008 1/21/2015 20 20-40 40 963 .903 31.19 0 932.71 Type II well
MW23 10/29/2008 1/21/2015 20 20-40 40 963.8 25 31 .79 0 932.03 Type II well
PZl 3/26/2001 1/21/2015 10 10-35 35 959.266 27 .16 0 932.ll Type II well
RWl(EWl) 3/26/2001 1/21/2015 10 10-45 45 959.568 26.80 0 932.77 Type II well
RW2 10/28/2008 1/21/2015 20 20-45 45 963.739 30.69 0 933.05 4 in . Type II well
RW3 10/29/2008 1/21/2015 19 19-44 44 963.856 31 .ll 0 932.75 4 in . Type II well
RW4 9/13/2010 1/21/2015 13 13-43 43 959.060 26.35 0 932.71 4 in . Type II well
RW5 9/14/2010 1/21/2015 14 14-44 44 959.230 27.12 0 932.11 2 in. Type II well
RW6 9/15/2010 1/21/2015 15 15-45 45 963.320 30.68 0 932.64 4 in. Type II well
RW7 9/16/2010 1/21/2015 14 14-44 44 959.870 27.76 0 932.11 4 In. Type II well
RW8 9/16/2010 1/21/2015 15 15-45 45 960.620 28.22 0 932.40 4 in. Type II well
RW9 9/16/2010 1/21/2015 15 15-45 45 961.040 28.57 0 932.47 4 in. Type II well
RWlO 9/16/2010 1/21/2015 7 7-37 37 960.550 28.10 0 932.45 4 in . Type II well
RWll 10/6/2010 1/21/2015 15 15-45 45 959 .080 27.98 0 931.10 4 in. Type II well
RW12 10/6/2010 1/21/2015 10 10-40 40 957.930 24 .36 0 933 .57 4 In. Type II well
RW13 10/6/2010 1/21/2015 13 13-43 43 958.620 26A8 0 932.14 4 in. Type II well
RW14 10/6/2010 1/21/2015 15 15-45 45 959.280 26.98 0 932.3 0 4 in . Type II well
RW15 10/6/2010 1/21/2015 15 15-45 45 959.060 27.03 0 932.03 4 in . Type II well
RW16 10/6/2010 1/21/2015 13 13-43 43 960.010 27.76 0 932.25 4 in . Type II well
RW17 10/6/2010 1/21/2015 15 15-45 45 960.760 28A2 0 932.34 4 in. Type II well
RW18 10/7/2010 1/21/2015 12 12-42 42 959.270 27.22 0 932.05 4 in. Type II well
RW19 10/7/2010 1/21/2015 10 10-40 40 958.720 31.13 0 927.59 4 in. Type II well
RW20 10/7/2010 1/21/2015 12 12-42 42 959.510 27.20 0 932.31 4 in. Type II well
All 9/14/2010 15 15-30 30 959.320 l in. Type II Well
Al2 9/14/2010 15 15-30 30 959A60 l in. Type II Well
Al3 9/14/2010 15 15-30 30 959.640 1 in. Type II Well
Al4 9/14/2010 15 15-30 30 959.630 l in. Type II Well
Al5 6/23/2010 15 15-30 30 960.560 l in. Type II Well
AJ6 6/23/2010 15 15-30 30 958.690 -l In. Type II Well
Al7 6/23/2010 15 15-30 30 960.360 --1 In. Type II Well
A18 6/23/2010 15 15-30 30 960.210 -1 in. Type II Well
Al9 9/14/2010 15 15-30 30 963.180 -1 In. Type II Well
AllO 6/23/2010 15 15-30 30 961.700 1 in. Type II We ll
Notes:
1. All units In feet.
2. MW4 is a Type Ill monitoring well used for vertical delineation.
3. -Not Measured .
4. OC :::e outer casi ng, IC= inner casing
S. Groundwater elevation measurements for we lls w ith product w e re corrected using the following equation :
(top of casing • dept h to water)+ (free product th ickness x 0.729) Note: 0.729 is specific to e:aso line.
6. • = MW12 has been paved over.
7. # = Mon ftoring well MW17 contained free produ ct, how ever, through an omission a water level wa s not collected for that well . Due to the omission an accurate fre e product thichness
could not be determined .
8. NA• Not App licable.
PFA
HHJT
ICS
LEGEND
41079 TYPE II GW MONITORING WELL
Quws TYPE Itl GW MONITORING WELL
4RIY2 DUAL —PHASE EXTRACTION WELL
®Aaa AIR INJECTION WELL
Analylirdl results far the '/21/15 groundwater
sampling event ore provided it ug/L.
Only petroleum —type compounds with detections in
excess of the GCLs ors listed,
Where present, the Ieet of free product is
listed next to ouch respective well.
Dote from the type III monitoring well MW4 was
not r,5ed in the construction of this mop-
Anclyticdl results ore summarized in Table 2. The
lull onolyticel report is provided In R.
w
GRAPHIC SCALE
0' 25' 50'
1" = 50'
100'
GROUNDWATER ANALYTICAL
WINSTON-SALEM, NC
OIL COMPANY, LLC
L!S
[.7
l.�
LaJ
O
CO
S
rn
iJ
ALLIED*/RDK
co
Lit
cn
O
PROJECT NO:
Ln

A
MW1 1
100'
90' /
80'
70'
60' -
50' -
40'
30'
MW13 MW2
MW4 MW5
/r
z
/r
+ + + + + + + + + ' 7 ' ' •- - .~r-- + + + + + + + + + + + + ...,-- + + + + ▪ + +
+ + + + + + + + + + + + + + + + + + 4- + + + + + + --k + + + . + + 4./ + + +
+ + + + + + + + + + 4 + + + + + + + + + + + + + + + + + + + + + + -+ + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + .90. + + + + f + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + -$ + + + +- + + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +/+ + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + Z►.+ + to'+ + + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + +..."+ t + + + + +
+ + + + + + 4- + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + 4- + + + + + + + + + + + + + + + + + + + + +
+ +++++++++++++++++++++++++++++++++++
+ ++++++++++++++++++++++++++++++++++++
+ + + + + + + + + + + + + + + + + + + + 4 + + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + + +
+ +++++++++++++++++++++++++++++++++++
+ + + + + + 3 + + + + t + + f + t + + + t + + + t + a + a 6 i + a +
20'
10'
HORIZONTAL SCALE - 1" = 40'
VERTICAL SCALE - 1 " = 20'
ELEVATIONS REFS
TO AN ARBITRAR'
PLANE OF 100'.
MW1
1001/
MW2
MW10
90'
- I /•
rX/Of Aev
+ +
+ + t t + t t t t t t t t t t + t t + t + + t t + t t + } + + + + t + + +
t t t + + t t + + t + t + + + t t t t t t + t t t + + + + + + + t + t + t i
+ t t t + + + + + t t + + + t t t t t t + t } t t t t t t t t + + + + t +
t + + + + + + + + + + t + + + + + + t + + + + + + t t t t + + + t + + t t -4
t t + + t + + + + + + + t + t + t + + + + + + t + t t + + + + + + + + + +
80'
70'
60'
50'
MW3

MATERIAL SAFETY DATA SHEET
Oxygen nioChem (OBC)®
l\>1',DS Ref. No.: Fl 8-44-8
DateApprnved: 04/30/2006
Re,•lslon No.: 2
'rbis document has been prepared to 1neet. the requirements ofthe U.S. OSHA Hazard Comn1unicatlon
Sr.atldard, 29 CFR 1910.1200: tho C.anadas Workplace lfuzardous Materials Information System {WHMIS)
and, the EC Directive, 2001/58/EC.
1. PRODUCT AND COMPANY IDENTIFICATION
PRODUCl' NAME:
GENl,'RAL USE:
MANUFACTURER
PMC CORPORATION
FMC Peroxygcns
1735 Marlcct Street
Philadelphia, PA 19103
[phone](Ckneral Infotruallon)
Oxygen BioChcm (OBC)®
For chemical oxidation and aerobic bioremed1ation, petroleum
hydroc.arbon remediation, creosote remediation and partially
halogenated hydrocarbon l'cmcdiation.
EMERGENCY TELEPHONE NUMBERS
[phone] (Medical· U.S .• Call Collect)
For lcnk, fire. spill, or accident emergencies, call:
[phone] (CHEM1'REC • U.S.A. &. Canada}
2. HAZARDS IDENTIFICATION
EMERGENCY OVERVIE\V:
co Odorlc$$, off.white fine granular solid (,nay hn ve separation or noticeable two-tone appearance).
c0 Oxidazer.
co Contact with combu.<itlbfes may cause fire..
t:tJ D~omposcs ill storage under conditions of moisture (water/water vapor) and/or exce:..~ive heal causing
release of ox.idc.'i of sulfur aod oxygen that supports combustion. Decompo!iiLioo could form a hi_gh
tc.mpcralllre melt, See Section IO ("Stability andRc8:(:tivity").
c0 Deluge cont:aincr with water at safe distance or in protected a1·ca.
oo May be severely irrltating to the eyes.
POTENTIAL HEALTH EFFECTS: Airbomcdmtmay bcirrit:atingtoeycs, nose, lungs,
throat and skfo upon contact. Exposure to high levels of dust may cause difficulty in breathing in sensitive
persons. No signific~ml l0rtg tcnn inhalation hazard; irritation usuaUy subsides after cx.posutc ceases.
Page 1 of10
Oxygen BioChem (OBC)® (Fl8--44-8) Date: 04/30/2006
3. COMPOSITION I INFORMATION ON INGREDIENTS
Chemical Name CAS# Wt,% EC No, EC Class
Proprietary Mixture None Not classified
4. FIRST AID MEASURES
EYES: Immediately flush with water for at least 15 minutes, lifting the upper and lower eyelids
intermittently. See a medical doctor or ophthalmologist immediately.
SKIN: Wash with plenty of soap and water. Get medical attention if irritation occurs and persists.
INGESTION: Rinse mouth with water. Dilute by giving 1 or 2 glasses of water. Do not induce
vomiting. Never give anything by mouth to an unconscious person. See a medical doctor immediately.
INHALATION: Remove to fresh air. If breathing difficulty or discomfort occurs and persists, obtain
medical attention.
NOTES TO MEDICAL DOCTOR: Modest irritation is the only expected effect. No
serious consequences are expected, except perhaps in the case of direct eye contact. Contaminated external
surfaces should be flooded with water, and direct eye contact deserves ophthalmologic evaluation. If
ingested, gastrointestinal irritation but not caustic burns are to be expected; dilution with water indicated as
may be gastric evacuation via emesis or lavage if large doses or severe irritation is evident. Demulcents
should be helpful. No systemic effects are expected though human toxicity data is sparse.
5. FIRE FIGHTING MEASURES
EXTINGUISHING MEDIA: Deluge with plenty of water.
FIRE/ EXPLOSION HAZARDS: Product is non-combustible. Under fire conditions, may
decompose and release oxygen gas, which may intensify fire. Presence of water accelerates decomposition.
Mixtures with polysulfide polymers may ignite,
FIRE FIGHTING PROCEDURES: Use flooding quantities of water. Use water spray to
keep fire exposed containers cool. Do not use carbon dioxide or other gas filled fire extinguishers; they
will have no effect on decomposition. Wear full protective clothing and self-contained breathing apparatus.
Page 2 of 10
Oxygen BioChem (OBC)® (Fl8-44-8) Date: 04/30/2006
FLAMMABLE LIMITS: .
Non-combustible
SENSITIVITY TO IMP ACT: Oxidizable materials can be ignited by grinding and may
become explosive.
SENSITIVITY TO STATIC DISCHARGE: Not available
6. ACCIDENTAL RELEASE MEASURES
RELEASE NOTES: Confine and collect spill, put into an approved DOT container (do not return
to original container) and isolate for disposal. Isolated material should be monitored for signs of
decomposition (fuming/ smoking). If spilled material is wet, dissolve with large quantities of water and
dispose as a hazardous waste. Runoff to sewer may create fire or explosion hazard ( do not flush powdered
material into sewer). Dispose of wastes according to the method outlined in Section 13, "Disposal
Considerations".
7. HANDLING AND STORAGE
HANDLING: Avoid contact by using personal protective equipment. Use respiratory protective
equipment when release of airborne dust is expected. If compounded with organics or combustible
materials be sure to exclude moisture. Use clean plastic or stainless steel scoops only.
STORAGE: Keep dry (reacts with moisture). Use first in, first out storage system. Store unopened in
a cool, clean, dry place away from point sources of heat ( e.g. steam pipes, radiant heaters, hot air vents or
welding sparks). Keep container tightly closed when not in use. A void contamination of opened product.
Avoid contact with reducing agents. In case of fire or decmpositoin (fuming/ smoking) deluge with plenty
of water to control decomposition, Fore storage, refer to NFPA Bulletin 430 on storage of liquid and solid
oxidizing materials.
COMMENTS: VENTILATION: Provide mechanical general and/or local exhaust ventilation to
prevent release of dust into work environment. Spills should be collected jnto suitable containers to prevent
dispersion into the air. If ventilation fa inadequate or not available, use dust respirator and eye protection.
8. EXPOSURE CONTROLS/ PERSONAL PROTECTION
EXPOSURE LIMITS
Cltemical Name ACGIH OSHA Supplier
Proprietary Ingredient 0.1 mg/m3 (TWA)
Page3 of IO
Oxygen BfoChem (OBC)® (F18-44-8) Date: 04/30/2006
10. STABILITY AND REACTIVITY
CONDITIONS TO AVOID: Heat {decomposes at 275°C), moisture, reducing
agents. Grinding with organics.
STABILITY: Stable (decomposition could occur when exposed
to heat or moisture)
POLYMERIZATION: Will not occur
INCOMPATIBLE MATERIALS: Grinding mixtures with organics {oxidizable
materials can be ignited by grinding and may
become explosive); heavy metals . Acids, alkalis,
halides (fluorides, chlorides, bromides and
iodides), combustible materials, most metals and
heavy metals, oxidizable materials, other oxidizers,
reducing agents, cleaners, and organic or carbon
containing compounds. Contact with incompatible
materials can result in a material decomposition or
other uncontrolled reactions.
HAZARDOUS DECOMPOSITION PRODUCTS: Oxygen that supports combustion and oxides of
sulfur, nitrogen, and calcium hydroxide.
COMMENTS: PRECAUTIONARY STATEMENT: Use ofpersulfates in chemical reactions
requires appropriate precautions and design considerations for pressure and thermal relief.
Decomposing persulfates will evolve large volumes of gas and/or vapor, can accelerate exponentially with
heat generation, and create significant and hazardous pressures if contained and not properly controlled or
mitigated.
Use with alcohols in the presence of water has been demonstrated to generate conditions that require
rigorous adherence to process safety methods and standards to prevent escalation to an uncontrolled
reaction.
11. TOXICOLOGICAL INFORMATION
EYE EFFECTS: No data available for the mixture.
Proprietary Component: Non-irritating (rabbit)
Proprietary Component: Severely irritaitng (unwashed); Minimally irritating (washed)
SKIN EFFECTS: No data available for the mixture.
Expected to be non-irritating.(rabbit)
DERMAL LDso: No data available for the mixture.
Proprietary Components: > 10 g/kg (rat)
ORAL LDso: No data available for the mixture.
Proprietary Component: 895 mg/kg (rat)
Proprietary Component: 5 g/kg (rat)
Page 5 of 10
..
Oxygen BioChem (OBC)® (F18-44-8} Date: 04/30/2006
13. DISPOSAL CONSIDERATIONS
DISPOSAL METHOD: Dissolve in water to allow the release of oxygen and dispose via a
treatment system in accordance with governmental agencies regulations. Contact appropriate regulatory
agency prior to disposal.
14. TRANSPORT INFORMATION
U.S. DEPARTMENT OF TRANSPORTATION (DOT)
PROPER SHIPPING NAI\'.IE:
PRIMARY HAZARD CLASS/ DIVISION:
UN/NA NUMBER:
PACKING GROUP:
LABEL(S):
PLACARD(S):
MARKING(S):
ADDITIONAL INFORMATION:
Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide)
5.1 (Oxidizer)
UN 1479
II
5.1 (Oxidizer)
5, I (Oxidizer)
Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide), UN1479
Hazardous Substance/RQ: Not applicable
49 STCC Number: 4918733
This matetial is shipped in 55 lb.
polyethylene pail with vented screw-on lid
(approx 6.5 gallon)
INTERNATIONAL MARITIME DANGEROUS GOODS (IMDG)
PROPER SHIPPING NAME: Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide)
INTERNATIONAL CIVIL AVIATION ORGANIZATION (ICAO) /
INTERNATIONAL AIR TRANSPORT ASSOCIATION (IATA)
PROPER SHIPPING NAME:
ADDITIONAL INFORMATION:
Page 7 of 10
Oxidizing solid, n.o.s. (sodium persulfate,
calcium peroxide)
Combination packaging is recommended
for air transport.
Oxygen BioChem (OBC)® (F18-44-8) Date: 04/30/2006
OTHER INFORMATION:
Place spilled product in suitable container and wash residue with plenty of water.
See Section 6 (Accidental Release Measures) above for additional instmctions.
15. REGULATORY INFORMATION
UNITED STATES
SARA TITLE III (SUPERFUND AMENDMENTS AND REAUTHORIZATION ACT)
SECTION 311 HAZARD CATEGORIES (40 CFR 370):
Fire Hazard, Immediate (Acute) Health Hazard
SECTION 312 THRESHOLD PLANNING QUANTITY (40 CFR370):
The Threshold Planning Quantity (TPQ) for this product, if treated as a mixture, is I 0,000 lbs;
however, this product contains the following ingredients with a TPQ of less than 10,000 lbs.:
None
SECTION 313 REPORTABLE INGREDIENTS (40 CFR 372):
Not listed
CERCLA (COl\fl>REHENSIVE ENVIRONMENTAL RESPONSE COMPENSATION AND
LIABILITY ACT)
CERCLA DESIGNATION &REPORTABLE QUANTITIES (RQ) (40 CFR302.4):
Proprietary component: Unlisted, RQ = 100 lbs., Ignitability
TSCA (TOXIC SUBSTANCE CONTROL ACT)
TSCA INVENTORY STATUS (40 CFR 710):
Listed (components)
RESOURCE CONSERVATION AND RECOVERY ACT (RCRA)
RCRA IDENTIFICATION OF HAZARDOUS WASTE (40 CFR 261):
Waste Number: D00l
CANADA
WHMIS (WORKPLACE HAZARDOUS :MATERIALS INFORMATION SYSTEM):
Chemical Name:
Product Identification Number:
Hazard Classification/ Division:
Ingredient Disclosure List:
Chemical Name:
Product Identification Number:
Hazard Classification/ Division:
Ingredient Disclosure List:
Proprietary Component
1505
Class C (Oxidizer), Class D, Div. 2, Snbdiv. B. (Toxic)
Listed
Proprietary Component
1457
Class D, Div 2, Subdiv. B, Class C (Oxidizer)
Listed
Page 8 of IO
Oxygen BioChem (OBC)® (FlB-44-8)
INTERNATIONAL LISTINGS
Proprietary Component
Australia (AICS): Listed
China: Listed
Japan (ENCS): (1)-1131
Korea: KE-12369
Philippines (PICCS): Listed
Proprietary Component
Australia (AICS): Listed
China: Listed
Japan (ENCS): (l)-181
Korea: KE-04518
Philippines (PICCS): Listed
Proprietary Component
Australia (AICS): Listed
China: Listed
Japan (ENCS): (1)-190
Korea: KE-04597
Philippines (PICCS): Listed
Date: 04/30/2006
HAZARD, RISK AND SAFETY PHRASE DESCRIPTIONS:
EC Symbols:
EC Risk Phrases:
EC Safety Phrases:
(Not classified as hazardous)
(Not classified as hazardous)
(Not classified as hazardous)
16. OTHER INFORMATION
Health 2
Flammability 0
Ph ysical Hazard 1
Personal Protection (PPB) J
Protection :;::; J (Safety goggles, gloves, apron & combination dust & vapor respirator)
HMIS :;::; Hazardous Materials Identification System
Degree of Hazard Code:
4=Severe
3 = Serious
Page 9 of IO
Oxygen BioChem (OBC)® (F18-44-8)
2=Moderate
1 = Slight
0=Minimal
NFPA
Health
Flammability
Reactivity
Special
SPECIAL = OX (Oxidizer)
2
0
1
ox
NFPA = National Fire Protection Association
Degree of Hazard Code:
4=Extreme
3=High
2=Moderate
1 = Slight
0 = Insignificant
REVISION SUMMARY:
This MSDS replaces Revision #1, dated December 12, 2005.
Changes in information are as follows:
Section 1 (Product and Company Identification)
Section 16 (Other Information)
FMC Logo -FMC Corporation Trademark
Oxygen BioChem (OBC) -Trademark of Redox Tech, LLC
© 2006 FMC Corporation. All Rights Reserved.
Date: 04/30/2006
FMC Corporation believes that the information and recommendations contained herein (including data and
statements) are accurate as of the date hereof. NOW ARRANfY OF FITNESS FOR ANY PARTICULAR
PURPOSE, WARRANTY OF MERCHANTABILITY, OR ANY OTHER W ARRANfY, EXPRESSED
OR IMPLIED, IS MADE CONCpRNING THE INFORMATION PROVIDED HEREIN. The information
provided herein relates only to the specific product designated and may not be applicable where such
product is used in combination with any other materials or in any process. It is a violation of Federal law to
use this product in a manner inconsistent with its labeling. Fw"ther, since the conditions and methods of use
are beyond the control of FMC Corporation, FMC Corporation expressly disclaims any and all liability as
to any results obtained or arising from any use of the product or reliance on such information.
Page 10 of lO