WI0400426_DEEMED FILES_20160115

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ENVIRONMENTAL CONSULTANTS, C
January 11, 2016 RECEIVEO/NCDEQ/DWR
JAN 15 2016
Shristi Shrestha
DWR-UIC Program
Waler Quality
Regiolilal()petaliud ......
1636 Mail Service Center
Raleigh, NC 27699-1636
Re: Injection Event Record
Holly Grove Texaco
NCDWM-UST Incident No.: 37563
Risk Ranking: High 114
Terraquest Project No.: 13309
Dear Ms. Shrestha:
On behalf of Hill Oil Company, Inc., Terraquest Environmental Consultants, P.C. hereby submits
the enclosed Injection Event Record for the Holly Grove Texaco facility located in Lexington,
Davidson County, North Carolina.
Sincerely,
TERRAQUEST ENVIRONMENTA.L CONSULTANTS, P.C.
Ryan D. Kerins
Project Manager
Enclosure
100 E. Ruffin Street • Mebane, North Carolina 27302
Telephone [phone] • Facsimile [phone]
www.terraquestpc.com
RECEIVED/NCDEQJDWR
INJECTION EVENT RECORD JAN 15 2016
WaterQ r
North Carolina Department of Environment and Natural Resources-Division ofWat~~=Section
Permit Number_w_10_40_04_26 ____ _
1. Permit Informatio~
Thomas and Vera Stephens
Permittee
Tommys Mini Mart
Facility Name
801 Mebane· Oaks Rd, Mebane NC 27302
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
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection _8 ___ _
Well names MW1,2,3,6,7,9,10, 15
Were any new wells installed during this injection
event?
D Yes Ii] N 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.
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.
4. lnjectant Information
Oxygen BioChem
, Injectant Type
Concentration =solubility=? weight %
If the injectant is diluted please indicate the source
dilution fluid. municipal water -----------
Total Volume Injected 1.6 gallons
Volume Injected per well O -2 gallon/well
5. Injection History
Injection date(s) 12121115
------------
Injection number (e.g. 3 of 5) 1 Of 8 ------
Is this the last injection atthis site?
D Yes [i] 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~-/4 OlgblylQ"lldbyRre,iO.Kefn
ON: en-Ryan 0. K8rlns, o, ou, emai:~.com . ..us
Dete:2.018.01.111.2:08:31.()5'00'
SIGNATURE OF INJECTION CONTRACTOR DATE
Brad Hayes
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
FmmUIC-IER
Rev. 8/5/2013
Permit Number WI0400426
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
Tommy's Mini Mart No . 2 -B
Location Address
801 Mebane Oaks Rd
Mebane
Owner
Owner Name
Thomas
Dates/Events
NC
Orig Issue
10/16/2015
App Received
10/9/2015
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27302
Stephens
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
10/16/2015
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Thomas Stephens
4672 Forest Lakes Rd
Mebane
County
Alamance
NC
Issue
10/16/2015
Effective
10/16/2015
27302
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Ro gers, Michael
From: Rogers, Michael
Sent: Friday, October 16, 2015 12:18 PM
To:
Cc:
Subject:
Ryan Kerins ([e-mail])
Knight, Sherri; Basinger, Corey
WI0400426 NOi
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for the Tommy's Mini Mart
No. 2-B, located at 825 Mebane Oaks Road, Mebane, Alamance County, NC 27302. The Central Office of the WQROS
received your complete NOi on October 9, 2015.
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://porta l.ncd e nr.org/web/wq/aps/gwprn/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 WI0400426. 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 w i ll already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDEQ-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.
1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Subject:
Attachments:
Friday , October 16, 2015 12:08 PM
Knight, Sherri ; Basinger, Corey
FW: WI0400426 NOi Part 1 of 2
20151016113221628.pdf
Please find attached a NOi (1 of 2).
-----Original Message-----
From : Michael Rogers [mailto:[e-mail]]
Sent : Friday, October 16, 2015 11 :32 AM
To: Rogers, Michael <[e-mail]>
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 10.16.2015 11:32:21 (-0400)
Queries to: [e-mail]
1
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Subject:
Attachments:
Friday, October 16 , 2015 12 :09 PM
Knight, Sherri; Basinger, Corey
FW: WI0400426 NOi Part 2 of 2
20151016113348838.pdf
-----Original Message~----
From: Michael Rogers [mailto:[e-mail]]
Sent: Friday, October 16, 2015 11:34 AM
To: Rogers, Michael <[e-mail]>
Subject:
This E-mail was sent from "RNPAC7DDO" (Aficio 2075).
Scan Date: 10.16.2015 11:33:48 (-0400)
Queries to: [e-mail]
1
October 6, 2015
Michael Rogers
DWR-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
P.C.nest
r
ENVIRONMENTAL CONSULTANTS,
RECEIVEDIDENRIDWR
O CT 14 20i5
Water Quality Regional
Operations Section
Re: Notification of Intent to Construct or Operate Injection Wells
Thomas Stephens —Tommy's Mini Mart No. 2
NCDWM-UST Incident No.: 37084
Risk Ranking: High 182R [.. CV 00 Cl ? 4
Terraquest Project No.: 00408
Dear Mr. Rogers:
RECEIVED
C. 0€ pt. of ENR
OCT 0 9 2015
Winslon -Salem
Regional Ct oo
On behalf of Thomas Stephens, Terraquest Environmental Consultants, P.C., hereby submits the
enclosed UIC/In Situ Remed. Notification (Rev 11/19/2013) for the former Tommy's Mini Mart
No. 2 facility located in Mebane, Alamance County, North Carolina, Supporting documentation
is also enclosed.
Sincerely,
TERRAQUEST ENVIRONMENTAL CONSULTANTS, P.C.
Ryan D. Kerins
Project Manager
Enclosures
100 E. Ruffin Street • Mebane, North Carolina 27302
Telephone [phone] • Facsimile [phone]
www.1erraquestpc.com

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 wizen construct,ed in accordance
with the rules of 15A NCAC 02C .0200. This fo rm shall be submitted at least 2 weeks prior to in ;ection.
AQUIFER TEST WELLS (1 5A NCAC 02C .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITUREMEDIATION (1 5A NCAC 02c .0225) or TRACER WELLS (15A NCAC 02C .0229 ):
1) Passive In jection Systems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale In jection 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 In jection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. illegible Submittals Will Be Returned As Incomplete.
DATE:~Jul=y,__· l=-__ _,, 20_15_ PERMIT NO. WJo'J ('.)'O LfJ-k ~!i~ED/~fOOWR
OCT l '4 2015 A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
Ai I · t· w 11 c 1 . B u ,aF'.nuality Regional ---r nJeC 10n e . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . .. . .. . . omp ete sections -~~()~rations Section
-----'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 sections B-N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: Thomas and Vera Ste phens
Mailing Address: 4672 Forest Lake Drive
City: Mebane State: NC Zip Code: 27302 County: Alamance
DayTeleNo.: Cf1 °(->'h Z-~-fl,Z,, CellNo.: ~ :3,3 eo-;),{Ro-I lj/$
EMAIL Address: /?00 ~ ~r, Fax No.: ~ 0 ----
UIC/In Situ Remed. Notification (Revised 11/19/2013) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: Tennant Pro perties of NC . LLC
Mailing Address: A TIN: Wal gr een Co .• P.O. Box 1159
City: Deerfield State: _IL_ Zip Code: 60015 County: __ _
DayTeleNo.: ______ Cell No.: __________ _
EMAILAddress: Fax:No.: __________ _
E. PROJECT CONTACT -Person who can answer technical questions about the proposed injection project.
Name: _____ __,,Rce.yL..::an"""-"K=e=r=in=s _______________________ _
Mailing Address: -------'l:..::0=0--=E=---R=-==uffi=1=n:..::S=-=t ___________________ _
City: ---~M=e=b=an=e~-----State: NC Zip Code: 27302 County: Alamance
Day Tele No.: ---~91=9~-5~6~3-~9~09~1~-----
EMAIL Address: __ ---=-r=dk=e=n=· n=s®=.te=rr=a=g=u=es'""tp"'"'c'"'"'.c=--=o=m=----
Cell No.: 919-906-0960
Fax No.: 919-563-9095
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: __ _,8=0__,,_l--"'M=e=b=an=e,c....O=alcs=c.:R=o=a=d _____________ _
_______________________ County: Alamance
City: Mebane State: NC Zip Code: ~2""'73"""'0=2~-----
(2) Geographic Coordinates: Latitude**: ___
0
--__ " or J..Q...___0 .0~7~7-6~--
Longitude**: ___ 0
__ __,, or -::1!1__0
•. 2~7~5_2~--
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-Mebane, NC
**FOR AIR INJECTION AND AQUJFER 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 (=s 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) Page2
L DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, s~pe, and goals of the proposed injection activity.
Well socks will be hung in ei ght {8) monitorin g wells.
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.org/webAvq/apslgwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services . Contact the VIC Program for more info (919-807-6496).
Injectant: Oxygen BioChem
Volume of injectant: _The volume is 0.2 gallons of solid per point. _______ _
Concentration at point of injection: The solubility is a pproximately 7 wei ght percent so that is the
concentration.
Percent if in a mixture with other injectants: 100%~C=n=o ~o=th=e~r)'-----------
Injectant: ______________________________ _
Volume ofinjectant: __________________________ _
Concentration at point of injection: _____________________ _
Percent if in a mixture with other injectants: __________________ _
Injectant: _____________________________ _
Volume ofinjectant: __________________________ _
Concentration at point of injection: _____________________ _
Percent ifin a mixture with other injectants: __________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: --~O __ ~Proposed __ ~g ____ 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/In Situ Remed. Notification (Revised 11/19/2013) Page3
L. SCHEDULES —Briefly describe the schedule for well construction and injection activities.
Well socks will be bane in October 2015 after the next well sampling event. Refill of the socks and rehan ina
will occur in MaylIune 2016 depending on anaMicaI results.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
Site is currently on a semi-annual sampling'. for VOCs plan re,ulated bv NCDWM-UST. That will continue.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "1 hereby certify, under penalty of law, that I am familiar with the information submitted in
this document and all attachments thereto and that, based on my inquiry of those individuals immediately
responsible for obtaining said information,1 believe that the information is true, accurate and complete. I am
aware that t 7ere are sign*• t penalties, including the possibility affirms and imprisonment, for submitting
false infor 1• tion. I agree * construct, operate, maintain, repair, and if applicable, abandon the injection well
and all rel red appurte es in accordance with the 15A NCAC 02C 0200 Rules "
Signature ofA plicanf
Ryan D. Kerins
Print or Type Fail Name
PROPERTY OWNER (if the property is not owned bv the_permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated 1 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 (15A NCAC 02C.0200). "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A
weII is real ioperty and its construction on land shall be deemed to vest ownership in the Land owner, in
the abseil of contrary agreement in writing.
sy tti s -
Signature* of l'rapert'Owner (if deerent from applicant) Print or Type FuI1 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:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone; [phone]
UIClln Situ Remec. Notification (Revised 11/19/2013) Page

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
Weil Contractor (Individual) Name
TerraQuest Environmental Cons.
Weil Contractor Company Name
STREETADDRESS 100 E Ruffin St.
Mebane NC
27302
City or Town State
( 919 )- 563 - 9091
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(if applicable) M W 1
STATE WELL PERMIT40f applicable) NA
DWQ or OTHER PERMIT IMF applicable) NA
WELL USE (Check Appdcahie Box) Monitoring 0 Municipal/Public ❑
Industrial/Comma:Val ❑ Agricultural ❑ Recovery ❑ Injection tl
Irrigation❑ Other 0 (list use)
DATE DRILLED 2/18/08
TIME COMPLETED 1100 AM O PM ❑
3. WELL LOCATION:
CITY: Mebane
825 South Fifth St.
COIFNTV Alamance
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
JSIope ❑Valley OM' RRidge a other
(check appropriate box)
LATITUDE 36 04' 39,30"N
LONGITUDE 79 16' 30.42'W
Maybe in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source; ❑GPS Er Topographic map
(location of wall must Oa shown on a USGS tops map and
attached to this form not using GPS)
4. FACILITY- is the rams of the boatmen where the wet' is tainted,
FACILITY ID #(if applicable) 0-023467
NAME OF FACILITY Tommy's Mini Mart No. 2
STREET ADDRESS 825 South Fifth St.
Mebane NC 27302
City or Town State Zip Code
CONTACT PERSON Tommy Stephens
MAILING ADDRESS 4672 Forest Lake Dr.
Mebane NC
City or Town State
( 919 )_ 260-1415
Area code- Phone number
5, WELL DETAILS:
a. TOTAL DEPTH: 50
27302
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
c. WATER LEVEL Below Top of Casing: TT.
(Use -s' if Above Top of Casing)
d. TOP OF CASING IS OM' FT. Above Land Surface'
'Top of casing terminated atfor below land surface may require
a Variance in accordance with 15A NCAC 2C .0116.
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
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 20 R. 2 Inch Sch. 40 PVC
From To Ft.
From To _ Ft.
7. GROUT: Depth
Material Method
From 18 To 18 Ft Bentonite Pour
From,ATo 16 Ft Portland Cement Pour
From To Ft
8. SCREEN: Depth Diameter Slot Size Material
From 20 To 50 Ft. 2 in. .010 in, PVC
From To Ft. In. !n.
From _ To FL in, in,
9. SANDIGRAVEL PACK:
Depth Size Material
From 18 To 50 Ft. coarse sand
From To Ft._
From _ To Ft.
10. DRILLING LOG
From To
0 20 BACKFILL
20 50
11. REMARKS:
Formation Description
SILT - some clay
ERTIFY 1W m THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wi
WELL TRUCfTON STANDARDS. AND THATA COPY of THIS
EE. 1DED TO DiE WELL OWNER.
3/6108
SIGNATUF CERTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 36 days. Attn: Information Mgt,
1617 Mali Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext668.
Form G W-1 b
Rev, 7/05

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CERTIFICATION f# 3329
1. WELL CONTRACTOR:
Nick Perry
Weil Contractor (individual) Name
TerraQuest Environmental Cons.
Well Contractor Company Nacre
STREET ADDRESS 100 E Ruffin St.
Mebane NC
27302
City or Town State
f 919 .- 563 - 9091
Area code- Phone number
2. WELL INFORMATION:
SITE WELL 10 Air applicable) _ MW2 _
STATE WELL PERMIT#Of applicable) NA
Zip Code
DWQ or OTHER PERMIT #(1f applicable) NA
WELL USE (Check Applicable Box) Monitofing ❑ Munlcipei/Public ❑
Industrial/Commercial ❑ Agrtcuttural Q Recovery 0 Injection D
lrrlgatIonLI Other CI (list use)
DATE DRILLED 2/18/08
TIME COMPLETED 1400 AM © PM
3. WELL LOCATION:
Cif`(_ Mebane COUNTY Alamance
825 South Fifth St.
(Steel Name, Numbers, Community, Sub:Neon, Lot No., Parcel, Zip Code)
TOPOGRAPHIC /LAND SETTING:
❑ Slope O Valley ❑ Fiat :Midge CJ Other
{check appropriate bad
LATITUDE _A 04' 39.30"N
LONGITUDE 79 16' 30.42"W
Latitude/longitude source: ❑GPS 0Tapographic map
(location of wet must be shown on a IUSGS fopo map and
attached to this farm itnof using GPS)
4. FACILITY• is the name ovine business where me welt Fa Ixated.
FACILITY ID#(if applicable) 0-023467
NAME CF FACILITY -fanny's Mini Mart No. 2
STREET ADDRESS 825 South Fifth St
May be in degrees,
minutes, seconds or
in a desimai format
Mebane NC 27302
City or Town State Zip Code
CONTACT PERSON Tommy Stephens
MAILING ADDRESS 4872 Forest Lake Dr,
Mebane NC 27302
City or Town State Zip Coda
919 J- 260-1415
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 50
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO p
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 +sing terminated odor below land surface may require
a variance in accordance with 15A NCAC 20 .0118.
e. YIELD Wpm): 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
S. CASING: Thickness/
Depth Diameter Weight Material
From To 20 Ft 2 inch Sch, 40 PVC
From To Ft.
From To
7. GROUT: Depth Material Method
From 16 To 18 Ft. Bentonite Pour
From 0 To 16 Ft For -trend Cement Pour
From To Ft.
8. SCREEN: Depth Diameter Material
From 20 To 50 Ft 2 in. PVC
From To Ft in.
From To Fi. In.
Slot Size
.010 In,
In.
In,
9. SAND/GRAVEL PACK:
Depth Size Material
From 18 To 50 Ft, coarse sand
From
From
Ta
To
10. DRILLING LOG
From To
0 16
16 20
20 30
30 35
11. REMARKS:
Ft.
Ft
Formation Description
BACKFILL
LEAN CLAY - with some slit
SILT - fewclay
LEAN CLAY - some silt
I AO HE f B LERTFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
t5A NNWELL CONSTRUCTION STANDARDS, AND THATA COPY Of THIS
REC Rk'H4 EEN OVIDEOTOTHE WELL OWNER.
3/6i08
SIGNATURCERTIFIED WELL CONTRACTOR DATE
Miok _L,r4
PRINTED N E OF/PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quaiity,within 30 days, Attn: Information Mgt,
1617 Mail Service Center— Raleigh, NC 27699-1817 Phone No. [phone] ext 568.
Form GW-1 b
Rev. 7/05

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Quality
WELL CONTRACTOR CEERTIIRICATION # 3329
1. WELL CONTRACTOR:
Nick Perry
Well Contractor (IndIvIdual) Noma
TerraQuest Environmental Cons,
Well Contactor Company Name
STREET ADDRESS 100 E Ruffin St.
Mebane NC
27302
City or Town State
( 919 )- 563 - 9091
Zp Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #{ir applic bre) MW3
STATE WELL PERMIT#(if applicable) NA
DWQ or OTHER PERMIT #(if applicable) NA
WELL USE (Check Applicable Box) Monitoring 0 Municipal/Pubtic °
Industrial(Commerciat 0 Agricuittarat
Irrigation° Other 0 plst use)
DATE DRILLED 3/5/08
Recovery 0 Infection ❑
TIME COMPLETED 1000 AM ❑ PM Cl
3. WELL LOCATION:
CITY: Mebane COUNTY Alarnance
825 South Fifth St.
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zip Coda)
TOPOGRAPHIC 1 LAND SETTING:
['Slope [Valley ❑Flat ❑ Ridge 0 Other
(cheek appropriate box)
LATITUDE _S_6 04' 39.30"N
LONGITUDE 79 16' 30,42'W
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑ GPS ❑ Topographic map
(location of well must be shown on a USGS tope map and
attached to this form d not using GPS)
4. FACILITY is tt:s nsme atha puniness where the well is located,
FACILITY ID f applicable) 0-023467
#I
NAME OF FACILITY Tommy's Mini Mart No. 2
STREET ADDRESS 825 South Fifth St.
Mebane
City or Town
NC
State
CONTACT PERSON Tommy Stephens
27302
ZIp Code
MAILING ADDRESS 4672 Forest Lake Dr.
Mebane NC
CilyorTown State
( 919 )_ 260-1415
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 50'
27302
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 0
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 requve
a variance in accordance with 15A NCAC 2C .D118.
e. YIELD (gpm): NA METHOD OF TEST NA
f. DISINFECTION: Type NA Amount NA
g. WATER ZONES (depot):
From NA To NA
From NA To NA
From NA To NA
6. CASING:
Depth Diameter
From 0 To 20 Ft, 2 inch
From To Ft.
From To Ft.
7. GROUT:
Depth Material
From NA To NA
From NA To NA
From NA To NA
Thickness/
Weight Material
Sch.40 PVC
Method
From 16 To 18 Ft. Bentonite Pour
From_,0 To 16 Ft. Portland Cement Pour
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 20 To 50 FL 2 1n. .010 in. PVC
From To Ft. In. In.
From To Ft in. in.
6. SAND/GRAVEL PACK:
Depth Size iViaterial
From 18 To 50 Ft coarse sand
From To Ft
From To 9
10. DRILLING LOG
From To
0 1
1 15
15 20
20 30
30 50
11. REMARKS:
Formation Description
ASPHALT
SILT - some to little clay
CLAY
LEAN CLAY- with some silt
SILT- some clay
I DO HERESYER7WFYTHAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wirth
15A NCI ' C vELL CDNsrRuc-1CN STANDARDS, AND THAT A COPY OF THIS
RECORD IA' _ EEN PROVIDED TO THE WELL OWNEn.
SIGIyATUR
fLWls,Y
PRINTED NAMEIOF PERSON CONSTRUCTING THE WELL
3 60
CERTIFIED WELL CONTRACTOR DATE
Submit tha original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mall Service Center— Raleigh, NC 27699.1617 Phone No. (910 733-7015 ext 583.
Form GW-lb
Rev. 7/05

Jul 30 ~ 09:31a Michael Ransler 9109494555 p.3
Non Residential Well Co11structlon Record
Nonn Carollna Department or Efnviron111ent end Natutal Resouroee-DMllkm i:ir Waler Quanty
WELL CONTRACTOR CERTIFICATION #1-251>1
1. WE1.L COKmACTOR~ d. TOP OFCASI NG IS -0.2 FT/obne Land Su~
Michael Ransier "Top of easlng1l!mlfnale(S a1/'or belwll.wldsurface may 1a1uile
Well Contractor llndivldual) Name a variance In OCCO!dance \\4IIJ 15A NCAC 2C .0110.
Ransler Environmenfa) DrilliM, Inc. e. YIEtD (gpm) METHOD OF TEST
Well Contractor Ccmpany Name f. DISINFECTION:l)'pe Amount
STREETADDRESS 1 Piney PoJnt g. WATERZONES (depth):
Whisoe rin g Pines NC 28327 From To From ___ To
Cil;yorTown State ZlpCode From To From To
910 949-4555 FfOf!L_To From To
Areac:ocfe Phone Nr.mber 6.CASING: Thickness
2. WELLINFORMATtON: Depth Diameter Weight Ma1erial
Sile Well ID # (if applicable) MW-6 From -0.2 To 60 Ft 5" sch40 pvc
STATE WELL PERMIT# (Jf sppfieal>re· na From ...0.2 To 70 Ft 2" sdl -40 DVC
DWQ or OTHER PERMJT f. (if applieal: na From To Ft. -Well USE (Cheek Appicab!e) Monlloong X Mun'Pu'c:Uc 7.GROUl: Depth Material Method
lndu:itdal/Commen;ial Agltculblral Reca.'elY ln}edian From 0.5 Ta _§!_ Ft. por11and ttemmle
lalgation Olher (UstUse) From 0.6 To ~ Ft. portland lremm~
Daf2 Drilled 7122/2008 From To Ff. --llme Completed 3:00 AM. PM x 8.SCRl:EN: Depth Diameter Slot Malerlal
3. WB.L LOCATION: From 70 Tc 75 Ft. 2" 0.01 PVC
CITY Mebane COUNTY Alamance From_ To Ft. --825 S. Fifth Street Ftom To Ft. --(Slmet Name. Numbecs. CunmunllV, Lot No... Parcel, Zip COde) 9. SANDIGRAVEL PACK:
TOPOGRAPHIC/ LAND SETTING Depth Size Material
Sbpe V~ey Flat)( Ridge Other From 6B To ~FL medflm quartz -{dleck aJllHOi:riate)
LATITUDE 36 04.49 IMay1>e1n~. ains.
From To Ft. ---From To Ft.
LONG:lllJD 79 16.25 I secs.. er 1itdedmal --10. DRILLING LOG:
LatlludeA..ongltude source: GPS X Topomap From To Fonnalfon Desc;ription
((ocallonof¥4!11nll!SlbelhcHmona USGSlopo rnapand 0 10 Ian brown silt
aUached fl> lllls fonn If not using GPS) 10 65 brown sa pro6te
4.FACIUTY bnc,,m,,ollha~'"'1etalllewellbloc$!ed 65 75 hard brown sa orolite
FACILITY ID f. (lfappUcable)
NAME OP FACIUTY Form. Tommy's Mini Mart
STREET ADDRESS 825 S. Fifth Street
Mebane NC
Clt/OfTawn state ZipCOde
CONTACT PERSON Michael Brown 11. REMARKS:
MAILING ADDRESS 100 E. Ruffin Street
Mebane NC 28227
CltyorTown Slate 2ipCode
819 5~1 IDOHSE!YCERJA1JIATTin'VSJ.WASIXlNS1f!Wl1iDINAccoe;:wte;II
Area code Nmnber 'Wmt 15.\ NCAC 2C waL~STA.'IDMDSAHnHAf A
S. WS.L DET~:
a. TOTAL DEPlli: 75
_,..t:1f'TIM:z7::.-'IOTllli v.e.l.OWNiR.
ht A ··.:1'G .A.~.A 7/31J/2008
b. DOES WE1L REPLACE EXIS1lNG WEU. NO SIGNIJURE OF CERTIAEDVIIEU. COfifflACTOR DATE
c. WATER LEVEL 8a<NITopofCasl 46 Michael Ransler lU• . ..,. if abowa 1q> of cmhil) PRINTED NAlvEOFPERSON CONSTRUCTIHG WELL
SUll!lll Gl1ginl!1oD1Y. DIWaterQwlityvdlhln30 days. Alll't lrtonnallolltllgl 1617"'-is.r.fca ~er-"ale1lfl.NC27II09-f617 fllcne(919J 7a3-70t&el:t568
NON RESIDENTIAL 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 Cons.
Well Contractor Company Name
STREET ADDRESS 100 E Ruffin St.
Mebane NC
27302
City or Town State
( 919 )- 563 - 9091
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ff(if applicable) MW7
STATE WELL PERM IT#',-(ifapp(icabte) NA
DWQ or OTHER PERMIT f applicable) NA
WELL USE (Check Applicable Box) Monitorfng ❑ Municipal/Pubiic L7
IndustriallCommercial ❑ Agricultural D
Irrigation{) Other ❑ (list use)
DATE DRILLED 8118/08
Recovery injection ❑
TIME COMPLETED 1300 AM ❑ PM ❑
3. WELL LOCATION:
CITY: Mebane
625 South Fifth St.
COUNTY Alamance
(Street Name, Numbers, Community, Subdivision. Lot No., Parcel, Zp Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope r7 Valley ❑ Flat ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 36 04' 39.30"N
LONGITUDE 79 16' 30.42'W
May ba in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
(location of we0must be shown on a USGS fopo map and
attached to fins form rf not using GPS)
4. FACILITY. is Me Dame of the Nusfneca where Iha wall la Io ted,
FACILITY ID Cif applicable] 0-023467
NAME OF FACILITY Tommy's Mini Mart No. 2
STREET ADDRESS 825 South Fifth St,
Mebane
City or TrAvn
NC
State
CONTACT PERSON Tommy Stephens
27302
Zip Code
MAILING ADDRESS 4672 Forest Lake Dr.
Mebane NC
City or Town State
C 919 ).260-1415
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 40'
27302
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ N0 ❑
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 atlor below land surface rnay require
a variance in accordance with 15A NCAC 2C ,011 S.
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
6. CASING: Thickness/
Depth Diameter Weight Material
From 0 To 20 Ft. 2 inch Sch. 40 PVC
From To Ft.
From To Ft.
7. GROUT: Depth Material Method
From 16 To 18 Ft, Bentonite Pour
From 0 To '16 Ft. Portland Cement Pour
From To FL
8. SCREEN: Depth Diameter Slot Size Material
From 20 To 40 Ft. 2 in..010 in. PVC
From To Ft, in. in.
From To Ft, in. in.
9. SAND/GRAVEL PACK:
Depth Size Material
From 18 To 40 Ft. coarse sand
From To Ft.
From To Ft,
19. DRILLING LOG
From To Formation Description
0 -I ASPHALT
1 5 LEAN CLAY - with little silt
5 15 SILT - with some clay
15 25 LEAN CLAY - with some silt
25 40 SILT - some clay
11. REMARKS:
I DOHEREEY �.ERT,FYTHAT THIS WELL WAS CONSTRUCTED INACCORDANCE WITH
i5A NC 2C +,'; ELL CONSTRUCP.4N STANDARDS, AND TM.TA COPY OF THCS
RECORO pE EN PROVIDED TOTHE WELL OWNER.
8/20/08
SIGNATURE - CERTIFIED WELL CONTRACTOR DATE
cU4r
PRINTED NAME OF 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 27699-1617 Phone No. [phone] ext 568.
Farm GWl b
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
Weil Contractor (Individual) Name
TefraQuest Environmental Cons.
Well Contractor Company Name
STREET ADDRESS 100 E Ruffin St.
Mebane NC
City or Town State
(_ 919 ). 563 - 9091
27302
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID 4/(if applicable) MN9
STATE WELL PERMIT#Of applicable) NA
DWQ er OTHER PERMIT #(if applicable) NA
WELL USE (Check Applicable Box) Monttoring 0 Municipal/Public 0
Industrial/Commerciai { Agricultural ❑ Recovery ❑Infection p
Irrigation❑ Other 0 (list use)
BATE DRILLED 8118/08
TIME COMPLETED 1500 AM ❑ PM ❑
3. WELL LOCATION:
CITY: Mebane COUNTY Alamance
825 South Fifth St.
(Street Name, Numbers, Comrnuntty, Subdivision, Loi Na., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑STope ❑Valley ❑ Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 36 04' 39.30"N
LONGITUDE 79 16' 30.42"W
May be in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
[location of well must be shown on a UJSGS topo map and
attached to this form rf not using GPS}
4. FACILITY. is the r+arne of the buafness whore the well Is [ocated.
FACILITY 1D #(if applicable) 0-023467
NAME OF FACILITY Tommy's Mini Mart No. 2
STREET ADDRESS 825 South Fifth St,
Mebane NC
City or Town State
CONTACT PERSON Tommy Stephens
27302
Zip Code
MAILING ADDRESS 4672 Forest Lake Dr.
Mebane
City or Town
1919 ?.260-1415
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 40'
NC
State
27302
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOO
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 easing 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 TQ NA
From NA To NA From NA To NA
From NA To NA From NA To NA
6. CASING:
Thickness/
Depth Diameter Weight Material
From 0 To 20 Ft, 2 inch Sch. 40 PVC
From To FL
From To Ft.
7. GROUT: Depth Material Method
From 16 To 18 Et Bentonite Pour
From Q To 16 Ft. Portland Cement Pour
From To Ft.
8. SCREEN: Depth) Diameter Slot Size Material
From 20 To 40 Ft. 2 in, •014 in, PVC
From To FL in. In.
From To Ft. in. in.
9. SAND/GRAVEL PACK:
Depth
Size Material
From 18 To 40 Ft. coarse sand
From{ To
From To
10. DRILLING LOG
From To
0 1
1 5
5
15
25
Ft
Ft.
Formation Description
ASPHALT
LEAN CLAY - with little silt
15 SILT - with some clay
25 LEAN CLAY - with some sift
40 SILT - some day
11. REMARKS:
100 HERE
t5A
RECOR
S]GNATURL&OF
CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wm4
'ELL CDNSTRtCT1ON STANDARDS, AND 71tkT A COPY OF THIS
EEN PkjEDTOTIEWELL OWNER.
iitck1
1
8/20108
:ERTIFIFO WELL CONTRACTOR DATE
PRINTED NAMEF 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 27599-1617 Phone No. [phone] ext 568.
Farm GW-1 b
Rev. 7105

NONRES.IDENTJAL WELL CONSTRUCTION RECORD
North Carolina Deportment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3329
1, WELL CONTRACTOR:
Nick Perry
Wall Contractor (Individual) Name
Terraquest Environmental Cons.
Well Contactor 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 #(tf applicable) MW1 0
STATE WELL PERM ITilv applicable) NA
DWQ or OTHER PERMIT #(if applicable)
Zip Code
NA
WELL USE (Check Applicable Boa) Mon toeing L7 Municipal/Public ❑
Indusiria&Commerclal 0 Agricultural GI Recovery ❑ Injection ❑
irrigation❑ Other p (list use)
DATE DRILLED 8/18/08
TIME COMPLETED 1600 AMU PM ❑
3. WELL. LOCATION:
CITY: Mebane COUNTY Alarnance
825 South Fifth St.
(Street Name, Numbers, Community, Subdivision, Lot Ito., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
EISIope ❑Valley 1E Flat ❑ Ridge ❑ Other
(check appropriate box)
LATITUDE 36 04' 39.30"N
LONGITUDE 79 16' 30.42"W
Maybe in degrees,
minutes, seconds or
in a decimal format
Latitude/longitude source: ❑OPS ❑Topographic map
(location of wed must be shown on a tJSGS Popp map and
a#ached to this form if not using GPS)
4. FACILITY- is the name of the business where the well le beefed.
FACILITY ID OR applicable) 0-023467
NAME OF FACILITY Tommy's Mini Mart No. 2
STREET ADDRESS 825 South Fifth St.
Mebane NC
City or Town State
CONTACT PERSON Tommy Stephens
27302
Zip Code
MAILING ADDRESS 4572 Forest Lake Dr.
Mebane
City or Town
{ 919 ) . 260-1415
NC
State
27302
Zip Coda
Area code - Phone number
5. WELL DETAILS: .
a. TOTAL DEPTH: 40'
b. DOES WELL REPLACE EXISTING WELL? YES Q NO
c. WATER LEVEL Below Tap 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 20.0118.
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 Ta NA
IL CASING: Thickness/
Diameter Weight Material
FL 2 inch Sch. 40 PVC
Depth
From 4 To 20
From To
From To
Ft.
Ft.
7. GROUT: Depth Material Method
From 16 To 18 Ft. Bentonite Pour
From_11_ To 16 FL Portfand Cement Pour
From To Ft.
8. SCREEN: Depth Diameter Slot Size Material
From 20 To 40 Ft. 2 In, .010 ln. PVC
From To Ft. In. In.
From To Ft. In. in.
9, SAND/GRAVEL PACK:
Depth
From 18 To 40 Ft. coarse
From To FL
From To Ft.
10. DRILLING LOG
From To
0 1
1 5
5 15
Size Material
sand
Formation Description
ASPHALT
LEAN CLAY - with little silt
SILT - with some cfa�r
15 25 LEAN CLAY - with some silt
25 40 SILT- soma clay
11. REMARKS:
IDOH
1SA
REC
E Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
nEEN PROVE>eD TO THE WELL OWNER.
8/20/08
SIGNATU F CERTIFIED WELL CONTRACTOR DATE
PRINTED NAMEr0F PERSON CONSTRUCTING THE WELL
Subrnit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617 Maii Service Center w Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-1 b
Rev. 71D5

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Dhrfalon cfWater Quality
WELL CONTRACTOR CERTIFICATION d 3404
1. WELL CONTRACTOR:
Wesieyr W. Herman
Well Contractor (Individual) Name
American Environmental Drifting, Ise.
Well Contractor Company Name
STREET ADDRESS 324 fields Olive. Suite C
Aberdeen NG 2831E
Cfty or Tovin Slate Zip Code
(910 ]- 944-314g
Area code- Phone number
2. WELL INFORMATION:
SITE WELL rrOIfapplicable) MW- 15
STATE WELL PERM* (lt applicable) _
DWRor OTHER PERM' f applicable)
WELL USE (Check Applicable Box) Monitoring ® Municipal/Public C3
I#duslriatlC:ornmerciai ❑ Agnculturai 0 Recovery ❑ lr ectlon ❑
irrigation ❑ Other ❑ (list use)
DATE DRILLED 10/31/08
TIME COMPLETED 9.30 AM ® PM
3. WELL LOCATION:
CITY: Mebane COUNTY Orange
826 S. 6°a Sheol
(Street Nance, Numbers. Community, Subdivision. Lot 14, Parcel. Zp Code)
TOPOORAPIifC 1 LANO SETTING:
©Slope OVaitey ®Flat ©Ridge QOlher
(check appropriate box)
LATITUDE Se° 04.050 may be b degrees,
mieutrs, seconds or
LONGITUDE 074° 16.485 Ina derimai Coruna
Latttodeltongitnde source: ®17PS El Tapegcsph(c map (1oce1lon of
well must be a►lown on a USGS logo map and attached la thts forrrl
lfrlol uslna UPS)
4. FACILITY• Is the naive or the business v nare the welt Is located.
FACILITY ID f lir applicable)
NAME OF FACILITY Tonvltyis HSInI Merl 28
STREET ADDRESS 925 S. 5°' Street
Mebane
NC 27302
City or Town -Stare
CONTACT PERSON Thomas Stephens
Yplvode
MAILING ADDRESS 4972 Forest Lake Drive
Mebane NC
27302
City or Town
f 33e 28O-1416
Area code - Phone number
6. WELL DETAILS:
R. TOTAL DEPTH: 95 ft.
State Zip Code
D. DOES WELL REPLACE EXISTING WELL2 YES © NO
c. WATER LEVEL Below Top of Casing: 33. 1 FT.
(Use "." If Above Top of Caning
d TOP OF CASINO IS 0 FT, Above Land Surface
*Top of casing terminated odor below land Surface may require
a variance in accordance with I5A NCAC 20 .D110.
e. YIELD Wpm) METHOD OF TEST
E DISINFECTION: Type Amount
g. WATER ZONES (depth):
From To From To
From To from To
From To From To
9. CASINO:
Depth Diameter Thickness/ Malerlai
Weight
From O To7S Ft 0' sch AO
_pva _
From 0 To 00 Ft 2" sch40 pvc
From To FL
7. GROUT: Depth Material Method
From 0 To84 FL portiand !ramie
From 84 To87 FL bentonite tremfe
From To FI.
B. SCREEN: Depth Diameter Slot Size Material
From90 To95 FL 2" In..010 In. pvc
_
From To Ft. in. In.
From To FL fn. In.
9. sAND1GRAVEL PACTS:
Depth Size Materiel
From 87 To95 Ft 6i 3 gravel
From To FL
From To FL
10. DRILLING Lat3:
From To Formation Description
0 90 _ Brown clay
90 95 Rock
11. REMARKS
1 DO MErit- Y CERTIVOHAT 'DVS WELL WASCONSTRLICTEDfk ACCORDR.NCE Wrrri
IRA HCIC2C, Wilt CONSTRUCTION STANDARDS. AND THATA COPYOF THIS
RECORD HAS 6EEN PROVIDED TO THE WELL OWNER.
� 1if4108
til0MA11J C TIRED WELL CONTRACTOR DATE
Wesley W. Herman
PRINTED NAME OF PERSON CON3TRUCTWG THE WELL.
Submit the origlna! to the Divlsiou of Water Quality within 30 (Jaya, Attn: information Mgt.,
1617 Mall Service Center- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-Tb
Rev. 7A15

WACHOVIA BANK
BISCUl7V1LLE
Baser,op prepared by Hunter Civil
Technologies, PLLC 10- The Crown
Companies, LLC. Aerial photo from
Alomance County GIS.
"f, --,..
(s.,.
ti�
g..:,‹\--,,,
,R.,,,,.urx-s �-9'
RBC CENTURA �� 130 �
MW1
NILLWd WIISq$, JR.
PROPERTY /
Mg -MATED EXTENT O
2L STANDR.RD
VIOLATION
,1CINI1Y 4WP
LEGEND
Type 11 Groundwater Monitoring Well
Type Ili Groundwater Monitoring Well
Potable Well
PW1 is sole source
Groundwater Recovery Well
Detected analytical results far the 10/16/14 sampling
event are displayed in ug/L.
Analytical dcto from the Type lit groundwater
monitoring wells MW6, kiW15, end MW16 was ignored
in the construction of the 21 Standard violation
plume.
Groundwater ❑nalytico! results ore summarized in Table
2. The complete analytical report is provided in
Appendix 8.
Contaminant of Conceal
c
,9
,°J
w
w
x
w
v
u
a
x
5
9
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o
4
s
a
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u
z
2
$
0.
c2
p-Ls apropyItoIuene
V
C
1
E
F
14
C
R
-
E
F
WelIID
collected
MW1
- 10/16/14
238
27
211
344
ii,70/0
717
<17.2
<4.20
<6.70
<9.80
<9.40
<6.50
<8.90
20J
151
MW2
10/16/14
0.66
4.0570
4.0920
47.298
311
1.51
<0.172
<0.0920
<.0670
<0.0980
<00940
<0,0650
<0.0890
<0.103
40.0870
.. 14N3 ..._..-.
10/1Q14
1/.6<0.0570
0.12J
0.425J
1,,4 0
29.6
<0.172
<0.0920
<D.0670
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<0p_ 0
<0,C890
,a.382_
_4.0870
W4
.10/1 114
<0.119
<0.0570
<0.0920
<0.2998
<0i69
<2.0920
<0.172
40.0920
s0.0570
<0.0980
-<0.0940
<0.0653
<0.0890
<a.103
e0,0870
W6
MA._II9.
<0./19
<0.0570
<0.0920
<8.248
171
409
<0.172
<0.0920
<0.0670<0.0980
<0.0940
<0.0650
4.0890
'<0.103
<0.0670
.._._
14W-2
L 10/25/14
2,,260
1LS J
T_ 1e1131
314
93
4160
18 J
<3.35
265
as J
42$
127
.
MW9
--•
10/08/14
<0.119
<0.0570
..
<0.0920
_
<0.298
0.79
<0.0920
<0.172
<0.0920
0.65
_VMS2R6
<0.0980.<0.6940
<0.26650
<0.0830
<0.1.03
<0.0870
. _
MW10
..
10/15/14
611
<0.0570 1_<0.0920
2.2211
<0.169
<0.0920
<0.172
<0.0920
<0.0570
0.271
<0.0940
<0.0650
<0.0890
<0.103
<0.0870
_ ...
_MW11 ....
10J11 14
<0.114
<0.0570
<0.0920
<0.298
<0.169
<0.0920
<0.172
<0.0920<0.0670
<0.0980
<0.0940
<0.0650
<0.0890
e0.103.
m.0870_
MVIW13
_
10116/14
<0.119
40.0570
<0.0920
<0.293
<0.165
4.0920
<0.172
<0,0920
4.0670_
4.0920
4.0940
e0,0_650
4.0690
a0.103
4,0870
MW1S
10/16.0.4
<0,119
<0.0570
45.0920
<0.298
541 G
11_9
<0.172
<0.0920
<0.0570
<0.0980
<0.0940
<0.0650
<0.0890
<0.103
<0.0870
MW16
10/15/14
<0.119
<0.0570
<0.0420
<0.298
<0.169
<0.0920
<0.172
<0.0920
<0,0670
<0.0980
<0.0940
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<0.103
<0.0870
R W1
104/14
191
195
50.7 __
326
3,920 D
563
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4.920
<0.670.
41
143.1 J
740 J
<ff.890
782
24.4
_ , _
RWa
10f1.J14
<0.119
4_0570
<0.0920
_
<0.298
149
2.67
<0,172
m;0920
<000670
<00980
4.0940
<0,0650
<0.0890
<0.103
43.0970
. RW3
_ 10/16/14
95.R
4.0570
1.29
6.02
46a D
22.7
0.22 J
0.3 J
4.0570
- .1.16
<e.0940
0461
0.42 J
1.36
_ 0.95
RW4
10/16/14
235
40570
4.0920
< .298
158D
6J16
<0.172
c0.0920
<0.0670
<0.0980
<00940
<0.0550
<0.0390
<U.103
<0.0370
aLStndards
1
600
600
500
20
70
70 I
70
6
70
6
70
25
100
400
OC.L
5,000
260,000
84500
85,500
20,000
70,000
70,9001 8.500
6.000
19,0.00
6000 130,000-11,700
28,500
29,000
GRAPHIC SCALE

0'-- A
80
70'
60' -
50' -
40'
7
30' -
20'
10' -
0'
r r t + +1 + +
+ + + + + + + + + + + + + + A + + +
+ + -1- + + + + + + + + -1- + + v+ + 4 +
+ + + + + + + + + + + + + + + 1 + + +
+ + + + + + + + + + + + + +' + +- +
+ + + + + + + + + + + + + + iv + - +
+ + + + + + + + + + + + + + + '+ + +
+ + + + + + + + + + + + + + + + \+ + +
1 10'- B
MEBANE OAKS RD,
7
•
•
•
•
•
".>� + + + + + +
+ + + + + + + + +
+ + + + + + + + +
+ + + f- + + + + + + +
+ + + + + + + + + + +
- + + + + + � + + + + + + +
+ + -F + + — + + + + + + +
�+ + + + + + + + + + + + +
% + + + + + + + + -1- + + + + +
+ +, + + + + + + + -1- + + + + + + +
+ +, + + + + + + + + -F + + + + + +
+ + + + + + + + + + + + + + + + +
+ + + + + + + + + + + + + + + +
+ I + + + + + + + + + + + + + + + +
+ 1+ + + + + + + + + + + + + + + +
4 + + + + + + + + + + + + + ++ +
+► + + + + + + + + + + + + + + + +
1+ + + + + . + + + + + + + -1- + + +
BUILDING
100'_
90-
80' -'
70'--
60' -
50'
40'
Nr-
-� —
20'
10'
A'
LEGEND
SILT NO
SAPROLITE
+ +
CLAY (CO
BEDROCK
Some monitoring wells and soil borings have been projected to
the cross section troce. Soil lithologies have been generalized.
Refer to the boring logs for detailed descriptions.
? — Indicates uncertainty in data.
Elevations are referenced to on arbitrary datL.m of 100.00 feet.
0' 20' 40'
HORIZONTAL SCALE 1"=40'
VERTICAL SCALE 1"--20'
CONTAMINATED SOIL
Concentration >stg—MSCC
EXTENT OF CONTAMINATED SOIL
So41 Samp;e
Outer Casing
it 4 Ntk¢ Vag,\
Inner casing
Screen
Potent:ametric Surface
stimoted Extent of
NCAC 2L Vio'ction
L)
z
z
GEOLOGIC CROSS SECTIONS
CO
0
in
Cc
CHECKED BY:
PROJECT NO: 00408
L:1
crs
1)1