WI0400419_DEEMED FILES_20151008

Rogers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael,
Jamie Honeycutt <[e-mail]>
Thursday, October 08, 2015 3: 11 PM
Rogers, Michael; Ghiold, Sharon
Wayne Watterson; Knight, Sherri; Basinger, Corey
RE: NOi WI0400419 TF 7904 Colfax Custom Frames In Situ Remediation Notification-
Guilford Co.
TF 7904 Colfax Injection Event Record -signed.pdf
Attached is the completed Injection Event Record forTF 7904 Colfax Custom Frames site. Call if you have any questions.
Thank you
From: Rogers, Michael [mailto:[e-mail]]
Sent: Monday, August 31, 2015 5:34 PM
To: Jamie Honeycutt <[e-mail]>; Ghiold, Sharon <[e-mail]>
Cc: Wayne Watterson <[e-mail]>; Knight, Sherri <[e-mail]>; Basinger, Corey
<[e-mail]>
Subject: RE: NOi WI0400419 TF 7904 Colfax Custom Frames In Situ Remediation Notification-Guilford Co.
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for the Colfax Custom
Frames (TF #7904) located at 3319 Sandy Ridge Road, Colfax, Guilford County, NC 27235. The Central Office of the
WQROS received your complete NOi electronically on August 26, 2015.
Please note the following:
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 WI0400419. 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
1
From: Jamie Honeycutt [mailto:[e-mail] ]
Sent: Wednesday, August 26, 2015 12:54 PM
To: Rogers, Michael
Cc: Wayne Watterson
Subject: NOi TF 7904 Colfax Custom Frames In Situ Remediation Notification-Guilford Co.
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOi} to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 7904 Colfax Custom Frames located at 3319 Sandy Ridge Road,
Colfax, (Guilford County). I will also mail a hard copy of the NOi to you. We plan to install O-SOXs at one exiting monitor
well located at the site. Please give me a call on my cell (910 977-7614} if you have any questions.
thanks
Jamie T. Honeycutt
Environmental Professional
$&&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the tenns of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
2
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Resources
Permit Number WlO400419
I. Permit Information
S&ME.Inc.
Permittee
TF-7904 Colfax Custom Frames
Facility Name
3319 Sandy Ridge Road. Colfax. NC 27235
Facility Address
2. Injection Contractor Information
S&ME.Inc.
Injection Contractor/ Company Name
Street Address 8646 West Market Street. #105
Greensboro NC 27409
City State Zip Code
Cl16J 288-7180
Area code -Phone number
3. Well Information
Number of wells used for injccti~n ~----
Well names MW-I ------------
Were any new wells installed during this injection
event?
D Yes [x No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection WeHs -------
Type of Well Installed (Check applicable type):
0 Bored O Drilled D Direct-Push D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form/or each
well installed.
Were any wells abandoned during this injection
event?
0Yes [iNo
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
O-SOX: Calcium Peroxide, Calcium Hydroxide
lnjectant Type (Solid)
Concentration 10-40 mg/L at injection point
If the injectant is diluted please indicate the source
dilution fluid. -----'~--------
Total Volume Injected 3 socks (2" x3')
Volume Injected per well 3 socks (2" x 3')
5. Injection History
Injection date(s)_9..._-...... J ... 7_.-2..,,0,...,,)..,5 ______ _
Injection number ( e.g. 3 of S)_~-----
ls this the last injection at this site? (unknown)
D Yes D 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. 0tl Ytj SLV\,\.C,O)( 9-17-2015
SIGNATURE OF lNJf;:CTION CONTRACTOR DATE
Ga Simcox S&ME Inc .. -A ent for NCDENR
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days ofinjection.
Attn: lJIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Fonn UIC-IER
Rev. 8/5/2013
Permit Number WI0400419
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
Colfax Custom Frames TF #7904
Location Address
3319 Sandy Ridge Rd
Colfax NC
Owner
Owner Name
Sharon
Dates/Events
Orig Issue
8/31/2015
App Received
8/26/2015
Re g ulated Activities
Groundwater remediation
Outfall
Waterbody Name
27235
Ghiold
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/9/2015
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
Guilford
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Sharon Ghiold
Geologist
NCDENR -Dwm Ust Section
Raleigh
Issue
8/31/2015
Effective
8/31/2015
NC 27699
Expiration
Req uested /Received Events
Streamlndex Number Current Class Subbasln
Rog ers, Michael
From: Ryals, Scott
Sent:
To:
Wednesday, September 02, 2015 4:25 PM
Ghiold, Sharon
Cc:
Subject:
Rogers, Michael; Michael Pfeifer ([e-mail]); [e-mail]
RE: General statement authorizing S&ME to be our agent for O-Sox NOls
Hi Michael,
I am fine with do this. What do you need from me for this to happen?
From: Ghiold, Sharon
Sent: Wednesday, September 02, 2015 1:31 PM
To: Ryals, Scott
Cc: Rogers, Michael; Michael Pfeifer ([e-mail]); aq [e-mail]
Subject: General statement authorizing S&ME to be our agent for O-Sox NOis
Scott,
Michael Rogers with UIC asked us to provide him with a general authorization for S&ME to act as our agent for the NOls
to install O-Sox at our State-Lead Cleanup sites. I explained that we are testing the product at about 10 sites, and after
evaluating their effectiveness, decide if we want to continue using them.
Thanks!
Sharon Ghiold, Geologist
NCDENR, Division of Waste Management
Underground Storage Tanlc Section, Trust Fund Branch
1646 Mail Service Center, Raleigh, NC 27699-1646
Phone and Fax number is 919-707-8166
http://p ortal.ncdenr.org/web/wm/
[e-mail]
Email correspondence to and from this address is subject to the North Carolina Public Records Law and may be disclosed to third
parties unless the content is exempt by statute or other regulation.
1
Ro g ers, Michael
From:
S~nt:
To:
Cc:
Subject:
Rogers, Michael
Monday, August 31, 2015 5:34 PM
'Jamie Honeycutt'; Ghiold, Sharon
Wayne Watterson; Knight, Sherri; Basinger, Corey
RE: NOi WI0400419 TF 7904 Colfax Custom Frames In Situ Remediation Notification-
Guilford, Co .
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for the Colfax Custom
Frames (TF #7904) located at 3319 Sandy Ridge Road, Colfax, Guilford County,NC 27235. The Central Office of the
WQROS received your complete NOi electronically on August 26, 2015.
Please note the following:
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 WI0400419. This number is also referenced in the subject fine of
this email. You may if you wish, scan and send back as attachments in re p ly to this email, as it wjll already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation
From: Jamie Honeycutt [mailto:[e-mail]]
Sent: Wednesday, August 26, 2015 12:54 PM
To: Rogers, Michael
Cc: Wayne Watterson
Subject: NOi TF 7904 Colfax Custom Frames In Situ Remediation Notification-Guilford Co.
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 7904 Colfax Custom Frames located at 3319 Sandy Ridge Road,
Colfax, (Guilford County). I will also mail a hard copy of the NOi to you . We plan to install O-SOXs at one exiting monitor
well located at the site. Please give me a call on my cell (910 977-7614) if you have any questions.
thanks
1
Jamie T. Honeycutt
Environmental Professional
*S&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 10~
Fayetteville NC 28306 ~
Ph: 910-323-1091 -
Fax: [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.c·om/email. If you received this meSS<!ge in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
2
Rogers, Michael
From:
Sent:
To:
Subject:
Attachments:
Please find attached a NOi.
Rogers, Michael
Monday, August 31, 2015 5: 31 PM
Knight, Sherri; Basinger, Corey
FW: NOi WI0400419 TF 7904 Colfax Custom Frames In Situ Remediation Notification-
Guilford Co.
NOi TF 7904 Colfax In Situ Remediation Notification-2015-8-25.pdf
From: Jamie Honeycutt [mailto:[e-mail]]
Sent: Wednesday, August 26, 2015 12:54 PM
To: Rogers, Michael
Cc: Wayne Watterson
Subject: NOI TF 7904 Colfax Custom Frames In Situ Remediation Notification-Guilford Co.
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 7904 Colfax Custom Frames located at 3319 Sandy Ridge Road,
Colfax, (Guilford County). I will also mail a hard copy of the NOi to you. We plan to install O-SOXs at one exiting monitor
well located at the site. Please give me a call on my cell (910 977-7614) if you have any questions.
thanks
Jamie T. Honeycutt
Environmental Professional
~S&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile : [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www .smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
1
Ro g ers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael,
Jamie Honeycutt <[e-mail]>
Wednesday, August 26, 201512:54 PM
Rogers, Michael
Wayne Watterson
NOi TF 7904 Colfax Custom Frames In Situ Remediation Notification-Guilford Co.
NOi TF 7904 Colfax In Situ Remediation Notification-2015-8-25.pdf
As discussed earlier, attached is the electronic copy of the Notice of Intent {NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 7904 Colfax Custom Frames located at 3319 Sandy Ridge Road,
Colfax, (Guilford County). I will also mail a hard copy of the NOi to you. We plan to install O-SOXs at one exiting monitor
well located at the site. Please give me a call on my cell (910 977-7614) if you have any questions.
thanks
Jamie T. Honeycutt
Environmental Professional
~S&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph : 910-323-1091
Fax: [phone]
Mobile : [phone]
ihone ycutt(al smeinc.com
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments . Please consider the environment before printing this email.
1
S&ME
August 28, 2015
North Carolina Department of Environment and Natural Rescources
DWR UIC Program
1636 Mail Service Center
Raleigh, NC 27699
Reference: Notification of Intent
To Whom It May Concern:
Please find enclosed Notices of Intent to Constrict or Operate Injection Wells for the following TF sites:
29194-02, 10765-02, 17393, and 7904-02. An electronic copy of each package was sent to Mr. Michael
Rogers, of the NCDENR, on August 26, 2015.
Sincerely,
$&ME Inc.
• �•eLJJ
Jennifer Powers Crank
Administrator, Environmental Department
S&ME, Inc.
RECEIVEDIDEWRICW
SEP - 2 20f5
Water Quality Regional
Operations Shoo
s&VE1-12N(40641g,Sfot5kEmalkiMkqgt,k6 113 §Wr bl . Mti yvfotWEIRlait €

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are ''permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This fo rm shall be submitted at least 2 weeks prior to iniection.
AQUIFER TEST WELLS 0 5A NCAC 02C .0220}
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION 0 5A NCAC 02c .0225 ) or TRACER WELLS (1 5A NCAC 02C .0229):
1) Passive Injection S stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale Iniection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air In jection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submi~dflWoioENRIDWRomplete.
DATE: August 25 , 2015__ PERMIT NO. W 1;"c) t.../{i) Y 19 (to be filled in by DWR)
SEP - 2 2015
A. WELL TYPE TO BE CONSTRUCTED OR OPERATE«ater Quality Regional
Operations Section
(1) -----'Air Injection Well ...................................... Complete sections B-F, K, N
(2) ----'Aquifer Test Well ....................................... Complete sections B-F, K, N
(3)
(4)
(5)
(6)
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 sections B-N
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Sharon Ghiold. NCDENR. DWM. UST Section
Mailing Address: 1637 Mail Service Center
City: Ralei gh State: NC Zip Code: 27699 County:_W'-'--=ak=e'--------
Day Tele No.: 919-707-8166 Cell No.: __________ _
EMAIL Address: [e-mail] Fax No.: __________ _
VIC/In Situ Remed. Notification (Revised 3/2/2015) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: James and Karen Q uick
Mailing Address: 5770 Stigall Road
City: Kernersville State: ~N~C ____ Zip Code:=27~2~8~4 _______ County: Forsyth
Day Tele No.: ________ _ Cell No.: _________ _
EMAIL Address: _____ _ Fax No.: ___________ _
E. PROJECT CONTACT-Person who can answer technical questions about the proposed injection project.
Name: Jamie T. Honevcutt (S&ME. Inc.)
Mailing Address: 409 Chicago Drive. Suite 107
City: Fayetteville State: ~N ........ C_ Zip Code: 28306 County: Cumberland
Day Tele No.: 910-323-1091 Cell No.: 910-977-7614
EMAIL Address: jhoneycutt@ smeinc.com Fax No.: ________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 3319 Sandv Ridge Road
County: Guilford
City: Colfax State: NC Zip Code:.____,2=7=2=3=--5 _____ _
(2) Geographic Coordinates: Latitude**: ___ 0 ____ " or 36_0 .099223
Longitude**: 0 __ " or 79_0 .996153
Reference Datum: ________ Accuracy: _______ _
Method of Collection:.---'G=o=oe.oglo:.e:::-.E=art=h...__ ________ _
**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 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be ,:s 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
UIC /In Situ Remed. Notification (Revised 3/2/2015) Page 2
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate , volume, and duration
of injection over time.
A release of gasoline from a former underground storage tank s ystem located on the pro pe rty has im pacted
gro undwater above the 15A NCAC 2L .0202 gr oundwater quali ty standards and Gross Contaminant Levels.
One monitor well (M W-1 ) is located on the site. Multi ple private water su pp ly wells are located within 1.000
feet of the release. The use of O-SOX ( Calcium peroxide or EHC-O chemical} using MW-1 is planned to
enhance the de gradation of petroleum contaminant levels in the groundwater to below the 2L Standards.
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved tnjectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/web/wq/aps/gwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
lnjectant: Calcium Peroxide in solid form . bv sock of chemical in monitor well, for oxyg en
Volume of injectant: Varies . by diffusion. 1.75 lb EHC-O or 0.2625 lb Oxyg en per well
Concentration at point of injection: ---'1"-'0'--4~0.a...=m=g/.,_L~-------------
Percent if in a mixture with other injectants : Calcium peroxide <75%, Calcium H ydroxide <25%
Injectant:
Volume of injectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants : ___________________ _
lnjectant: --------------------------------
Volume of injectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: _____ .Proposed. __ --=1 __ --'Existing (MW-1)
(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 3/2/2015) Page3
WellType
t bGroat
Qls)
Screen
(tit bls)
Casing
(ft-bis)
Well Contractor
Cent#
MW-1
Permanent
Pro tiled
20-35
0.6-20
SAEDACCO
2284
Well Construction Record is Attached.
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Monitoring well MW-1 was installed in March 2007. Passive om_gen releasine O-SOXs will be placed into
the existing well following receipt of the notification permit number from NCDENR.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in S 3bchdprer 02 L. result from the injection activity.
The injection of ox • en is not expected tp result in violations of the 2L Standards. The monitor well will be
sampled on a regular basis and additional O-SOXs installed Lasser NCDENR). This ma% be followed to, post-
remediation sampling without oxygen infusion to check for rebound of contaminant levels.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I herebycerlf under penalty of law, that lam familiar with the information submitted in this
document and all attachments thereto and that, based an my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties. including the possibility of fines and imprisonment, for submitting false
information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the 15.E NG4C 02C 0200 Rules."
��i!:));i, i .sgrrf e � „ ► et iuR) Jamie T. Hone) cutt (S&ME, Inc,
Signature ofAp irant J Print or Type Full Name
PROPERTY OWNER (if the property is not owned by the permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(! _ NCA i1 ice( Tih'Ij.'o
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached access agreement with Mr.James Quick dated March 2. 2007
Signature* of Property Owner (if different from applicant) Print or Type Full Name
s An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form,
Submit the completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 4

RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
S7P. ji1CA' ---+{CZ--
Well Contraaiw {Individual] Marne
5PI)25/1iCO
Wet Contractor Company Name
STREET ADDRESS Via' Jul [ NF1f'+vo ( n
+ t SC_
City or Town State Zip Code
WO 1- n'rc—C3S 3
Area code- Phone number
Z WELL INFORMATION:
SITE WELL ID #prapptl;able)
STATE WELL PERMIT#{hfapplicable)
DWQ or OTHER PERMIT #(t applicable)
WELL USE (Check Applicable Box): Residential Water Supply [p
DATE DRILLED 3 - / 1 0 7
TIME COMPLETED A ` D 4) AM ❑ PM
3. WELL LOCATION:
CITY: 4.f112-;I- ►(.SicrtC) COUNTY AfA0+1t--e �
�' {Strom! Na
NutrNbe m muniy, SuhdMsfvn, Lot No., Parcel, Z]p Cddej
TOPOGRAPHIC t LAND SETTiWG:
❑ Slate ❑ Valley lifir 13 Ridge CiOthor
(check appropriate box)
LATITUDE 3
LONGITUDE
May be in degrees,
minutes, rRmnds ar
in a decimal format
Latitude/longitude source: tGPS oTopographic map
(lacatfon of well m ist be shown on a USGS topo ►nap -and
attached fa this fors Inot using GPS)
4. WELL OWNER f
OWNER'S NAME C•C.-fi�`� Cc tS! r/w1 ACkliFI fit
STREET ADDRESS
GA6 P►l.1.6 o.rl &IC_
City or Town Slate Zip Code
Area code-- Phone number
6. WELL RETAILS:
a. TOTAL DEPTH: 3 1--
b. DOES WELL REPLACE EXISTING WELL? YES {7 NO q
c. WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
d. TOP OF CASING IS . FT. Above Land Surface'
'Top of casing terminated allot below land surface may require
a variance in accordance with 15A NCAC 2C .Q110.
O. YIELD (gprn): ____ METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth};
From To Frorn To
From To From To
From To From To
B- CASING: Thicknessr
Depth Diameter Wei hl Maerial
From C.)rb TQ �C Ft- A {AEG r7LJL
From To FL
From To Ft.
7, GROUT: Depth Material Method
From To Fl.
From To Ft.
From To _ FL
8. SCREEN:�Aepth ` Diamer Siuf Size3 Materilal
From '0..0 - To 36 Ft. ? in, t [J In. 4 i'
From To Et, in- in_ '
From To FL in_ in.
8. SAND/GRAVEL PACK:
Depth I I S' Maierea]
From i k To 3S Ft. as 30 SY C ite4 . -#94--
From To _ Ft,
From To Ft.
10. DRILLING LOG
From To Formation Description
- C-' f22I) SW- i � C c -4J
11. REMA-RICS:
:Do HEREBY CERTIFY THAT THIS WELL WAS CUNSTRUiTED 4! ACCORDANCE WITH
ISA NCAC 2C, WELL CONSTRt1Crc STANDARDS, ANA THAT A COPY Or ThIE
RECORD HAS eREN PROy1DFC E.WELL OWNER.
SIGNATURE 7F CERTIFIED WELL RACTOR DATE
PRINTED NAME OF 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) T33-7015 ext 568.
Form GW-1a
Rev, 7/05

1
1
CEDER Sj
1,2,4-Trimeth yl be nze ne
1,2-D1bromoethane
1,2-Dlchioroethane
1,3,5-Trimethylbenzene
Benzene
Ethylbenzene
I PE
Isopropylbenzene
Methyl tert-butyl ether
Naphthalene
n-Propylbenzene
I Styrene
Toluene
Total Xylenes
LEGEND
s MONITOR WELL LOCATION
SAMPLE COLLECTED JUNE 13, 2014
ug/L - MICROGRAMS PER LITER
* INDICATES EXCEEDENCE OF 2L STANDARDS
" INDICATES EXCEEDENCE OF GROSS CONTAMINATION LEVEL
4
PROJECT NO:
r7 4305 14 120
SCALE: 1" = 40'
DATE- AUG. 2014
DRAWL By BTR
IMAGE SOURCE: NC ONEMAP, DATED 2010
un/L
1572 . .
"*72.5.
"5.3
179
*$9 -
451
9.9
24.3
5.6
*199
60
12.1
*1,870' -
*2,150
GRAPHIC SCALE
20 0 10 20 40
( IN FEET )
a
i
A-4504
ScME
WVVVV.SMEINC.COM
NC ENGINEER LICENSE #F-0176
3201 SPRING FOREST RD, RALEEGH, NC 27616
GROUNDWATER CONSTITUENT MAP
COLFAX CUSTOM FRAMES TF #7904
COLFAX, NORTH CAROLINA
FIGURE NO-
55

Sharon Ghiold
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Ghiold:
RE: Site Access Agreement
Colfax Custom Frames
3 319 Sandy Ridge Road
Colfax, Guilford County, NC (WSRO)
Incident Number 7904
I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby pennit the Department of Environment and Natural Resources (Department) or its
contractor to enter upon said property for the purpose of conducting an investigation of the
groundwaters under the authority of G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.
3, Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the neare~t public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.
6. The activities to be carried out by the Department or its contractor are for the primary benefit
of the Department and of the State of North Carolina. Any benefits accruing to the owner are
incidental. The Department or its contractor is not and shall not be construed to be an agent,
employee, or contractor of the land owner.
Me agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
.11 11,3A ivic-e
Type/Print Name of Owner or. Agent
a3 - - 5'.2.5
Phone Number
13 / c1 3 /3, j RoC i )
Address
/-• NC .292V5_
City/State/Zip Code
0 2
Date

1 ADVENTUS
‘441.0411' CYcarrvr tJ11, 40clrr.1011(;1.; Lh4urr.r riorrn
Roopy'rtt.inrrlr ii!P•h arlilpr't
Safety ,Data
MATERIAI. SAFETY DATA SHEET:
0-SOX"
Page: 1 of 6
1. PRODUCT IDENTIFICATION:
PRODl1C 1' USE:
MANUFACTURER:
Adventus Americas Inc.
287I W. Forest Rd_. Suite 2
Freeport. IL
61032
O SOXTM
Soli and water treatment.
EMERGENCY PHONE:
Office Hours: 815-235-3503
After Hours: 815-235-35I6
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid. n.o.s. i Calcium Peroxide). Class 5.1, PG Il, UN 1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Calcium Hydroxide
3. PHYSICAL DATA
Chemical Formula
CaO,
Cat OH ),
FOR CHEMICAL EMERGENCY
Spill, Leak. fire Exposure or Accident
Call INFOTRAC - 24-Hour Number:
1-800-535-5053
Otnnidc atlas United Sac Cal174-Hour Number
001432-32c3S00
CAS No. Percentage
1305-79-9 45%-7O%
I3i1_+-f+2-G 104-2t ►
Appearance, White & brown granules
Physical state Solid
Odor threshold None
Bulk Density_ 500-650g/L
Sialubiliiy in Water insoluble
pH -1 1
Decomposition Temperature Self -accelerating decomposition with oxygen aelease starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent. contact with other material may cause tire. Under fire condismiis this material may
Llecnmpa se and release oxygen that intensifies fire. This product also contains crysralline silica. Long iced{
exposure to hazardous levels of silica dusts can cause lung disease (silicosis). The World Health
Organization had indicated that there is limited evidence that crystalline silica is carcinogenic to humans.
but the NTP and OSHA have not classified this ingredient as carcinogenic.
Potential Health Effects:
• General Irritating to mucous membrane and eyes.

1 ADVENTUS
1�1 ��Ilnal "+<,;r, Srrlrrrinni, rrxl [..nururimr ..r
Safety pat.a
MATERIAL SAFETY DATA SHEET:
O•SOXTM Page: 2 of 6
• Inhalation Irritating to respiratory tract_ Long term inhalation of elevated Inds
may cause lung disease (silicosis).
• Eye contact May cause irritation to the eyes: Risks ari'serious or permanent eye
lesions.
• Skin contact May cause skin irritation.
• Ingestion Irritation of the mouth and throat with nauyOar and vomiting.
5. FIRST Ail) MEASURES
• Juhailati++ti Remove affected person to fresh air. Seek medical attention if. t eCON
persitit.
• Eye contact Flush eye.~ with running water for ail ieaxn 13 minutes witli eyelids
held open. Seek specialise advice.
• Skin cr+ntact.. —Watch affected akin with snap and mild il.letecin and large amount,. ill
water.
• Inilemion if the person is conscious and not convulsing_ Iliie 2-4 cupfuls nt'
water to dilute the chemical and seek medical .ntentiort inmtrdiatel)
Do net induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Point
■ Not applicable
Flammability
• Nut tpplit-ahle
Ignition Temper:ttttre
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• Water
Fire Hazards
+ Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite comnbustittles. Oxygen release due tat
exothermic decomposition rimy support combustion. May ignite other crrtnbustible materials.
Avoid contact with incompatible materials such as heavy metals, nCdueing agents. adds, haws.

IJ
ADVENTUS
-�1 t�I( &.•'itidia, rl•u p u, ;OW r 0,1Jllit1i for
Y Remo:rlorrrr f. rrrrrdo, •r
Safety -:Data
MATERIAL SAFETY DATA SHEET;
0-SOX ill Page: 3 of (
combustible i wood. papers. cloths etc.) Thermal decomposition releases trsyeen and heat.
Pressure bunt, may occur due 10 gas evolution. Pressurization if outlined when heated or
decomposing. Containers may burst violently.
Fire fighting Measures
• Evacuate .111 ntnt-essential personnel
• Wear protective clothing and self-contained breathing apparatus.
• Keriusin upwind of fire to avoid hazardous vapors and decomposition pii ducts.
• Its water spray to cool fire- exposed containers.
ACCIDENTAL. RELEASE MEASURES
Spill Clcan-up Irrtrcedure
• Oxidizer. Eliminate at] sources of ignition. Evacuate unprotected lxrumnel from equipment
recommendations found in Section 9. Never exceed any occupational esp(.ore limit.
• Shovel or sv,cep material into plaatic hags or vented containers for tt'rspo sal. Do not return spilled
or contaminated material to inventory. Avoid making dust,
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direr
discharge to sewers Mid Surface waters. Notify authorities if entry toGc:urs.
• I)n not touch stir ►walk through spilled material. Keep away from combustibles (wood. paper. oils.
etc.). Do ant return product to container because of risk of contantinatit+n.
HANI]LING AND STORAGE
Storage
• Oxidizer. Snore in a cool, welt -ventilated area away from ail source of igniiion and otit Or direct
sunlight. Store in a dry location away From heat.
• Keep away from incompatible materials. Keep containers tightly closed. I)u not store in
unlabeled or mislaheied containers,
• Protect from moisture, On not store near combustible materials. Keep emu :tiners well sealed.
Ensure pressure relief and adequate ventilation.
• Sisne separately from organics and reducing materials Avoid contamination that may Lead rs+
decomposition.
Handling
• Avoid contact with eyes. skin. and clothing. Use with adequate semi l:tt i, m.
• I)o not swallow. Avoid breathing vapors, mists. or dust. Do not eat. drink, or smoke in work
a Ira.
• Prevent contact with combustible or organic materials.
• t_uhr! containers and keep them tightly closed when poi in use.
• Wash Ilrurrsu_.It1y alter handling.
9. EXPOSURE CONTROLS/PERSONAL PROTECTION

)ADVENTUS
,J Orm + ti'rl 'ftrlk,r !. Il r: 1,ifutil1ilivair+J
PonTPrb,rieirr r'r'!Irlrriiuijd-c
S fety Data
MATERIAL SAFETY DATA SHEET:
O-SOxt M Page: 4 of fi
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, proccsw enclosures or other
engineers controls may be needed to maintain airborne levels below rccrutimended exposure limit~.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keels levels below exposure limits. To determine exposure llnuis. mnnitorina should he
performed regularly.
Re piratory Protection
■ Ear molly condition. no respiratory protection may be needed; however. in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH swim respirator.
Eye/Face Protection
■ Wear chemical hufety goggles and a full face shield while handling this product.
Skin Protection
• Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC. neoprene or rubber)
Other Protective Equipment
• Eye -wash station
• Safety shower
• impervious c lulhing
• Rubber MIN
General Hygiene Considerations
■ Welsh with soap ;and water before meal times and at the end of each work +hill. Good
manufacturing practices require gloss amounts of any chemical coin wed fsv+m skin as soon us
practical. especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
• ' StahIc Linder normal conditions
Condition to Avoid
• Water
• Acids
• I3.ues
• Stills of heavy metals
• Reducing. agents
• Organic materials
• Flammable substances
Hazardous Decomposition Products
• Oxygen which xuppnns combustion
1 I. TO X I C O I OG 1 CA 1.1NFORMATION

(')ADVENTUS
1MV1.:ri 1e,r7'N.' i,uii qd,:au! r,row tgtowV•
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Safety ,,Data
MATERIAL SAFETY DATA SHEET:
O-SoXTM
Page: 5 of ti
• I_D5(1 Oral: Min.2000 nig/kg, rat
• LD50 Dermal: Min. 2000mglkg, rat
■ LD511 Inhalation: Min. 4580 mg/kg, rat
12. ECOI,()GICAL INFORMATION
EculoxicoingicnlInformation
• Hazards for the environment is limited due to the product properties of no hivaccmtlulation, weak
solubility and precipitation in aquatic environment,
Chemical Fate lntormatinn
• As indicated by chet►iical properties oxygen is released into the enuiimune 1.
13. DISPOSAI. CONSIDERATIONS
Waste 'Treatment
• Dispose ut'in an approved waste futility operated by an authorized contractor in compliance with
local regulations.
Package Treatment
■ The empty and clean containers are to he recycled or disposed of in conformity with local
regulatiunv.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Chess: 5,1
• Labels: Si.(Oxidiser)
• Packing Clomp: II
I. REGULATORY INFORMATION
• SARA Section Yes
• SARA (3131 Chemicals No
• EPA TSCA inventory Appears
• Canadian WHMIS Classification C, D2B
• Canadian DSI. Appears
• EINI:CS Inventory Appears
16. PREPARATION INFORMATION
Prepared Bv:
Kerr` 13i11anos-Shaw
Ads enuis Remediat ion Technologies
345 I ewster Drive
Mississauga. Ontario
i_ IW 2A5
Date Prep./Rev:
Print Date:
Phone:
Fax:
1/3/07
113/07
905-273-5374
905-273-4367