WI0400513_DEEMED FILES_20190306

WELL CONSTRU(.llON RECORD {GW-1 / For Internal Use Only:
1. Well Contractor Information:
Matt Ed mund 14. WATER ZON.ES
FROM TO DESCRIPTION Well Contractor Name 22 ft. 35 ft. 4451-B silty sand
ft. ft.
NC Well Contractor Certification Number 15. OUTER CASING 1for multi-cascd\nllsJfRLINER \if a r,rlkable l IET FROM I TO I DIAMETER THICKNESS I MATERIAL
ft. ft. ' in.
CompanyName WIQ 00513 16. INNER CASING OR. TUaING (~eotbermaJ closed-loo Pl
2. \Yell Construction Per·mit #: 4 FROM TO DIAMETER THICKNESS MATERL.\L
List all applicable well constn1ction permits (i.e. County. State. Variance. etc.) 0 ft. 33 ft. 1.75 in. AW Rods Steel -
3. Well Use (check well use): ft. ft. in.
1 Water Supply Well: 17.SCREEN
FROM -TO DIAMETER SLOT SIZE THICKNESS MATERIAL B Agricultural □Municipal/Public 33 ll. 35 ft. 2.25 in. 1/8" holes 1/8" Steel
Geothermal (HeatingiCooling Supply) □Residential Water Supply (single) ft. ft. in..
Q industriali Commercial □Residential Water Supply (shared) 18. G,RQUT
7 1rri ·•ation ~'ROM TO J\,IATER1AL EMPLACEMENT METHOD & AMOUNT
Non-\Vater Supply Well: ft. ft.
7 Monitoring n Recovery ft_ ft.
Injection \Veil: ft. ft. '.:J Aquifer Recharge .Soroundwater Remediation
19. SAND/GRAVEL PACK lif an olkablel :J Aquifer Storage and Recovery □salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
□Aquifer Test Qstormwater Drainage ft. ft. None
:JE:-..1>erimental Technology □Subsidence Control ft. ft.
J Geothermal (Closed Loop) Ori-acer 10. IIIULI I -.r; I Ot; (attach additional sheets lfnecess 1r-a1
i]Geothermal (Heating/Cooling Return) n other(explain under #21 Remarks) FROM TO DESCRIPTION (color hardness, soil/rock t :1ic, 1 ain size, etc.
rt. ft. No sampling -rods driven
Well ID#A 1-4 4. Date Well(s) Completed: 2122 J2 0 19 ft. ft.
Sa. \:Veil Location: ft. ft.
Former Johnson Grocery ft. ft. -~,rnEQJO\NR
ft. RECi.'' .......
Facility/Owner Kame ,, !, 1J1r1v1tnc
5870 NC Hwy 268, Dobson rt. ft. .. ~ 'Jn\q
Physical Address, ., and Zip ft. r\J I\K v" -
Surry 11. REl\1ARKS .... ,
;;ater u .... ~-·-, tiof\
County Parcel Identification No. (PIN) ln-jection scrce q; ~~tg@'ft bgs at four lo ___ :_-,:
Sb. Latitude and Ion itude in de rees/minutes/seconds or decimal dearees:
~eg1 g g
(if well field, one lat/long is sufficient) 21. Ce1·tificalion:
36.3429 80 6572 ______ N_·------~~ / 2725-A for Matt Edmund 2/27/19
6. ls(are) the well(s)QPermanent or jEfTemporary
7. Is this a repair to an existing weU: 0Yes or _fflNo
{fthis is a repair,.fill out kno-,n wall construction infomwtion and explain the nature of the
renair untk,·#21 rf?marb .~t?cti011 nrm, the back: nfthis t"nmr.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, onJy 1 G\V-1 is needed. Indicate TOTAL :Nll1...IBER of wells
drilled: Four
S1gnalui-e
By signing this form. I hereby certify that the wel/(s) was (were) constmcted in accordance
with 15.4. NCAC 02C .0100 or 15.4 NC AC 02C .0200 Well Constn1ction Standards and diat a
copy of this record has been provided lo the well o-,ner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site detaiJs or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
36 9. Total well depth below land surface: _____________ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different (example-3@200 • and 2@100') construction to the following:
10. Stanc water level below top of casing: ~22 (ft.) Division of Water Resources, Information Pronssing Unit,
If wafer level is above casing. use "+.. 1617 Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: _2_.2_5 _____ (in.)
12. Well construction method: _D_P_T ______________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ________ Method oftest: ________ _
24b. For In jection \\lells: In addition to sending the form to the uddress in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of\Vater Resources, Underground Injection Control Program,
16361\'Iail Service Center, Raleigh, NC 27699-1636
24c. For Water Su nn h & Injection Wells: In addition to sending the fonn to
the address(es) above, alrn submit one copy of this form within 30 days of
13b. Disinfection type: Amount: completion of well construction to the county health department of the county L..::.:::...:=::.::.:.:.:=::....~:..========-_:===-=========:J "·here constructed.
kin• I \\ I , •nh 1r " Department of Environmental Quality -Division of Water Resources 2-22-2016
WELL ABANDONMENT RECORD
I. Welt Contractor Inlbrnu tion:
Matt Edmund
Well Contractor Name (or well owner personally abandoning well on Mae rropeny)
4451-B
I ET
Company Name
2. Weld Construction Permit #: Wi 040051 3
1 iar all app1cabk null consvuetlnafprima .
3. Well use (check well use):
stare, larienca, • ((know:
'Water Supply Well;
❑Agricultural
❑Geothermal (Hoatingroaline Supply)
o lnduatriali Commere ial
' ❑Irri ation _
Non ester Supply Well:
❑Monitoring
Inject kill Well:
°Aquifer Recharge
❑Aquifer Storage and Reeovery
❑ Aquifer Test
CILxperimental Technology
11 ❑Geothermal (Closed Loop)
OGaothermat (Henting'Cooling Return)
❑Mnnicipal/Publie
❑Rcsidemiial Water- Sappfy (single)
❑Residentistl Water Supply (shared)
°Recovery
ilGroundwater Rem ediation
Salinit►' Barrier
❑Stormwater Drainage
❑Subsidence Control
°Tamara -
❑Other (explain under 7g)
4. Date well(s) abandoned: 2/22/19
5a. Well location:
Former Johnson Grocery
Facilirylpwner None
WELL ABANDONMENT DETAILS
7u. For GenprohelDPT or Closed -Loop Geothermal Wells having the same
well construction/depth, only 1 G►V-30 is needed Indicate TO'f.A.I, NUMBER of
wells abandoned: Fa+r
76. Approximate volume of water remaining in well(s): 2.5
(gal.)
FOR WATER SUPPLY WELIS ONLY:
7c. Type or disinfectant used: -
7d. Atununt of disinfectant used:
7e. Sealing materials used (check all that apply):
❑ Neat Cemmn Grout ■ Bentonite Chips orPeileta
O Sand Cement Grout 0 Dry Clay
❑ Concrete Grout 0 Drill Cuttings
11 Specialty Grout vo >'1JED111.' 0 Gravel
❑ Bentcrnite Slurry ❑ 0.0er (ea -plain under 7g)
7E For each material sefectetf93k+k'ide amount of materials used:
-50 ibs Hole Plug (bentonite)
YM
7g. Provide a brief description ufthe abandonment procedure:
Removed injection screen and drive rods, filled
boring with 3/8" bentonite chips.
N. Certification:
5870 NC Hwy 266, Dobson -7,�,�
�� I lL 2725-A for Matt Edmund
Physical Address, City, and Zip Siorctturr c rlilici.1 Weil. Contractor or Well Owner
Sully
County
Pane t Identification /Vo
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
Orwell Yield, env letlkmg is sufficient)
36.3429 N 80.6572
Ha-
CONST'RUCT1ON DETAILS OF WELL'., BEING ABANDONED
.-cloth well construction r ecorrl jai ifmwiivbls- Y'or multiple injorthan orator- woirrsupply walla
ONLY with the same construction/abandonment, you can subrrrit one foots.
6a Well Ill#: A 1-4
4b. Total well depth: 35 [$ ]
6r. Borehole diameter: 2.25 (in.)
ad. Water level beiow ground surface: M22 (ft.)
6e. Outer casing length Of !mown): _ (f1i.)
33
Gf. Inner coaing/tubing length (if known): (1t.)
6g. Screen length (if known): 2 (ft.)
2/27/19
By srgrriag Ike form, I hereby certdf}+ shad the welf(sI was •
fro
ac•cordonce mirth 15.4 NCAC 02C .0100 or 2C .0200 Well C onarrvarttnn Standards
Rrtrd rho: a cops of this r ocard ha. been provided to she well owner.
9. Site diagram or additional well details:
1-on may use the book of this page to provide additional well site details or well
abandonment details. You may also attach additional pages ifnceevanry.
SUBMITTAL INSTRUCTIONS
10n. Fo MLWas: Submit this forth 'ithin 30 days of completion of well
Abandonment to the following:
Division of Water Resources, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For InjectionWells: In addition to sending the form to the address in 1{la
above. also submit one copy of this form within 3 t) days of completion of well
nbandoomemt to the following
Division of Water Resources. Underground Injection Control Program,
1636 Mail Service Center, Raleigh. NC 27699.1636
10t. For Water Suply& Infection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form vrithin 31) days of completion
of well abandonment to the county health department of the county where
abandoned.
Department of Envrrnrunentat Quality - Division of Water Resaurco

North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400513
1. Permit Information
Ter.-acon (Charlotte )
Permittee
Fonner Johnson's Grocer v
Facility Name
5870 NC-268 . Dobson . Surry Count ,·
Facility Address (include County)
2. Injection Contractor Information
Matt Edmund / JET
hljection Contractor/ Company Name
Street Address 232 Hw ,· 49 South
Concord , NC 28025
City State Zip Code
(980 ) 781-0008
Area code-Phone number
3. Well Information
Number of wells used for injection __i
Well IDs _.-c.A___,1-__ 4 _________ _
Were any new wells installed during this injection
event?
X Yes D No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells 4
Type of Well Installed (Check applicable type):
D Bored D Drilled X Direct-Push
0 Hand-Augured D Other(specify) __ _
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
X Yes O No
If yes, please provide the following information:
Number of Monitoring Wells ------
Number of Injection Wells __ ...:.4~----
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Potassium Persulfate , Sodium Persulfate . Ferric
Oxide
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Pot. Persulfate 5. 7% by weight
Sodium Persulfate 8% by weight
Ferric Oxide 3.5% by weight
Water 82.75% by weight
If the injectant is diluted please indicate the source
dilution fluid . On site water su up h
Total Volume Injected (gal) 2700
Volume Injected per well (gal)_6a..a7 __ 5 ____ _
5 . Injection History
Injection date(s) Februan 21-22 , 2019
Injection number (e.g. 3 of 5)_1 ___ o __ f ..._1 ___ _
Is this the last injection at this site?
X Yes D 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
ST AND ARDS LAID OUT IN THE PERMIT.
~ T _ 2J25-A _ _ 2/26/2019
SlGNA n m OF [N.TECTION CONTRACTOR DATE
Matt Edmund _ _ _
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: DIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
D~ \./V ':u,) if O O 51 3
North Carolina Department of Environmental Quality -Division of Water Resources
INJECTION EVENT RECORD {IER}
Permit Number WI0400513
I. Permit Information
Terracon (Charlotte)
Permittee
Former Johnson's Grocery
Facility Name
5870 NC-268, Dobson , Sur rv Coun tv
Facility Address (include County)
2. Injection Contractor Information
Matt Edmund/ IET
Injection Contractor I Company Name
Street Address 232 H wy 49 South
Concord , NC 28025
City State Zip Code
(980 ) 781-0008
Area code -Phone number
3. Well Information
Number of wells used for injection _4::,__ __ _
Well IDs _.;.A.::....:::..l•-=4 _________ _
Were any new wells installed during this injection
event?
X Yes D No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells_ ..... 4;.__ ___ _
Type of Well Installed (Check applicable type):
D Bored D Drilled X Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
X Yes D No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number oflnjection Wells __ ..,::4 ____ _
Please include a copy of the GW-30 for each well
abandoned.
4. lnjectant Information
Potassium Persulfate. Sodium Persulfate, Ferric
Oxide
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Pot. Persulfate 5. 7% by weight
Sodium Persulfate 8% by weight
Ferric Oxide 3.5% by weight
Water 82. 75°/4 by weight
If the injectant is diluted please indicate the source
dilution fluid. On site water su pp ly
Total Volume Injected (gal)_..:::2"""7.::::.;00:::....._ ___ _
Volume Injected per well (gal)_6 __ 7"""'5"'------
5. Injection History
Injection date(s) Februa ry 21-22, 2019
Injection number (e.g. 3 of S) ____ l ___ o=-f.:.l ___ _
Is this the last injection at this site?
X Yes D 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.
-,,.,1 ·L -~ rru,re,t1., /~ 2725-A 2/26/2019
SIGNATIJ RA;70F INJECTION CONTRACTOR DATE
Matt Edmund
PRINT NAME OF PERSON PERFORMING Tiffi 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
r �►�al<-r-�rin
WELL CONSTRUCTION RECORD !GW-11
1. Weil Contractor Information:
Matt Edmund
Well Contractor NameREiv►+cDl
COWR
4451-B
NC Well Contractor Certification Number ��
IET 062019
Company Name
�
11:
V 1F1� ���[t�f]]]]riFE 14Y
2, Well Construction Permit #: s
Liv'r all amlicahle well carairecrion pe.rrlp rx (I-C. LIf£ , Catni6,, Slaw. arrarrce, etc-1
3. Will Use (cheek well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cooling Supply)
Industrial/Commercial
Initiation
Non -Water Supply Well:
Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed loop)
Geothermal (Heating/Cooling Return)
DI Municipal/Public
0Residenlial Water Supply (single)
r3Rcsidential Water Supply (shared)
°Recovery
QI
Groundwater Remediation
°Salinity Barrier
DStormwuter Drainage
°Subsidence Control
01 -I-racer
n Other (explain under 421 Remarks)
4. Date Wellts) Completed:2/22/2019
.5a. W'ell Location!
Former Johnson Grocery
Well ID#A 1-4
Fee iliry/Owrwr Nome I acility ID6 (if applicable)
5870 NC Hwy 268, Dobson
Physical Address, City, and Zip
Surry
County Parcel Identification No. (MN)
5h. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
{ifwc11 field, oue Iatllin g is sufficient)
36.3429
n 80.6572
6. Is(are) the wellts)OPermanent or E3 Temporary
7. Is this a repair to as existing well: ®1'es or Elm,
lithos Is ❑ repair, Jilt ern !max well Lmrrsrruerron irrfrrr iallw1 and erplairr the ,MI re of die
repair varier r. 21 remarks reertaa or on the hack of lair form.
8. For GetlprohefDPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. indicate TOTAL NUMBER of wells
drilled: Four
4. Total well depth below land surface: 36
For audtq k wells list all depths ff differclrl (crumple- 3@20t' and 261tI4 )
10. Static water level below lop of rasing: -22 (rl.)
If wafer level Is above casing, use "* "
11. Borehole diameter: 2.25 (in.)
12. Well construetiou method: OPT
(i.e. auger, rotary, cable, direct push. etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: _ Amount:
For Internal Use Only:
14. WATER ZONES
FROM -
TO _
DESCRIPTION
22 f'
35 R•
silty sand
ff.
ft,
15. AUPCERCASING [tar raulti-cased weliel OR LINER Of sip
licabkf
PROM
TO
DIAMETER THICKNESS
MATERIAL.
fl.
fr.
j1 in.
16. INNER CASINO OR'TURING geothermal elated-loo,p)
FROM
TO
DIAMF.7ER THICKNESS
MATERIAL
0 f
33 n•
1.75 is
AW Rods
Steel
ft.
ft.
in.
17. SCREEN
FROM
33 r'
TO
r DIAMETER
SLOT SI7.E
THICKNESS
MATERIAL _
35 it
2.25 in'
118" holes
1 /8"
Steel
R
D.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
t1.
ft.
1 v. SANDIGRAVEL PACK
Of applicable)
FROM
TO
MATERIAL
EMPLAM inrrmEHOD
e•
None
ft
ft.
i
20. DRILLING
LOG length
additiunal sheets if ncoe,sar )
FROM
TO
DLSCRIPTION rMar, hawdne r. soiilroek ry pe, train size. err.!
h
ft•
No sampling - rods driven
ft,
ft.
ft.
ft.
fa.
ft.
ft.
ft.
fL
ft.
-
ft.
ft.
1
21.1LEMARKS
L .,1:
tjeetie n e R-te-35L s-
22. Certification:
i
Siguatu=
2725-A for Matt Edmund
ettifutd Well Contractor
2/27/19
Date
Hy .signing ehds filrnr, 1 hereby certify thy the well(s) iiwr (acre) cinam w'/ed Oi acemyl nee
with 15.4 MAC 02C.0MO or 15 3 N(.'AC q7C .0200 Well (1onstmclian Standards and that a
copy of this record has hceir provided to the well rrwner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
constructions details. You may also attach additional pages if necessary_
SUBMITTAL INSfRUCTIQVS
24a. For All Wells: Submit this form within 30 days of.completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Rsltigh, NC 2764E-1617
24h. For Injection Wells: In addition to sending the form to the address in 24a
above_ also submit one copy of this form within 30 days of completion of well
construction to the following_
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Sumuli & lniectiun Wells: In addition to sending the form to
the address(es) above, 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.
Form GW-I
North Carolina Derailment of Env iranme
ntal Quality - Division of Water Resources Revised 1-22-201e

WELL ABANDONMENT RECORD
For Internal use ONLY.
1. Well Contractor Iofarmatioo:
Matt Edmund
Well Contractor Name for well wvtier personally abandoning well ost hisiber property)
4451-B
NC well Contractor Certification Nuutber
IET
Company Name
2. Well Construction Permit #: WI0400513
Llet all applicable well cwiunncuanaern1,M fi.e. CIIC; county, Slate. F'arittnce, etc. if known
3. Weil use (check well use):
Water Supply Well:
❑ Agri cuRural
❑Geothemral (HeatinWCaoling Supply)
°Industria I/Commercial
CI irrigation
°Municipal/Public
DResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Welt:
❑Monitoring
CIRe.covery
Injection Well:
°Aquifer Recharge •
°Aquifer Storage and Recovery
CI Aquifer Test
❑ Experimental Technology
o Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
4. Date well(s) abandoned: 2/22/1
9
5a. Well location:
Former Johnson Grocery
Facility/Owner Name
5870 NC Hwy 268, Dobson
Physical Address, City, Ind Zip
Spiry
UGroundwater Rentediation
°Salinity Barrier
OStolmwater Drainage
°Subsidence Control
0Tracer
DOther (explain under 2s)
Facility ITW (i f applicable)
County Parcel identification Nu. (PIN)
5b. Latitude and longitude in degreeslminuteslseroxds or decimal degrees:
(if wall field, one Jar:long is sufficient)
36.3429 N 80.6572
W
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach wellctivarucvlon rev ird(rj of ararlahle. 1•ur multiple tiyrctron oriron itxrlerstyyrly wrllr
ONLY mph the .ware criirvrrsrctlnn aharrdanmrxl, ywr con ,vrihruli axe frriiri,
63, Well IIH#: A 1-4
6b. Total well depth:35
6e, Borehole diameter: 2.25 [in.i
6d. Water level below ground burbler* -22 (1%}
6e. flnler easing length (if known):
61 inner rasing/tubing length (if known): 33
fig. Screen length (if known): 2
Funk) CiW.:10
(IL)
(It.)
(ft.)
WELL ABANDONMENT DETAILS
7a. Fur Ger/probell)r1 or Closed -Loop Geothermal Wells having the same
well construction/depth. only 1 GW-30 is needed Indicate TOTAL NUMBER of
wells abandoned: Four
7h. Approximate volume of water remaining in well(s): 2'5
(gal-)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
Id. Amount of disinfectant used:
7e. Sealing materials used (check ail that apply):
E Neat Cement Grout
❑ Sand Cement Grout
0 Concrete Grout
O Specialty Grout
• Bentonite Slurry
• Bentonite Chips or Pellets
° Dry Clay
C Drill Cuttings
O Gravel
O Other (explain under 70
7E For each material selected above, provide amount of materials used:
-50 Ibs Hole Plug (bentonite)
7g. Provide a brief description of the abandonment procedure:
Removed injection screen and drive rods, filled
boring with 3/8" bentonite chips.
8. Certification:
7 / 2725-A far Matt Edmund 2/27/19
Signature of yT tVied Well Contractor CC Well Owner Dare
By signing this form. 1 hereby rerllfv that the well(s) was 6rerrej abandoned rrz
accordance with 15.4 NCAC 02C .0100 of 2C ,0200 Well Construction Standards
Anil Mg: a copy of this record has been provided to the well otvner.
9. Site diagram or additional well details:
You may use the hack of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRLUCTJONS
Ha, For All Wells: Submit this form within 30 days of completion of well
abandonment to the following'
Division of Water Resources, Information Processing Unit,
16I7 Mail Service Center, Raleigh, NC 27699-1617
LOb, For laieletion Wells: In addition to sending the form to the address in 10a
above. also subntit one copy of this fore within 30 days of completion of wail
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Sutritih & Injection Wells: In addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonnent to the county health department of the county where
abandoned.
North Caroline Department of Environmental totality - division of Wilier Resources Revised 2-22-.Olb

Permit Number WI0400513
Program Category
Deemed Ground Water
Permit Type
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Johnson's Grocery
Location Address
5870 NC 268
Dobson
Owner
Owner Name
Gary
Dates/Events
NC
Orig Issue
1/28/2019
App Received
1/17/2019
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27017
Hodges
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
1/30/2019
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
Surry
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Gary Hodges
1558 Pratt Rd
Ararat
Issue
1/28/2019
Effective
1/28/2019
NC 27007
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 (1 5A NCAC 02c .0220)
These wells are used to inject uncontammated fluid into an aquifer to determme aquifer hydraulic characteristics.
IN SITU REMEDIATION (1 5A NCAC 02C .0225 ) or TRACER WELLS (15A NCAC 02C .0229 }:
1) Passive Injection S ystems -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: January 15, 2019 _ PERMIT NO. N Io 4-0 0 5 Io (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
____ Air Injection Well ................................... ~R~:Ctions B through F, K, N . -.,.~c~~ . ___ Aquifer Test Well ....................................... Comple M ectlons B through F, K, N
___ Passive Injection System .......................... l~\t:~l~te sections B through F, H-N
X __ Small-Scale Injection Operation .................... :~~dsg~ B through N
,,,. ~0 ns
____ Pilot Test.. ..................................... ' ie9'ot\~~ete sections B through N
___ Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
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): Gary and Teresa Hodges ______________________ _
Mailing Address: 1558 Pratt Road
City: Ararat State:~ Zip Code:_2~7~0~07~ ___ County: _____ _
Day Tele No.: 336-374-6178 Cell No.: __________ _
EMAIL Address: [e-mail] Fax No.: __________ _
Deemed Pennitted GW Remediation NOI Rev . 3-21-2018 Page 1
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: --~S=a=m=e~as~ab~o~v~e _____________________ _
Company Name ---------------------------------
Mailing Address: ________________________________ _
City: __________ _ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ____________ _ Cell No.: ___________ _
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONT ACT (Typically Environmental Engineering Firm)
Name and Title: Haley Hindes / Staff Geolo gist
Company Name : ~T~err=ac~o=n~-----------------------------
Mailing Address: --~2~70=1~W~e=s..,tp~o=rt~R=o=a=d~---------------------
City: Charlotte
Day Tele No.: 704-509-1777
State: ~ Zip Code: 28208 County: Mecklenburg
Cell No.: 704-506-8107
EMAIL Address: hale [e-mail] Fax No.: 704-509-1888
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: "-'Jo=hn=s=on='....,,s__,G=r=o=c=ery:...,..... ____________________ _
5870NC268
City: --~D~o~b~so=n~ ________ County: Surry Zip Code: ___ 2~7~0 ~17~
(2) Geographic Coordinates: Latitude**: 36 ° 2Q___' 33.84 "or 0
Longitude**: 80 0 39 ' 23.94 "or 0
Reference Datum: _____ .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:~2=0~0~0~0 ____ square feet
Land surface area ofinj. well network: 1 250 square feet (,:S 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (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.
Deemed Pennitted GW Remediation NOi Rev . 3-21-2018 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
Terracon prop oses to in ject potassium and sodium persulfate activated b y ferric iron throu gh four DPT injection
oints in the area of MW-7 attached fi ure to kee the contaminant lume from mi ratin off the site. The
target injection interval is between 25 and 35 feet below ground surface. Sodium and p otassium persulfate were
chosen in order to have a staggered release.
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 hun ://de<.1.nc.gov/about/divisions/water-
resources/water-resources-nermits/wastewater-branch/ gr ound-water-r rotection/ er ound-water-anproved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (9 I 9-
807-6496).
Injectant: Sodium Persulfate ___________________ _
Volume of injectant: 1800 lbs
Concentration at point of injection: -=-1=3=-=.0'-"o/c.,..o...,w_,_,_/_,_w'--------------------
Percent if in a mixture with other injectants: ___ 4"""'6,c.,._,_4""%.__ _______________ _
lnjectant: Potassium Persulfate
Volume of injectant: -""'1:..::3"""0""'0...:.lb""'s"------------------------
Concentration at point of injection: --""'9~.""'4-'-o/c"-o ~w:..:..lw~------------------
Percent if in a mixture with other injectants: --~3~3~.5~0~1/o~----------------
lnjectant: Ferric Iron
Volume of injectant: 700 lbs
Concentration at point of injection: --""'5~·=6..a..o/c.a..o '""w"'"/w~------------------
Percent if in a mixture with other injectants: 20.1%
K. WELL CONSTRUCTION DATA
REC1aVEr-1r
(1) Number of injection wells: NIA Proposed,_ _____ Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-1 s, provide well <JA~ction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
\I
multiple wells with the same construction details. Well constructllegbtlils shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribu~on 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 Pennitted GW Remediation NOi Rev . 3-21-2018 Page3
02/06/2014 00:t3 FAX
Zoos
L. SCEEDULES - Briefly describe the schedule for well construction and injection activities.
n activities are d to start on Februa 7 1 end be ca t Febru $ 2019
M. MONITORING PLAN - Describe below or in separate attachment a ntonitoring plats to be used to determine
if violations of groundwater quality standards specified in Subchapter a2L result from the injection activity.
l ijn,dwater samples 1,61lin collected from the on -sits monitoring wcl1s_approximatelp 2 months after iniec;i;n
activities are comrlert.,
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Wc]i OwncrlAnplieant: "I hereby cerlfjy, under penalty of Taw. that I am familiar with the rnjormarion
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 offlnes and imprisonment.
for submitting false information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the
injec i well and all related appurtenances in accordance with the 151 NC4C NC OJQQ Rules."
m ica O&M eft--
elm ApptkPrint or Type Full Flame and Tttic
Proms Owner (if the property is nQt Qwned by the Well Owner/Applicant):
"As owner of the property, on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) co )arm to the Well Construction Standards
(' ' 4 Ni.AC 02C .O2OO). „
"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 rn lieu ofa signature on this form,
Please send X (one) hard color copy of his NOT along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to tnlectlon to:
DWR - UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Pennined GW Rome Nation Ntal Rev. 3-2I.2O18 Page A
O1/04/2019 8:19AM (GMT-06:00)

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71149156A
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Approval by:
CLC
Data:
November2018
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TOPOGRAPHIC MAP IMAGE C0LXiTESY OF THE U.S. GEOLOGICAL SURVEY
QUADRANGLES INCLUDE: COPEtAND, NC (1/1/1994).
lrerracon
2701 Westport Road
Charioth, NC
SITE LOCATION MAP
Former Johnson's Grocery
5870 NC Highway 268
Dobson, Surry County, NC

MW-6
_ _ _ _ _ (Not Located)
'Mw_`---------------Ridge ------e_----___—_______
rnw-s - -
Not Located)
Pilot area 25-35' bgs
with 4 intecr Uon points
MW4
DIAGRAM IS FOR GENERAL LOCATION ONLY,
AND IS NOT INTENDED FOR CONSTRUCTION
PURPOSES
Project Manager;
HE H
Drawn by
HEH
Checked by: CLC
Apprevedby' CLC
VACANT FORMER
GROCERY STORE
FORMER TANK
BASIN
Preledt No.
71149156A
Scala:
1"-60'
Fite Neme:
2
Date:
Nov. 2018
MW-1
r—
CANOPY
MW-2
1Ferrcon
2701 Westport Road
Charlotte, NC
AUTO REPAIR
SERVICE CENTER
GARAGE
•
•
LEGEND:
�� denotes approximate site
boundary
Qdenotes approximate 10' radius
of influence injection point
— denotes approximate location of
drainage feature
denotes groundwater monitoring well
•
•
•
•
,
•
•
4
denotes proposed monitoring well
SITE PLAN
Figure
Former Johnson's Grocery (incident #30594)
5870 NC Highway 268
Dobson, Sorry County, NC
2

.r 4-
MW-7
(Eievahon Unknown)
DIAGRAM IS FOR GENERAL LOCATION ONLY,
AND 15 NOT INTENDED FOR CONSTRUCTION
PURPOSES
MW r
____ 77Rid e
tNotLocated)----��—.-- _.._-- --9-Llii$-
MW-5 / 79' era - _ _.
(Not Located) p +•
/ i `•,
i•
f / / •�`•
•
MW-6 /
83'
/•
t of f / / J `•
/ ••
i - e. ; / I �•
MW 2 / , `•
/ i7.2aj / / •♦
/ / •.
/
Psopet Uan.ger.
HEH
ProiNtNo.
71149156A
Dram y:
HEH
SWP:
Chaekadby: CLC
Fat Halm:
2
App eby: CLC
Nay. 2018
lFerracon
270T Waalper! ROC'
Charlotte, f!C
•
•
LEGEND:
approximate site boundary
denotes approximate location
of drainage feature
estimated groundwater
contour
' — estimated groundwater
flow direction
groundwater monitoring
well
GROUNDWATER ELEVATION MAP
Figure
Former Johnson's Grocery (Incident #30594)
5870 NC Highway 268
Dobson, Surry County, NC
3

Sample ID: MW7
Groundwater Sample
6200 -Benzene: 3,900 pg.L
Chloromethane: 37.1,1 pejL
Ethyl benzene: 665 KgIL
leap re pylb enzene: 21.6J ugh_
Naphthalene: 139 nil_
Styrene' 16.6J ug/L
Toluene:7,740 ugh_
1,2,4 Trlmeihylbenzene:425 pgrL
Total xylenes: 3,200 ugh_
'Values above 2L Standards are in bold.
•'J Indicates estimated value.
Sample 10: 5W-01
Surface Water Sample
6200 - Benzene:. 141 pg7L
1,2-D chloroethane: 0.474 Ugh_
Diisoprcayl Ether:3.8 ugh._
Ethylbenzene: 6.3 mil_
ISOOro9y1benzene: 1.5 ugh_
MT66: 179 pg1L
Naphthalene: 4.5 ugh_
TtMerle:142 pBIL
12,4 Trime0lylbenzene- 3.9 pgIL
Total xy1enes 14.6 ugIL
'Values above 26 Standards are in hold.
J indicates estimated value.
MW-fi - - ^ _ _ _ Ridge Line
(Not Located)
MW-5
(Nat Located)
PAW-8
NC HIGHWAY
DIAGRAM iSFOR GENERAL LOCATION ONLY,
AND IS NOT INTENDED FOR CONSTRUCTION
PURPOSES
Sample ID: MW-1
Groundwater Sample
Not Sampled - Free Product
Project Manager.
HER
Orrin by:
HEH
Checked by: CLC
APMovedbY CLC
Sample ID: MW.d
Groundwater Sample
6200-Benzene:BSA ugfL
EO1ylbenzene; 15.9 iv&
lend ropylbenzene:16.4 ugh_
Toluene:66A ugh_
12,4 Tfrtrettlytbenzene: 308 ugh_
1,3,5 Trimethylbenzene: 180141
Total xylenes: 124 ugh.
'Values above 2L Standards are in bold,.
Project ins.
71149156A
Beale:
1" -- 8a'
Filo Name:
2
nate:
Nov. 2018
Sample ID, 6118.2
Groundwater Sample
6200 -Benzene: 58.2 pgJL
Elhylb a nzen e: 103 ugh_
Isooropyleenzene: 14 ugh_
Naphthalene: 292 pglL
Toluene:431 ugh_
12,4 Trimethylbenzene: 314 pgIL
1,3,5 Trimethylbenzene: 93.5 pglt
Total xylenes: 6B7 ugh_
'Values above 21. Standards are in hold_
lierracon
2701 Westport Road
Che done, NC
•
•
Sample ID: MW-3
Groundwater Sample
6200 - No ahalytes detected
LEGEND
denotes approximate site
boundary
denotes approximate location
of drainage feature
denotes groundwater
monitoring wetl
denotes surface water
sample location
GROUNDWATER ANALYTICAL RESULTS (Nov_ 2018)
Former Johnson's Grocery (Incident #30594)
5874 NC Highway 268
Dobson, Surry County, NC
Figure
4

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Sample ID: raV47L
Benzene Cancliktakipn
3.900 KA ♦
ad-�
•�, r a
. \ a
•
a a
♦
♦ ♦• ♦
•
DIAGRAM IS FOR GENERAL LOCATION ONLY,
AND IS NOT INTENDED FOR CONSTRUCTION
PURPOSES
♦ MW-8 3,000
Sample ID: IIW.6
Well Not Located
•
•
-
T
Sample ID: TAWS
Well Rol Located
Ridge Line
.
- ♦ ♦ ♦ Sample ID: M1W1
♦ 5.\ \, .` Benzene Concentration
♦ i FREEPRODUCT
. ■
- —.— ♦ ► ■
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FP ..
-
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r;
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Sample 13: MW2
Benzene Concentration
%t58.2 p6R
LEGEND:
denotes approximate 10' radius
of influence injection point
denotes approximate site
boundary
denotes approximate location
of drainage feature
denotes groundwater
monitoring well.
Project Hamper.
HEN
Darm eY
HEN
Cfindcedby:
CLC
approved by:
CLC
Project*.
71149156A
!Seek:
Dale Nov. 2018
lrerracon
2701 WeetportRoad
Charlotte, NC
BENZENE CONCENTRATION MAP (November 2018)
Former Johnson's Grocery (Incident #30594)
5870 NC Highway 268
Dodson, Surry County, NC
Figure
5

1100
45
90
80
75
70
65
A
MW-7
SANDY CLAYS
SILTY CLAYS AND PARTIALLY
WEATHERED ROCK iPWRJ
SANDY CLAYS
13.900
MW-4 mw- I
MINN
N0TE5: I - WATER LEVEL5 MEASURED ON 1013 1,120 ! 8
2. BENZENE CONCENTRATION5 REPORTED IN MICROGRAMS PER. UTkR-
3. WELL AAW-7 I1A5 NOT BEEN SURVEYED THEREFORE 1-5 VERTICAL °09ITION IN RELATION
Tr1E OTHER WELLS r5 NOT TO SCALE.
HORIZONTAL 5CALE
(IN FEET)
a
n
VW-2
I—m5 I I 55.2 I
A'
MW-3
CLAYEY SILTS
13
5APROLRE
4
sL
llerracon
Consulting Engineers and Scientists
nG, 11101P 1T KA)
PSI. MAo StSrin
;XX IronY-1
PARTIALLY WEATHERED ROCK
v
58-2 I
VERTICAL SCALE
ON FEET)
0
5
LEGEND
MONITORING WELL is
FREE PROD $CY LEVEL
WATER LEVEL -
WL`LL scRE[N I NYERVAL
. :E
SECTION A - A'
FIGUREIDRAW ING
JOHNSON'S GROCERY
DOBSON, NORTH CAROLINA
oiSH7NM
,166155.40 G1G
6