WI0400502_DEEMED FILES_20180924

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400502
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Three Boys Citgo (Fonner Gant #831 Station)
Location Address
5000 Old Walkerton Rd
Winston Salem
Owner
Owner Name
Gant Oil Company
Dates/Events
NC
Orig Issue
9/19/2018
App Received
8/29/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27105
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/24/2018
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
Forsyth
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Robert E. Gant
PO Box68
Walkertown
Issue
9/19/2018
Effective
9/19/2018
NC 27051
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Wednesday, September 19, 2018 2:31 PM
Knight, Sherri; Wang, Shuying
Subject:
Attachments~
WI0400502 FW: [External] RE: Application for NOi Three Boys Citgo
NOi for BAM injections at former Gant 831 site 8.27.18.pdf
Please find attached a NOi.
From: Bruce Edward Tease [mailto:[e-mail]]
Sent: Wednesday, September 19, 2018 1:51 PM
To: Rogers, Michael <[e-mail]>
Subject: [External] RE: Application for NOi Three Boys Citgo
CAUTION: External email. Do not click links or open attachments unless verified Send all suspicious email as an attachment to
i~t~l 1<] 0: -->: 11:
Michael
Lat/long for 5000 Old Walkertown Road in Winston-Salem, NC are as follows
Latitude
Longitude
36 09' 28.56"
80 12' 16. 70"
Bruce Edward Tease
Senior Managing Consultant
D [phone]
M [phone]
btease@ramboll .com
"For what is reality but an image we create to explain uncertainty" (The Little Chicopee Boy, 1987)
From: Rogers, Michael <michael.rogers @ncdenr.gov>
Sent: Wednesday, September 19, 2018 12:40 PM
To: Bruce Edward Tease <btease @ramboll.com>
Subject: RE: Application for NOi Three Boys Citgo
Pleae give me the lat/long for this site.
From: Shrestha, Shristi R
Sent: Tuesday, September 18, 2018 4:29 PM
To: btease @ramboll.com
Cc: Knight, Sherri <[e-mail]>; Rogers, Michael <michael.rogers @ncdenr.gov>; Watts, Debra
<debra.watts @ncdenr.gov>
Subject: RE: Application for NOi Three Boys Citgo
Good afternoon,
1
We just received the approval letter for use of BAM. I am on leave from tomorrow so I have forwarded the NOi package
to Michael Rogers. You will hear back from us soon.
Thank you,
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919-707-3662 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.
2
From: Shrestha, Shristi R
Sent: Friday, September 14, 2018 2:09 PM
To: btease @ramboll.com
Cc: Knight, Sherri <[e-mail]>; Rogers, Michael <michael.rogers @ncdenr.gov>; Watts, Debra
<debra.watts @ncdenr.gov>
Subject: Application for NOi Three Boys Citgo
Good afternoon,
We have received a NOi application Three Boys Citgo located at 5000 Old Walkertown Road, Winston.:salem,
NC 27105. The additive proposed in the application Bioavailable Absorbent Media (BAM) is not on our
approved list, hence cannot be injected. Please find the approved list in the following
link http s://deg .nc.gov/about/divisions/water-resources/water-g uality-reg ional-o p erations/groundwater-
p rotection
NC DEQ: Groundwater Protection
deq.nc.gov
Purpose and Function. The Water Quality Regional Operations Section's Groundwater Protection
Programs are responsible for protecting and preserving the high quality of North Carolina's groundwater
resources.
Thank you,
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 707-3662 office
[sh risti .shrestha@ncde n r.gov ]shristi [e-mail]
3
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
4
Ro g ers , Michael
From: Rogers, Michael
Sent:
To:
Wednesday, September 19, 2018 2:31 PM
'Bruce Edward Tease'
Cc: Shrestha, Shristi R; Knight, Sherri; Wang, Shuying
Subject: WI0400502 RE: [External] RE: Application for NOi Three Boys Citgo
Attachments: Deemed Permitted {NOi) In-Situ GW Rem Notification & Aquifer Test Well ( .... docx
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for the above referenced
site. Please note we have a newer NOi form (attached). If you look at the signature page, you will see where we
request the signature of the "Well Owner". When you submit the forms below after injection please include a revised
signature page with the signature of Robert Gant. He is the permittee/applicant and well owner.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies of
the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct push
or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If well
construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form . These forms can be found on
our website at
http :ljde q.nc.gov/about/divisions/water-resources/water-resources-p ermits/wastewater-branch /ground-water-
p rotection /ground-water-re porting-forms
2) Injection Event Records (IER). All injections, including ai~ 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.). Also, only one IER is
needed for passive injection wells-indicate estimated total number of socks to be injected over lifetime of
remediation.
You can scan and send these forms directly to Shristi.shrestha @ncdenr.gov or via regular mail to address below. When
submitting the above forms, you will need to enter the nine-digit alpha-numeric number on the form (i.e., WI0XXXXXX)
that has been assigned to the injection activity at this site. This notification has been given the deemed permit number
WI0400502. This number is also referenced in the subject line of this email. You may if you wish, scan and send back as
attachments in re p ly to this email, as it will already have the assigned deemed permit number in the subject line.
Thank you for your cooperation.
From: Bruce Edward Tease [mailto:[e-mail]]
Sent: Wednesday, September 19, 2018 1:51 PM
To: Rogers, Michael <[e-mail]>
Subject: [External] RE: Application for NOi Three Boys Citgo
CAUTION: External email. bo not click links ·or open attachments unless verified . Send all suspicious email as an attachment to ,
I 1 I • • • 1 r--.··"'~ ' ·.,.;.,...._~-,I I -1 1!1.1,•'-.:•;·Jl\~ . ____ I __ __ ~--.
Michael
1
Lat/long for 5000 Old Walkertown Road in Winston-Salem, NC are as follows
Latitude
Longitude
36 09' 28.56"
80 12' 16. 70"
Bruce Edward Tease
Senior Managing Consultant
D [phone]
M + 1 ( 413) 8755896
btease@ramboll .com
"For what is real ity but an image we create to expla in uncertainty" {The Little Chicopee Boy, 1987)
From: Rogers, Michael <[e-mail]>
Sent: Wednesday, September 19, 2018 12:40 PM
To: Bruce Edward Tease <[e-mail]>
Subject: RE: Application for NOi Three Boys Citgo
Pleae give me the lat/long for this site.
From: Shrestha, Shristi R
Sent: Tuesday, September 18, 2018 4:29 PM
To: [e-mail]
Cc: Knight, Sherri <[e-mail]>; Rogers, Michael <[e-mail]>; Watts, Debra
<[e-mail]>
Subject: RE: Application for NOi Three Boys Citgo
Good afternoon,
We just received the approval letter for use of BAM. I am on leave from tomorrow so I have forwarded the NOi package
to Michael Rogers. You will hear back from us soon.
Thank you,
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
2
919-707-3662 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.
From: Shrestha, Shristi R
Sent: Friday, September 14, 2018 2:09 PM
To: btease @ramboll.com
Cc: Knight,Sh!:!rri <[e-mail]>; Rogers, Michael <michael.ro gers @ncdenr.g ov>; Watts, Debra
<debra. [e-mail]>
Subject: Application for NOi Three Boys Citgo
Good afternoon,
We have.received a NOi application Three Boys Citgo located at 5000 Old Walkertown Road, Winston-Salem,
NC 27105. The additive proposed in the application Bioavailable Absorbent Media {BAM) is not on our
approved list, hence cannot be injected. Please find the approved list in the following
link https://de g .nc.gov/about /divisions /water-resources /water-q uality-regional-o p erations/groundwater-
p rotection
3
NC DEQ: Groundwater Protection
deq.nc.gov
Purpose and Function . The Water Quality Regional Operations Section's Groundwater Protection
Programs are responsible for protecting and preserving the high quality of North Carolina's groundwater
resources.
Thank you,
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 707-3662 office
[sh risti.sh [e-mail] )shristi.shrestha@ ncdenr .gov
512N . Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
4
ENGINFEp5
North Carolina Department of Environmental Quality
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
RE: NOTIFICATION OF INTENT TO CONSTRUCT OR
Three Boys Citgo (former Gant #t831 Station)
5000 Old Walkertown Road
Winston-Salem, NC
Incident #3355, Facility # 0-016565
Dear DWR — UIC Program Manager;
July 25, 2018
ppr.7.1YEDINCOECVDWR
OPERATE IN]ECTION WELLS
AUG29 Z013
Water Quality Regional
Operations Section
REUS Engineers, P.C., (REUS Engineers) formerly Environ Engineers of North Carolina, P.C. is pleased
to submit this notification of intent (NOI) to conduct a small-scale injection operation at the above
referenced site on behalf of the Gant Oil Company (Gant). Included with this NOI are the following
required documents:
• Contaminant plume map with isoconcentration lines that show the horizontal extent of the
contaminant plume in sail and groundwater, existing monitoring wells, and proposed direct
push technology (DPT) injection points;
■ Cross-section to the known depth of contamination that shows the horizontal and vertical
extent of the contaminant plume in soil and groundwater, existing monitoring wells, and
proposed DPT injection points;
• Potentiometric surface map indicating the direction of groundwater movement, plus existing
wells and proposed DPT injection points;
• Safety data sheet (SDS) for bioavailable absorbent media (BAM);
■ SOS for PermeOx® Ultra; and
• Summary table of DPT injection point details.
Should you have any questions concerning the information presented in this NOI, please contact Bruce
Tease at [phone].
Sincerely,
REUS Engineers, P.C.
16---/-)
Russell S. Kernp, PE
cc: Assad Elkhoury, Property Owner
Christina 5chroeter, NC DEQ Hydrogeologist
Bruce Tease, PhD
Project Manager

North Carolina Department of Environmental Quality-Division of Water Resources
NOTIFICATION OF INTENT 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 iection.
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 (15A NCAC 02C .0229 ):
1) Passive In jection S ystems -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 p erations -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 shaU 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. Illegi,ble Submittals Will Be Returned As Incomplete.
DATE: July 25 , 2018 PERMIT NO. f,,...Yf c9 :{ 00~02--(to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(1)
(2)
___ Air Injection Well ...................................... Complete sections B-F, K, N
___ Aquifer Test Well ....................................... Complete sections B-F, K, N
(3) ___ Passive Injection System ............................... Complete sections B-F, H-N
(4) X Small-Scale Injection Operation ...................... Complete sections B-~CEIVED/NCDEQ/OWR
(5) __ Pilot Test.. ............................................... Complete sections B-N AUG 2 9 2018
(6) ___ Tracer Injection Well ................................... Complete sections B-~ .
ater O~ahty Regional
Operations Sectio STATUS OF WELL OWNER: Business/Organization n
WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Robert Gant, Gant Oil Com pany
Mailing Address: 5177 Main Street
City: Walkertown State:_ NC_ Zip Code: 27051-0068 County: Forsy th
Day Tele No.: (336 ) 595-2152 Cell No.: NA
EMAIL Address: __ ~N~A=---------Fax No.: NA
UICI In Situ Remed. Notification (Revised 3/2/2015) Page I
D. PROPERTY OWNER (if different than well owner)
Name: -----'A-"s=s=a=d =E=lkh=o=u,,,rv.,_,.'-'5'"""'B=oy""'z"-"'C""'it~g=-o -"o"-w=n=e=d"""b.,_y--'K=o=u=r..,_v"""an=d"""L~o=k=a=-s =P~ro=p=e=rt'-'-v--'L=L=C~-------
Mailing Address: ----=3"'-50=2=-M=e=ad=o .... w-'---"G=le=n_,__C=o=urt=-=----------------------
City: Clemmons State: _NC_ Zip Code:~2~7~0 =12=----__ County: Fors yth
Day Tele No.: ____ N.....,__A=-------------Cell No.: (336 ) 624-9290
EMAIL Address: ___ a=s=s=ad=e=lkh=o=u'--'-rv-'--'@=gm==a=il=.c~o=m~--FaxNo.: ___ N....,,._A~-------
E. PROJECT CONTACT -Person who can answer technical questions about the proposed injection project.
Name: ---~B,,_,ru=ce=---"T.,,_ea,.,s.,.e'------------------------------
Mailing Address: -----=2 ,,_8 _,_Am""""'i'-'..Jl)'----' S=tr=e=e=t.....,S=u=it=e_,,,2,_,_A..__ __________________ _
City: Amherst State: MA_ Zip Code: 01002 County: Hampshire
Day Tele No.: (413 ) 835-4355 Cell No.: (413 ) 875-5896
EMAIL Address: ___ b~t~ea=s~e@~.r=am~bo~l~l.~co~m~----Fax No.: __ ___,_N,.._A..__ ______ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: --~5"-'0~0=0~O~l=d ---'W-'-'a=lk=e=rt=o~wn==-=R=o=a=d'-----------------
County: Fors h
City: Winston-Salem
(2) Geographic Coordinates:
St te: NC Zip ypde: 27105 _
Latitude**: J(:; ()°1 d-'1 ( f/U)IVI, L/11;.;J;; j-~
Longitude**: 8 DD Ii! 1.-::t" 5 g,U,,«-r~
Reference Datum: J 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 COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume:~6~.4~0~0 ____ square feet
Land surface area ofinj. well network: 400 square feet (S 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 6.25% (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.
UIC/In Situ Remed. Notification (Revised 3/2/20 I 5) 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.
A 10% aqueous solution ofBioavailable Absorbent Media (BAM) shall be in jected under pressure at ei ght direct
push technolo gy (DPT) locations with each boring to receive u p to 250 eallons. Similarly. a 5% a queous solution
of PermeOx® Ultra shall be injected under pressure at four DPT locations with each boring to receive u p to 100
gallons. Immediate! followin g each injection. the DPT borehole will be plugg ed with h drated bentonite chi ps
from the bottom to to p. To prevent da yli ghting, subs eq uent DPT in jections will occur at o pp osite corners of the
planned grid (see attached fi gures ). This procedure will provide more time for the h ydrated bentonite to set u p
and permanentlv seal the o pen DPT boreholes. The actual volume of BAM and PermeOx® Ultra (calcium
peroxide) injected will be empiricall determined based on its acce ptance b y the surrounding saprolite soil
matrix. The dis persion of the BAM and PermeOx® Ultra solutions is expected to occur via the same fracture
network that the li gh t non-aq ueous phase li quid (LNAPL ) mi gr ated through. To assist in the migr ation of the
BAM solution, vacuum extraction will be used simultaneously durine: the in jection event. The g oal of the BAM
and PermeOx® Ultra in jections is to reduce free product thickness to< 1/8 inch in site monitoring wells. The
BAM will begin to absorb LNAPL once in jected throu l!h its hi cl1 abso rp tion ca pacitv created b v the honev comb
pore structure. The purp ose of the PermeOx® Ultra is to enhance the BAM absorption and dis persion efficienc y.
A ggr essive fluid/va por recovery (AFVR) will occur durin g the in jection event to enhance treatment dis persion
as well as recover LNAPL. if present. Additional in jection and AFVR events ma be performed. should LNAPL
persist followin g the first injection event.
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/weblwqlapslgwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
lnjectant: ______ B_io_a_v_a_il_a_bl_e_A_bs_o_r_b_en_t_M_e_d_ia_(~B_AM_~)~-------------
Volume ofinjectant: A pproximately 2 ,000 gallons. Actual volume will be em piricallv
determined based on acce ptance ofsurroundim1 cla /silt matrix.
Concentration at point of injection: ___ l""'0"""o/c""'o""'a=q""u=e=ous=-s=o=l=ut=i=on=--------------
Percent ifin a mixture with other injectants: NA
Injectant: PermeOx® Ultra
Volume ofinjectant: A pproximatel v 400 gallons. Actual volume will be em piricallv determined
based on acceptance of surrounding clay/silt matrix.
Concentration at point of injection: 5% a queous solution
Percent if in a mixture with other injectants: NA
UICl!n Situ Remed. Notification (Revised 3/2/2015) Page3
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: 12 DPT borinri s Proposed ___ O~ __ Existing
(2) Provide well construction details for each injection well in a diagram or table format. A single
diagram or line in a table can be used for multiple wells with the same construction details. Well
construction details shall include the following:
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
( c) well contractor name and certification number -to be determined
The remedial treatments shall be injected directly into soil via Oeoprobe at depths corresponding to the zone of
contamination (i.e. 25-40 feet) and soil permeability. Treatment injections may occur at existing wells in the
event the DPT injection of treatment solutions is not accepted by the soil formation. The total treatment
volume into the existing site wells, within the treatment area, will be the same as that proposed for DPT into
soil.
L. SCHEDULES-Briefly describe the schedule for well construction and injection activities.
Week 1 -Utilitv clearance;
Week 2 -BAM/PermeOx® Ultra in jection with simultaneous AFVR event;
Week 6 -LNAPL gaugim! and OW monitorin g:
Week 10 -LNAPL au •in and OW monitorin ·
Week 14 -LNAPL gam?in g and OW monitorin g:
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 Subchauter 02L result from the injection activity.
The dispersion of BAM shall be monitored b the evidence of black suspension in nearbv monitoring and/or
remedial wells , and clear sight tubes positioned on each of the AFVR extraction hoses. Additionallv. three
groundwater monitoring events will be conducted monthlv . as warranted after the injection event.
UIC/Jn Situ Remed. Notification (Revised 3/2/2015) Page4
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "1 hereby certtifi; under penalty of law, that ! am familiar with the information submitted in this
document and till attachments thereto and that, based on my ingot?), of those individuals immediately responsible
for obtaining said information, 1 believe that she infarr►tation is true, accurate and complete. 1 am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. l agree to construct, operate, maintain, repair, and if applicable, abandon the injection well an
all related appttrter ces in tic yrtrdalIce with !{ft+l NCC,4C 02C O2QtRules. "
Signature of Applicant
Russell Kemp
Print or Type Full Name
PROPERTY OWNER {if the propert} is not owned b) the ermit appiicantp
"As owner of the property an which the injection wells. are to be constructed and operated, 1 hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(1 S A NCAC 02C . na rm t .. ,
"Owner" means any person who holds the fee or other property rights in the welt being constructed. A well
is real property and its construction on land shall be deerned to vest ownership in the land owner, in the
absence of contrary agreement in writing,
Assad EIkhour
Signature of Property Owner (it different from applicant) Print or Type Full Fame
k An access ureenterrr between the applicant and property owner may be submitted in lieu of a signature on this farm
Submit the completed notification package to:
DWR - UIC Program.
1636 Mail Service Center
Raleigh, NC 27699-1636
feiephone: [phone]
L1C11n Situ Remed, Notification (Revised 3a12015) Page 5

Former Gant Station #831
5000 Old Walkertown Road, Winston-Salem, North Carolina
Number of Type
Injection Borings
8 Direct-Push
4 Direct-Push
Notes:
ft. bgs -feet below ground surface
BAM -bioavailable absorbent media
HD ENGINEERS
Drilling Contractor
To Be Determined
To Be Determined
Boring Dia. Target Depth lnjectant Solution
(inches) (ft. bgs)
2 25 -35 10% BAM --
2 25-35 5% PermeOx Ultra
Volume/Boring
(gals .)
250
100 -l
RE
U5
ENGINEERS
-3 280
r-' 2Q nnn
OLD W ALKERTOM ROAD
EW-4
O 0 0
o w o
>=Nv -z
O O 0
0 •
RW-6
0 0
0 Proposed DPT Injection Boring
Not To Scale
January 2017
EPH C9-C18
Concentration (ug/i)
• 900,000
• 25,000
10,000
• 4,000
• 1,000
LEGEND
GROUNDWATER
CONTOUR (feel arm!)
PROPERTY BOUNDARY
(APPROXIMATE)
• MONITORING WELL
• RECOVERY WELL
+}F OEEP INJECTION WELL
EPH Fractions C9-C18 (January 2017) and
Proposed DPT Injection Boring Locations
FORMER GANT STATION #831
5000 OLD WALKERTON RD, WINSTON-SALEM, NC
FIGURE
1

Former UST Grove
Former Pump
Island
0 ,m--..r= - _. a - t..._. -
10 i s1W-25
EsIW-1
40
50
0
DIW-1
SIW-2D SIW-3
January 2017
EPH C9-G1B
Con cenuadonCu9►k1
• 900.000
• 25,000
10000
• 4,000
• 1,000
EW-1 EW-3
EW-2
AP Proposed DPT Injection Boring
10 20
Distance (feet)
30
40
town
2016
er
RE
US
ENGINEERS
Cross Section of EPH Fractions C9-C18 (January 2017) and
Proposed DPT Injection Boring Locations
FORMER GANT STATION #831
5000 OLD WALKERTON RD, WINSTON-SALEM, NC
FIGURE
2

72.6
72.8
73.0
RE
US
ENGINEERS
Not To Scale
® Proposed OPT Injection Boring
d'3 &13 t3
LEGEND
GROUNCFNATER
ccNTaluR nes ows•
PROPERTY E*..e..CARY
(APPFOWNrE
F..ChlTORN 3'AE.J.
DEEP IVECTON ?.EL
Potentiometric Surface Map (August 7, 2017) and Proposed DPT Injection Boring Locations
FORMER GANT STATION D631
5cDa OLD WALKERTON RD, VI NSTON-SALEM. NC
FIGURE
3

SDS
Safety Data Sheet
Section I Chemical Product and Company Identification
Product Name
Synonyms
CAS Number
DAM
HAM -MILLED
7440-44-0
Active Ingredients
Pyrolyzed Cellulosic Material
Recommended Use
Soil Stabilization, Remedial Activities
Restrictions on Use
None
Formulated by
ORIN Technologies, LLC
Address
405 Investment Court, Verona, WI 53593 USA
Emergency Phone Number
8 AM-5PM CST: 608-838-6699
5 PM -8 AM CST, Weekends, Holidays: 262-821-7024
Section II Hazard(s) Identification
Signal Word
Warning
Hazard Statements
Precautionary Statements -
Preventian
Precautionary Statement — Response
May cause Respiratory Irritation
Ma) form combustible dust concentrations in air
Do not brcaathe dust, fume, gas
Wash thoroughly after handling
Use only outdoors or in a well -ventilated area
Wear cloves, eve, respiratory protection, face protection, and protective clothing
IF ON SKIN — Wash with plenty of soap and water
IF INHALED — Remove victim to fresh air and keep at rest position comfortable for
breathing.
IF IN EYES —Rinse cautiously with water for several minutes. Remove contact lenses, if
present and easy to do- Continue Rinsing
Call a POISON CENTER or doctor if you feel unwell
If skin irritation occurs: Get medical advice or attention.
If eye irritation persists: Get medical advice or attention,
If respiratory irritation persists: Get medical advice or attention.
Take off contaminated clothing and wash before reuse.
Storage Store in a well ventilated place. Keep container tightly closed. Store in a secure manner.
Exposure Limits Synergistic Products Sensitization/Irritancy: CarcinogenicitylTeratogenicityl
Mntagenicity/Reproductive Effects:
ND ND ND None Known
Section III Composition and Information on Ingredients
Chemical Name
CAS# wtlwt %
Carbon (Wood Derived)
7440-44-00
85-95 (dry basis)
Minerals (Wood Derived)
N/A
5-10 (dry basis)
Water
7780-20-0
10-30%
Hazardous Ingredients: NONE

Section IV First Aid Measures
Skin
Eyes
Inhalation
Ingestion
Prolonged contact with skin may result in slight irritation/redness in sensitive individuals.
Seek medical attention if persists. Wash with soap and water. Not expected to be harmful
under normal conditions of use.
May irritate the eyes and cause watering and redness in sensitive individuals. Rinse
thoroug hl y with plenty of water to remove forei i;n bodies. Seek medical attention if persists.
Inhalation of dust may irritate nose, throat, and lungs. May aggravate pre-existing
conditions. Remove affected person to fresh air. Seek medical attention if persists.
If suffering gastrointestinal discomfort, treat symptomatically. Do not ingest.
Section V Fire-Fighting Measures
Flammability This product should not come into contact with naked flames.
Means of Extinguishing Foam, Water Spray, CO2, Dry Chemical,
Advice for Fire Fighters Wear self-contained breathing apparatus for firefighting if necessary
Flashpoint NA Auto-Ignition Temperature ND
UEL NA TDG Flammability Class ND
LEL NA Hazardous Combustion Products NA
Section VI Accidental Release Measures
Personal Precautions, Protective
Equipment, Emergency Procedures
Environmental Precautions
Methods and materials for
Containment and Cleanu p
Reference for other sections
Avoid dust formation. Avoid breathing vapors, mist, or gas. For personal protection, see
Section 8
No specific environmental precautions required.
Sweep up and shovel. Keep in suitable, closed containers for disposal.
For disposal, see section 13.
Section VII Handling and Storage
Engineering Controls Ventilate
Leak or Spill Procedure Sweep up into suitable container. Prevent entry into waterways.
Handling Procedures and Equipment Avoid direct and prolonged contact with skin
Storage Requirements Store in a cool, well ventilated, dry place
Section VIII Exposure Controls/Personal Protection
Personal Protective
Equipment
Respiratory:
Eyes:
Gloves:
Proper dust masks should be worn if prolonged use of this product is expected. Use type
N95 dust masks for nuisance levels. Use respirators and components tested and approved
under a ppro priate 2.ovemment standards !NIOSH J.
Use of safety glasses recommended to avoid contact with eyes (NIOSH).
Use of gloves recommended to avoid direct skin contact.
Section IX Physical and Chemical Properties
Physical State Solid
Odor and Appearance Slightly earthy odor. Brown or black solid particles
Odor Threshold NOA Specific Gravity 1.5-2.1 for solid matrix, Evaporation NDA bulk densi ry varies. Rate
Vapor Pressure NOA Vapor Density NDA Density Varies
Boiling Point NA Freezing Point NDA pH 7-9.5
May form
Flammability combustible Explosive Properties Dust Explosion dust Kst=32 +/-30% St 1 (solid, gas) concentrations Barm/s Class
in air
Water Solubility Not soluble Auto Ignition Temp. NDA Relative NDA Density
Partition Coefficient NOA Decomposition NDA Viscosity NDA Tem p .
Section x Stability and Reactivity
Chemical Stability: Stable
Incompatibility; Strong acids, alkalis, and oxidizing agents.
Conditions of Reactivity: NA
Hazardous Decomposition Strong oxidizers such as ozone, liquid oxygen,
chlorine, permanganate, etc. may result in rapid
Products: combustion. Avoid contact with Strome acids.
Section XI Toxicological Information
No Data Available
To the best of our knowledge, the chemical, physical, and toxicological properties have not been thoroughly investigated.
Section XII Ecological Information
No Data Available
Section XIII Disposal Considerations
Disposal Sweep, vacuum or shovel material into labeled container. if at all possible, reuse product. Keep out of
an bodies of water.
Section XIV Transport Information
Shipping Information Not regulated (DOT)
The information and recommendations set forth herein are presented in good faith and believed to be correct as of the date hereof. The
information and recommendations are supplied upon the condition that the persons receiving same will make their own determination
as to its suitability for their purposes prior to use. En no event will OR1N Technologies, LLC, or any of its agents be responsible for
damages of any nature whatsoever resulting from the use of or reliance upon the information and recommendations_ No representations
or warranties, either expressed or implied, of merchantability, fitness, or a particular purpose or of any other nature are made here
under with respect to information or the product to which information refers_
Preparation Date: July, 2018 MAR
Reason for Revision: Updated Field Values

SAFETY DATA SHEET
PermeOx® Ultra
SOS # : 1305-79-9-2
Revision date: 2015-04-21
Format: NA
Version 1
PeroxyChem
1. PRODUCTAND COMPANY IDENTIFICATION
Product Identifier
Product Name
Other means of identification
CAS -No
Perme0x® Ultra
1305-79-9
Recommended use of the chemical and restrictions on use
Recommended Use:
Restrictions on Use:
Manufacturer/Supplier
Emergency telephone number
Environmental applications
Use as recommended by the label.
PeroxyChem LLC
2005 Market Street
Suite 3200
Philadelphia, PA 19103
Phone: [phone] (General Information)
E-Mail: sdsinfo[ peroxychem_com
For leak, fire, spill or accident emergencies, call;
1 800 / 424 9300 (CHEMTREC - U.S.A.)
1 7031527 3887 (CHEMTREC - Collect - All Other Countries)
1 303/ 389-1409 (Medical - U.S. - Call Collect)
2. HAZARDS IDENTIFICATION
Classification
OSHA Regulatory Status
This material is considered hazardous by the OSHA Hazard Communication Standard (29 CFR 1910.1200).
Serious eye damage/eye irritation
Specific target organ toxicity (single exposure)
Oxidizing Solids
Category 1
Category 3
Category 2
GHS Label etementsjggluding.gr$cajtippary statements
EMERGENCY OVERVIEW
Danger
Hazard Statements
H318 - Causes serious eye damage
Page 1 / 8

PernieOx® Ultra
SDS # : 1305-79-9-2
Revision date: 2015-04-21
Version 1
H335 - May cause respiratory irritation
11272 - May intensify fire; oxidizer
Precautionary Statements - Prevention
P260 - Wear eye protection/ face protection
P261 - Avoid breathing dust.
P271 - Use only outdoors or in a well -ventilated area
P210 - Keep away from heat
P220 - Keep/Store away from clothing/combustible materials
P221 - Take any precaution to avoid mixing with combustibles
Precautionary Statements - Response
P305 + P351 + P338 - IF IN EYES: Rinse cautiously with water for several minutes. Remove contact lenses, if present and easy to
do. Continue rinsing
P310 - Immediately call a POISON CENTER or doctor
P304 + P340 - IF INHALED Remove person to fresh air and keep comfortable for breathing
P312 - Call a POISON CENTER or doctor if you feel unwell
P370 + P378 - In case of fire: Use water spray for extinction
Precautionary Statements - Storage
P403 - Store in a well -ventilated place
Precautionary Statements - Disposal
P501 - Dispose of contents/ container to an approved waste disposal plant
Hazards not otherwise classified t_HNOCY.
No hazards not otherwise classified were identified.
Other Information
Reacts with moisture to liberate oxygen
Unknown acute toxicity
0% of the mixture consists of ingredient(s) of unknown toxicity
3. COMPOSITION/INFORMATION ON INGREDIENTS
Chemical name
CAS -No
1
Weight %
Calcium Peroxide
1305-79-9
1
>75
Calcium Hydroxide
1305-62-0
<25
Synonyms are provided in Section 1
4. FIRST AID MEASURES
Eye Contact
Rinse thoroughly with plenty of water for at least 15 minutes, lifting lower and upper eyelids
intermittently. Consult a physician.
Skin Contact Wash off with soap and water. Get medical attention if irritation develops and persists.
Inhalation Move to fresh air. If breathing is difficult, give oxygen. If not breathing, give artificial
Page 2 / 8

PermeOx® Ultra
Ingestion
Most important symptoms and
effects, both acute and delayed
Indication of immediate medical
attention and special treatment
needed, if necessary
SDS # : 1305-79-9-2
Revision date: 2015-04-21
Version t
respiration. If breathing difficulty or discomfort occurs and persists, obtain medical attention.
Rinse mouth with water and afterwards drink. plenty of water or milk. Do not induce vomiting
or give anything by mouth to an unconscious person. Call a poison control center or doctor
immediately for treatment advice. Never give anything by mouth to an unconscious person.
Corneal lesions and irreversible damage if contact with the eyes
Treat symptomatically
5. FIREFIGHTING MEASURES
Suitable Extinguishing Media
Unsuitable extinguishing media
Specific Hazards Arising from the
Chemical
Explosion data
Sensitivity to Mechanical Impact
Sensitivity to Static Discharge
Protective equipment and
precautions for firefighters
Flood with water.
Dry chemical. Foam.
Decomposes under fire conditions to release oxygen that intensifies The fire
Not sensitive,
Not sensitive.
As in any fire, wear self-contained breathing apparatus pressure -demand, MSHA/NIOSH
(approved or equivalent) and full protective gear. Move containers from fire area if you can
do it without risk.
6. ACCIDENTAL RELEASE MEASURES
Personal Precautions
Other
Environmental Precautions
Methods for Containment
Methods for cleaning up
Avoid contact with the skin and the eyes. Avoid dust formation. Ensure adequate
ventilation. For personal protection see Section 8.
For further clean-up instructions, call PeroxyChem Emergency Hotline number listed in
Section 1 "Product and Company identification" above.
Prevent material from entering into soil, ditches, sewers, waterways, and/or groundwater.
See Section 12, Ecological Information for more detailed information.
Vacuum or shovel waste into a drum and label contents for disposal. Do not return product
to the original storage container/tank due to risk of decomposition. Keep combustibles
(wood, paper, oil, etc) away from spilled material.
After cleaning, Flush away traces with water. Do not flush powdered material to sewer;
Runoff to sewer may create fire or explosion hazard.
Handling
Storage
Incompatible products
7.'HANDLING AND STORAGE
Avoid contact with skin and eyes. Ensure adequate ventilation. In case of insufficient
ventilation, wear suitable respiratory equipment if release of airborne dust is expected. If
compounded with organics or combustible materials be sure to exclude moisture.
Keep tightly closed in a dry and cool place. Keep away from heat and sources of ignition
i.e., steam pipes, radiant heaters, hot air vents or welding sparks. Reacts with moisture.
Keep container tightly closed.
Heavy metals. Combustible materials.
B. EXPOSURE CONTROLS/PERSONAL PROTECTION'
Control parameters
Page 3 / 8

PermeOx® Ultra
SAS # : 1305-79-9-2
Revision date: 2015-04-21
Version 1
Exposure Guidelines
Chemical name
ACGIH TLV
OSHA PEL
NIOSH
Mexico
Calcium Hydroxide
1305-62-0
TWA: 5 mg/m3
TWA: 15 mglm3
TWA: 5 rn /m3
TWA: 5 mglm3
Mexico: TWA 5 mglm3
Chemical name
British Columbia
Quebec
Ontario TWAEV
Alberta
Calcium Hydroxide
1305-62-0
TWA: 5 mglm3
TWA: 5 mglm3
TWA: 5 mglm3
TWA: 5 mglm3
Appropriate engineering controls
Engineering measures
Ensure adequate ventilation.
Individual protection measures such askersona[Erotective equipment
Eye/Face Protection
Skin and Body Protection
Hand Protection
Respiratory Protection
Hygiene measures
General information
For dust, splash, mist or spray exposure, Wear chemical protective goggles.
Wear suitable protective clothing. Protective shoes or boots.
Rubber/latex/neoprene or other suitable chemical resistant gloves. Wash the outside of
gloves with soap and water prior to removal. Inspect regularly for leaks.
For dust, splash, mist or spray exposures wear a filtering mask.
Clean water, preferably an eyewash station and a safety shower, should be available for
washing in case of eye or skin contamination. Handle in accordance with good industrial
hygiene and safety practice_
If the product is used in mixtures, it is recommended that you contact the appropriate
protective equipment suppliers. These recommendations apply to the product as supplied.
9. PHYSICAL AND CHEMICAL PROPERTIES
information on basic physical and chemical properties
Appearance
Physical State
Color
Odor
Odor threshold
pH
Melting point/freezing point
Boiling Point/Range
Flash point
Evaporation Rate
Flammability (solid, gas)
Flammability Limit in Air
Upper flammability limit:
Lower flammability limit:
Vapor pressure
Vapor density
Density
Specific gravity
Water solubility
Solubility in other solvents
Partition coefficient
Autoignition temperature
Decomposition temperature
Viscosity, kinematic
Viscosity, dynamic
Explosive properties
Granules
Solid
White to off white
odorless
Not applicable
(1% solution) 10.5 -11.8 co 25'C
Decomposes on heating @ —275 °C
No information available
Not flammable
No information available
Substance does not burn but will support combustion
Not applicable
No information
No information
2.g2 glcm3
2.92
slightly soluble
No information
No information
Product is not s
275 °C
No information
No information
No information
available
available
available
available
elf -ignitable.
available (Solid)
available
available
Page 4 / 8

PermeOx® Ultra
Oxidizing properties
Molecular weight
Bulk density
Strong oxidizer
72.8 (CaO2)
45 Ibfcu ft (loose)
SDS # : 13O5.79-9-2
Revision date: 2015-04-21
Version 1
10. STABILITY AND REACTIVITY
Reactivity
Chemical Stability
Possibility of Hazardous Reactions
Hazardous polymerization
Conditions to avoid
Incompatible materials
Strong oxidizer.
Stable under recommended storage conditions. Decomposition can occur on exposure to
heat or moisture.
Oxidizable material can be ignited by grinding and may become explosive.
Hazardous polymerization does not occur
Heat (decomposes at 275 °C). Humid air. Grinding with organics.
Heavy metals. Combustible materials.
Hazardous Decomposition Products Oxygen which supports combustion. Calcium Oxides.
11, TOXICOLOGICAL INFORMATION
Product Information
Unknown acute toxicity
LD50 Oral
LD50 Dermal
LC50 Inhalation
Serious eye damage/eye irritation
Skin corrosion/irritation
Sensitization
Information on toxicological effects
Symptoms
O% of the mixture consists of ingredient(s) of unknown toxicity
• 5 glkg (rat)
> ID g/kg (rat)
> 17 mg/L 1 hr (rat)
Corrosive. Risk of serious damage to eyes.
Non -irritating (rabbit). May cause skin irritation in susceptible persons.
No information available.
Dust is irritating eyes, nose, throat, and lungs.
Delayed and immediate effects as well as chronic effects from short and long-term exposure
Chronic toxicity
Carcinogenicity
Mutagenicity
Reproductive toxicity
STOT - single exposure
STOT - repeated exposure
Aspiration hazard
No known effect.
There are no known carcinogenic chemicals in this product.
This product is not recognized as rnutagenic by Research Agencies
This product is not recognized as reprotox by Research Agencies.
May cause respiratory irritation.
No information available.
No information available.
12. ECOLQGICAL INFORMATION
Ecotoxicity
Page 5 1 8

PermeOx® Ultra
Ecotvxicity effects
Persistence and degradability
Sioaccumulation
Mobility
Other Adverse Effects
SOS # : 1305-79-9-2
Revision date: 2015-04-21
Version 1
The environmental impact of this product has not been fully investigated
Biodegradability does not pertain to inorganic substances
Does not bioaccumulate.
No information available.
None known.
Waste disposal methods
US EPA Waste Number
Contaminated Packaging
13. DISPOSAL CONSIDERATIONS 1
This material, as supplied, is a hazardous waste according to federal regulations (40 CFR
261). Dispose of in accordance with local regulations.
D001
Empty remaining contents. Empty containers should be taken to an approved waste
handling site for recycling or disposal.
14. ,TRANSPORT INFORMATION
DOT
UN/ID no
Proper Shipping Name
Hazard class
Packing Group
TDG
UNIID no
Proper Shipping Name
Hazard class
Packing Group
ICAO/IATA
IMDG/IMO
UN/ID no
Proper Shipping Name
Hazard class
Packing Group
ADR/RID
UN/ID no
Proper Shipping Name
Hazard class
Packing Group
OTHER INFORMATION
1457
CALCIUM PEROXIDE MIXTURE
5.1
11
1457
CALCIUM PEROXIDE MIXTURE
5.1
!t
Oxidizers are prohibited from aircraft.
1457
CALCIUM PEROXIDE MIXTURE
5.1
I1
UN 1457
OXIDIZING SOLID, n.o.s. (Calcium Peroxide)
5.1
it
This material is shipped in 25 lb. plastic pails, and 30 lb. and 100 [b. fiber drums.
15. REGULATORY INFORMATION
U.S. Federal Regulations
SARA 313
Section 313 of Title III of the Superfund Amendments and Reauthorization Act of 1986 (SARA). This product does not contain any
chemicals which are subject to the reporting requirements of the Act and Title 40 of the Code of Federal Regulations, Part 372
Page 618

ParmaOx® Ultra
SDS # : 1305-79-9-2
Revision date: 2045-04-21
Version 1
SARA 3111312 Hazard Categories
Acute health hazard Yes
Chronic health hazard No
Fire hazard Yes
Sudden release of pressure hazard No
Reactive Hazard No
Clean Water Act
This product does not contain any substances regulated as pollutants pursuant to the Clean Water Act (40 CFR 122.21 and 40
CFR 122.42)
CERCLA
International Inventories
Component
TSCA
(United
States)
DSL
(Canada)
EINECSIEL
INCS
(Europe)
ENCS
(Japan)
China
(IECSC)
KECL
(Korea)
PICCS
(Phlilpptnes
)
AICS
(Australia)
NZloC
(New
Zealand)
Calcium Peroxide
1305-79-9 ( >75 )
X
X
X
X
X
X
X
X
X
Calcium Hydroxide
1305-62-0 , <25 )
X
X
X
X
X
X
X
X
X
CANADA
WHMIS Hazard Class
C - Oxidizing materials
E - Corrosive material
16. OTHER INFORMATION
NFPA
Health Hazards 2
Flammability 0
Stability 1
Special Hazards OX
HMIS
Health Hazards 2
Flammability 0
PhysicaI hazard 0
Special precautions J
NFPA/HMIS Ratings Legend
Revision date:
Revision note
Special Hazards: OX = Oxidizer
ProtectionnJ (Safety goggles, gloves, apron, combination dust and vapor respirator)
2015-04-21
Initial Release
Disclaimer
PeroxyChem believes that the information and recommendations contained herein (including data and statements) are
accurate as of the date hereof. NO WARRANTY OF FITNESS FOR ANY PARTICULAR PURPOSE, WARRANTY OF
MERCHANTABILITY OR ANY OTHER WARRANTY, EXPRESSED OR IMPLIED, IS MADE CONCERNING THE INFORMATION
PROVIDED HEREIN. The information provided herein relates only to the specified product designated and may not be
applicable where such product is used in combination with any other materials or in any process. Further, since the
conditions and methods of use are beyond the control of PeroxyChem, PeroxyChem expressly disclaims any and all
liability as to arty results obtained or arising from any use of the products or reliance on such information.
Prepared By:
PeroxyChem
PERMEOX - Trademark of PeroxyChem
Page 7F8

PermeOx® Ultra
© 2015 PeroxyChem. All Rights Reserved.
End of Safety Data Sheet
Page 8 / 8
SDS # : 1305-79-9-2
Revision date: 2015-04-21
Version 1