WI0400495_DEEMED FILES_20180727

D~
North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (I ER)
Permit Number_WI0400495
1. Permit Information
__ Ashley Barham ______ _
Permittee
_ Fonner Country Store ____ _
Facility Name
_ 325 W. Main St, Randolph Co., Seagrove, NC_
Facility Address (include County)
2. Injection Contractor Information
_ECS Southeast, LLP ______ _
Injection Contractor / Company Name
Street Address_4811 Koger Blvd ___ _
Greensboro NC 27407 -City --State ____ Zip C_od_e __
(336_) _856-7150 __
Area code -Phone number
3. Well Information
RECENEDINCOEQ/D
WaterQuafhy
Number of wells used for injection ReglynalOperatlons
WelJ IDs MW-1
---' -------
Were any new wells installed during this injection
event?
D Yes ~ No
_Jfyes, please provide the following infonnation:
Number of Monitoring Wells _____ _
Number of Injection Wells. ______ _
Type of Well Installed (Check applicable type): 0 Bored D Drilled D Direct-Push 0 Hand-Augured O Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
0 Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells ______ _
Please include a copy of the GW-30 for each well.
abandoned.
4. lnjectant Information
___ 0-Sox:....._ _______ _
lnjectan1(s) Type (can use separate additional sheets
if necessary
Concentration ___ 100% ____ _
If the injectant is diluted please indicate the source
dilution fluid. -----------
Total Volume Injected (gal) ___ l 13in3 __
Volume Injected per well (ga1) __ 113in3 __
5. Injection History
Injection date(s). ___ July 10, 2018 ----
Injection number ( e.g. 3 of S), ___ 1 of 1 __
Is this the last injection at this site? D Yes ~ No
I DO HEREBY CERTIFY THAT ALL THE
JNFORMA TION ON THIS FORM IS CORRECT TO
THE BEST-OF MY KNOWLEDGE AND THAT THE
IN TION WAS PERFORMED WITHIN THE
S '..<\..H~,nn~~~ D O TIN 1HE PERMIT
1 ID
Submit the original of this form to the Division of Water Resources within 30 days of injection. Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400495
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Fom1er Country Store
Location Address
325WMain St
Seagrove
Owner
Owner Name
Ncdeq Ust Section
Dates/Events
NC
Orig Issue
7/3/2018
App Received
6/28/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27341
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
7/3/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Hassan Osman
1646 Mail Service Ctr
Raleigh
County
Randolph
NC
Issue
7/3/2018
Effective
7/3/2018
27699
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 (NOTE: This form must be received at least 14 DAYS p rior to in jection )
AQUIFER TEST WELLS (1 5A NCAC 02C .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (1 5A NCAC 02C .0225 > or TRACER WELLS t 15A NCAC 02C .0229):
1) Passive In jection S v 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 (lER) do not need to be
submitted for replacement of each sock used in ORC systems).
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~UJ\L ll ,201.8_ PERMIT NO. N JC) lfO O q.-qS' (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(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 Bt.1e"o ~~/NCOEQJDWF,.
___ Tracer Injection Well ................................... Complete sections B through N
JGN ~ 8 2018
STATUS OF WELL OWNER: State Government 1Vater Quality RegioM'
°'!)f! tiors C:.Pr-.ion
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): ---"-N.,_,C""'D~E""'O:.::......:aU::...::S::....eT'-'S=e=c=ti=on~--------------------
Mailing Address: --------'l'--'6:....:4--"'6---"M=ai=l --"'S""erv"----'---"ic"--'e"--C-=en""t""e"-r ______________ _
City: Raleigh State: _NC_ Zip Code: 27699 County: Wake
Day Tele No.: _919-707-8263___ Cell No.: __________ _
EMAIL Address: ___ T=h=o=m=as~.c=h=a·p=m=an=c...-""n=c=d=e=nr= ..... e:o~v~ FaxNo.: ___________ _
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page I
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: ___ M_s_. B_e_ttv~·_A_u_m_an ________________________ _
Company Name ---------------------------------
Mailing Address: ------=-l =-30"--'8=--O-==ld=-C=ox=R=o=ad~A=p-'-t -=-3 ___________________ _
City: Asheboro State: _NC_ Zip Code: 27205 County: Randol ph
DayTeleNo.: 33'.P-lJ>S?:,-q £.j 2 } Cell No.: _______ _
Fax No.: EMAIL Address: _____________ _ ------------
E. PROJECT CONT ACT (Typically Environmental Engineering Firm)
Name and Title: Ashle \ Barham -Assistant Staff Pro ject Manager
Company Name ___ E_C~S~S~o_uth_e_as~t~L_L_C ___________________ _
Mailing Address: 4811 Ko!!er Blvd
City: Greensboro State: _NC_ Zip Code: 27407 County: Guilford
Day Tele No.: 336-856-7150 Cell No.: __________ _
EMAIL Address: ___ a=b~ar=h=am=r __ a;..c, e=c=sl=im=it-'-ed=·~co=m~--Fax No.: ___________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Former CountrY Store
325 West Main Street
City: ___ S_e_a~!!~ro_v_e ______ County-'--: ----'R=an=d=o=l p""h"'--__ .Zip Code: ---=2c....c.7-=-34-'-l=---
(2) Geographic Coordinates: Latitude**: ___ 0 ____ "or_35.5408765°_
Longitude**: ___ 0 ____ "or_79.781597°_
Reference Datum: Goo gle Earth Accuracy: _______ _
Method of Collection: ______ --'G=-o=o=!!l""e=-=E=arth=----
**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: 13 ,247 square feet
Land surface area of inj. well network: 20 square feet(~ 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 100% (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 Pennitted GW Remediation NOi Rev. 3-21-2018 Page 2
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.
Installinll two ORC Soxs in two on-site monitoring wells to assist with the biodeiu adation of
the h ydrocarbons in the groundwater
J. APPROVED INJECTANTS -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 injected. Approved injectants can be found online at h ttp ://deg.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-app roved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UJC Program for more info (919-
807-6496).
Injectant: ORC Sox
Volume of injectant: _____ 1_13_in_3 ___________________ _
Concentration at point of injection: 100%
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant: ___________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
Injectant: ----------------------------------
Volume of injectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
K. WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: --~O ___ Proposed ___ 2 ___ Existing (provide GW-ls)
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 numbe
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page 3
Ix SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Wells alreadk constructed. Will take 1 day to install ORC soxs
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.
The monitorinu wells are sampled even six months and will be sampled six months after installation of
the ORC sox to determine effectiveness.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "1 hereby cert, under penalty of Iaw, that 1 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 sub Hitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injec r well an related ■ . ,urtenances in accordance with the 15.4 02C 02(10 Rules."
bfank- 5-tcthf
1t511 (IL/ Ectmarrz - PI fcf M Ct>r. � r
Print or Tye Full Name and'Title
nature of r pplican
Propert, Owner (if the properl\ is not owned by the Well Owner/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
(1 ,q .\tit' 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.
Acerb Rrr+
Signature* of Property Owner (if different fkyrn 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 his NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — LTIC Progrann
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 3-22-20I8 Page 4

.Z1
74
err
74
73
(73.23)
MW-2 r - 1 �.t-�•
wr
_ ■ 4
LEGEND
(74.42) Groundwater Elevations
-3 Groundwater Flow Direction
SOURCE:
RANDOLPH COUNTY GIS
INTERACTIVE MAPPING WEBSITE
SCALE: 1 INCH = 60 FEET
I•
141:-
73
.•
Sa•
i
FIGURE 6
GROUNDWATER FLOW MAP
FORMER COUNTRY STORE
325 WEST MAIN STREET
SEAGROVE, NORTH CAROLINA
INCIDENT No. 44124
ECS PROJECT 49.3541

.r
1
I
1
Pi5411) 1111V
•
!'
■
r
-111- mar
110
■
LEGEND
(100) Concentration in ppb
Isoconcentration Line
SOURCE:
RANDOLPH COUNTY GIS
INTERACTIVE MAPPING WEBSITE
SCALE: 1 INCH = 63 FEET
•
ti
4
4
•
• •-•
•
•
ai
r
FIGURE 7
ISOCONCENTRATION MAP FOR BENZENE
FORMER COUNTRY STORE
325 WEST MAIN STREET
SEAGROVE, NORTH CAROLINA
INCIDENT No. 44124
ECS PROJECT 49.3541

WELL CONSTRUCTION RECORD
Thin rain OAD be used forlen& ar multiple wells
I. Well Contractor information:
Wafter Lea Davis
Wen Conlracta r Hama
3162-A
NC Well Coneacter Ce tthratioa Hatcher
3D Environmental Investigations, LLC
Company Name
2. WeILConstruction Penult if:
Ws OM applicaiih well permits a. County, Siare, Irarvm er. me)
3. Well Use (check well use):
Water Supp1Y Weil:
°Agricultural
°Geothermal (Heating/Cooling Supply)
Q Industrial/Commercial
°Irrigation
❑MtuticipaiIPubl'sc
❑ Residential WatsrSoppiy (single)
°Residential Water Supply (shared)
Noit-Water Supply Wen:
la Monitoring
1njeetioe Well:
c Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
ClEeperintental Technology
RGentlte1mei (Closed Lilvp)
❑Geothermal lllrating/Cooling Return)
°Recovery
°Groundwater Retnediation
❑Salinity Barrier
Q Stormwatet Drainage
USubsideoce Control
RTracer
°Other (e+piain under 621 R.emarksI
4. Date Well(a) Completed: i 2 ' Well ID* N.1144 3
Sa. Well Location:
Faelily/°tuner 1Vaate Facility LD (if applicable)
26" t.) 5 r f yJ' t /1)4
Physical Address, City. and Zip
Pastel Identilira&intto. (PIN)
5b. Latitude and Longitude in degreeslminuteslseconds or decimal degrees:
if mit Field, olie latliong S mammalf
6. Is (are) the well(s): 7I1!rrraaneut or °Temporary
7. Is this a repair to an csisting well: Oyes or ir
1f this Lsa repatr./I11 out known welt carearrncfim+ bfarmalion end explain the mmnrc of Me
repair :Judo LI1 terrorke section or an the bac* offer* form.
X. Number of well constructed: al
1•Ftr multiple Frryecrlun or non -water apply wells OPILF with ihr same consrrrnclial• yen can
ere/ mg.+ acne farm. j
9. Total well depth below hand surface: a.?. O
Far 111,1410e welk tits all depths if different (example- 3@ 0ff' and 1011.100)
O. Static water level below top of casing: _ (It.)
If water level is above rasing 14,4 ". "
I 11. Borehole diameter: 6 (in.)
12. Weil construction method: t Iv f C
(i a anger, rotary. cable. throat picsh, eta.}
Farintemal Use ONLY:
I4. WMU ZONE$
I,j
via
inscRr-flat+
n,
it
It.
ft.
15. OUTER
CASING (for mina-e
sad wells' OR LINER (if applioIdde)
'fir
TCI
DIAMETER
THICKNESS 1 MATERIAL
k
It
In.
—
!j
16. 1NYER
CASING OR TUBING
(geothermal closed -loop)
PROM
7b
DIAMETER
THICKNESS
1iTA FI*L
° a•
4 ' it
s2 In.
S�i
iflG
Ti.
T f4
ia:
17. SCREEN
FROM
. 112
DIAMETER
S Sl7E
Tinckandis
MATERIAL
IL
0it
• lla.az,)
ititiv,
tv
Ms
ft.
1& GROUT '
]M
TOMATERIAL
EMPLAC�. NT METHOD & AMOUNT ,
ft
d .
/ 0 a
fr
He,,, C
/Lfll�/ -
fr.
ft.
19. SAND/GRAVEL
PACli�if
applicable)
Nlflt?al.
TO
MATERIAL
HMPLacroiSNTi.1 TfOD
3e) h.
>',)? s-lv !
ft.
It.
20. DRILLING
LOG (Aiken
additional sheets if ercesraryj
FROM
Tu
DESC RI PT ICI lc lcuI... ha dueei, wllirac4 1Ype, vain xhm etc.1
tl.
I#.
R.
I1.
y
rt.
is.
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-
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II:
Y1. REMARKS
FOR WATER SUPPLY WELLS ONLY:
Oa. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
signalure ofCertifled Wdi Contractor
A.) 246
Dec
By slgnhig this form f hereby cerl fr that for wnflfx) nos *se) rnhxrrncted +rI aCaordaner
with 15ANCAC 02C ,0100 or 154 NL:4f' 02C .02011 Well Cwufrrectlmt SrRndarac wtd Aviv
ropy ufthls iseoirf has been provided to the well owner
23. Site diagram or additional well details:
You may use the back of this page to provide additional weal site details or well
construction details. You may also attach additional pages i f necessary.
24a. Fur All Wails Submit tins form within 30 days of completion of well
construction to the fallowing -
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
246. For !election Wells ONLY: in addition to sending the form to the address in
24aabove, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground lujecdon Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to fie county health department of the county where
Constructed,
Form GW-1
North Carolina Gepatuaear of l2nvironmen; and Nalwal Resources -Division of Water Revised A 2013

-
Herb Berger
Hydro geologist
DWM UST Section
163 7 Mail Service Center
Raleigh, NC 27699-1637
RE: Access Agreement
Former Country Store
325 West Main Street
Seagrove, NC
Incident#44124
Dear Mr. Berger:
I arn/W e are the owner( s) of a parcel of property, located at or near the incident in question, and hereby
permit 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.
I am/We are granting permission with the understanding that:
1. The investigation and remediation shall be conducted by the UST Section of the Department's Division of
Waste Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and is a
public record, in accordance with North Carolina 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 Depal uient or its contractor is not and shaII not be construed to be an agent, employee, or
contractor of the land owner.
IIWe agree not to interfere with. remove, or any way damage the Department's wells) or its
contractor's well(s) and equipment during the investigation,
S incerely, till/ma)
ek"-kreg--
Jle Ll%• J4 tir7�x�y ►
1I31.2 ► or-ncy .
14151e4or a /+ d7dQ5
1� �sc'-icy A . C
&Li°r £id -T cy Rd.
Asheboro a, . _2265
f -s-flt 3q‘-3Y1-359y
Signature
Type/Print Name of Owner or Agent
Phone Number
Address
City/State/Zip Code
Date

110'
MW-1
100'
90'
80'
J
MW-3
Clayey Silt
70' ■
60'
Silt
110'
100'
90'
80'
T0'
60'
SCALE
Horizontal Scale: - 40'
Vertical Scale: - 10'
CROSS SECTION
Former Country Store
325 West Main Street
Seagrove, Randolph County, NC
ECS Project No, 49-3541A