WI0400506_DEEMED FILES_20181114

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400506
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Jeff's Grocery
Location Address
2996 NC Hwy 268
Clayton
Owner
Owner Name
NCDENRDwm
Dates/Events
Orig Issue
11/14/2018
NC
App Received
11/5/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27528
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
11/14/2018
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
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Linda Blalock
1646 Mail Service Ctr
Raleigh
Stokes
Issue
11/14/2018
Effective
11/14/2018
NC 27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
----------------------------------··
November 30, 2018
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality-Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Injection Event Record
Jeff's Grocery ·
2996 NC Highway 268
Pinnacle, Stokes County, North Carolina
NCDEQ Incident #37041
Injection Permit #WI0400506
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for Jeffs
Grocery on behalf of the North Carolina Department of Environmental Quality State Lead
Program. The record documents the installation of Provect ORS sleeves in one monitoring well
(MW-1) associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Elizabeth A. Allyn
Project Scientist
cc: Linda Blalock, Engineer for NCDEQ
Attachments
Ashley M. Winkelman, P.G.
Senior Project Manager
REC!I\IEDfNco~
DEC l 8 2018
Water Ow?,
Regional Operati .
Injection Event Record
Jeff's Grocery, P innacle . North Carolina
INJECTION EVENT RECORD
/4.TC
EIVlll!lllmAL•,EITUIDll:Ai.
IIIUIIISCIHCES•■lTEIIILSlllTll!I
North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400506
1. Permit Information
NCDEO
Permittee
Jeffs Grocery
Facility Name
2996 NC Highwav 268 . Pinnacle, Stokes Countv
Facility Address (include County)
2. Injection Contractor Information
ATC Associates ofNC, P.C.
Injection Contractor/ Company Name
Street Address 2725 E. Millbrook Road. Ste 121
Raleigh NC 27604
City State Zip Code
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection.~1 ____ _
Well IDs_----=-cM=--W'-'------'-1,____ _________ _
Were any new wells installed during this injection
event?
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number oflnjection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form/or each
well installed.
Were any wells abandoned during this injection
event?
D Yes [8J 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. Injectant Information
Provect ORS sleeve
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration -~7~5~-8~5_o/c_o ________ _
If the injectant is diluted please indicate the source
dilution fluid. Not Applicable
Total Volume Injected (gal) 346 in3-sleeve volume
Volume Injected per well (gal) 346 in3-sleeve vol.
5. Injection History
Injection date(s) November 14, 2018
Injection number ( e.g. 3 of 5)--'1=--=of=--1"----------
Is this the last injection at this site?
D Yes [8J No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT. ~ ~, -11 !~a{I (
SIGNATURE OF INJECTION CONTRACTOR DATE
ATC Associates of North Carolina. P.C.
PRINT NAME OF PERSON PERFORMING THE INJECTION
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
ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrouk Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgrou pse rvi ces. com
N.C. Engineering License No. C-1598
October 24, 2018
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Jeff's Grocery
2996 NC Highway 268
Pinnacle, Stokes County, North Carolina
NCDEQ Incident #37041
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of the North Carolina Department of
Environmental Quality State Lead Program. The permit application covers the performance of
passive rernediation in one monitoring well associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Elizabeth A. Allyn
Ashley M. Winkelman, P.G.
Project Scientist Senior Project Manager
cc: Linda Blalock, Engineer for NCDEQ
Attachments
.ECEI'EDINCrlEQ;O Ji
Kin 0 5 DWI
ldiater Quattty Region='
•-ineratioT• Swr,th-

2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598

October 24, 2018

Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636

Reference: Notice of Intent to Construct or Operate Injection Wells
Jeff’s Grocery
2996 NC Highway 268
Pinnacle, Stokes County, North Carolina
NCDEQ Incident #37041

Dear Ms. Shrestha:

ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of the North Carolina Department of
Environmental Quality State Lead Program. The permit application covers the performance of
passive remediation in one monitoring well associated with the above referenced site.

If you have questions or require additional information, please contact our office at [phone].

Sincerely,
ATC Associates of North Carolina, P.C.

Elizabeth A. Allyn Ashley M. Winkelman, P.G.
Project Scientist Senior Project Manager

cc: Linda Blalock, Engineer for NCDEQ

Attachments

/\TC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
Notice of Intent to Construct or Operate Injection Wells
Jeff’s Grocery, Pinnacle, North Carolina

NOTICE OF INTENT FORM
/\.TC
(fftl!U ■m-1•1umw1m
IUd.DI•' SCILllm · M.11UUU TUltHG
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 1
North Carolina Department of Environmental Quality – Division of Water Resources

Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.

DATE: October 24 , 20_18___ PERMIT NO. (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) x Passive Injection System…………………..……..Complete sections B through F, H-N
(4) Small-Scale Injection Operation………………….Complete sections B through N
(5) Pilot Test………………………………………….Complete sections B through N
(6) Tracer Injection Well………………………….….Complete sections B through N

B. STATUS OF WELL OWNER: Choose an item.

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): Linda Blalock – Engineer, North Carolina Department of Environmental Quality
Mailing Address: 1646 Mail Service Center
City: Raleigh State: _NC_ Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8165 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: Not Available
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 form shall be submitted at least 2 WEEKS prior to injection.

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) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - 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 Operations – 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.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 2
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Nelson Easter
Company Name Not Applicable
Mailing Address: 1212 Hauser Road
City: Pinnacle State: _NC__ Zip Code: 27043 County: Stokes
Day Tele No.: 336-706-6014 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available

E. PROJECT CONTACT (Typically Environmental Engineering Firm)

Name and Title: Ashley M. Winkelman, Senior Project Manager
Company Name ATC Associates of North Carolina, P.C.
Mailing Address: 2725 E. Millbrook Road, Suite 121
City: Raleigh State: _NC_ Zip Code: 27604 County: Wake
Day Tele No.: 919-871-0999 Cell No.: 919-830-3576
EMAIL Address: [e-mail] Fax No.: 737-207-8261

F. PHYSICAL LOCATION OF WELL SITE

(1) Facility Name & Address: Jeff’s Grocery
2996 NC Highway 268
City: Pinnacle County: Stokes Zip Code: 27528
(2) Geographic Coordinates: Latitude**: 36o 24′ 44.41″ or o.
Longitude**: 80o 23′ 55.33″ or o.
Reference Datum: WGS84 Accuracy: 10-meter
Method of Collection: DOQ-Acme Mapper 2.1
**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 of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)

H. INJECTION ZONE MAPS – Attach the following to the notification.

(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells. – There is one monitoring well associated
with the site and no vertical extent monitoring well. Cross-sections were not identified in previous
work conducted at the site.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 3

See Figures 1 and 2 for a site location and injection zone map. A groundwater flow direction map has not
been constructed for this site as there is only one monitoring well associated with the site.

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 a Provect ORS sleeve in monitoring well MW-1 in order to aide in natural attenuation and
reduce compounds concentrations to below the North Carolina Groundwater Quality Standards (2L Standards).
Based on the most recent sampling event performed in March 2018, the following compounds exceeded the 2L
Standards in MW-1: methyl tert-butyl ether at 82.5 g/L. The sleeves come in 3-foot sections. ATC will install
one 3-foot section at the base of the well, across the well screen. The sock will release oxidizing solids into the
groundwater for approximately 6 months, at which point the chemicals in the sock will have depleted.

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 http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-injectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).

Injectant: Provect ORS sleeves
Volume of injectant: 346 in3 – volume of socks
Concentration at point of injection: 75-85%
Percent if in a mixture with other injectants: Not Applicable

See Appendix A for MSDS.

K. WELL CONSTRUCTION DATA

(1) Number of injection wells: Proposed 1 Existing (provide GW-1s)
(2) For Proposed wells or Existing wells not having GW-1s, 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
See Appendix B for well construction details.

L. SCHEDULES – Briefly describe the schedule for well construction and injection activities.

Two weeks after submitting the NOI, ATC will install the Provect ORS sleeve in monitoring well MW-1.

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 TC will collect one sample approximately 6 months after the installation of the Provect ORS sleeve in MW-1
(November 2018. with sampling to occur May 2019). During the sampling event. ATC will collect a sample
from monitoring well MW-1 for analysis of volatile organic compounds by EPA Method 6200B. The sample
will be shipped to SGS Accustest in Scott. Louisiana. ATC will also measure dissolved oxygen. conductivity.
temperature. pH. and oxygen reduction potential in MW-1 during the May 2019 sampling event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the 15A NCA C 02C 0200 Rules."
~---Ashley Winkelman on behalf of Linda Blalock. NCDEO (see next page)
Signature of Applicant Print or Type Full Name and Title
PROPERTY OWNER (if the property 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
(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.
See Appendix C Nelson Easter
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 011 this form .
Submit TWO hard copies of the completed application package with an electronic version in CD or USB
Flash Drive to:
Deemed Pennitted GW Remediation NOI Rev . 8-28-2017
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page4
1
Liz Allyn
Subject:FW: NOI Signature Authorization

From: Blalock, Linda [mailto:[e-mail]]
Sent: Tuesday, September 25, 2018 4:27 PM
To: Ashley Winkelman <[e-mail]>
Subject: NOI Signature Authorization

I, Linda Blalock, authorize Ashley Winkelman from ATC Associates, to sign Notices of Intent (NOI) as an agent for
DWM. If you have any questions or need more information, please let me know.

Linda Blalock
[e-mail]
~~~~~

inda Blalock
Em•ironm ma/ Engineer, Division of Wast .\fanagem 111
orth lina Department o Environmental Qualit
1646 Mail er ·cc enter
Ralei h. 699 · 1646
919 . 0 16 (0 1cc)
Notice of Intent to Construct or Operate Injection Wells
Jeff’s Grocery, Pinnacle, North Carolina

FIGURES

/\.TC
(fftl!U ■m-1•1umw1m
IUd.DI•' SCILllm · M.11UUU TUltHG
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
FIGURE 1
SITE TOPOGRAPHIC MAP
PROJECT NO: SLP3704101
REVIEWED BY: EA SCALE: 1:24 000 DATE: 6/5/15
JEFF’S GROCERY –INCIDENT #37041
2996 NC HIGHWAY 268
PINNACLE, NORTH CAROLINA
N
Site
Quadrangle: Pilot Mountain, North Carolina USGS 2013 Topographic Map available at http://store.usgs.gov/
/\TC
I _i..",%• r:
a
m
z
rrI
1
1
c
Ln
0
0
13AVHD/SSViU
0
13AViO/SSW10
73nda0/SSV O
1I AVd /S SV ft
(II 3dA.1) 173M ON18011NOV
m
C)
m
0
NOTES,
TITLE FIGURE 2
SITE MAP
FORMER JEFF'S GROCERY - INCIDENT #37041
2996 NORTH CAROLINA HIGHWAY 268
PINNACLE, NORTH CAROLINA
Raleigh, North Carolina 27604
[phone] FAY [phone]
,�►TC
ENVIRONMENTAL • GEOTECHNICAL
l3UILD1NG SCIENCES • MATERIALS TESTING
CAD FILE
1254177.DWG
TYPE COPE
PREP. BY
AW
REV, BY
AW
SCALE
1 " = 20'
04-
❑ATE
07-2016
PROJECT NO.
SL3704103

Notice of Intent to Construct or Operate Injection Wells
Jeff’s Grocery, Pinnacle, North Carolina

APPENDIX A

MSDS FORM

/\.TC
(fftl!U ■m-1•1umw1m
IUd.DI•' SCILllm · M.11UUU TUltHG
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 USA: 1-[phone]
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide), Class 5.1, PG II, UN1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
CAS No. Percentage
1305-79-9 75%-85%
Ingredients Chemical Formula
Calcium Peroxide CaO2
Inorganic Nutrients 15%-25%
3. PHYSICAL DATA
Appearance White & brown granules
Physical state Solid
Odor threshold None
Bulk Density 500~650g/L
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.
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 contact May 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 Point
•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,
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 3 of 5
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. Avoid contamination that may lead to
decomposition.
Handling
•Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
•Do not swallow. Avoid 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.
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
•Oxygen which supports combustion
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
•LD50 Oral: Min.2000 mg/kg, rat
•LD50 Dermal: Min. 2000mg/kg, rat
•LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological 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
Notice of Intent to Construct or Operate Injection Wells
Jeff’s Grocery, Pinnacle, North Carolina

APPENDIX B

MONITORING WELL CONSTRUCTION DETAILS

/\.TC
(fftl!U ■m-1•1umw1m
IUd.DI•' SCILllm · M.11UUU TUltHG
Resources ugust
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
For multiple injection or non-water supply wells ONLY with the same construction, you can
submit one form.
For multiple wells list all depths if different (example- 3@200’ and 2@100
If water level is above casing, use “+”
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.

_______________
Daniel Summers
2579-A
Carolina Soil Investigations, LLC
✔
03-03-16 MW-1
Jeff's Grocery
2996 NC 268 Hwy Pinnacle, NC
Stokes
36.244487 -80.235485
✔
✔
1
35
0
2
Air
0 15 2 sch 40 pvc
15 35 2 010 sch 40 pvc
0 11 portland mix & pour
11 13 bentonite tremie
13 35 10/30 silica sand prepack
0 35 brown silt loam and brown silty clay
03-03-16Daniel Summers Digitally signed by Daniel
Summers
I
Notice of Intent to Construct or Operate Injection Wells
Jeff’s Grocery, Pinnacle, North Carolina

APPENDIX C

ACCESS AGREEMENT FROM SITE PROPERTY OWNER

/\.TC
(fftl!U ■m-1•1umw1m
IUd.DI•' SCILllm · M.11UUU TUltHG
ROY COOPER NORTH CAROLINA
Environmental Quality Governor
MICHAELS. REGAN
Secretary
MICHAEL SCOTT
Director
Mr. Linda Blalock
Engineer
DWM UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
RE: Site Access Agreement
Former Jeffs Grocery
2996 NC 268 Highway
Pinnacle, North Carolina
Incident Number 37041
Dear Ms. Blalock:
September 21, 2018
I am/We 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 assessment and/or
remediation of the groundwater and/or soils under the authority of G.S. 143-215.94G.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Depaiiment'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 in accordance with the acceptance of the site into the State-Lead
Program. The Depatiment or its contractor shall protect and prevent damage to the surrounding
lands. Any damages will be restored by the Department or its contractor to as close to the pre-
work condition as practicably possible.
North Carolina Otpartment or En,1roomen1al Qualtty I Division of Waste Managtment
217 West Jones Street I IMC. Mail Ser\'ice Q-ntrr I Ral('lgh. N<x1h Carolina 2769'Mb4()
<:n<l.7071\200
Former Jeff's Grocery — Incident #37041
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 will notify
the land owners 48 hours prior to entry and 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 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 landowner.
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Type/Print Name of Owner or Agent
Phone Number
(72 li/eq-,c)
Address
/ // C
City/State/Zip Code
/9 //y
Date
_EQ4
,4
North Carolina UtparIment of Environmental Quality I Division of Waste Mar tment
217 West Jones Street 11646 Mail Service Center I Raleigh, North Carolina 27699 I646
919,707.8200