WI0400491_DEEMED FILES_20180601

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400491
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
M&P Grocery -NCDEQ lncident#23626
Location Address
7712 NC Hwy 194
Lansing NC
Owner
Owner Name
Ncdeq State -Lead Program
Dates/Events
Orig Issue
6/1/2018
App Received
5/18/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28643
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
6/1/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Ashe
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Mark Petermann
1646 Mail Service Ctr
Raleigh
Issue
6/1/2018
Effective
6/1/2018
NC 27699164
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasln
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 (NOTE: This form must be received at least 14 DAYS p rior to in jection)
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 (15A NCAC 02C .0225 1 or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection S y 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 Submittals Will Be Returned As Incomplete.
DATE: ~M=a .............. 11~ __ , 2018 PERMIT NO. _N~J.~O~lf_O_O_l./-_q_J __ (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well. ..................................... Complete sections B through F, K, N
____ Aquifer Test Well ....................................... Complete sections B through F, K, 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 !~fi, '~0/NCDEQ/OW f,
___ Tracer Injection Well ................................... Complete sections B througµ N
MAY l 8 2018
STATUS OF WELL OWNER: State Government Water Quality
)oerations
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): NCDEO -State Lead ProP:ram
Mailing Address: 1646 Mail Service Center
City: Ralei!ih State: NC Zip Code: =-27~6~9~9 ______ County: Wake
Day Tele No.: 919-707-8260 Cell No.: Not Available
EMAIL Address: andrew.de [e-mail] Fax No.: --"""'"9~1~9--'-7-=-0-'-7-"""'8=-26"""'0'--_____ _
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 1
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: =M=&=P~G=r=o=ce=rv...,_ _____________________ _
Company Name ---------------------------------
Mailing Address: 7712 NC Highway 194
City: Lansing State: NC Zip Code: 28643 County:_A_s_h _e ___ _
Day Tele No.: Not Available Cell No.: ___ Na....:..aao-=-t "'"'Ao..:cv-=a=il=ab=l=e ___ _
EMAIL Address: __ ~N~o~t~A~v~a=il=a~bl_e ______ _ Fax No.: ------=-N=o=t =A,,_,v_,,a=il=ab=l=e'---------
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: --~An~""dr,..,,e'-'w,_D=e,,.pp""e""n""s""'m"""it!:!ch,_------"'-P-"--'ro"'-j"""ec,,_,t'--"S"--"c""'ie""n""ti""· s"'---t _______________ _
Company Name ---=A=T~C~A~s=so=c=ia=t~es~o=f~N~orth~~C~ar=o=l=in=a=·=P~.C~. _______________ _
Mailing Address: --~7~6~0=6_Whi~=·t=eh=a=ll~E=x=e~c=u=ti~v-=-e ~C~e=n=te=r=D~r=iv~e=·=S=u=it=e =8~0-=-0 ________ _
City: Charlotte State: NC Zip Code:.~2=82=7=3 ____ County: Mecklenburg
Day Tele No.: 704-529-3200
EMAIL Address: andrew.depp ensmith@ atct!s.com
F. PHYSICAL LOCATION OF WELL SITE
Cell No.: 704-281-3281
Fax No.: 704-529-3272
(1) Facility Name & Address: M&P Groce rv -NCDEO Incident #23626 -7712 NC Highwav 194
City: Lansin° County: Ashe County Zip Code: 28643
(2) Geographic Coordinates: Latitude**: ___ 0 ____ " or 36 °.48274 ____ _
Longitude**: 0 __ "or -81 °.50241. ___ _
Reference Datum: ___ W~G~S~8~4 ___ Accuracy: Not Available
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 COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: ______ ---'square feet
Land surface area ofinj. well network: square feet(.::: 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must bes. 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
{l) 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. 3-21-2018 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.
ATC will install Provectus ORS (oxygen-releasing socks) in monitoring wells MW-1. MW-2. and MW-3 to
promote accelerated petroleum compound biodegr adation and reduce compound concentrations to below the
North Carolina Groundwater Q uality Standards (2L Standards). The socks come in 3-foot sections and three
socks are antici pated to be installed in wells MW-1 . MW-2, and MW-3 durin g the installation events, de pendine.
on water volume in the well. The socks will deliver controlled-release oxygen into the groundwater for four to
ei e:ht months, at which point the chemicals in the socks will have de p leted.
J. APPROVED INJECT ANTS-Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only irif ectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ ground-water-protection/ 2:round-water-approved-inj ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: --~P~r=o_,_v-=--ec=tu=s~O=R=S~------------------------
Volume of injectant: 3 socks at 113.1 in.3/sock: total volume= 339.3 in.3 per monitoring well/
1.017 .9 in. 3 per installation event (Monitoring wells MW-1 . MW-2. and MW-3 )
Concentration at point of injection: ___ 7-'---'5"----....,,8=5_,_o/c-=--o--=c=al=c=ium= .... P=e-=--ro=x=i=d-=--e ___________ _
Percent ifin a mixture with other injectants: __ __,7c.-=5c...-=8=--5°-'----'1/o'--c=a=lc.:.:i:.::um==-.c:.Pe.:.:r""o""x:::.aid:.:e.._(,_,l=-=5--'-2=5"---0'-'1/o"""in=o.a..r g.,.,an=ic
nutrients )
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 if in a mixture with other injectants: ____________________ _
K WELL CONSTRUCTION DATA
(1) Number of injection wells: ______ Proposed ___ 3 ___ Existing (provide GW-1 s)
(2) For Proposed wells or Existing wells not having GW-1 s, 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
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page3
( c) Well contractor name and certification number
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
A pproximatel y two weeks followin g submittal of this NOi. ATC will install three socks in each existing wells
MW-1 , MW-2, and MW-3. It is antici pated that chanf!e-outs may occur on a quarterl y basis.
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.
A pp roximate semi-annual sampling events in monitoring_ well MW-1. MW-2, and MW-3 will be performed
startin!l six months after the installation of these socks. Durin11 each sam plin!! event. ATC will collect a sample
from the well for analysis of volatile ornanic com pounds (VOCs) by EPA Method 6200B. ATC will also measure
dissolved oxvg en, conductivity. tem perature. pH , and oxygen reduction potential in the well during sam pling
events.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/A pp licant: "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
injectiQn.J:Vell and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
.1 /1 ,,/-~~ v . on behalf ofNCDEO Andrew Deppensmith. on behalf ofNCDEO
( Signature of Applicant Print or Type Full Name and Title
Pro pertv Owner (if the pro perty is not owned bv the Well Owner/App licant):
"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
(.1 5A 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.
NCDEO UST State Lead Pro gr am -Herb Berger
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.
Please send 1 (one) hard color copy of this NOi along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page4
Well ID
MW-1
MW-2
MW-3
MW-4
TABLE3
MONITORING WELL CONSTRUCTION DETAILS
M&PGrocery
7712 NC Highway 194
Lansing, North Carolina 285 86
NCDEQ Incident #23626
Date Installed Screen Interval Well Diameter Total Depth
(feet) (inches) (feet)
11/24/2009 2.0 -12.0 2 12
8/25/2011 5.0 -15 .0 2 15
6/17/2015 5.0 -15.0 2 15
3/28/2016 4.0 -14.0 2 14
Top of Casing
Elevation
100.00
97.34
98.47
95.60
REFERENCE: USGS 7.5-MINUTE MAPS, WARRENSVILLE AND
JEFFERSON, NORTH CAROLINA. DATED 2016
LATITUDE: 36.48274° NORTH
LONGITUDE: -81.50241 ° WEST
0 500 1 000
2 000
APPROXIMATE SCALE IN FEET
fT« FIGURE 1
SITE LOCATION MAP
M&P GROCERY - NCDEQ INCIDENT #23626
7712 NC HIGHWAY 194
LANSING, ASHE COUNTY, NORTH CAROLINA
;ETC
ATC GROUP SERV10Es LLC
Cwiolts, North Carona 21270 UO4) BOO FAX
(:AfT f II 4
MPGROCSM
PREP. 8Y
AD
GA
SCALE
AS SHOWN
DATE
11.9.17
PROJECT Na.
SLP2362601

RMER
DISPENSE
MW- ISLA,F
EXCAVATION �C�
4.tmvci
MW-4
S urce: NC Geospatial Database
0 15 30 60
APPROXIMATE SCALE IN FEET
HEATING
OIL AST
1
WSW-1
(Inoperable)
FORMER
UST BASIN
RESIDENCE
LEGEND
$ WATER SUPPLY WELL
LOCATION
• MONITORING WELL
LOCATION
▪ SURFACE WATER
SAMPLE LOCATION
TITLE FIGURE 3
SITE MAP
M&P GROCERY — NCDEQ INCIDENT #23626
7712 NC HIGHWAY 194
LANSING, ASHE COUNTY, NORTH CAROUNA
ATC
ATC GROUP SERVICES LLC
Charlotte. North Corolla 25Z?3 [phone] FAX [phone]
CAD HL.0
MPGROCSM
PREP. BY
AD
REV. 8Y
GA
SCALE
AS SHOWN
DATE
11.9.17
Pf.'D.f E C T NO.
SLP2362S01

•
rovectus
ENVIRONMENTAL PRODUCTS"
MATERIAL SAFETY DATA SHEET: PROVECT-ORS
Page: 1 of 5
1. PRODUCT IDENTIFICATION: PROVECT-ORS
PRODUCT USE: Soil and water treatment.
MANUFACTURER: EMERGENCY PHONE:
PROVECTUS ENVIRONMENTAL
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
USA: (}I5) 650-2230
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s_ (Calcium Peroxide), Class 5.1, PG TI, UN1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITIONIWFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Inorganic Nutrients
3. PHYSICAL DATA
Chemical Formula CAS No. Percentage
CaO2 1305-79-9 75%-85%
I5%-25%
Appearance White & brown granules
Physical state Solid
Odor threshold __________�___ None
Sulk Density ---50O--65Og1L
Solubility in Water Insoluble
PH —11
Decomposition Temperature Self -accelerating decomposition with oxygen release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product. contains <1% non -respirable crystalline
silica. The NTP and OSHA have not classified non -respirable crystalline silica as carcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (silicosis). ORS does not
contain respirable crystalline silica.
Potential Health Effects:
• General Irritating to mucous membrane and eyes.

4 rovectus
ENVIRONMENTAL PRODUCTS -
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 2 of 5
• Inhalation Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
• Eye contactMay cause irritation to the eyes; Risks of serious or permanent eye
lesions.
• Skin contact May cause skin irritation,
• Ingestion Irritation of the mouth and throat with nausea and vomiting.
5. FIRST AID MEASURES
• Inhalation Remove affected person to fresh air, Seek medical attention if effects
persist.
• Eye contact Flush eyes with running water for at least 15 minutes with eyelids
held open. Seek specialist advice.
• Skin contact Wash affected skin with soap and mild detergent and large amounts of
water.
• Ingestion If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Paint
• Not applicable
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• Water
Fire Hazards
• Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,

,pa ·rovectus
ENVIRONMENTAL PRODUCTS"
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 3 of5
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution. Pressurization if confined when heated or
decomposing. Containers may burst violently.
Fire Fighting Measures
• Evacuate all non-essential personnel
• Wear protective clothing and self-contained breathing apparatus.
• Remain upwind of fire to avoid hazardous vapors and decomposition products.
• Use water spray to cool fire-exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper, oils,
etc.). Do not return product to container because of risk of contamination.
8. HANDLING AND STORAGE
Storage
• Oxidizer. Store in a cool, well-ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
• Keep away from incompatible materials. Keep containers tightly closed. Do not store in
unlabeled or mislabeled containers.
• Protect from moisture. Do not store near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Store separately from organics and reducing materials. A void contamination that may lead to
decomposition.
Handling
• Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
• Do not swallow. A void breathing vapors, mists, or dust. Do not eat, drink, or smoke in work
area.
• Prevent contact with combustible or organic materials.
• Label containers and keep them tightly closed when not in use.
• Wash thoroughly after handling.
' rovectus
ENVIRONMENTAL PRODUCTS'
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 4 of 5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no respiratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
• Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
• Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC, neoprene or rubber)
Other Protective Equipment
• Eye -wash station
• Safety shower
• Impervious clothing
• Rubber boots
General Hygiene Considerations
▪ Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
• Stable under normal conditions
Condition to Avoid
• Water
• Acids
• Bases
• Salts of heavy metals
• Reducing agents
• Organic materials
• Flammable substances
Hazardous Decomposition Products
s Oxygen which supports combustion

I al 1 rovectus
ENVIRONMENTAL PRODUCTS''
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
• T,D50 Oral: Min.2000 mg/kg, rat
• LD50 Dermal: Min. 2000mglkg, rat
• LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecntoxicological Information
• Hazards for the environment is limited due to the product properties of no bioaccumulation, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste Treatment
• Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations.
Package Treatment
• The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Class: 5.1
• Labels: 5.1 (Oxidizer)
• Packing Group: II
15. REGULATORY INFORMATION
• SARA Section Yes
• SARA (313) Chemicals No
• EPA TSCA Inventory Appears
• Canadian WHMIS Classification C, D2B
• Canadian DSL Appears
• EINECS Inventory Appears