WI0400481_DEEMED FILES_20180202

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400481
Injection Deemed In-situ GroundwaterRemediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Faclllty Name
Former Caviness Grocery
Location Address
3904 McConnell Rd
Greensboro
Owner
Owner Name
NC 27405
Ncdeq Dwm Ust Section-Federal & Stsate Lead Program
Dates/Events
Orig Issue
2/2/2018
App Received
1/22/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
2/2/2018
Permit Tracking Slip
Status.
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Sharon Ghiold
1637 Mail Service Ctr
Raleigh NC 27699
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Mark Petermann
1646 Mail Service Ctr
Raleigh
Region
Winston-Salem
County
Guilford
NC 27699164
Issue
2/2/2018
Effective
2/2/2018
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
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 iniection.
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION nsA NCAC 02C .0225 ) or TRACER WELLS nsA NCAC 02C .0229 ):
1) Passive In jection S vstems -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 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 Submittals Will Be Returned As Incomplete.
DATE: _\__,_/~2-~2.-~~· 20 -12._ PERMIT NO. w J.O 4: DO Lfg 1 (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) ___ Air Injection Well ...................................... Complete sections B through F, K, N
(2) ___ Aquifer Test Well ....................................... Complete sections B through F, K, N
(3) ___ Passive Injection System ............................... Complete sections B through F, H-N
(4) XXXX Small-Scale Injection Operation ...................... Complete sections B through N
(5) ___ .Pilot Test ................................................. Complete sections B through N
(6) __ Tracer Injection Well. .................................. Complete sections B throuR.~CE.\\JEO/NCOEOJDWR
B. STATUS OF WELL OWNER: Choose an item. JAN 2 2 2018
C. WELL OWNER(S)-State name of Business/Agency, and Name and Title of person delega , · r Regional
sign on behalf of the business or agency: Operations Section
Name(s): NCDEO . DWM. UST Section-Federal & State Lead Pro gram (TF# 30236)
Mailing Address: --~1=6~4~6=M=a=i~l =S=erv~ic~e~C~e=n=te=r~--------------------
City: Ralei gh State: NC Zip Code: 27699-1646 County: WAKE
DayTeleNo.: 919-707-8166 CellNo.: _________ _
EMAIL Address: Sharon.Ghiold c ,ncdenr.gov Fax No.: --~9_1~9-~5~7_1-_4~71~8~
Deemed Permitted GW Remediation NOi Rev. 6/1/2017 Page 1
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: ----'H=ar~o=ld~R=e~y=no=l=d=s .~P""'r-'-o,._pe~rt_y~O~w~n~e_r _________________ _
CompanyName ____ N~IA ____________________________ _
Mailing Address: ___ 3_90_0_M_c_C_o_nn_e_l_l R_oa_d _______________ _
City: Greensboro State: NC Zip Code:----'2=7'"""'4""0=6 ____ County: GUILFORD
Day Tele No.: 336-707-3907 Cell No.: NIA
EMAIL Address: __ ---=-N""""l""'A,....._ ________ _ Fax No.: NIA
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ----'K=ev""'i=n""'B""u=c=h=an=an==-------------------------
Company Name ----'-W""'i=th=e=rs=R=a""v""'e=n=el"'".=In=c""". ______________________ _
Mailing Address: --~1~1=5~M=ac=K=e=n=an~D~n=·v~e~----------------------
City: Carv State: NC Zip Code:_=2~75~1~1,....._ ___ County: WAKE
Day Tele No.:. 919-469-3340 Cell No.: 919-422-1141
EMAIL Address: __ --'k=b~u~c=h=an=an~@ ....... w~it=h=er=s=ra~v~e=n=el~.c~o=m~ Fax No.: --~9~1~9-~4~67~-~6~00~8,....._ __ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ---~(F_o=rm~e=r~) ~C~av~m~· ~e=ss~G~ro~c~e~ry~--------------
3904 McConnell Road
City: ___ G_r_e_en_s_b_o_ro ________ County_,_: G=-=u=il=fo=r--=d ______ Zip Code: 2=--7'--4'"""0'-"-5 __ _
(2) Geographic Coordinates: Latitude**: ___ 0 --__ " or 0
Longitude**: 0 "or 0
Reference Datum: _______ ---'Accuracy: ________ _
Method of Collection: _________________ _
**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: ""4.000 (Est) square feet
Land surface area ofinj. well network: < 500 square feet (:s 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: :::,IQ% (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.
Deemed Permitted OW 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.
Pu rp ose: Reduction of Gross Contaminant Level concentrations of petroleum com pounds.
Sco pe: In jection of EnviroClean surfactant into two existing 2" diameter monitorin g wells followed by the
performance of a surfactant enhanced recove ry event (Aggressive Fluid/Va por Recove ry).
Goals: Reduction of source area contamination throu eh removal of dissolved-phase petroleum contamination
with the aid of surfactants.
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be irijected. Approved irijectants can be found online at hnp://deq.nc.s:wv/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-iniectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: EnviroClean Surfactant
Volume of injectant: __ 7'-6""1=---=G=a=ll=o=n=s ..._{1=5'-=e.a=l=lo=n=s'--'E=n=-v'-'i""'ro""C=l=e=an=--=d=il=u=te=d=-w-'-'-'-'ith=---'w'-'-'a=t=e=---r =to=-5=--0'-'¼'---s=o=l=ut=io""n=-),____
Concentration at point of injection: 5% Mixture with potable water
Percent ifin a mixture with other injectants: ---=5"-'o/i-=-o-=E=n=v-=ir"""o""C=l=ean=·-=9-=5""'¾""0..,p-=o=ta=b=le"-'-'w=a=te=r _____ _
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent ifin amixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: __ O ___ Proposed ___ 2 ___ 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 Contractor Name: NIA NC Certification #:_~N~/ A~_
Deemed Permitted GW Remediation NOi Rev. 6/1/2017 Page3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Following approval. schedule includes:
1. Gauging, of site monitorino. wells (Da% 1 #,
2, Performance of apre-injection AFVR event (Da% 1)
3. Injection of surfactant into wells (Da\ s 1 /2)
4. Performance of a post -in iection AFVR event (Week 2 i
5, Performance of a site -wide groundwater caugion and monitoring event (Week 5j
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 completion of infection and post -injection AFVR event at the facility. WR proposes a groundwater
sampling event at the site after three -weeks' time to determine whether: a] the injection of material has had the
desired effect (e.g.. reduction ofpetro]eum contaminants in eroundwater of the site).
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty oflaw, 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
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 appurtenances in accordance with the 15A ACM: 1)2C 020f) Rules."
Mark Brown. LG RSM, on behalf ofNCDEQ-DWM. UST Section. TF#30236
Signature of Applicant Print or Type Full Name and Title
PROPERTY OWNER jif the prapert\ 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
(? J: i NCA C 02 ( o 11(J) „
"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 NCDEQ STATE -LEAD ACCESS AGREEMENT FOR PROPERTY
Signature* or Property Owner (if different from applicant) Print or Type Full Name and Tide
*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]
Deemed Permitted OW Remediation NOI Rev. 6/1/2017 Page 4

Sharon Ghiold
DWM UST Section
163 7 Mai] Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Ghiold:
RE: Site Access Agreement
Caviness Grocery
3904 McConnell Road
Greensboro, Guilford Cmfnty;NC l:. WSRO -~ ·t
Incident #30236
Risk/Rank: High H260D
20! 5 SEP 14 PM 3: l 8
I am/We are the owner(:s) of a pai~I of property, Iocit~ 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. l 43-2 l 5.3(a)2.
t, . .,.., • f }•' • n ~ • '" ~ •,"
I am/We are granting·pennissfon with the underst~ding 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, ~d m8i{ntmaqoe qf t~e site .. and .:~ess shall be home by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.
3. Unless otherwise agr:eed, the Department or its contractor shall have access to the site by the
shortest feasible route tri the near~ publiC.•'toad :; '•The Department or its contractor may enter
upon the land at reasonable times and have fulJ right of access during the period of the
mvestigation.
4. Any claims which may arise against the Department or its contractor shall be goveJTied by Article
31 of Chapter ·143 of the North Carolina Oenentl Statutes; Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The infonn.ation derived from the investigation shall be made avaHable to the owner upon
request and is a public record, in accordaQ.ce 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.
Caviness Grocery
STF #30236
Page 2
I/We 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.
Signatu
RRDid
Type/Print Name of Gwne- or Agent
Phone Number
YyyD lyeZoNNeiJ 4)
Address
4g. Es,P5445 A / 7406
City/State/Zip Code
Date

5
•
•
:JECT SIT
0.46 ACRE
•
/ I
F
nel Wm
GRAPHIC SCALE
250 500
I ch=500 n.
1000
aroWithersRavenet
Engineers I Planners I Surveyors
115 MxHcr• n Drive [Cary RC 275111 c 914,1492NC f 1.se+nc a! CAB 321 wnw.wf[icnrarcr.d.com
FORMER CAV1NESS GROCERY
(INCIDENT R30236)
B9D4 M.CONNELL ROAD
GREENSBORO GUILFORD COUNTY NC
GENERAL LOCATION MAP
DRAWN BY:
MOF
SCALE
1"=500'
FIGURE ND.'
1
APPROVE° 8Y:
SMB
DATE:
12/11/17
PROJE CT NO.:
02170214.09
KNIT -421,717Eif6A11-ilm111 - Cabo* ImerAllainatifLORICEM Y-r1.1 It! 1101T.d - Dwwlrr 11. 101i - RCnNNI RIN

WELL CONSTRUCTION RECORD
This fot m cnn be IL~cd for sinl!lc c,r multiple well~
1. Well Contractor Information:
James D. Barker
Well Co111rnctorNamc
3106A
NC Well Controctor Cenific<iti,m Number
Quantex, Inc.
C<>mp3ny Name.
l. Well Construttion Permit#: NA
J,i.<I all opplit•t1b/,• """ ,o,1.<1ruc#oJ1,J>rrmit., (i.,·. Cmin~•·· Stair, l'nriu11N, "'")
3. Well Use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (He:iting!Cooling Supply) .□Residential Water Supply (single)
OlndustrialtCommcrcial □Rc~idential Water Supply (shared)
□Irrigation
Non-Water Suppl~• Well:
@Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□AquiJer Storage and Recovery □Salinity Barrier
□Aquifer Test O Stom1watcr Drainage
□Experimental Technology □Surn.idcncc Control
OGeothennal (Clo,cd Loop) □Tracer
OGcoth~'flllal (Heating •Coolin~ Return) □Other (explain Ullder #21 Remark.'\)
4. Date Well(s) Completed: 12/22/15 W.eDID# MW-1R
SR. Well Location:
Former Caviness Prprty NA
FacilityiOwnor Name· Fncility ID# (if applicable)
3904 McConnell Road, Greensboro, NC 27406
Physical Addres.s. City. and Zip
Guilford NA
County 1•~rcel Jdentiikatk•n No. (PIN)
Sb, Ladtude and Longitude In degrees/minutes/seconds or decimal degrees:
( 1f we II field. <>ne latlll'ng is sufficient)
36.0539921 N 79.6890857 w
.. 6. ls (are) the \\eO(s). f;11Permanent or □Temporary
7. ls this a repair to an exisdng well: □Yes or f!Jlio
/{/his is a repoir,ji/1 out k"°"" wt'// ,•,mstnJr.tio11 inf,rmt11itm and e,,p/ain the nature of 1/,e
repair und,:r #21 remark< .uction t>r u11 the hack nf this fi.,.,,,,
8. Number of wells construrted: _O_n_e ________ _
For n,11/liple Injection or hOn-urzter .,upp{1• well., ONLJ' 11,itb the sa,nt' ron.,trMction, yo11 """
M,bmil one form.
9, Total well depth below land surface: 40' (rt.)
FQr mulliple wells list all d~plhs ifdiffcr1•n1 (example-3@200' u11d l@J(J(I')
JO. Static water level below top of casing: _N_A ________ (ft.)
(fwater lewd Is ubo,·e ca.r/11g. tlSe "f"
711 11. Borehole di11meter: _~ _______ (In.)
12. Well construction method: _A_u....;::;g_e_r ___________ _
(i.e. auger. rowy, nble. direct push, CIC .)
}.OR WATER SUPPLY WELLS ONLY:
Ba. Yi~ld (gpm) _______ Mt>thod of lest: _______ _
I For lnirrn:il Use ONLY :
14, WATER ZOM:S
t'RO~I TO Dt:SC:RIPTION
33 fl. 35 ft. Orange Brown Silty CLAY
It. ft.
1!1. OUTER C" ASJSG I for multkaHd welll l ()It J.!Nf.R llr a Do Uc-bld
•·Jl<IM I TO I DIAMlTElt I THICKNE...S I MA1ERIAL
0 It. 25 rt. 2 In, Sch 40 PVC
J6. INNER CASING OJt TlJBlN(; li!l.'tllllerm1I rlosrd.;aoon1
FROM TO DIAMt:n:R THICKNESS MATEIUAL ,,. fl, In.
fL fl. In.
J7.SCREEN
FRO.\t TO DIAML"T£R Sl,OTSIZE 'l'IIICKN~ !IIATEltlAL
25 fl, 40 ft, 2 lo. 0.010 Sch40 PVC
fl. ft. in.
18.GROUT
FR.OM TO MATERIAi , l!,~ll'LACEI\IEN1' l\ll.'Tlt(lb &. AMOUNT
0 fL 21 fl. nea1 cement Pour -370 lbs. neat cement
21 fL 23 fl. bentonite Pour• 35 lbs. 3/8" bentonite
fL ft,
19, SAJl.1)/CRA\"EL PACK llfAnnUl'llblt}
FRO:\! TO MATERIAL EMPLAC1::Jl1£1\T Mt:THOD
23 ft. 40 ft. #2sand Pour
ft. ft.
lO. DRILLING LOG (attach IKldJ«-1 •lltet• If ntt&anll
HtO~t 1'0 Dl..•,CIUl'TJO;\, f<nlnr, banla<,•• so!U-k lrnc:, nala ,lzr. rte.I
0 ft. 12 fl. Brown Moist Medium SANDS
12 fL 35 fl. Reddish Brown SILT
35 fL 40 ft. Orange Brown Silty CLAY
fl, ft.
It. ft.
ft. fl,
ft. ft.
21. llL\IARKS
22. Certifii:.+ on:
~' 6L--~ 12/24/15 -Siguture of J · ertifled Well Contractor Date
.By signi!IJ; thi.< .forn,. 1 btrrby ctTtify thfll th~ ll'cll(s) was ,.,..,,,~ cm.-rructed in act1>rda11ee
with 15A NCAC 02C'. 0100 ,., J 5A NCAC ll2C . ()WO Wei/ Ct1n.<1n,ct/1J11 Standard• and that o
t:fJPJ ' u/J/,u-~,cl)l'd has fx-~·11 pn•vidtd ,,. 1/w wd/ owner.
23. Site diagram or additional wdl details:
You may uw the back of this page to provide addiiional well site details or well
construction dctaili.. You may 11lso attach additional pages if necessary.
SUBMJTIALINSTIJCTJONS
24a. For AH Wells: Submit this fonn within 30 days of completion of well
construction to the following:
Division of W11ter QuRlity, Jnformation Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699~1617
24b. f'gr Injection W,Us: In addition to sending the form to the address in 24a
abo ve, also submit a 1,:opy of this fom1 within 30 days of completion of well
construction to the following:
Division of Water Quall!)·, Undrrground lnjertion Control Program,
1636 Mall Stn•ife Center, Raleigh, NC 27699-1636
24r. For W11ter Sup ph· & lnirdlon Well~: Tn addition to sending the form to
the addn:~s(cs) abcve, also submit one copy of this fonn within 30 days of
13b. Dl sinfiection typA,• complction of well construction lo the county health department of the county L.::::.:.=.:=::.:.::::..::~•:.:__=====--_:A:.:-.::IDll:::.:u:.::n:.::t::__:=======-.l where con~1ructcd .
Fonn GW-J N11rth Carolina Derartntent of Environment and Natural Resources Dh-ision of W;,tcr Quality Revis~ Jan. 201~
WELL CONSTRUCTION RECORD
Thi$ for m c~n be used for single or multiple welt~
J.Wrll C I f ontractor n ormat1on:
James D. Barker
Well Co ntractor Nanic
3106A
NC Wtll C'ontroctor Certification Nunii>cr
Quantex, Inc.
Company Name
l. Well Construction Permit#: NA
Li.•t oil app/i,-able u~•// c,>1i.s/rut•tion permit< (i.,•. Co111•~••• Stole. l'oriunu. r/t·J
3. Well Use (check ""ell use):
Water Supply Well:
□Agricultural □MunicipaliPublic
O(,eothermal (Heating/Cooling Supply) □Residential Water Supply (single)
DindustriaL'Commercial □Residential Water Supply (shnrcd)
Olrri~ation
Non-Water Suppl)' Well:
@Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test OStormwater Drainage
Ofap.,"tlmcntal Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
D<.cothennal (Heatill!! Cooling Return) DO:thcT{c.\plain undcr#21 Remarks)
4. Date Well(li) Completed: 12/22/15 Well ID# MW-2R
Sa. WeU Location:
Former Caviness Prprty NA
Fae ility/OWlK.'I" Name Facility ID# (if'applk.ahle)
3904 McConnell Road, Greensboro, NC 27406
Physical Addi=. City, and Zip
Guilford NA
Coun1y Pan:d ldentilication No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or dl'Cimal degrees:
(tf well field, one laVlong is •uffi&rcnt)
36.0542164 N 79.6890255 w
6. Is (are)thewell(s). 1i11Pennanrnt or □Temporary
7. Is this a repair to an existing weU: □Yes or i!!No
If this is o repair, fill nu/ lmo•ni ..-ell cunstnmiun infi>rmation and explain 11,c nature '!f the
rrpair under t:21 remartr sectio11 or'"' the lxwk of Jhls form .
8. Number of wells constructed: 008 -----------F <>r m1tlt;p/t i,yeclion or non-water supply well< ONLI' u;1J, th e sam, con.,tr11ct/on, )"'" can
$1tbmi1 on~ form.
9. Total weU depth below land surface: 40 1
. (ft.)
Ft>r m11/tiplc ..-t'lls li!t all drplhs ((diffi,i•,:111 (,~ample-3@200' und 2Cfj_;l(lf.l'/
10. Static water level below top of casing: _N_A ________ (ft.)
JJ,w,te:1 · levt'I is above cosiJ1g. use •-~"
711 ll, Borehole di11meter: _~ _______ (in.)
12. Well construction mttbod: _A_u_g~e_r __________ _
(k alljler. rotary, cable. direc1 push. tic,)
FOR WATER SUPPLY WELLS ONLY:
13a. \-1eld (gpm) _______ Method of test: _______ _
13b. Dlslnfet'tlon type: Amount:
11'or lnt~m.11 l 1se ONLY:
14, WATER 7..0NES
FROM TO DESC:Rll'TIOS
33 rt. 35 ft. Orange Brown Silty CLAY
ft, fr,
15. OIJTER CAS1"'C lfor 111attkawd ,n•lls l OR LIN£R ti! a1>ollcllbk\
•'RO!II I TO I l>IAMf,'TI:R I l"HICKNESS I MAlt:RIAL
0 ft. 25 ft. 2 In. Sch 40 PVC
16. INNER CASISG OR TUBl~G leeoi.rmal tlMtd-1"""'
FROM TO DIAMt:n:R 1HICKN~S MATERIAL
(t. n. In.
ft. ft. In.
17.S(1lE'£S
FROM 'J'O DIAMl:'Ft:R SLOT SIU ·rmCKML'I.~ I\IATI:RIAL
25 fl. 40 fl. 2 ht. 0.010 Sch40 PVC
fl. ft. In.
18.GROL'T
t'ROlll TO lll.\1·ERL<l.l, £1\tPLACE.ME!\11' J\11-..'TIIOD & AMOUNT
0 ft. 21 ft. neat cement Pour -370 lbs. neat cement
21 ft. 23 n. bentonite Pour -35 lbs. 3/8" bentonite
ft. ft.
19. SA."liD/GRA VEL PACK (If ■n11 Ucablrl
t'ROM TO MAl"ERL-\1. K\tPLAC'E.\tE.._T i\lE"OIOD
23 ft. 40 ft. #2sand Pour
ft. fl.
.28. l>RlLUNG LOG (attaeb lldd!Ckmal •111.-eb U _,.._)
FRCl!II ·10 DES<:IUI' flO."i itolar. llanloN,. ••ll'rotl< ,,.,,,. ,rain du.. et<, I
0 ft. 11 ft. Brown Moist Medium SANDS
11 ft. 35 n. Reddish Brown SILT
35 ft. 40 ft. Orange Brown Silty CLAY
ft. ft.
ft. ft.
ft. ft.
ft. ft.
2l. ltL\1ARKS
"(jt\~
~I 6L 12/24/15 --Sienarore off ertifled Well Contractor Date
.By signing this f"tm. J herrbJ· 1·"'1ifi.· 1h01 the 11rl/{s) ,..,,. (wr-rt'.I ""n.<1n,r,tc'd in uc~r,rdam,c
wiih 15A NC,J(' 01(' llJOfJ or I 5A NCAC ll2C ,IJ1llll Well Constn,rt/011 Srundard, and thar o
mp)' of thir rt>,•1,nl ho., t,,,,·n pt<>t1dt'd lo the 11,•I/ o».,<'r.
23. Site diagram or additional well details:
You may use 1he back of this page to provide additional well site details or well
construction details. You may also altach additional pages if ncccss~.
SUBMITIAL INSTUCTJONS
24a. For All WeUs: Submit this foml within 30 days of completion of well
construdion to the following:
Division or Water Quality, Information Processing Ualt,
1617 Mail Service Center, Raleigh, NC 17699-1617
24b. for lnjrrtion WeUs: In addition to sending the form to the 11ddrcss in 24a
above, also submit a copy of this fom1 \\ilhin 30 days of completion of well
construction 10 the followi:1g:
Division ofWatu Qwilil), Uaderground Jnjtttion Control Progra111,
16.'16 Mail Service Center, Raltigh, NC 27699-1636
24r. Fpr Watt>r Supph· & Injection Wells: In addition 11) scndint? the form lo
the address(cs) abCl\::, al~o submit one copy of this form wiihin 30 days of
completion of well construction to the county hc-.llth dcpartm"'nt of the county
where constructed.
Fom1GW-I Nc,rtb Car"lina Department c,f 1!1wirontnc:n1 and Natural R~ourc ,-s -DM$ion "f Water Qualil~· Rc\.'is~J Jan .2013
WELL CONSTRUCTION RECORD
This form can be used for ~in1tle or multiple wells
l. Well Contrartor Information:
James D. Barker
Well Contraclor Name
3106A
NC Well Conlractor Certifi~ation Nuntber
Quantex, Inc.
Company Name
2. Well Construction Permit#: NA
Lisi all applicable well ro11s//w:tio11pe1•mi1.< (I.e. County, Sro1,·, l'nri1111u, elt'.)
3. Well UM: (l'heck wrll use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal <Heating'CC101ing Supply) □Residential Water Supp ly (single)
Oindust.rial!Commcn:ial □Residential Water Supply (shared)
Olrri~ation
Non-Water Suppl)' Well:
@Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery O Salin:ity Barrier
□Aquifer Test □Stonnwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Clo~ed Loop) □Tracer
OGcothennal (Hcatilll!iCoolinJ.: RctumJ □Other /exl)lain under #21 Remark.~)
4. Date Well(s) Cornplrted: 12/22/1 5 Well JD# MW-3R
Sa. Well Location:
Former Caviness Prprty NA
Facility/Own~-r Name Facility ID# (if applicable)
3904 McConnell Road, Greensboro, NC 27406
Physical Address. City, and Zip
Guilford NA
Conni}' Pan:el Identification No. (PIN)
Sb. Latitude and Longitude in degrffl/minutl'Slseconds or decimal degrees:
lif well field, one latllong is suffi~icnt)
36.0539735 N 79.6889784 w
6. Is (are) the \lell(s): @Permanent or □Temporary
7. ls this a repair to an existing well: □Yes or ~No
!ftl,is is it repuir,.fi/10111 /wo1>., w<'II ct1hstn1ction in,/imnatitm und e:rplailt 11,e na1ure q(1he
repair und,'r #211·enuirk< .<e<'tio11 or on tl,c buck nfthi.•form.
8. Number of wells construrted: _O_n_e ________ _
For mu/liplr 111/ertion or non-11·ater .,upflJ' wdl, ONLY ,iith the saml! con.,tr11ction, yo11 ,•un
.,ubtnil one form.
9. Total well depth below land surface: 40' (ft.)
For multiple well, list all depths if d!ffe,,,111 (example-3@20/J • and 2@JfKI')
10, Static water lenl below top of r:asing: _N_A _________ {ft.)
if llU/er /ere/ is above ca.ring. use ;,+ "
7" 11. Borehole diameter: _..., ______ (in.)
12. Well construction method: _A_u ___ g_e_r ___________ _
(i.e. auger, rotary, cable, direct p~h, ct".)
FORWATERSUPPLYWELLSONLY:
I l''<>r lnltm.11 Use ONJ. Y:
14, WAT&R7.0NES
•1m~1 TO DESCRIPTION
33 rt. 35 ft, Orange Brown Silty CLAY
(L (t,
15. OVTl:R CASING lfnT mllllkllffll wtllll OR UNER ttf aoolJca ltld
FROM TO l DIAMt::Tt:R I THICKNESS MATERIAL
0 fl. 25 Cl. 2 In. Sch40 PVC
16. INNER CASING OR 'fUBl:-IG l11eolbrnnll do.ed-la11nl
FR0!\1 ·m DIAMt:Tt;R THICK.'iESS MATERIAL
(I, fr. In;
Cl. ft. In.
17.S<.'IUm'i
tltOM TO DIAMt:'fER SI.OT SIZE TIUCKNES.~ MAU:RIAL
25 11• 40 ft. 2 In. 0.010 Sch40 PVC
ft. ft. In.
lll.GROl'T
FROM TO MATERIAi. EMPLACEME"T ~U,'THOll & AMOt!l'i"T
0 fl, 21 fl, neat cement Pour• 370 lbs. neat cement
21 fl. 23 n. bentonite Pour • 35 lbs. 3/8" bentonite
fl. fl.
19. SA?\1>/GRA VEL PACK (If au11llcablel
FRI>:\! TO MATERIAi, E!\ll'LACEMENT lllETHOD
23 fl. 40 ft. #2sand Pour
fl. ft.
2ft. DRILLING LOG lattarb additional 1lteetl ll nttesun'\
FROM 1'0 DF.st:llll'fll)l'i trolor.mnln,.,. ••Hlm<l< h'D<. ,nm dz,. ett.l
0 ft. 10 Cl. Brown Moist Medium SANDS
10 fl. 35 ft. Reddish Brown SILT
35 ft. 40 ft. Orange Brown Silty CLAY
fl. ft.
fL ft.
ft. ft.
fl. ft.
?J.RL'\tARKS
22. Certifi~ion: if), 6L -~ 12124/15
Signature off ertit1ed Well c.-.ntractor Date
By .,;gni11g lhi.• fim11. I h~rchy ,·m[/1" tha/ /he well(•) waJ (..-,~.,,) ,·mt<lttlf'leJ in ucrorda11ce
with 15,1 NCAC fl2C .0100 or 1511 Nl.'AC ()2C .()l{l(J ll'ell Constmt•lit>n S1a11dard< arid that a
,•or.i• Dflhi.• reeOl'd has f>een pnH'iilM/ 11, tire W<'ll 01mer.
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 aL~o attach additional pages if necessary.
SUBMITTAL INSTUCTJONS
24a. For AU Wells: Suhmit this form within 30 days of completion of well
construction to the following:
Dlvhion of Water Quality, Jnforrnation Processing Unit,
1617 Mall Service Crnter. Raleigh. NC 27699-1617
24b. For Initttlon Well!i: In addition to sending the form to the address in 24a
abo,·c:, also submit a copy of this fonn \\ithin 30 days of completion of well
construction to the followin8:
Dhision of Waler Quall~, Underground Injection Control Program,
1636 J\tail Sen•ice Centl.'r, lblcigh, NC 27699-1636
13a. Yield (gprn) ________ Method of trst: _________ 24c. Fpr W?lt·r Suppl\' & lnjl'dion Wells: In addition to sending the form lo
the addms(cs) abow, also submit one copy of this form within 30 days of
13b. Dlsinfeetion type: Amount: ________ complet ion of well eor.s1r..ic1ion to ll1e county healll1 d:partment of the col!llty L.::=-====:..::~::.:...-=====--....:.:=::::::.:=======-_J where constructed.
FormGW-1 N011h Camli,1a Department nfEn\'iro11ment and Natural .Resow.:cs .. DM~fon nf\\'u1cr Quality Revi<t:d Jan. 10 I 3
EnviroClean
Degassing/Hydrocarbon Removal/Remediation Chemistry
PHYSICAL PROPERTIES
Product Name
Physical Form
Color
EnviroClean
Clear Liquid
Colorless unless dyed
Specific Gravity (Water= 1)
Solubility in Water
Freezing/Melting Point
Flash Point (°F)
pH
Reportable Quantity (RQ}
1 .028 +/-.01
100%
NE
>200° F
8.5 +/-.25
None
Complete information on health hazards, protective
equipment, handling precautions, environmental
hazards and disposal is listed in the current
EnviroClean Safety Data Sheet (SDS) for this product.
SUMMARY
EnviroClean is a non-flammable, non-toxic,
water-based, proprietary blend of non-ionic
ethoxylated octylphenolic surfactants that has
been specifically engineered as a
cleanup/mitigation agent for a wide range of
hydrocarbon products. EnviroClean has been
shown to be effective for quickly and effectively
suppressing or completely eliminating voes,
LEL's, benzene and low levels of H2S and
mercaptans in open or confined spaces.
EnviroClean has been used for cleanup of
hydrocarbon spills and soil remediation. In these
applications , EnviroClean effectively conditions
(physically) the hydrocarbon such that the
microbes that naturally· occur can more readily
consume it. It turns hydrocarbons into a nutrient
source for the microbes . When sufficiently mixed
with hydrocarbon and water, the EnviroClean
forms a homogeneous solution of hydrocarbon,
EnviroClean and water, whi _ch is very stable.
EnviroClean is a concentrated product that
readily biodegrades.
EnviroClean is commercially available in ~allon
units , 5~allon drums , 275 and 330-gallon totes
and bulk from Oklahoma City, Oklahoma and
Houston, Texas .
Page 1 of 2
FLUID DESIGN
EnviroClean is a proprietary blend of surfactants
that needs to be diluted to be effective and it is
very safe to workers and the environment.
EnviroClean does not contain caustic, therefore
does not have the common harmful side effects
associated with caustic based products. The
product is designed for use as a degassing agent
and a cleaner/degreaser for remediation. The
product does not contain any enzymes or
biomass itself. It works by conditioning the
hydrocarbon so that the naturally occurring
microbes (bacteria) are able to readily consume
it. Through the application of the appropriate
dilution and mixing, the EnviroClean will capture
the hydrocarbon and tie it up in a solution that is
very stable. The formation of this solution results
in extremely small particles that will not
recoalesce. It is important to note that if
EnviroClean reaches its saturation point the
oversaturated hydrocarbon will breakout of
solution very quickly. This will allow for easy
removal or reclamation of any hydrocarbon that is
not preconditioned for remediation.
In addition to tying up the hydrocarbon in
solution, the product is very effective when
contacted with hydrocarbon vapors at
suppressing volatile organic vapors, gases, and
odors. Once combustible and flammable
hydrocarbon vapors are tied up in the resultant
solution, the solution will be very difficult to ignite .
It also accelerates the biodegradation process of
the hydrocarbon, thereby enhancing recycling or
reclamation of water.
EnviroClean has been demonstrated to be
effective on gas, oil, lube oil, hydraulic oil, most
petroleum-based products, animal and vegetable
oils, fats, and tallow oils. EnviroClean cleans the
heavy tar build-up, asphaltenes or oily residue
from inside of tanks and vessels . Furthermore ,
once a surface has been cleaned with
EnviroClean , the cleaned surface will resist the
deposition of oily materials .
EnviroClean can be used to cleanup oil spills
whether in/on soil or hard surfaces. The first step
in this process is to remove as much of the free
oil as possible. This step is followed by
contacting the contaminated surface
appropriately with the proper dilution of
EnviroClean and water. The treatment solution
will contact the hydrocarbon molecules and
change their behavior such that they are now
essentially water soluble . The large increase in
interfacial surface area creates conditions that
are favorable to degradation and consumption by
bacteria and microbes. The product converts
hydrocarbons into a very good nutrient source for
bacteria and microbes.
EnviroClean is typically fed at concentrations
between 1 % and 6%, depending on the nature of
the hydrocarbon contamination problem. It can
be diluted with most types of water -hard, soft or
brackish water. The product has an unlimited
shelf life when unopened. EnviroClean is
effective at ambient temperatures. However, the
effectiveness will increase as the tem perature
of the a lication is increased. EnviroClean
does not require the use of steam, but has been
shown to be very effective when injected into the
steam (vapor) phase.
FIELD MIXING PROCEDURES
Mixing Concentrates
EnviroClean is usually delivered as a concentrate
and must be diluted with water to work properly.
Cleaning solutions can be formulated by
premixing or eduction. It is not necessary to
provide high shear agitation when preparing a
batch of cleaning solution since EnviroClean is
100% soluble in water. It is recommended that
when preparing the cleaning solution you first
add the water into the mix container and then
follow by the addition of EnviroClean. This will
minimize foaming as the EnviroClean and water
form a homogeneous solution.
For premixing, the following procedure may be
used:
1. Add the correct amount of water to the
container.
2. Depending on the desired strength, add
the correct amount of EnviroClean to the
container.
3. If the final solution is not a consistent
pink color, mild agitation may be
required until a consistent pink color is
achieved.
Quality Control Testing
There is no easy field testing procedure to
monitor the concentration of active ingredients in
the EnviroClean formulation. Visually the color
changes from rose color to lighter pink as the
product is further diluted. Effectiveness can also
be predicted by quantifying the amount of
hydrocarbon that is to be picked up. By
observing the effluent from the use of
EnviroClean, an adjustment in the cleaning
solution concentration can be made. If it is
observed that free oil is floating on the effluent
Page 2 of 2
solution, then the concentration should be
increased.
MATERIAL REQUIREMENTS
For specific protocols and application rates,
please refer to the available Product Usage
Guide, product label, or consult with the
manufacturer or authorized distributor for
additional guidance.
SECTION 1
EAR ICCLEAN
SAFETY DATA SHEET
MATERIAL IDENTIFICATION
PRODUCT NAME / DESCRIPTION: EnviroClean
DISTRIBUTED / MANUFACTURED BY:
ENVIRO CLEAN PRODUCTS & SERVICES
PO BOX 721090
OKLAHOMA CITY, OK 73172
DATE: 05/18/2015
PHONE: [phone]
EMERGENCY PHONE: [phone]
FUNCTION: Industrial Cleaner and Remediation Agent
SECTION 2
HAZARD IDENTIFICATION
CLASSIFICATION:
Acute Toxicity- Oral
Category 4
Skin Corrosion/Irritation
Catecor\ 3
Eye Damage/Irritation
~ Category 2B
Target Organ Specific Toxicity: Single
Category 3
Target Organ Specific Toxicity: Chronic
Category 2
SIGNAL WORD:
WARNING!
HAZARD STATEMENTS:
Harmful if swallowed
Causes mild skin irritation
Causes eye irritation
May cause respiratory irritation
May cause damage to organs through prolonged or repeated exposure
PRECAUTIONARY STATEMENTS:
Obtain special instructions before use
Do not handle until all safety precautions have been read and understood
Use personal protective equipment as required
Avoid breathing dust/fume/gas/mist/vapors/spray
Use only outdoors or in a well ventilated area
Wash all exposed skin thoroughly after handling
Avoid release to the environment

ENVIR • : LEAN
Store in a well ventilated place
TOXICITY INFO:
See Section 11.
SECTION 3 HEALTH HAZARDS
CHEMICAL NAME %WIW CAS NUMBER
(Proprietary Formula)
Proprietary Blend of Ethoxylated Octylphenolic Surfactants
Non-ionic water based liquid blend, concentrate
This product does not contain any hazardous ingredients as defined by CERCLA and California's Prop. 65.
SECTION 4 FIRST AID
Potential acute health effects:
Eyes: May cause irritation with redness and pain.
Skin:
Inhalation:
Ingestion:
May cause irritation with redness and pain.
Inhalation may cause irritation.
Ingestion may cause severe irritation, corrosionfulceration, nausea, and vomiting.
Medical Conditions Aggravated by Exposure:
None known.
Eye Contact:
Skin Contact:
Inhalation:
Ingestion:
SECTION 5
In case of contact, immediately flush eyes with cool running water. Lift and
separate eyelids while flushing with plenty- of water for at least 15 minutes. Get
medical attention_
Wash with soap and water. Get medical attention if irritation occurs. Wash
clothing before reuse. Destroy contaminated shoes.
Remove victim to fresh air and keep at rest in a position confortable for breathing.
If not breathing, give artificial respiration. If breathing is difficult, give oxygen.
Seek medical attention if symptoms develop.
Do NOT induce vomiting unless directed to do so by medical personnel. Never
give anything by mouth to an unconscious person. If large quantities of this
material are swallowed, call a physician immediately. Give plenty of water.
FIRE FIGHTING MEASURES
Fire Hazard Classification (OSHAINFPA):
Extinguishing Media:
Special Fire Fighting Procedures:
Hazardous combustion products:
0
As required for fire being fought.
Use self-contained breathing apparatus.
No known.

E NVI R • <>' LEAN
rextuors ra tart r:En
SECTION 6 ACCIDENTAL RELEASE MEASURES
Personal Precautions, PPE, and Emergency Procedures:
Wear protective clothing as described in Section 8 of this safety data sheet.
Containment Procedures: Stop the flow of material, if this is without risk. Wear appropriate protective
equipment and clothing during clean-up. Do not allow the spilled product 10 enter
public drainage system or open water courses.
Clean -Up Procedures:
Sweep up or gather material and place in appropriate container for disposal.
Wash spill area thoroughly. Wear appropriate protective equipment during
cleanup_ Dispose of collected material according to regulations.
SECTION 7 HANDLING AND STORAGE
Handling:
Storage:
Avoid contact with eyes, skin and clothing. Do not take internally. For industrial
use only. Wash after handling. Don't breathe dust, vapor, or gas. Keep this and
all chemicals out of reach of children.
Keep away from heat, sparks, and open flames. Prevent spills, Keep container
tightly closed and in a coos, well -ventilated place away from incompatible
materials. Empty product containers may contain product residue, do not reuse.
SECTION 8 PERSONAL PROTECTION / EXPOSURE CONTROLS
Ventilation System: Always keep exposure below permissible exposure Limits. In genera], dilution
ventilation is a satisfactory health hazard control for this substance. However, if
conditions of use create discomfort to the worker, a local exhaust system should
be considered.
Airborne Exposure Limits: None Established,
Personal Protection: As prescribed in the OSHA Standard for Personal Protective Equipment (29 CFR
192O.132), employers must perform a Hazard Assessment of all workplaces to
determine the need for, and selection of, proper protective equipment for each
task performed.
Eyes: Wear face shield, safety glasses, or chemical goggles.
Hands & Skin: For prolonged or repeated handling, use impervious gloves. Gloves should be
tested to determine suitability for prolonged contact. Use of impervious apron
and boots are recommended.
Respiratory: If ventilation is not sufficient appropriate NIOSHIMSHA respiratory protection
must be provided.
Work Practices: Eye wash fountain and emergency showers are recommended.
SECTION 9 TYPICAL PHYSICAL AND CHEMICAL PROPERTIES
Physical Form: Liquid
Color: Red

ENV IROCLEAN
Odor:
Odor Threshold:
pH:
Boiling Point:
Melting Point:
Flash Point:
Evaporation Rate (Butylacetate = 1)
Flammability:
UEL:
LEL:
Vapor Pressure:
Vapor Density:
Specific Gravity (Water = 1):
Solubility Water:
Partition Coefficient:
Auto -ignition Temperature:
Decomposition Temperature:
Viscosity (CPS):
SECTION 10
Wintergreen
NE
8.5+1-0.5
NE
N/A
>200 deg F
NE
Non -Flammable
NE
NE
NE
NE
1.03 +1- .05
Complete
NE
NE
NE
NE
STABILITY AND REACTIVITY
Stability:
Incompatibility:
Decomposition Products:
Conditions to Avoid:
SECTION 11
This product is stable under normal temperatures and pressures.
Strong Oxidizers and strong acids.
No Known hazardous products.
Sparks/flames/high heat.
TOXICOLOGICAL PROPERTIES
Raw Material
Test
Result Route
Species
N/A
See Section 4 for symptoms.
CARCINOGENICITY:
No known carcinogens, mutagens, or reproductively toxic ingredients
SECTION 12
ECOLOGICAL INFORMATION
Raw Material
Test
Result
Time
Species
N/A
PERSISTENCE & DEGRADABILITY:
NE

EN1►PR ■%' LEAN
BIOACCUMULATION:
NE
MOBILITY
NE
SECTION 13 DISPOSAL CONSIDERATIONS
Whatever cannot be saved for recovery or recycling should be managed in an appropriate and approved
waste disposal facility. Processing, use, or contamination of this product may change the waste
management options. State and local disposal regulations may differ from federal disposal regulations.
Dispose container and unused contents in accordance with federal, state, and local requirements.
SECTION 14 TRANSPORT INFORMATION
Not Regulated by DOT or IATA.
SECTION 15 REGULATORY INFORMATION
US FEDERAL REGULATIONS
SARA (SUPERFUND AMENDMENTS AND REAUTHORIZATION ACT):
SARA 302 EXTREMELY HAZARDOUS SUBSTANCES LIST- NA
SARA 312 HAZARD CATEGORY: NA
SARA 313 TOXIC CHEMICALS LIST: NA
CERCLA (COMPREHENSIVE ENVIRONMENTAL RESPONSE. COMPENSATION AND
LIABILITY ACT): NA
RCRA (RESOURCE CONSERVATION AND RECOVERY ACT) LISTED HAZARDOUS WASTES:
NA
CWA (CLEAN WATER ACT) LISTED SUBSTANCES: NA
FDA (FOOD AND DRUG ADMINISTRATION): NA
TOXIC SUBSTANCES CONTROL ACT (TSCA): NA
IATA: NA

ENVIRO' CLEAN
NFPA HAZARD INFORMATION SIGN
[01
[01
4 - DEADLY
3 - EXTREME DANGER
2 - HAZARDOUS
1 - SLIGHTLY HAZARDOUS
0 -NORMAL MATERIAL
FLASH POINTS:
4 - BELOW 73 F
3-BELOW 100F
2 -BELOW 200 F
1 - ABOVE 200 F
0 - WILL NOT BURN
[01 REACTIVITY TY HAZARD (YELLOW DIAMOND)
4 - MAY DETONATE
3 - SHOCK AND HEAT MAY DETONATE
2 - VIOLENT CHEMICAL CHANGE
1 - UNSTABLE IF HEATED
0 - STABLE
SPECIFIC HAZARD (WHITE ❑IAMOND)
OXY OXIDIZER
ACID ACID
ALK ALKALI
COR CORROSIVE
W USE NO WATER
SECTION 16 OTHER INFORMATION
THIS INFORMATION IS OFFERED IN GOOD FAITH AS TYPICAL VALUES AND NOT AS A
PRODUCT SPECIFICATION. NO WARRANTY, EXPRESSED OR IMPLIED, IS HEREBY MADE. THE
RECOMMENDED INDUSTRIAL HYGIENE AND SAFE HANDLING PROCEDURES ARE BELIEVED
TO BE GENERALLY APPLICABLE. HOWEVER, EACH USER SHOULD REVIEW THESE
RECOMMENDATIONS IN THE SPECIFIC CONTEXT OF THE INTENDED USE AND DETERMINE
WHETHER THEY ARE APPROPRIATE.

FORMER PUMP ISLAND
FORMER UST AREA
(UST#1&#2)
FORMER CAVINESS
GROCERY
GRAPHIC SCALE
1inch •10 ft.
LEGEND
TYPE II MONITORING WELL
!•OTES
1.) 2014A2RtAL OBTAINED BROLM THE LOCI. COUNTY GIS DEPARTMENT.
CC 1.61 u
a z
4, oRu
v�,a
La 0 o
5 0
.s x
Ao
z
Lt
c4
o
2
a
1

FORMER PUMP ISLAND
A
FORMER UST AREA
(UST#1&#2)
GRAPHIC SCALE
0 0
finch =10ft
20
LEGEND
TYPE II MONITORING WELL
(23,210) TOTAL BTEX CONCENTRATION (ug/L) - O9r28116
(1,1381 TOTAL BTEX CONCENTRATION (ug;L) - 812104
(BOL••)
NO BTEX COMPOUNDS DETECTED ABOVE
LABORATORY METHOD DETECTION LIMITS-12/22115
NOTES
1. IC!4 AERIAL OBTAINED FROiFTHE LOCAL COUNTY GIS DEPARTMENT.
2. ESTIMATED EXTENTOF TOTAL BTEX IN GROLUNMATER PICLUDESM ALY MA
DATA FOR SAMPLES OBTAINED ON OBf2d&16 {LAW-1RR MIL MW-3R),12122/15
(MW-R)AND o32? 41tW...
I
ESTIMATED EXTENT OF
_ BENZENE AT CONCENTRATIONS
B'EXCEEDING GCL
4_(19,660)
MW-1RR
1
MW-4
(1,1381
N
ESTIMATED EXTENT OF
TOTAL BTEX IN
GROUNDWATER
FORMER UST AREA
-�� (UST #3)
t t
r 1
r 1 ,�
/ / 1
r l 3 / f
(23,210 .� _ � f1
MW-3R � r ' ! '
, .
A'
J
a M
Y
15
02170214.09
0
kl
•
n
4 H
CO5,4
CO
APPROVCUtl1:
Engineers I PLanners 1 Surveyors
2
I
J

FORMER PUMP ISLAND
(BOt'
FORMER UST AREA
(UST #1 & #21
LEGEND
TYPE 1I MONITORING WELL
123,210) TOTAL 8TEX CONCENTRATION (ugR) • 0928/16
(1,1381 TOTAL BTEX CONCENTRATION (uglt) - 8/21104
IOU")
2 2
NO BTEX COMPOUNDS DETECTED ABOVE
LABORATORY METHOD DETECTION LIMITS - 12127J15
NOTES:
1. 2014 AER[AL OBTAINED FROM ThE LOCAL COUNTY GIS 0 EPAR'Ne4r.
2. ESTatATED EXTENT OF TOTAL BTEX IN GROUNDWATER INCLUDES ANALYTICAL
DATA FOR SAMPLES WANED ON WANE (I114'-1 RR AND MW3R). 42c7115
i 4-ZR'. AND 6F7211S4 011044).
GRAPHIC SCALE
0 1y° 20
fInch =10ft.
31V3S1V IiH3A
01
110
100
90
80
1 inch = 15 ft.
0 7S 15 30
HORIZONTAL SCALE
1
4(19.660)
MW-1RR
I
MW-4
(1.138•I
70
60
(23.210
IW-3R
ESTIMATED EXTENT OF
BENZENE AT CONCENTRATIONS
EXCEEDING GCL
�- ESTIM ATED EXTENTOF
TOTAL BTEX 1N
GROUNDWA`
FORMER UST AREA
Div 73)
r $I
r r a
L
A'
a
GROUNDSURFAC:_ 2
SILT
31V3S 1WD11U13A
0-01
.1 sti-W?��x
120 120
110
100
90
80
70
rx
C� ❑ ❑ ;
1-STORY BLOCK BUILDING 5
1 inch =15 ft.
SILT
L-
oc
a
GROUND SURFACE
ESTIMATED EXTENT OF
BENZENE AT LEVELS ABOVE
GCL VALUE
ESTIMATED EXTENT OF
TOTAL BTEX IN GROUNDWATER
1,138'
GROUNDWATEN ELEVATION
D /2Sl16(MW1>%Ft-MW 3N
23.210
0 7.5 15
HORIZONTAL SCALE
1-STORY BLOCK BUILDING
1 4 i1Ii2]
1 _r
'- `--' -1— 1
ESTIMATED EXTENT OF
BENZENE AT LEVELS ABOVE
GCL VALUE
BDL*•
ESTIMATED EXTENT OF
50 TOTAL BTEX IN GROUNDWATER
ax
IX
I'
SILT
9,660
* 1,138"
30
60
SO
3
J
SILT
GROUNDWATER ELEVATION
23,210 09/214116 MW W-11M-M3K)
SILT
110
100
90
80
70
60
50
110
100
90
80
70
60
50
4a
n
x
0
1
02170214.09
m m
3
m
I
1�
1
6
1
w
aJ
ro
CC
s�
Lam.
1■
En
77s MrFnw�[kwrtC.nr :1. 17-97Y.{6P[