WI0400473_DEEMED FILES_20171116

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400473
1. Permit Information
Were any wells abandoned during this injection
event?
Yes ❑ No
S&ME, Inc.
Permittee
TF-12339 West Yadkin Superette
Facility Name
4420 Old Highway 421, Hamptonvilie, Yadkin County
Facility Address (include County)
2. Injection Contractor Information
S&ME, Inc.
Injection Contractor / Company Name
Street Address 9751 Southern Pine Boulevard
Charlotte
North Carolina 28273
City
( 704 ) 724-4814
State Zip Code
Area code — Phone number
3. Well information
Number of wells used for injection 1
Well IDs MW-1R
ReCEIvebo,v
VEC o 6
Ft • Water ()
lagi"al Op ratr n19
Were any new wells installed during this injection
event?
X❑ Yes
❑ No
If yes, please provide the following information:
Number of Monitoring Wells 1
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑X Drilled ❑ Direct -Push
❑ Hand -Augured 0 Other (specify)
Please include a copy of the GW-1 form for each
well installed
If yes, please provide the following information:
Number of Monitoring Wells MW-1
Number of Injection Wells
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Calcium Peroxide
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 10-40 mg/L
If the injectant is diluted please indicate the source
dilution fluid.
Vanes, by diffusion. 1.75 lb EHC-0
Total Volume Injected (gal) oro.2625lb Oxygen.per well
Ltd/ Vanes, by diffusion. 1.7e51b EHC-O
C'&ume Injected per well (gal) or 0.26251b Oxygen per well
?UV Injection History
Injection date(s) 11/17/17
Section
Injection number (e.g. 3 of 5) 1
Is this the last injection at this site?
❑ Yes ❑ No
Unknown, depends on water quality changes from the one event. To
be determined by NCDEQ, UST Section, Chnstina Schroeter
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
STA ARR.E.A1D OUT IN THE PERMIT.
eti-dfir
STGNATUJ.ECTION CONTRACTOR DATE
L ?PM
JGO+ r0An+,
PRINT NAME. CYI PERSIDN PERFORMING THF tN,IECTIL!NN
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: WC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016

1 MR. ..•.••
WELL CONSTRUCTION RECORD (GW-1)
1. Well Contractor Information:
ail iris n q g ett-
Well Conuactor Name
1}.3$(0
NC Well Contractor Cem5cation Number
For Internal Use Only
{
r it. WATER ZONES --•---
rJROM 4TO ' DE.souF't10N _. _.-�-
fL ; O.
I
ft R
15. OUTER CASLNG (for multi -cased weds) OR LINER (d appLubk}
H FROM •,F„ TO __ft+ otANtrrF7t t TRIC70t'SSS Hx-rica At.
E. nv�ro+�me►ltal O�,tl„� q-- t f btnc 5eral'tes
Company Name
2. Well Construction Permit #:
1 at all applicable well ronsen own permits ire f 7(• ('oann .State Variance etc
3. Well Use (check well use):
Water Supply Wen,. r
Agricultural
Geothermal (Hcatutg/Coohng Supply)
Industrial/Commercial
anon
ater Supply Weil:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Expenmental Technology
Geothermal(Cioscd Loop)
Geothermal (Helton ooh
4, Date Well(s) Completed:
0 ( inoundwater Rcmedrauor.
DSaltnrty Barrier
E3slormwater Drainage
0Subsidence Control
Tracer
Return) nOther (explain under 421 Remarks)
�}' + Wetl1Da 14-1g
5a. Wen Location:
W es+. t/0A; n S %Tam*,
Fachty'Owner Name
w 7 O (f)id Nw+i 4 zi 1{a+mp+orrJ ills. t
Physecsl Address. C sty. and 7tp
County
51s. Latitude and longitude in do reeslminuteslseconds or decimal degrees:
(if well bold. one Iat'Iong its sufficient,
Factbt) 1D41 (tf appb able)
ti
Pared !denukcavoo `;, ,P1`• s
6. Is(are) the well(satiermsnent or QTcmporar, /
7. Ls this a repair to an existing well: OYes or L! JNo
if this tr o repair fhl out known well construction trtfnrmotton and explain the nature o' the
repass. under d21 remmt, section or of the back of ohs: form
8. For GeoprobeiDPT or Closed -Loop Geothermal Wells having the same
construction, only t CiW-I is needed Indicate TOTAL NUMBER ur wells
9. Total well depth below land surface: -_ + Lt9
For multiple wells list al depths ifdiferent ierample Jtu.:'00 snd 2(4'10',
10. Static water level below top of casing:
1 f water few; tr above Lasing, use
11. Borehole diameter: O (in-)
12. Well construction method:
(1 anger. rotary, cable direct push etc
Alex
FOR WATER SUPPLY WELLS MIA:
13a. Yield (gpm) _-_ __ Method of test:
13b. Disinfection type: --- _ Amount:
i • ` '
f lb. Ll`u'P(ER CASING oA TUBIIdG rseother�l cies�iaog) -.
__FROM nuttarrs,R 1 TRrr•t cries 1 MA11Rt/it.
'7�_t_'tt O ft Z is l>+ir1.40. i PYC.
tn.---•-
,
1 77. SCREEN
. FROM ; "f0--- -• DIiiit'ttR 3[AT srLE T rititrioaSS ; MATERIAL
Munmapa.b ubit. 'N 01f, 3 Li h- Z 1- 0 .O 1 I. 601-40
DResldentla. Water Stipp ly rsingle I I L
0 Resldentrai Water Supply I shared) 18. GROUT
RRO?at TO MATER2AL EMPLACEMENT !,[E'rHOD & AIaioUNT�
-a i 3 x. ft- 3 D ft R�erv1'oni;ta ' ?OWL
0 rL 0 ft gibkfrt" POOPI 1
ft 2 i
r19. SAND/GRAVEL PACK (if app Tel
FROM ro t MA'7 EEtIAJ. --- -' EMFt.ACEMENT METHOD --,4
1 y q ft ' a 2. i 2 ry e.c, pova
1 1
l ft.
20. DRILLING LOG (attach additional sheets if eirce.•••ryI
FROM TO
(fit
1 DP-SCF/1110:4Soler. tandaeai suinsck try.. - eh. •en.)
f. ' ft
22. Certification:
L���� E1-)D•17
•
Signature of t'artrfied +Fell C
naontacsrn - Date
yt stgnenr this Torn. 1 hereby .cmJs that the r'elIrsf .errs (Imre, constructed in accordance
with j! .h'CA(' st2C 01:1+.0 sr 154 Vesle 02C 11:00 Well C omm.:Don _%ar.dardls and Mar a
. op, ,.l oho record hat been provided to the ,eel) Owns
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction, details You may also attach additional pages if necessary
SU SAIITT•A1.IIsiSTRUCTI ONS
24a. For All Wells: .uhmit this kart~ within i!} days of .o,rnoietton ,.t well
msini,:t 1.1Tbt, Sit@ nli, I)l:
1)ivision of Water Resources. information Processing L'nit.
161" Mail Service ( enter. Raleigh, NC 27699-161^
24h. L-ur lolection IN ells: !r: sdditnit ter• ;ending the fora) it the address in 24a
.:ht.,e..us .uhnu± .'tie ;.•p'• .t this ;,non within it; .gays of compleuun o1 well
,..xtrl riot war±t. the t.,lio,wing
1)n±s,nn of V Rear Resources. 1 nderground Injection Control Program.
1636 Mail Service ( enter. Raleigh, tit" 27699-1636
24c. I -or dater Suaoh & Infection N.N ell*: [r. addition tt .ending the farm to
;her uddresstcx) sh<'„c slat. suhm:l :one t+,a•• .of this tarm within ;at .iay. of
,:.sit; lcuon .,t well consinAttion :t the .:aunt} hcalth department of the aunt,,
u) arc ,. t mstr acted
Form OW -I
North Caroitna Deparnnens of Envonnmeotai Qualm • )tsts,on of 'A ater Resource`
Rcvned 2-22-2016

WELL ABANDONMENT RECORD
1. We Contractor Information:
ro."1i s R, 6,5 to S
Well Contractor Name (or well owner personally abandoning well on hisrlher property)
M 3$ (e
NC Well Contractor Certification.Number
E'rkvifonmeri-o O{atiny d- Prob !`ng ervr`cf5
Company Nam
2. Well Construction Permit #: 'J- 0'61 & —
List all applicable well construction permits (i.e UI(: County. State. Variance. etc) ifknown
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
Olndustrial/Conarnereial
❑Irrigation
No Water Supply Well:
Q7'IYfonitoring
.aMimic ipallPub1ic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date well(s) abandoned:
5a. Well location:.
`l kr re:K
Facility,'Owner Name
4 zQ D 1a 1-lwl� 4t'
Physical Address, City. and Zip
lkst,
County
►)`7
❑Groundwater Remediatior.
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
Tracer
❑Other gplarn under 7g)
y) i JPPKK NEO/meta p0/ tare
DEC A 8 2017
per, 1,
}-lc�t�tpi�nv�;
Parcel identrllcanon `+o (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one lavloag is sufficient)
CONSTRUCTION DETAILS OF WELL -IS i BEING ABANDONED
,Utach well construction recordist lfavailable For multiple injection or non-warersvpp(r wells
ONLY wirh the same constmatareabandonmenr, tau can submit one form
6a. Well ID#:
6b. Total well depth: 50 (ft)
6c. Borehole diameter:
6d. Water level below ground surface: (n-)
6e. Outer casing length (if known): (ft)
6t Inner easing/tubing length (if known): (ft.)
6g. Screen length (if known): (ft)
Form ow-30
rig 1At "
(m)
For Internal Use ONLY -
WELL ABANDONMENT DETAILS
7a. For GeoprobefDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned: CAUL. _
7b. Approximate volume .of water remaining in well(s): (gal-)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. dealing materials used (cheek all that apply):
Ip'Neat Cement Grout
❑ Sand Cement Grout
O Concrete Grout
O Specialty Grout
D Bentonite Slurry
❑ Bentonite Chips or Pellets
Dry Clay
❑ Drill Cuttings
❑ Gravel
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
7g. Provide a brief description of the abandonment procedure:
boom -tv + ;
Gtvtd cp pQA. w Co-rvt rt-F,
8. Certification:
11--10-1'7
Signauue ofCernied Well Contractor or Well Owner Date
By signing.this form, I heregt• certifi• that the welts) was (were) abandoned in
accordance with 15A NC4C 02C .0100 or 2C .0200 Wei! Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617'.sail Service Center, Raleigh, NC 27699-1617
10b!For lniectiou WeLis: In addition to sending the form to the address :n 10a
above. also submit one copy of this form within 3(t days of completion of well
abandonment to the following
Division of Water Resources, t'nderground injection Control Program.
1636 Nfait Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Inl ection Wells: In addition to sending the form to the
addresses) above, also submit one copy of this form wtthun 30 days of completion
of well abandonment to the county health department of the county where
abandoned
North Carolina Department of Environmental Quality - Division of :rater Resources Revised 2-22-2016

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400473
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
West Yadkin Suprette
Location Address
4420 W Old US 421 Hwy
Hamptonville
Owner
Owner Name
NC 27020
Ncdeq Dwm Ust Section-Federal & Stsate Lead Program
Dates/Events
Orig Issue
11/16/2017
App Received
11/10/2017
Regu lated Activ ities
Groundwater remediation
Outfall
Waterbody Name
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
11/16/2017
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project ·
Permit Classification
Individual
Permit Contact Affiliation
Christina Schroeter
1646 Mail Service Ctr
Raleigh NC 27699164€
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
· Government -State
Owner Affiliation
Mark Petermann
1646 Mail Service Ctr
Raleigh
Region
Winston-Salem
County
Yadkin
NC 27699164
Issue
11/16/2017
Effective
11/16/2017
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From:
Sent:
To:
Cc:
Subject:
Shrestha, Shristi R
Thursday, November 16, 2017 3:26 PM
'Scott Young'
Schroeter, Christina; Knight, Sherri
WI0400473 NOi We-;,t Yadkin Superette
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for the above referenced
site.
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 (ori ginals 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
h ttp ://deq .nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/gr ound-water-
protection/ gr ound-water-rep orting-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 [e-mail] 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., WIOXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number WI04004 73. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in r eply to this email, as it will already have the assigned deemed permit
number in the subject line.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shrestha @ncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Scott Young [mailto:[e-mail]]
To: Shrestha, Shristi R <[e-mail]>
Subject: [External] NOi TF-12339 West Yadkin Superette
1 CAUTION: External email. Do not click links or open attachments unless verified. Send all suspicious email as an attachment to
l:..eport.spa~@nc.gov. ____ -------------------------------------
Please find attached a Notice of Intent to Construct or Operate Injection Wells for the West Yadkin Superette site
(NCDEQ Incident #12339). Please let us know if you have any questions or need anything else from us.
Thank you,
Scott Young
Scott Young, PG
Project Geologist
S&ME
9751 Southern Pine Blvd.
Charlotte, NC 28273 map
0: 704.523.4726
M: 704.724.4814
[e-mail]
www.smeinc.com
Linkedln I Twitter I Facebook
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.
Shrestha, Shristi R
From:
Sent:
To:
Subject:
Attachments:
Please find the attached NOI.
Shristi
Shristl R. Shrestha
Hydrogeologist
Shrestha, Shristi R
Thursday, November 16, 2017 2:51 PM
Pitner, Andrew; Basinger, Corey
WI0300361 NOi Hickory Express
Injection Notification Package Hickory Express 11.6.2017.pdf
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shrestha@ ncdenr.g ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
North Carolina Department of Environmental Quality -Division of Water Resources
NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This fo rm shall be submitted at least 2 WEEKS prior to in jection.
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 (15A NCAC 02C .0225 ) or TRACER WELLS (1 5A NCAC 02C .0229):
1) Passive Iniection S stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small-Scale Injection 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 Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Suhmittals Will Be Returned As Incomplete.
DATE: November 10 . . 2017 PERMIT NO. VV :J_Q '+ 0 0 '-fr 3 (to be filled in b_y~
A.
RECE\VEOfNCO' .
WELL TYPE TO BE CONSTRUCTED OR OPERATED NO\/ i O 2G'7
(1)
(2)
(3)
(4)
(5)
(6)
___ Air Injection Well ...................................... Complete sections B throug\}lat~lilY .
t.ie ns section ___ Aquifer Test Well ....................................... Complete sections B •DglM Pp~N
=X~ __ Passive Injection System ............................... Complete sections B through F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B through N
___ Pilot Test ................................................. Complete sections B through N
--~Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER(S) -State name of Business/ Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): --~C_hr_i~st_in~a~S~c_hr_o~e_te_r .~N_C~D_E~O_. _D_WM __ . _U_S_T_S_e_ct_io_n _____________ _
Mailing Address: --~1~6~4~6~M~ai=l ~S~e~rv~ic~e~C~en=t~e~r ____________________ _
City: Raleigh State: NC Zip Code: 27699-1646 County: ___ ~W~a=k=e-
Day Tele No.: 919-707-8260 Cell No.:
EMAIL Address: christina.schroeterr@ ncdenr.!!ov Fax No.: ________ _
Deemed Permitted GW Remediation NOi Rev. 6/1/2017 Page 1
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: ------'R~on=a=l=d..a.A=•....,&~L=--v~m=1-=-e-=-H=a=n=e~s ____________________ _
Company Name ---"-N""o""t "-A=p=p=li-=-ca=ba..al-=-e ________________________ _
Mailing Address: ----"-P_,O"--=B""o=x--'1=2=2 _________________________ _
City: Hamptonville State: NC Zip Code:____,2=7--'0=2=0 ____ County:_---=-Y""a=dk=i=n __
Day Tele No.: ---~3~3~6_-4_6_8_-4_9_6_5 ___ _ Cell No.: ___________ _
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ S-=-c"-o~tt"-Y~o~un~g~/P_ro~i~ec"-t~G"-e"-o~l~o~gi~s"-t __________________ _
Company Name ___ S.a.,.&~M=E~I=nc~·-------------------------
Mailing Address: --~9~7-=-5-=-l ~S~o~u=th=e-=-m~P=in=e--'B~o"-u=l-=-ev~a=r~d __________________ _
City: Charlotte State: NC Zip Code:--'2~8=2~7-=-3 ____ County: Mecklenburg
Day Tele No.: 704-523-4726 Cell No.: __________ _
EMAIL Address: s voung@ smeinc.com Fax No.: 704-525-3953
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: West Yadkin Superette. 4420 W. Old US 421 Hi !!hwav
City: ----'H=am=pt=o=n""'v"""il=le'--______ County"-: ___ Y~ad=k=i=n----'_-~Zip Code: --=2~70=2~0----'
(2) Geographic Coordinates: Latitude**: 36° 07' 19.54" or ______________ _
Longitude**: -80° 47' 12.60" or ______________ _
Reference Datum: _______ ~Accuracy: ________ _
Method of Collection:_G=oo=g=l=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 COO RD INA TES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ .square feet
Land surface area ofinj. 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.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOi Rev. 6/1/2017 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
A release of gasoline from an underground storag e tank s vstem located on the pro pe rrv has impacted
groundwater above the 15A NCAC 2L .0202 e.roundwater g ualitv 'standards. The use of oxve:en releasing socks
{Provectus ORS ) usin e. one well {MW-lR) is planned to enhance the de gradation of petroleum contaminant
levels in the .!lroundwater to below the 2L Standards. U p to four 3-ft long ox vg en release socks are planned to
be installed in the well.
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only irifectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at htt p://deq .nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-a p proved-in jectants.
All other substances must be reviewed by the DHHSprior to use. Contact the UJC Program for more info (919-
807-6496).
lnjectant: ___ C_al_c_ium __ P_e_ro_X1_._d_e_in_s_o_li_d_fi_orm_._b_v~so_c_k_o_f_c_h_e_m_1_·c_a_l _in_m_o_n_it_o_ri_n~g_w_e~l=l.~fi~o_r ~o~x~y._..!.!e=n~
Volume ofinjectant: Varies. by diffusion. 1.75 po und EHC-O or 0.2625 pound per well
Concentration at point of injection: -----~l ~0--4~0~m~g/L~---------------
Percent ifin a mixture with other injectants: Calcium peroxide >75%. Inorganic Nutrients <25%
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: _____ Proposed ___ l ___ Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Well Type Grout Screen Casing Well Contractor Cert# (ft-bis ) (ft-bls ) (ft-bis )
MW-IR Permanent 0-31 34-49 0-35 EDPS, Inc. 4386
Deemed Permitted GW Remediation NOi Rev. 6/1/2017 Page3
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Ox yg en release socks will be installed one week after submittin g the NOL Socks to be removed and re placed
a pp roximatel y 6 months followin g installation. The socks will be removed from the wells a pproximatel v 6
months followin g the second installation event.
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.
After removal of the socks followin g the second installation event. the wells will be sam pled for VOCs by SM
6200B parameters.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I 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, 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. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related aJlpurtenanc_fts in accordance with the 15A NCAC 02C 0200 Rules."
-I •{4-/ ----/-:.1DP, ~7'.,,,. Scott Young, Project Geolocist
Signature of Apt51icw t Print or Type Full Name and Title
PROPERTY OWNER (if the propertv 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
(15A NCAC 02C .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached signed Access Agreement
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Submit the completed notification package to:
Deemed Permitted OW Remediation NOi Rev. 6/1/2017
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page 4
r
0
2,000 4,000
(1N FEET)
REFERENCE: USGS USA TOPO STREAMING MAP LAYER
GIS RASE MAPPING WAS OBTAINED FROM THE USGS NATIONAL MAP. THIS MA P IS FOR
INFORMATIONAL PURPOSES ONLY. ALL FEATURE LOCATIONS DISPLAYED AR E APPROXIM AT ED.
THEY ARE NOT BASED ON CIVIL SURVEY I NFORMAT ION, UNLESS STATED OTHERWISE.
* Project Location
SCALE'
1' =2,000'
DATE
7-18-17
DRAWN DY:•
DOH
PP.»ECf I1
4305-17-104
SS&ME
TOPOGRAPHIC MAP
WEST YADKIN SUPERETTE TF#12339
4420 OLD HIGHWAY 421
HAMPTONVILLE, YADKIN COUNTY, NORTH CAROLINA
FIGURE NO.
1
1
alA3D51171104 West Yekln Superet6e11_TOPam xd plotted by OHonans 07-1e-2017

:*0
MIN-4
0
50 100. ,;
• IIN FEET) FI:.
•
1
MW$
MW-7
- -U: OLD -US. ,2
C4 4
•
•
i
4
}
REFERENCE: 2014 A ER IAL PHOTOGRAPH
GIS DATA LAYERS WERE OBTAINED FROM YADKIN COUNTY GISAND NC ONEMAP THIS MAP IS FOR
INFORMATIONAL PURPOSES ONLY ALL FEATURE LOCATIONS DISPLAYED ARE APPROXIMATED.
THEY ARE NOT BASED ON CIVIL SURVEY INFORMATION. UNLESS STATED OTHERWISE.
R'
••frit .L .
@ Monitoring Well
-I:I Water Suply Well
Project Parcel
SCALE:
PROJECT NO
1 = 50
4305-17-104
$S&ME
SITE MAP
WEST YADKIN SUPERETTE TF#12339
4420 OLD HIGHWAY 421
HAMPTONVILLE, YADKIN COUNTY, NORTH CAROLINA
FIGURE NO

3ti
FORMER
TANK PIT
60
'(IN FEET)
REFERENCE: 2014 AERIAL PHOTOGRAPH
GIS DATA LAYERS WERE OBTAINED FROM YADK IN COUNTY GISAND NC ONEMAP THIS
MAP IS FOR INFORMATIONAL PURPOSES ONLY. ALL FEATURE LOCATIONS DISPLAYED ARE
APPROXIMATED. THEY ARE NOT BASED ON CIVIL SURVEY INFORMATION, UNLESS STATED
OTHERWISE.
IIAVII�B
- •-•• • Relative Groundwater Surface Contours (ft.)
{57.81) Relative Groundwater Elevation (ft,) on 7/6/2017
NM Not Measured
® Monitoring Well
0 Water Suply Well
11111
Project Parcel
SCALE.
1 =30'
DATE:
7-18-17
DRAWN BY:
DDH
PROJECT NO.
4305-17-104
$S&ME
GROUNDWATER ELEVATION MAP
WEST YADKIN SUPERETTE TF#12339
44200L❑ HIGHWAY421
HAMPTONVILLE, YADKIN COUNTY, NORTH CAROLINA
FIGURE NO.
4
J
vailon.mxd plotted by ❑Hv
IV
cc
0:14305117110

ti. WSW-2
MW-2
,NM1
(19
MW-7
All Below Detection Limits
J
1-4
ri
10 60
I�rri
4INFEEiI
REFERENCE: 2014 AERIAL PHOTOGRAPH
GIS DATA LAYERS WERE OBTAINED FROM YADKIN COUNTY GI SAND NC ONEMAP TN'S MAP
IS FOR INFORMATIONAL PURPOSES ONLY. ALLFEATURE LOCATIONS DISPLAYED ARE
APPROXIMATED. THEY ARENOT BASED ON CIVIL SURVEY INFORMATION, UNLESS STATED
OTHERWISE.
FORMER
TANK PIT
le
bLALE
DRAWN BY:
,ECT No.
1 "= 30'
7-18-17
4305-17-104
ItS&ME
MW
All < 2L Standards
!MA
Naphthalene= 100
Total Xylenes= 1,980
MW-9
Benzene= 1.3 J
1,2-Dichloroethane= 3.0
Naphthalene= 73
J
02)
♦IJ
Results in exceedence of 2L Standards are
shown in pg/L
Estimated concentration between method
detection limit and method reporting limit
NM Not Measured
Monitoring Well
- Water Suply Well
Project Parcel
GROUNDWATER QUALITY MAP
July 6, 2017
WEST YADKIN SUPERETTE TF#12339
44200LD HIGHWAY421
HAMPTONViLLE, YADKIN COUNTY, NORTH CAROLINA
FIGURE NO.

WELL CONS#'RUCTION RECORD + CW-1 j
For internal L•se Only
Faeihty, Owner Name
Physical .address_ try, and rep
NItk,
Camay
1. Well Coen -actor lafarmatson:
ffo.l5 (210�j
Well rocersee r Nuns
3$3
toe wdi Combiner Catificai on Number
E neuron MQniul Orilli>',g A'obiny Sergitts
Company Nuns
2_ Well ('Onso-rection Permit ia:
r or all a+piierbfe vw11 roaiiut icaair permit' h e f TC' 1 •niprl'i Skim Variance etc
3. W eLl Use (check well use):
Water SnppIy Well: .,--
Agneulturai 0Mmicipatf•Publ:c
Geothermal airoune/Cooling Supply ❑Residential Water Supply 'stapler
indtxstnal/Commereiel ORtxidenual Water Supply r shared
lrri armor
N•. aterSimply Weil:
Morutonnp
[n" Weil:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Eig+asneutal Technology
Geothermal {{Closed hoop)
la. WATER ZONES
Imam I TO nlss=Rlrnow
rt. ; tL
1
r 15. OMER CASING (rer mr W-cased warn OR LIM QQf }
rulri + To _ own -roc L T1uCiorrss �T>�1A1. -
ft. ! fF
r l 60TEit c a+fG OR TUBING ,xcrc c ml douse loss►
leftrAl ; TO aultti:'rra 1 nuctort ss IrAT;wRL
- 314 1 0 Z ' sth.ge, pvc
In.
{
11. SCRUM
'11tOM TD DEAMErga SLOT S17/Tg9 10011 1 MAs.
Tlvia
L h 3 Z: 0_o l $c l-i• es_--- y1--- pvc
mi—
is. i
Q Recave .
0tfroundwales Remed:xtton
0 alinety Barrier
fSiorrnuatcr Drainage
f Subsidence L ontrai
l8. GROAT
mom 4_ To r i MATEe1,+.L —1-i.ACCWINT METSOD & AMIWNtt
i 3x.rt 30 f nt -
r pewit.
It. SAND/GRAVEL FACic Ofa/Vacabha !
F nom ro srArrx1Aa. I Ithel.a1L$rurrMFrsoD
' H9 It 30 I { A.►a mere, 1 FOUR
R-• 1'. i
DTI -ricer 2aa, RCt1i,.LING LOG launch additional ramp d weesaeerf)
Mats To Drsc f riot• (enter,a+e+4si adYracktrim.traiir'atie
Geothermal (ileattng. Cooling Return) rj( Moir explain wader 421 Ratnarksk J 1---'—
4. Darr W DD(i) Completed:
5 . Weil Location:
iti=�—�� WrI LDM
mw-
1 es# \likalcin S t1 jre*e '
}salty} I0a if upplauele
Pane! Meer Atawa tic Pt+
Sb. Latitude and longitude In dsltscraiaiiuutc fserends or decimal degrees:
If wail field, oar Wien is sufteicme
>ti
w
6. Is(arel the well(s)erui atni .or Di'r:unparsr. .!
7, is this at repair to as existing well: ElY•es orEt/Nu
if dm u a .epcar, fill awl beown wrU 02$150141112A arhinnatiaa and =plain the whin ur the
,-Parr ioickr all .uncorks 'mbar, ai• in the awl. of lhir (arm
R. For GeoprobcJDPT or Closed -Lop Geothermal Wells bovine the usmc
construction. Linty 1 CiW-1 es needed lndtcatc TUTAL NI MBER u7 wells
9. Total well depth below land sorrier: 1 tfti
ior+rwhiPtr►urns ham aft ricprhr tfdiff.rni rexar+rptr !rn~.:OO.md ?.'tit;coin
la Static water level below top of rising: ifY
lfe•arrr Ir+ri n above E:Wmm sae -
11. Borehole diameter: D fia.
l2. Wen rnsanwc6ao method:
(Lc saga, wary, cable &wet push CIE
FOR WATER SUPPLY WELLS O1+11-t:
13a. Yield ()goal Method of test.
I3h. Dialtirretion type: Amount:
R e H.
- 1636 !Amid Servir•e c eater, Raleigh. Nit- 2709.1636
.24c- For Weser Supph dr lniectinn " ells: Is xddtiivin EL . dinp, stir ilium tt=
;In sd.dres.tes1 :hhote e1.. .uhn::1 one c,ev'. ,11 this taro+htthin 'i' .layer of
completion of well e_c+rstinictitin ..1 the .t Uni) health dipar.rnen r+i tlw count)
J where titnllfll*Lec
21- REMARKS -
21. Csrtet cadoa:
1j-ID-17
smnaurr,,ft•gy$ed %Vet! Ccasanciar Due
Ih :+(!none Lkas irrrn 1 Arredti .err, lhm the wiles, lbw M1verrl cuaarucred 8r aawrdtnce
with ' S-t NfA(' t1:4' iriUP > f SA V{ •ie d?l' 0200 Wed Cunfrruerecre Staac we and aim a
rap rJehtr rrrerrd her bervrpvnaiderl rv, ehr w!! owner
23. Site diagram or additional well devils:
You may wLFc the hack of this page to provide additional well site dcW is or well
caostruenon details 't ou may also attach additonai pngcs if-ma:w uy
5S•EhIn TAU1+S RLCTs_i�144
24a. For All NeJ: tiuhmrt this ti,rr:r wthin 11t dins .•t :tmtpleorm .+! well
",nfitsyruion. sv the F. olio •wail:
IAvisioo or Water Resources. Information Proem -tog twit.
161' Mali Service Center. Raleigh, N" 2?694-161'
1411 I;vr lo}ettion erix: lt: tildluvvt is +ending the kii'm k the address in 144
si.vle• au st1hit t :uric wry+: i thi+ ti+rltl utthin 31 Sa}ti .if vmp1Ctiim c+f wel,
t.tn�rRli;lt+IS tt the t+rliowing
Illy cilium of V afer Reanurces. t ndergruund Injection C'earrol Program.
Far OW -I North Cazoiurs Oeparmrnt of Leviro mrema: Qualm • :h•isirmo or -water Resurfaces
Rn ae4 2-n4'1

TO: Steven H. Kelly, P .E.
Engineering Consulting Services, Ltd.
8349 Arrowridge Boulevard, Suite S
Charlotte, North Carolina 28273
OCT 7 1996
RE: Authori7.ation to enter property to perform site assessment and other mnedial activities
SITE NAME: __ ...,.W......,est--....X...,14-ki-·o ..... s....,,uomu ... -.-c_ .. ______ _
ADDRESS: __ ___.44 ... 2IQIQ'""'W~est~O'"'ld ... Hi ..... &hlWWIU. 1r,1.,):.;a;,42..,J _____ _
CITY: ____ .... H_amp.....,.t_oniw:vi.....,·11_e _________ _
COUNTY: ___ v .... a ... dlci_'_n ___________ _
-REGION: pjf4mont INCIDBNTNUMBBR....12ll2..,. ___ _
Dear Mr. Kelly:
I am/We are the ~wner{s) of a parcel of property at the incident in question, and heieby pemdt
the Department.of Environment, Health & Natural Resomces (Department) or its comractor, ID
enter upon said property for the puq,ose of pemmnina various si1e IINSsmeot activities which -
may include collecting soil and p,tmdwater samples, installation of groundwater monitor wells,
collecting water samples · :&om drinkmg wells, providing altemative water fbr human
consumptio.D. mccavatfD& and removing UDderground storage 1lmk systems (USTs) and
potentially other remedial activities.
I am/We m; paating pmnissiou with the vodmtawting ihat:
1. All work shall be ccmducted by tho Groundwater Section of the Department's Division of
Water Quality (DWQ) or its contnctor.
2. 1be costs of construction and maintenamce of the site and access sball be bom by tbe
Departmmt and its contract.or. The Depmtmmt or its c:mttractor, shall po1ect and
prmmt damage to the surrounding lands.
3. Unless otherwise ap:ed, the Department or its contractor, shall have access to the subject
property by the shortest feasa"ble mute from the nearest public road. The Department or
its contractor may .enter upon the subject property at reasonable times and have 1bll right
of access during the life of the project. · ·: ....
4. Any claims which may arise against the Department or its CODtnctor shall be govemed by
Article 31 of Chapter 143 of the North Camlina General Statutes, Torts Claims Against
State Department and Agencies, and as otherwise provided by law.
I
------------··--· ----··-
S. The information gathered during the life of this project shall be made available to the
owner upon written :request and is public information in accordance with G.S 132-1 a
~
6. The activities to be. carried out by the Department are for tbe primary benefit of the
Department and of the S1ate of North Carolina and any benefi1s accruina to the owner are
incideat.al. The Department is not and sba1l not be construed to be an agent, employee or
contractor of the owner of the land, and
7. 'J/We agree not to mterferc with, tamper with, iemove or in any way damage the
Departmeat•s weJl(s) or equipment during the life o~tbe project. The Departmeat, upon
timely request of the undersiped. will provide acecss to· 111e subject pmpaty 1br any of
the previously mtmtioned tasks. Such use shall be at the conveaience and muler the duect
supervision of Department penonnel.-/ /J 0
SIGNATURBOFPR.OPER'IYOWNBR: ~t{i:-1/ ~ Jt I
PRINTNAMB OF PROPBR.TY OWNBlt: .. ___ R_g.o-N4-. ,..A.,., H-n-m--------
ADDRESS OF PROPER.TY: _ __,.._ .M-2111,Q~W1.11est-0wa14.,.U ... ia51bwMY•J,.:4uoZ..,t _______ _
CITY/STATE/ZIP CODE: ___ H_amp..,..t-oa-YJ-·lJ .. e.. .... N_,c_-, ..... 2.,.7:_02_0...._ _______ _
HOME PHONE: C2lID 46Hffl
WORK PHONE: J,210) §19-2397
DATE: k>/y/zt, .
-.
L'\ENIUONIREl'OITS\R.~1161-1.00C
----------