WI0400507_DEEMED FILES_20181120

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400507
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former 109 Shell Service Station
Location Address
4396 Thomasville Rd
Bear Creek NC
Owner
Owner Name
Quality Oil Company LLC
Dates/Events
Orig Issue
11/20/2018
App Received
11/8/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27207
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
11/20/2018
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
Donald Mciver
PO Box2736
Winston Salem
Issue
11/20/2018
Effective
11/20/2018
NC 27102
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 prior to injection)
AQUIFER TEST WELLS (15A NCAC 02c .0220)
These wells are used to inject uncontaminated fluid into an aquifer to detennine 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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: ___ O=ct=o=be=r--=2=9 _ _,. 20_1L PERMIT NO. /l'J'J.0 <f'OD~~to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(I)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B through F, K, N
--~Aquifer Test Well ....................................... Complete sections B through F. K, N
-~X~ Passive Injection System ............................... Complete sections B through F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B through N
--~Pilot Test ................................................. Complete sections B through N
___ Tracer Injection Well ................................... Complete secti?~ • I lif,W ,,1 EQ/DWi
STATUS OF WELL OWNER: Choose an item. NOV O 8 2018
. /\fater uality rs:.
WELL OWNER(S) -State name of Busmess/Agency. and Name and Title of persij J ~~&tf authority to
sign on behalf of the business or agency: ·
Name(s): __ ....,Q'--'u=a=li::...,.ty....;O=i,...l--=C=o=m""p=an=vc:..•-=L=L:...::C'-------------------------
Mailing Address: -----"1-=-5..,.40=--=S=ilas=--C=r=e=ek=-=-P=ar=k"-'-w'-=a:;.L.y ___________________ _
City: Winston-Salem State: NC Zip Code:.---=2c.:...7=10=2,__ ___ County:_F_or_s~yth ___ _
Day Tele No.: ---~3""'3--=6--7=2=2-=-3'-'4'--'-4-=-1 _______ Cell No.: _______ _
EMAIL Address: __ ~d=m=c=iv~e=r=®=q'"""o~c=nc=·~co=m~----Fax No.: __________ _
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 1
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: SAME
Company Name ---------------------------------
Mailing Address:---------------------------------
City: _____________ State: __ Zip Code:. _______ County: _____ _
Day Tele No.: ____________ _ Cell No.: __________ _
EMAIL Address: ______________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: _______ J"-'e=ffr=ey,-..=B=al=l=si=e"""pe=r~, =L"'-'.G=-=--. __________________ _
Company Name ------=-P"-'ro=g=r=es=s-=E=n"""v"""ira.-=o=nm=e=n=ta=l-=G=r=o=u""p.~I=n=c~. _____________ _
Mailing Address: -----~PO~B~o=x~5~8~8~4 _____________________ _
City: Winston-Salem State: NC Zip Code:-=2~7~1 =13 ____ County: Fors yth
Day Tele No.: ___ 3~3~6~-7_2_2-~9~99~9____ Cell No.: ___ 3~3~6~-7~8=2~-9~7~25~---
EMAIL Address: jballsie1 er(@ pro gres senvironmental.com Fax No.: ----=3=-36=-___,7-=2=2'-'-9'--"9'--"9--=8'---------
F. PHYSICAL LOCATION OF WELL SITE
(I) Facility Name & Address: ---~Fo=rm=e=r-=l-=0=-9-=S=h=el=l -=S~erv~ic"-'e~S=t=at=io=n=--------------
4396 Thomasville Road
City: ___ W--'--'--"in=s=t=on=--=S=a=le=m=---------County : Forsyth Zip Code: 27107
(2) Geographic Coordinates: Latitude**: ___ 0 ____ " or 0 36.030357°
Longitude**: 0 __ "or 0 -80.167154°
Reference Datum: ________ A_ccuracy: ________ _
Method of Collection: GoogleEarth
**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:----=l-=0-'-'0"""0-=0----square feet
Land surface area of inj. well network: 400 square feet(:::: 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 4% (must be:::: 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(I) 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.
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page2
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page3
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -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.
Progress will place a water soluble tube containing Enviro-BAC into
monitorin g wells MW-7 , MW-9 . MW-14 . MW-16 . MW17 . MW-18 ,
and MW-22. Each water soluble tube will contain a pp roximatel y ½ of
Enviro-BAC in the powder form. The powder Enviro-BAC will mix with
gr oundwater within the well.
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 htt p://deq .nc.gov/about/divisions/water-
resources/water-resources-p ermits/wastewater-branch/Qround-water-protection/gro und-water-a pproved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: ----------'E=n"'"v""ir""'o'"'"-B=A=-aC"---------------------
Volume of injectant: ½kilogram
Concentration at point of injection: -----~10~0~0~1/o~----------------
Percent if in a mixture with other injectants: ___ N_A _________________ _
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) Number of injection wells: ---"-O ___ Proposed'----'-7 ___ Existing (provide GW-1 s)
(2) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page4
(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
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page5
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Planned in jection acfryities to occur on November 15 , 2018.
Subse quent sam pling activities to occur a pp roximatel y 30 days from in jection.
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.
Pro gress will collect a groundwater sam ple from the monitorin g well in December 2018.
The groundwater sam ple will be analyzed for volatile organic com pounds using
Standard Method 6200B.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/A pp licant: "I hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submittingfalse information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
ini.on well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
w-M ~ ~ tmQ~cl r\ M'-;::r vu .:ZO: cSe11 ;v1 l!,'u...f>f'Q,,; l ~
Signature of Applic~ Print or Type Full Name and Title
Pro perty Owner (if the pro pert is not owned b v the Well Owner/A pp licant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
15A 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.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
* An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form .
Please send 1 (one) hard color copy of his NOi along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Deemed Permitted GW Remediation NOi Rev . 3-21-2018 Page 6
Telephone:[phone]
~med Pennitted GW Remediation NOi Rev. 3·21·2018 l'age7
I
I
I
I
i I
I
I
I
I
I
I
I
I
I
I
I
I
I
I
MONITORING WELL INSTALLATION DETAIL
TURNER ENVIRONMENTAL CONSULTANTS, P.C. WELL NO: MVfi
PROJECT: 109 SHELL PROJECT NO: 01497
LOCATION: WINSTON-SALEM, NC
CLIENT: QUALITY OIL COMPANY, LLC WELL TYPE: II
CONTRACTOR: SGI DRILLING BORING NO: MW7
DRILLER: JAMIE LOCATION: SEE SITE MAP
FIELD GEOLOGIST: MICHAEL BLAGG
SUPERVISING GEOLOGIST: MICHAEL BLAGG INSTALLATION DATE: 12/11/97
SURVEY
DATUM:
GROUND --ELEVATION: I -□ TOP OF WELL CASING OR RISER PIPE I DEPTH 0.00 0-15 Red, Lean 1, ELEVATION:
clay with sand Ii
(CL) Mostly clay,
1, CEMENT PAD Some sand, Few I, TYPE OF SURFACE SEAL
silt I I, THICKNESS OF SURFACE SEAL 0.20
Neat ,~·.'
w MANHOLE ...I Cement TYPE OF PROTECTIVE CASING <( u INSIDE DIAMETER 6 1/) Grout TOTAL LENGTH 1.00
0
I-
BOTTOM OF PROTECTIVE CASING
I-ELEVATION: DEPTH 1.00
0
~
8.0 TYPE OF WELL CASING OR RISER PIPE
SCH40 PVC
Bentonite INSIDE DIAMETER 2" >-a: Pellet Seal <( 6" :i: 15-20 9.0 ~ APPROXIMATE BOREHOLE DIAMETER ::> Greenish-grey, 1/)
Lean clay with !:: TOP OF WELL POINT
sand (CL) Mostly ~ ELEVATION: DEPTH 10.00
~
CJ clay, Some sand,
~
'-z Washed '-TYPE OF WELL POINT SCH40 PVC a: Few silt ,_
0 Filter Pack -ID 1--
-~ 0.010 Sand -SCREEN GAUGE OR SLOT SIZE -INSIDE DIAMETER 2" ...I 20-25 Tan ,Lean -
0 1--FILTER PACK NO2SAND 1/) clay with sand ~
1--
(CL) Mostly clay, ~
~
Some sand, Few
,_ BOTTOM OF WELL POINT ~ 25.00
silt -ELEVATION: DEPTH -
ALL DEPTHS ARE BOTTOM OF BOREHOLE 25.00 FIGURES ABOVE REFER TO REFERENCED TO ELEVATION: DEPTH
DEPTHS IN FEET GROUND SURFACE
10.00 15.00 25.00 NOTE: ALL LENGTHS AND
LENGTH OF RISER PIPE LENGTH OF POINT TOTAL LENGTH
DEPTHS IN FEET UNLESS
DENOTED OTHERWISE
I
I
I
I
I
I
I
I
I
I
11
I
I
I
I
I
I
I
I
MONITORING WELL INSTALLATION DETAIL
TURNER ENVIRONMENTAL CONSULTANTS, P.C. WELLNO: MW9
PROJECT: 109 SHELL PROJECT NO: 01497
LOCATION : WINSTON-SALEM, NC
CLIENT: QUALITY OIL COMPANY, LLC WELL TYPE: II
CONTRACTOR: SGI DRILLING BORING NO : MW9
DRILLER: JAMIE LOCATION: SEE SITE MAP
FIELD GEOLOGIST: MICHAEL BLAGG
SUPERVISING GEOLOGIST: MICHAEL BLAGG INSTALLATION DATE: 12/11/97
SURVEY
DATUM:
GROUND --ELEVATION: I -□ TOP OF WELL CASING OR RISER PIPE I ELEVATION: DEPTH 0.00 0-8 Lean Clay 11 :
(CL) Mostly clay, • I
Few silt, Few sand
CEMENT PAD TYPE OF SURFACE SEAL
THICKNESS OF SURFACE SEAL 0.20
8-25 Silt with Sand 1,
'
w (ML) Mostly silt, Neat . MANHOLE ._J Some sand, Few Cement TYPE OF PROTECTIVE CASING < 1! ,t. u clay INSIDE DIAMETER 6 (/J Gtout r 1,
' TOTAL LENGTH 1.00
0
I-
IU' BOTTOM OF PROTECTIVE CASING ·, ELEVATION: DEPTH 1.00 I-.,
0 1,1:-!i ~ ' 1~,.
8 .0 TYPE OF WELL CASING OR RISER PIPE
SCH40 PVC
Bentonite INSIDE DIAMETER 2" > cc Pellet Seal < 6" :E
:E 9 .0 APPROXIMATE BOREHOLE DIAMETER :::>
(/)
'= TOP OF WELL POINT -ELEVATION: DEPTH 10.00 -
C, -
z -TYPE OF WELL POINT SCH40PVC ic Washed .... ....
0 Filter Pack .... m I--0.010 Sand .... SCREEN GAUGE OR SLOT SIZE .... INSIDE DIAMETER 2" ._J ....
i5 .... FILTER PACK NO2 SAND (/J .... .... .... .... .... BOTTOM OF WELL POINT .... 25 .00 .... ELEVATION: DEPTH -
ALL DEPTHS ARE BOTTOM OF BOREHOLE 25.00 FIGURES ABOVE REFER TO REFERENCED TO ELEVATION : DEPTH
DEPTHS IN FEET GROUND SURFACE
10.00 15.00 25 .00 NOTE: ALL LENGTHS AND
LENGTH OF RISER PIPE LENGTH OF POINT TOTAL LENGTH
DEPTHS IN FEET UNLESS
DENOTED OTHERWISE
WELL CONSTRUCTION RECORD
This form can It used for single or nmldpta wells
1. Welt Contractor Information:
NICK PERRY
Well Connector None
3329
NC Well ContractorCertW tion?Zomba
Terraquest Environmental Consultants, P.C.
Company Nemo
2. Well Construction Penult I!:
Litt all applicable well pernetes tie. Cotten% State, Variance, Injection etc)
3. Well -Use (check well use)
'Water Supply Weil:
❑Agricultural
UQewhennaI (Heat ingtCoolingSupply)
dlndusuialVCommereial
[}irrigation
❑Municipai/Pubiic
❑ Residential Water Supply (single)
❑ Residential Water Supply (shored)
Non -Water Supply Well:
VIMonitoring °Recovery
Injection Welsl
[]Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
DQeothermal (fieatiapfCooling Returnl
d, Date WeII(s) Completed: 2/3/15
❑ Groundwater Remedietioa
DSatinity Barrier
❑ Stormtirater Drainage
❑ Subsidence Control
❑Tracer
❑Otter (explain under #2I Remarksj
wen Inn MW14,MW15
Sa. Well Location:
109 5hell/Quallty Oil Comp. LLC 0-010579
Ratty/Owner Name Fa,:iiity 110 (if applicable)
4696 Thomasville Rd., Winston-Salem NC 27107
Physical Addtesa CIty, and Zip
Forsyth
6853-41-8955
County Parcel Identification No. (PIN)
56. Latitude and Lbugitudc in degreeshnieluteaIseconds or decimal degrees:
(ifweli field, out latliaag is sufficient)
36.0302 N 80.1675
6.Is(are)the wcll(s): 121Permaneot or ° emporary
W
7. Is this a repair to an existtag dell: ❑Yes or PJNo
Jf this u a repot:, ftll out known swell construcrIon'Omar lon and expfefn the nature of the
►epalr under *2 1' remarktsection Aran the bock of this form.
& Number of wells constructed: 2
For enthlple triectiatt nr non -water sarpply wells ONL YWeb the sw+u construction, year can
snbnrir one fbrna.
9. Total well depthbelow land surface: 2 a@30'
For tnrdrlpfe wear bit all depths lfdij rent (emuvple- 3@200' and2[0r601
10, Static water level below top ofcasIeRt 18'781, 21.16'
*waterfewerle °have casing use "+"
11. Borehole diameter: 8.5" _ On.)
12. Well construction method: Hollow Stem Auger
(t.e. wet, roury. cable, direct pad', ere.)
(ft)
(n-)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield(gpm) Method or test:
13b.Disinfection type: Alnouutt
Fox interest Use ONLY:
14. WATER 1;ONF.S
FROM
TO
nEecawnott
rt.
lt.
A5.OUTER CASING (fci m l- iaid;rigs) OR LINER t[F,ip neib1sl. ,.
i'ROM 1 TO -J orAMEThR r THzacNzss MATERIAL
'16.INNER CASINO ORTOWNG(ie'dthdi lfibledlotip), S ;
-MOM
7O
AIOLEI E ER
TR147CIrss
aL5.TDIAL
fr.
fk
la
ft.
le.
:17. SCREEN'
FROM
16' n
it
70
so. ft.
A.
BIAM1.T*7r FSLOTMEE r T'nit]OrEL4 t IdA•rFR1AL
21n
in
0.010
Sch. 40
PVC
01
Crit011F " : ti" L.)?
oaf MATERLIY. rtermacEsmatwagon os Nauru
70
B'
1,.
Portland Pour
t3'
er.
8' rt
Bantonife
t Pour
a.
It
:19. sM[WGR1vF.I:'PACic rlrappikrihli] `. °., ;- `S..
FROM
TO
MATERIAL
6' Q.
ft,
30'
tt
N0,2 Sand
Pour
i
20. DRILLING LOG (Anrath odd] rioted sheets It necessary}
FROM
0'
R.
15' ft.
TO
15
30'
ft.
ft.
RESEW i1ON (color, Ern aw avrVroek I:14erarn slat, vat
SILT
SANDY SILT
R.
it
ItG
R
At.
a.
fr.
ik
+11. REtdro KS .
22. Ceti ahbn:
Signeluta C Tied Well Contractor
2111115
Dale
By slgntng lhls far% ! hereby etrlrfy that the hratl{sj war hare) eansmncted rr, accordance
wfh )jA 1'L'AC INC.0100 or 154 NCAC 01C.0200 We Conrrnrnon Srmrme * and that a
copy old&reeend has been pmt4dad to rlra well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details nr well
construction details You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All We11s: Submit this form within 30 days of completion or well
construction to the following:
Division of Water Resources, Iafbrmetlao Processing Unit,
1617 Mall Service Center, Raleigh, XC 27699..1617
24b. for Ialertton Wells ONLY: In addition to sending the toms to the address in
24a above, also submit a copy of this form Within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Fragrant,
1636Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply d6 Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
FaroOWI
North Carolina Depravtrnect of Environoaot
sad Natural Resources - Division of Water Resources
Revised August 2013

WELL cONSTRUcTXON RECORD
This form GM be used for single or eiuitiplo wefts
1. Wen CuntraetorInformation :
NICK PERRY
LYaiI Conus torName
3329
ABC Wei ConsmrtorOffrecation Number
Terraquest Environmental Consultants, P.C.
Company Nams
2. Well Construction Penult fk
Ltrt tall ❑ppllcalde well perm* (i• e. Cores am% Yarlarnce. Infection ere)
3. Welt Use (check well use):
Water Supply Well:
CUAgricuitura[
['Geothermal (Heating/Cooling Supply)
❑industriaYCoramerctat
F7lrrigatten
❑MunicipatiPublic
❑Residcutlet Water Supply (single)
['Residential Water Supply (shared)
Non -Water Supply Wed:
mManitoring ❑Recovery
Injection Well:
❑Aquifer Recharge
{iAquifer Storage and Recovery
❑Aquifer Test
['Experimental Technology
OGoothermal (Closed Loop)
r OGeothsmal4i]e et inglCool ing Return)
ClOroundwater R.emediation
❑Salinity Barrier
❑ Stonnwater Drainage
▪ Subs[dersge Control
❑Tracer
❑Dther (explain under d2] Remarks)
4, Dale Well(s) Completed: 2/3115 Wen IAN MW 16
Sin, Well Loeaticn:
109 Shell Quality al Comp_ LLC 0-010579
PecilIylOwwerNanme Faculty IDt4 (ifspplfcable)
4896 Thomasville Rd., Winston-Salem NC 27107
Phyaieei Address, City. seriZip
Forsyth
6853-41-8955
County Parcel 1deatidsatioa No. ('IN)
Sb. Latitude and Longitude la degrees/minutes/seconds or decimal degrees:
(il'wd field, one ladtong is sufficient)
36.0302 N 80.1675
6. Is (are) the well(s): OPerruaeant or ['Temporary
W
7. Is this a repair to so existing well: L1Yes or E:i\a
yrim is a repair, fin out known lief) ranstrucife4 Info marten and explain the nature of the
repot, under 021 remarks section aron she back ofthts form
S. Number of wells constructed: 1
For mxlilpte ntjeerrou orrnwrxalersrpply wells ONLY with the someoanslrucHan, you con
=both one farm.
9. Mimi well depth below land serfsee: 30' (ft)
PPor multiple welts Install depths lfdrerenl (example- 3@200r and100)
10. Stacie water level below top of Gulag; 19-05'
ywnrsrisivi tt ebom�: eosin& the "r'•
5t 8.
11. Borehole diameter:(ia.)
12. Well construction method: Hollow Stem Auger
(to. anger; rotary, cable, direct pull. ere,)
(•)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: - Amount:
For l$onniUse ONLY:
• 14.WATERZONES =;
ram To
ft.
ft.
l. ft.
DESCRIPTION
J
▪ 15. MITER CASING (ieei'nnIfte'ased Wens) ORLFNERpfIp REM)
P 031 7U DEMETER THICKNESS MATERIAL
fL
ft
hr.
7I6a INNER CASINO ORTOMN{i lgathermsi ihnitt-legp] .::: `7;'"
FROM
TO DIAMETER
THIL3tr SS
•
ft.
ft.
to
is
37. SCRRP.N:_
FROM
10'
Yo
30' ft.
DIAMETER
tin
tar
Lo'r SITE
0.010
TRIMNESS
Sch. 40
MATERIAL
PVC
fL
ft.
la
s*a"GROffr
FROM
0'
SL
so
8, ft.
MATERIAL
Portland
EMPLACEMENT METUOD a AMOUNT
Pour
6'
8'
Hentonite
Pour
rt.
ft.
: f9.'§AND/GRAVL1iPACK iLiipplreiets ',-
most Tit
8'
30'
ft
MATERIAL
No.2 Sand
•
EM?IACEMENr METHOD
Pour
ft
il.
te. DRILLING LOG Winch a a d[Hanat ghee r Ir ne e showy)
FROM
TO
0' 11. '� R
2 a 3' r
tJ} CRtrr1ON Odo,kardaps, r.Nrack etphlld* the, NO
LEAN CLAY
SANDY SILT
3' ft. 15' fa
LEAN CLAY
15' •
30 IL
SANDY SILT
ft
fL
ft.
R,
ft.
tti
2I E1.1ARKS %. _ h ,
bent
Signature of citified ell Contractor
2111115
1oty:,
By rrgnrng rd hurray carthy that the wrIIN ays (were) eonrrmrted in accordance
wish LEA NC.IC 02C. )100 or 1SAh'CAC 02C_oleo Wolf Construealeir SYandprds and theta
ropy of thin rsrwd ins been provided fa the well otnnar.
23. SIte diagram or additional well details:
You may use the back (Willis page to provide additional well site details or well
rAm-truction details. You may also attach additional pages if necessary.
SUBMITTAL IN8TUCITONS
242. FIE AII We1I Submit this form within 39 days of completion of well
construction tothe following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Lntectiae Was ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the £oilowing
Division of Water Rcsoums,lindcrground Injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24e. For Witter Simply & Injection Wells:
Also submit ono Copy of ibis form within 30 days o f completion of
well construction to the county health department of the county where
constructed.
form OW-1
North Carolina Department of PJLViioni coo an
dNatural Resources — Division of Water Res/sums
Revised Moo 2013

WELL CONSTRUCTION RECORD
This form can be v.scd for sing[• or 111ultiple wells
1. Well Contractor Information:
NICK PERRY
WeU Contractor Name
3329
NC Well Ccnrreetor Certification Jl.'umbu
Terraquest Environmental Consultants, P.C.
Company Namo
l, Well Constructton l'erllllt #:
List all oppltcable well p;,rnila (I.e. Cou/lly, State, Yarla,rce, lnject/011, etc.)
3, Well Use (thcck well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commerefal □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
Q!Monitoring □Recoveiy
Jnjection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recoveiy □Salinity Barrier
□Aquifer Test □Stonnwater Drainage
□Experimental Technology □Subsidence Control
□Oeothennal (Closed Loop) □Tracer
D Geothermal (Heating/Coolin g Return) □Other (explain under #21 Remarlcs)
4. Date Well(s) Completed: 2/4/15 WellIDI# MW17
Sa, Well Locadon:
109 Shell/Quality OH Comp . LLC 0-010579
Faclliry/OwnetNIIDl!I Faciliey ID# (If applicable)
4696 Thomasville Rd., Winston-Salem NC 27107
Physical Addr .. ., City, 811d Zip
Forsyth 6853-41-8955
County P&l:QCl Identification No. (PIN)
Sb. Latitude and u,nglfude in dtarees/mlnntes/seconds or decimal degrees:
('If well field, ono lat/long ls sufficient)
36.0302 N 80.1675 w
6. Is (are) lhe 'ffcll(s). @Permanent or □Temporary
7. Is this a repair t-0 an existing well: □Yes or lllNo
lftl,/s if a npa!r,flll out hioirn -.·ell ~onrlnJcllon informal/on and oploln the nalure o/11,e
,epalr 1mdtr #21 remar'/cs s«llon or 011 the hack oft/1/s fonn.
8. Number of wells C6nsfruded: _1-....,.,-------:-,----
For mullfple tnjeclfoi, o, 110n-1rater supply wells ONLY with the Srtme consrr11ctlon, you can
mbmit one form.
I For Intemal Use ONLY:
14. WATERZONF.S ."'.': ,_-.:, ~ :.:.:.~: ·.:.:;: ~ ·./?· ·:·.:;,;..?: ~-~~::': :,:::-_ ·: . .'/ .\.< ·; ;:~-~\: :':_:~-'.\":~-~:-,.:·: :~;_.>,:::·;·:-~;~:_;
:EROM TO DESCKlf'llON
ft. ft.
ft. ft.
· 15, OUTER CASING /for mulri~iili!tl \>'tllt l OR LINER nf ani>llcilble) ,::' :,,: ;;:::-.'->:·:' ,_:-:
FROM TO I DIAMETER I TlllCKNESS I l\lATEIUAL
ft. n. in.
'16.-INNER CASING OR TUBING lieolhemial cloffCl..loo'n) ;_:,;~:.: ; ,.:.· ·:. :.-. ,:_ ··: '. :-x·:.";.'
l!ROM TO DrA.'\IEl"ER nllCKNESS JIIATEllL\L
It, ll. in.
ft. ft. In.
f:17.-SCREEN '\:•.: ··_;·:: ,:·. :.:.:·:'. :-::.::.: .. '.Xi>-· ;· .·.-_::;. -:~·_:· .. >:-.:tC::::::~:·: ~-~:·:: : • ::.1,~.:-~~ _:4~::t_:~·:.~
FRO.'f TO DL\M&TER SLOT SIZE nncrao:ss lt!An:RIAL
10' n. 28' ft, 21n. In. 0.010 Sch.40 pVC
n. ft, In.
.;' 18:GROlJT, ·: ;;_-·_:-_-,,,; '.~·::,.-;:/', : '\;_;_ ·::t ~; ;-.~ ... ~: :, 1 ·-,.':,.._ •· ··;t~~-:.. ,_:.,.~~~;·~ _·:E:-.: ,.,.,;:.-. ·_;.~ .• -~ : . >
FR(»t TO MATl!RL\L EMPLA.Ct:MEl'l'T METIIOD & Al\lOVNT
O' ft, 6' n. Portland Pour
6' ft. 8' ft. Bentonite Pour
n. fl.
:>19.'.SANDIORA VEL PACK lir ,fo'iiUcablii'2~ '.(:: ·,;.::_ · :•-~-. '$,
mO!II TO IIIATERL\L EMl'LACEltlJ:1''T &1 £IHOD
8' ft, 28' ft. No.2Sand Pour
fL n.
:20. DRILLING LOG /attach addltionahbceti if noceii1n\ -~,,.-,o..._,_,. " -· ":.. ~
FROM TO DESCRIPTION (oolo, b.>J'tlntu .. tvrock ,v.,., ovlo 1bz ti<,)
O' fl. 20' n. LEAN CLAY
20' fl. 27' n. SILT
27' n. 28' ft. BEDROCK
ft, ft,
n. ft.
ft. ft.
ft. n.
,21.'REMARKS (.::';:·:_-_;;i _ -~ ·.t.~~---:' _;:-::,_~-.. '\~? ·;;.·.-:. '.f:·•"_'<, ........ ;:·-):"•:: __ ··.~:-·.~-·:·f_" .. ,-.·-
I I
I 1 22t;mf';x:;
2/11/15
Signatuie ofCell~ntmtor Dato
By slgnI11g this form. I h•r>1by cert//; that 1/,e w,1/(s) ,rar (\>·er,) constructed In accordonu
wllh IJA NC.AC 0lC ,()100 or TJA NCAC 02C ,0100 Well Cl1nstruc1/on Standards and that a
copy of this record ha< bt8n provided to ths w,ll 01+11er.
23, Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also altach additfonal pages jfneccssaiy.
SUBMITTAL INSTUCTIONS
9, Total well depth below land surface: _2_8 .. '__,,.....,._....,... _________ (ft.} 24a, For All Wells: Submit this form within 30 days of completion of well
For mull/pie 11-.IT, llsl oil dtplhs ff dlffircnt (example-3@)00' and 2@100') construction to the following :
10. Static water level below top of casing: _2_4_._4_2_' ________ (ff,)
Jf11,-arer le,:el ts abo,:e ca.r1118, use u+ •
11. Borehole diameter: 8.5" (in.)
12. Well construction 111elhod: Hollow Stem Auger
(io. au,gcr, rowy, cablo, direct push, etc .)
FORWATERSUl'PLYWEL~ONLY:
13a. Yield (gpm) ______ Method oftest: ______ _
Division ofWater Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
l4b. For InJecHon Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this fonn within 30 days of completion of well
construction to the following :
Division of Water Resourca, UndeQlronnd Injection Control Program,
1636 Mall Service Center, Ralel&h, NC 27699-1636
24c. For Water Su pp ly & In jection Welb:
Also submit one copy of this fonn within 30 days of completion of
13b. Disinfection type: Amount: well construction to the county health department of the county where c.=..:===:.::.~=-======:....:==:::.:=======.J constructed.
FonnGW-1 North Carolina Department of&virollDIOnl and Natural Resources -Pivislon of\Vater ResOllfCCs Revised August 2013
WELL CONSTRUCTION RECORD
This limn warts', used fat defile or multiple wells
1. Well Contractor Information:
NICK PERRY
Well Cantraet*rHim
3329
NC Well Cantiacsor Cerritfcafion Number
Terraquest Environmental Consultants, P.C.
Fee -Ireton' use ONLY:
14. WAT6P.7AY£8
IROM
>w
10
It.
DESCRIPTION
•15. urf.R.CASING tlofcmulH rassd Waft) oR LINER (KO- Mite} _ :•;: ` .'r
SRoM TO mA,xr rieR 1111EIMESS MATXRIAL
n n Ian
Company Name
2. Will Construction Permit lit
Litt atl sppitcable wee prrrraip tl e: Cnra+i}s SYctA 34arh:rrn0 Iryrrlloi ei J
3. Well Cse (check well Mae):
,15: riiN R cASiNGOft Ti18LNRtieot3eMal iioaed•loop)
FROMMATERIAL
TO
DIAMETER
31rick:lras
4.
in.
it.
SCRRFI't:
Water Supply Went
°Agricultural
°Geothermal (HcatingICooling Supply)
Din dustria1/Conunercial
Clintoion
DMw icipalUPublie
[Residential Water Supply (single)
Residential Water Supply (shared)
Non -Water Supply Well:
ldMonitaring DRecovey
Injection Well:
°Aquifer Recharge °Groundwater Reniediation
°Aquifer Storage and Reeoveiy °Salinity Barrier
°Aquifer Test DSt0nnwater Drainage
°Experimental Technology DSubsidertce Control
❑Geothermal (Closed Loop) °'Tracer
novothern}al (iicating/Cooiing Return) ❑Other (explain ender #21 ReinarkD)
4. Data WdRs) Cemrpieled: 214/15 Well ID M111118
Ss. Well Location:
109 Sh& I/Quality Dui Comp. LLC 0-010579
Focilipdt}wnerNemo
Facility 1Dit Cif applicable)
4696 Thomasville Rd., Winston-Salem NC 27107
PhysicalAddresf. City, end gig
Forsyth 6853-41-8955
County Parcel ldeaufiethon Yv. (PIN)
56. Latitude and Longitude in degrees/minutes/sesands or riecimai degrees:
anvil Seta. onnikolong is sun drat)
36.0302 N 80.1675
W
6. h (arc) the well(s): fLPer urasent or °Temporary
7.ISthis arepair toanexisting well: ❑Yes or El No
/fahirLs a repeir, fill axtiMaio well cwtsrrrrtian information and Explain rho whereof sits
repair under 021 remarks section or on the backofi'lls farm_
B. Number ofHells coustrucled:
For mini* rxjecitan arnon-saaser rrrppiy wells ONLYwrh As some cabatrurtren, }na can
a Irarrrli ono form.
9. Total well depth below land surface: 30' (It.)
Far asulsiple.saltf Hsi all drpahs if different (example- 3@700'and ?IWO9)
10. Static water level below top of casing: 23.51' (rt.)
I Moire la poi Is above essiox use "+„
11. Borehole diameter: 8.5n
12. Well construction method: Hollow Stem Auger
(ie. anger, rotary, cabiedirner push, etc)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) biethod of test: -
13b. Disinfection type: Amount:
FROM
1Or 1r,
Ta
30'
DIAMETER
2in
marine
0.010
731ICER SS
Sch. 40
■3.1TE IAL
PVC
Im
, t& GRGIfr.
FROM
6'
ft,
TO
61 ft.
8t
MATERIAL
Parlfand
Bentonite
flenecei ureasenioneAllf0II! T
Pour
Pour
1L
ft
'19-SANDiftRAVEGFACii ftfieolicihle}.... .:._ _ :..
FROM
To
btAtikni.i
EMPLACEMENT METUOD
8' :w 30' IL
Nn.2 Sand
Pour
iL
20. DPILIANG LOG tattieb addrllonat tOtt ts it atrestury)
FROM
0'
5'
f.
n.
TO
5'
ft,
30' R.
DI -SCRIP -MN {r else h ardpetf. son/rock Om train lie eral
LEAN CLAY
SILT
ft.
>w
it.
R
n.
fL
n.
,11: REMARKS .. . .' F::.... ,.•
-
22. C.
CA
Slgnslura ofCetti sue*[ amlecter Data
By signing Air fomr��f hereby ceri.jy rhos site svelt(s) WAS (Swere) coarnricred Os accordance
with ISA NC IC O1C .0100 or 1SA NCAC 01C.0200 iltill Construction Standards on.1 ant
copy opts record has barn 'wider! to the well etriler,
23. Site diagram or additional well delall
You may use the back of this page to provide additional well silo details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Welk: Submit this form within 30 days of completion of weI1
construction to the following:
Dh'islon of Water Resources, Information Processing Unit,
161711Snit Service Center, Raleigh, NC 27699-1617
24b. li?er Injection Welk ONLY: In addition to sanding the farm to the address in
241 above, also submit a copy of this form within 30 days of completion of well
constriction to the &Rowing
Division of Water Resources, Underground injection Control Program,
1635 Mail Service Center. RaIrigh, NC 27699-1636
24e. For Water Snarly & Injection Wells:
Also submit one copy of this form wlihm 30 days of completion of
welt construction to the county health depamnen' of the county where
constructed.
21i 1/15
FOsm OW-1
Noah Carolina Dspertmeot of Environment AndNeusraiRetovrees - Division of Water Reseusres Revised Angust 2013

WELL CONSTRUCT1QN RECORD
'1 his form tan ISO used for fin* or saultiplowetts
1. Well C'ontrot tor Information:
Wesley J. Sorrells
Welk ,drectarName
3577
WC WelI Conpactur.CeniricalifmnNunrher
Terraquest Environmental Consultants, P.C.
Company Name
2. Well Collstrnc1Ion Permit ift
IJsrell gFpiirahaa nrllpewriirs:lte. roan*: Seale. YaNear.-14e nail ear)
3. well Rise (check well use):
Water Suppkv Wen:
DAgricuiturel
[J(1tofberme (I hating/Cool ing Sui+ply)
❑ Industrial/Commercial
Dinh:alion
QtlrunicipailPublic
❑Residential Water Supply (single)
LIResidential Water Supply (shared)
Non Water Supply Well:
l3A3nnitaralg
fRecoVery
Injection Well:
El Aquifer Recharge
°Aquifer SIotage and Recovery
o Aquifer Test
❑ E1 perimental Technology
❑Geothermal (Closed Loop)
❑Genibcrmal (HcalingfConlusg Rewrrt)
4. Date Wett(s) co ntpletcd: 6111 / 15
Ea. Well Loco lion:
109 Shell/Quality 011 Comp, LLC
FMilslyfOmrrxrNaaie
C ICenund{,rater. Remedisttim
DSaltnity Barrier
AStormwa1cr Drainage
❑Subsidence Control
OTrocef
❑other (explain under 821 Remarks)
►'Fill tom MW22
0-010579
raeiiisy li ; (if applicable)
4696 Thomasville Rd., Winston-Salem NC 27107
Physical Address. City, end Zip
Forsyth
County
6853-41-8955
Pucci tdentiko uaa )io: (PIN)
Sh.LatItude and Longitude to degrees/minutes/seconds or declmai degrees;
(Orwell fold, ort0laolongis monition)
36.0302 N 80.1675
W
6. is(ore) theweli(s): GAPermanent or °Temporary
7. Is this a repair to no existing well: Cr Yes or ?JNi
f d os Is a r.•pab. Jr'ls sate known well ermrrsmruelon furarnratmil aid expiate) the adhere of dee
repair trader a21 rtrrainla senior) ornmm the bar& of rims fame.
8. Number of wells rnns(rurtcdt 1
For multiple Hdretran arnaa-natersrrpply rrrlls.ONLY lath (berme roasrrncrlan. yaa can
atitutat onelama.
9. Total pelt depth below land surface: 30'
Far ntwilllpla lea a nal oil drprhs tfdr fenm. (exempts-3@AD' and 2431110)
111. Stank water level below fopef easing: 19.58'
!jrtalerlevel A abase casiIg use "-"
iI.Boreholediameter:4.25" (in)
I2 Wellaonstructlonmethod: Solid Stem Auger
(i.e. auger, rotary, tsbft. direet pUOh. 010.
«t.)
01.)
FOR WATER SUPPLY WELLS ONLY:
I3u. Yield (gpm) Method °flest: _
13b, Disinfection type: Amount:
FormOW-1
Fat kutcrnai Ilse ONLY:
1 S. WATER 1ZONE.
FROM TO-
RE at:Li mos
f2.
0.
ft
5. MU CASINOtreemall¢qued melts) OR LINER. . cif applicable)
FROM TO m.taJSl'ERTTRIcroarsS
rr. 11. In.
MAT[I1fAL
rd f1SNER 1iC OWfUBIt (s:euttnorrio 1 eroeea-Ieorl
PROM i 7O
ft. fe.
h
DL(METhA
In.
Taittichress f MATERIAL
in.
17. SCREEN
FROM TO
*MOM
auaIsr7R
2111 ire.
SLOT SUE
0.010
TatiCetelna
Sch. 40
MATERIAL
PVC
Iir
FROM
.70
6'
6'
fl.
rt.
Portland
Bentonite
rl,ACIMIE rMUDDP.. 3iOvrtr 1
Pour
Pour
O. SA44DXRAVEL PACK 1if.ypiltaldel
FROM LTC T MATER/AL
ad n' 30' ftr No.2 Sand
EMPLACEMENT
Pour
R. if:
24, DRILLING earl tans I{.ddisJunal sheen rr areentn)
1'
3'
R1
et.
ar5C erPr{O�merr r.aud�rr..mLroeYmit r rlee.!RI
Gravel
SANDY SILT
1.51 11.
LAN CLAY
SANDY SILT
t:.
A.
ft.
21. REmmaiS
22. Cern&
Sigiatens efCe
8)18J15
Date
Bpalgultag des j l ti j eery ehal.ane well(s). war (were) causrracarrd rn.+rrccrdkmce
pith 15A nr:,lco r: or 15A IYCAC O1e.020Pl Wert Carurruertoa Sses,doa4 mil lbw a
Cop) of this reeved has beeh.prnvfded fo the !tell 0lrrtdr.
23. Site *grain of add lllonsll well details:
You may use the back of this page to provide additional µmeli.sirc details or well
construction details You may also *Mich R44itWaal pages if necessary.
SVI3Allt$TAL NSTUCTIONS
24a. For Alt Wetla: Submit this Arms within 38 da+is of completion of well
construction to the following:
.Division of 11'ater Resources, Information Processing Unit,
1617 Mail Se mire Center,.Baleigh, NC 27699-1617
23b. for 3niectiyn Well! ONLY: In addition to sending the form to the address in
24a above, also submit: a copy of this form within 30 days of completion of ooeIl
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Um ii Service Center, Raleigh, NC27699-1636
24e. Par Water Soppy & injection Wells:
Also submit one copy of this fart- within 30 days of completion of
loon cons:nlction to the comity health deplsnment of the county where
constructed.
Noah Candies DCparitotos of Environniont and Nenni Resources Division cif Wator Romulus Revised August 20i3

~
Monitoring Well lastallation
ID Date
MW-7 12/11/1997
MW-9 12/11/1997
MW-14 2/3/2015
MW-16 2/3/2015
MW-17 2/4/20 15
M W-18 2/4/2015
MW-22 6/11/2015
Table B-7
Well Construction Information
109 Shell Service
Groundwater Monitoring Report
Incident Name and No.: 109 Shell Service, 17824
Well Screened Total Depth to
Diameter Interval Depth to Water
(illebes) (feet) (feet} (feet TOC)
12/15/2817
2 10-25 25 17.25
2 10-25 25 19.09
2 10-30 30 18.92
2 10-30 30 19.03
2 10-28 28 26.12
2 10-30 30 24.11
2 10-30 30 19.46
Aelattve Greuadwater
ElevatiDR Elevation
(feet TOC ),.. (feet)
97.74 80.49
98.51 79.42
98.98 80.06
98.76 79.73
99.47 73.35
99 .09 74.98
98.92 79.46
Figure 1
Topographic Site Map
t09 Shell Service
4396 Thomasville Road
Winston-Salem, Forsyth County, North Carolina
'r
11 :y
=
S•
ys
Ssc�
r
it ; ''•
tiL ,-; r 'r'
ti a .
'
''DAVIDSON=COr - ---
-,-� A!0!1'S7tT1YR'•Q�. .,,' rr li, �� _�Z.,. ?=i
77
rL�
lON
I
%}� YQKt•
6►r!Rtkil
�I1`
/`
~• y't, DI �-1jl �•.
�,j,PWCQCftq. .11 -- $ l . � 3 �� ; r. � � . �.it:ti _.9�y¢
iz
• L ; `•
._.. •I '1,, `- .-' '''' - _ r, ) '�• t 1 r `• ' ;�\ -
•
1 ,
a.' . )/rw . it
•il . �'
i,r ti.., \ l - I
-_!.. Illy iJ,, (fl . "i. ti )'\'\ T .!1 .. _`:=,f
r_ �l tr{. .. w -�. 1
_ _ F J: .v,
V.
j j- ' .Y, n •,
`'': Acres— ■.. `;"_ g _- .
by , f �', —' 6 - � f r r 1 ,l ,c
P.O.i3ox5884
Winston-Salem, NC 27113
Telephone: [phone]
Fax: [phone]
Progress
- • �_ ,-:cifiAE0,1' �. - . Ai*
mrir zit-.
4 ��.
jl'r=ti,, f
f
104
SGS
United States Department of the Interior
USGS 7.5 Minute Series Topographic Map
Contour Interval: I0 feet
Scale: 1"=2400'
Farmington, North Carolina
Date: 20I6
8
Project: 109 Shell Service
Client: Quality Oil Co.
Progress Job #: 1017029.002
Date January 2018

\ri.z.
M W-1 0
. -- 1.. AS-1 MINri , 6 ,
-+ ,
PZ-f BV 1 -�- MWWF1s
,y11; AMW12
u. qn FLSr'.•
�y,w1d
Alltt LL��`
new-2 , 4 4 MW-20
ill
APPROXIMATE MONITORING WELL LOCATION
AS- 1+ APPROXIMATE AIR SFN GE 1hELL LOCATION
M ,APPROXIMATE TYPE lil VIELL LOCATION
APPROXIMATEAEANDONEO WATER SUPPLY WELL LOCATION
APPROXIMATE FORMER fISPENSER LOCATION
APPROXIMATE FORMER EXCAVATION LOC'AT1ON
MINA
•'#0, MW21
MW-7
CRAKE iCALE
W
N
z 6

iI
MW-8
PZ-1
6-2 :
-52-14
MWS�
LEGEND
APPROXIMATE MONITORING WELL LOCATION AND REIA WE
•
GROUNDWATER ELEVATION
-1
• 4- APPROXIMATE AR SPARSE LAELLLOCATiON
- APPROXIMATE TYPE III VuELL LOCATION
APPROXIMATE ABANDONED VWTFR SUPPLY INF—U. LOCATION
APPROXIMATE FORMER DISPENSER LOCATION
APPROXIMATE FORMER EXCAVATION LOCATION
GROUNDWATER CONTOUR ELEVATION
CALCULATED GROUNDWATER FLOW DIRECTION
N
MW-8
r (79.42
MW-18
(79.73)
MVV-14
(80.06)
AS-9
+17
(80. 9)
80
4 MVIF26
i
S.-10
N
w�.avie
rear
N
W E
z

-
-
a
f
j
1
1
-
;
#-
.7
-
1
.
jf
T
1-
wnes.r.e
spa..
o:•�14
.
MI CO
..,
w
1a
t :r,
.a
*1
gra
,,.
ma
w
wk •
tar
v
r'
a
'4
.4
.a
IAA
IS
ILA
irs
�.
.r
Y •
ILM
r,
:a.
NI
n
SA.
.
• no
v.
_-
..1
n.
i..
,LIP
N
-
i
aRft!
ErIli
OR
NI
.1r
..
W
Siwf
AV.•
M
RI
.1.
NI
-44 f
14i
40'
.M
_ _:
u41•
11
Y,
II
LB
WI
1
1.
q
'1
�
..
..
w
.MLO
`
MIL
s
W
4
w I
.,F.yM
1-
WA ILLMIN.M.LMEN %ULM.
ILL
.i
IN. o�ww.L.
IMI
.-
f z}s;
..M
u_•
Trx
lc,.
.E.e
:@_gg
=14.
:s ,t
5
LEGEND
APPROXIMATE MONITORING WELL LOCATION
APPROXIMATE ARSPARGF AEU,LOCATION
APPROXIMATE TYPE III VIELL LOCATION
APPROXIMATE ABANDONED WATER .SUPPLY WELL LOCATION
APPROXIMATE FORMF-R DISPENSER LOCATION
APPROXIMATE FORMER EXCAVATION. LOCATION
MVu1O
4
D
nci
]
C7 w
To
MPr
Q
z
7 �

LEGEND
MWS
- APPROXIMATE MONITORING V1ELL LOCATION AND
BENZENE CONCENTRATION
APPROXIMATE AIR SPARGE WELL LOCATION
t4• APPROXIMATE TYPE Ili NELL LOCATION
APPROXIMATE ABANDONED WATER SUPPLY hAELL LOCATION
APPROXIMATE FORAAER ISPEN,%R LOCATION
. - - APPROXIMATE FORMER EXCAVATION LOCATION
AS-
zpz
MV -1O
r2. 4M
BENZENE ISOCONCENTRATION CONTOUR
AA'Uhf�6
r (69)
AS-9
7
(BQL)
MNF20
A
w
-

A MWB
100'—
90'
80'
70'
60'
r��r rr�r rrr.�r
r-+ rrrr-rr ,.--0 -+
�r—�
r r
MW3 MW4 MW1
CST2 CS4 CSS
+ + .J.
141
_.-rrr
r.
FIE 0+
,1-„,„4„,„
r-
„, fir..
A,
4-r_
//-
\\.
/.,
11--p•••11•--11•••II••II•••11•••I- • - II• •;
1 stu--.p...11....11...11.-_11...11...11...11-• 1N..
IIJ N II II !1 11 11 // 11 11 II
NEW USTs
MW7
•••11- 11'•/I•'•11•'•d-••11...11--•11.--H•• J-1/•-•11•••11'••11.••II••;/f•• IP - 11 "y' •y•••11•••11••.11•••11' •11•.••H'••11
11-.-11••-)A---#••-a-•-11••-1/'-•1I-' II---II-II-••1-•-11'.II- •.11,•II•'•II••-II•••p ••p•••y••d••-N.-41-• I! •11'•-11---
11.. AV !*-A
* ..11...p..H..11..h...N 11.11...H...11...yfe..1. AV - A1...1i 11• '1� AV AV.
11• AV AV 11.. A
--1/---11---11-•�Mr�11•••II-• •11-•-11••-11---1/•--II-•oe1/••-11••-11---11---N-••/1••-II-..II•-•II••-11-'-II--•11•••11•••11.
100' MW9
90' -
80'
7Q
60'
C513 MWB8 CS11 CS10
T r rc
Do a
MW2 U
L-
.11...11- ..11..-11...11• •11• - •11• -•11...11...11...\1...11...1\• .11...1
•11•• II ••11•••11• •ll'••il• ••11• •1/••4.•-11•--11---N...11•--11 •N•--11-
U• •11 11 11 11 �11 11 11 11 11' •11...11...1 . -11- • -11•
-•II-••11••-II•--11•--11-•-Ilt •11••-II•••11•••I1.••11.•.11••• •••II•••el-
a
YEr1CAL SCALE
1" 16' +a
c
0011111111111
A} LEGEND
le' 70'
HORIZONTAL SCALE
20'
Clos a Sample
Location
Estimated extent
of sal impact
- 'OTENTIOMETRIC SURFACE
LEAN CLAY 10 SILT WITH SAND
Brown / red fill material. mostly Leon day
With some sand and grovel, medium tit
SILT WITH 5AN6 To SILTY CLAY SAPROUTE
Orange to red with yellow and white -sine
Sit clay and sand with remnant structures
medium atlR.
BEDROCK
GRANITE
MONITORING WELL MW4, BB, CSS, C. CS9, CS12, MO
CS11 WERE PROJECTED OR THE CROSS-SECT'.ON,
TYPE II WELL
TANK PIT
TYPE nl WELL Sa11 Sample
Locution
141W1 - —Well Ill--u- MW4 B8
—Coring
t
--
Interpreted extent a NCAC 2L
eiatoti0n
Screen--._
-.—Sereari
Outer Casing
14< CBI
10W1
fl
6
z
CC
03
0
a

100'
90'
80'
0'
60'
MW8 MW3 MW4
•
MW1
r,Sti rsq CSR
*gill
Artltaiiiitd.?rfivorrA.5,
rtyzaw7
•
Ar://,,,,_11_, n• 11 -1• H I -11•1-.11.•11.•1/.-11I
.11...11...11.•-\V••11..-►1•-
•1
•1••4/.-•1•••1•••1/•••H•••1
n---►1---u---]}•--►►---►1---A1---►►---u-• AI- •-H---u---A---A•--.
11• y...11••11•,11•• 11.--#.•-11- -11.. ,..#-,.11.•-1►...1/---/1. •-11.- II- -11•-I1.--y.•11.•-11.•.1/...11.-.-N..11.
-A- • •NN..11- - ►► • -A- •A• •►■- - -A- AN- •w• u ..p.. -A- A- •A 1 •u• ►► ►1 ►►• 11 ►1 • •h • n - •►►
H•-•/I-•.jt--•H••,H...H•_•//-••//--•H•••IIa•H•.•//-••11•••11••-11a.•,H..•l1•-•I1...//--•//.../I...H...11--•11•..11-•.H..
-►..•11._*V4,•11...11...11...11...11...11,-11•-•11...11..•A•- ..Il...11...A-•-1...11-•A•..11,,.11...11...A-••11..,u,.•V
11•••//--II-'AFy11-•-11-•-11•••11••-/I- ••.11--•11• 1-.0.711••-11•-•11•-.11••-11-•11•--H--11•••11••11.-11---11•-1/• -II
B
100r MW9
90'
80'
70'
60'
CS1 3
INWb
MW2 B1
CSL1 C510
- ire
- .,l.. •V..• - . - .■■• - 1■ -• ►N, • .11• n• ■S.-..n.. -A n• •'A 11
.11...//. , ./I. •-11...H. , .jk...11- • .11...11.. 11...11...11. • .11- -II/ •1/- - -//-
h-..11.,,11...11.,.11.,.11• ��1•-•►■,..u,-.u...lh• Il �1 ■ 1� - 1►•
•--11-••H••.11•'.11•••11..../ _II• II II •:H••.11• ••11•..►1
VERTICAL SCALE
iO'
A
NEW USTs MW7 A' LEGEND
POTENTIOMETRIC SURFACE
LEAN CLAY TO SILT WITH S H
Brown / red fill material. mostly lean clay
with some sand and gravel. medium stif
EZZa
ALLii
SILT WITH SAHR TO sIL.TY CIAY SAPROLRE
Orange to red with yellow and white veins
Silt cloy and sand with remnant structures
medium still.
OEOROCK
GRANITE
MONITORING WEU. IRW4. 58. C58. cs . C59. C512. AND
C511 WERE PROJECTED ON THE CROSS-SECTION,
TANK PR
TYPE H WELL TYPE III WELL Soil Sample
Lacotion
MW1-.--W'I MW4 88
-o—Cosing
Screen
Outer Casing
-----
Interpreted extent of NGAC ?L
violation
ra• .Ir
HORIZONTAL SCALE
2p'
1
.A •
MW1
4
Clow. a Sample
Locotfan
Estimated extent
of soR impact
A'
7
Screen—._
MW2