WI0400515_DEEMED FILES_20190513

Permit Number WI0400515
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
Ruby's Mini Mart
Location Address
9118 NC Hwy 62 S
Yanceyville
Owner
Owner Name
Ncdeq Dwm
Dates/Events
NC
Orig Issue
2/5/2019
App Received
1/29/2019
Re gulated Activities
Groundwater remediation
Outfall
Waterbody Name
27379
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
Permit Tracking Slip
Status
Active
Project Type
New Project
5/13/2019
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Linda Blalock
1646 Mail Service Ctr
Raleigh
Region
Winston-Salem
County
Caswell
NC 27699164
Issue
2/5/2019
Effective
2/5/2019
Expiration
Req uested /Received Events
Streamlndex Number Current Class Subbasin
ifAtTC D fc'
ENVIRONMENTAL - GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
w 00 51 S 2725 East MiHbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
March 13, 2019
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 — WI0400515
Ruby's Mini Mart
9118 NC Highway 62 South
Yanceyville, Caswell County, North Carolina
Incident #19825
Dear Ms. Shrestha:
MAR 2 0 2019
4' TUB' Ji.:y
Cfr_rntcyi lw�
ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Ruby's Mini Mart site on behalf of the North Carolina Department of Environmental Quality State
Lead Program. The record documents the placement of Lnviro-BAC in one monitoring well (MW-
1) associated with the above referenced site.
If you have questions or tequire additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Linda Blalock, Engineer for NCDEQ
Attachments

Injection Event Record
Rub y 's Mini Mart. Yanceyville, North Carolina
INJECTION EVENT RECORD
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EIIYJRIIHIEIITll•UnEl:Hllt:ll
HIUIIIII SCIEICES • IIATEIPLS TUllH
North Carolina Department of Environmental Quality -Divisi!)n of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400515
1. Permit Information
NCDEO
Permittee
Rub y's Mini Mart
Facility Name
9118 NC Highwav 62 S, Yanceyv ille, Caswell
County
Facility Address (include County)
2. Injection Contractor Information
ATC Associates of NC. P.C .
Injection Contractor/ Company Name
Street Address 2725 E. Millbrook Road. Ste 121
Ralei oh NC 27604
City State Zip Code
(919 ) 871-0999
Area code -Phone number
3. Well Information
Number of wells used for injection.-=! ____ _
Well IDs._-=MW:....:..a......a-1=-------------
Were any new wells installed during this injection
event?
D Yes [8J No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number of Injection 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 for 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
Enviro-BAC
lnjectant(s) Type (can use separate addjtional sheets
if necessary
Concentration -~8=.8'--'-o/c-=-o _________ _
If the injectant is diluted please indicate the source
dilution fluid. Ci ty of Raleigh Munici pal Water
Total Volume Injected (gal)_5 ____ _
Volume Injected per well (gal)_-=-5 __ _
5. Injection History
Injection date(s) February 2 1, 2019
Injection number ( e.g. 3 of 5)~~1 ~o~f ...... 1 ____ _
Is this the last injection at this site?
[8J Yes O 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.
~ , 3 (13 /.14
SIGNATURE OF INJECTION CONTRACTOR D ATE
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
Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400515
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Ruby's Mini Mart
Location Address
9118 NC Hwy 62 S
Yanceyville
Owner
Owner Name
Ncdeq Dwm
Dates/Events
NC
Orig Issue
2/5/2019
App Received
1/29/2019
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27379
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
2/5/2019
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Linda Blalock
1646 Mail Service Ctr
Raleigh
County
Caswell
NC
Issue
2/5/2019
Effective
2/5/2019
27699164
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.G. Engineering License No. C-1598
January 15, 2019
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, IIIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Ruby's Mini Mart
9118 NC Highway 62 South
Yanceyville, Caswell County, North Carolina
Incident #19825
RECENEDMCDEG,OYVR
Dear Ms. Shrestha:
.IAN 2 9 2W9
ATC Associates of North Carolina, P.C. (ATC) has prepares he enclosed Notice of Intent to
p Injectiona
Construct or Operate Wells on behalf of�, ,4a0egmAR a 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.
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Linda Blalock, Engineer for NCDEQ
Attachments

Notice of Intent to Construct or Operate Injection Wells
Rub y's Mini Mart, Yance vv ille . North Carolina
NOTICE OF INTENT FORM
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EITIIUNIIHJIL•&EIITEl:KIIUL
IUILDIIIStlENCU•IIATEIIALSTEmH
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. This fo rm shall be submitted at least 2 WEEKS prior to in iection.
AQUIFER TEST WELLS 05A 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 In jection Sy stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small-Scale In jection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air 1n· ection 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, 20_1_2__ PERMIT NO. (/y .1.0 '+0 0 5 t S (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
___ Air Injection Well ...................................... Complete sections B through F, K, N
___ Aquifer Test Well ....................................... Complete sections B through F, K, N
___ .Passive Injection System ............................... Complete sections B through F, H-N
X Small-Scale Injection Operation ...................... Complete sections B through N
___ Pilot Test. ................................................ Complete sections B through N
___ Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: State Government
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 Q ualit y
Mailing Address: 1646 Mail Service Center
City: Ralei oh State: NC Zip Code: 27699-1646 County:_W~ak=e~---
Day Tele No.: 919-707-8165 Cell No.: ___ N~o~t~A~v~a~il=a~bl~e ___ _
EMAIL Address: [e-mail] Fax No.: Not Available ------------
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page I
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: ___ L~oft=in~S~c~o~tt~A=ldr=id=g=e~. J=r~. ____________________ _
Company Name ___ N~o-'---'t ~A=p=p=li-'---'ca=b~l~e ________________________ _
Mailing Address: --~9 _10_2_N_C_H_1~·g~h_w_a~y _6_2 _S_o_u_th ___________________ _
City: Y ancevville State: NC Zip Code:_2_73_7_9 ____ County: Caswell
Day Tele No.: 336-514-5972 Cell No.: Not Available
EMAIL Address: ___ N~o-"-t ~A"""v-=a1=·1a=b=l-=-e ______ _ Fax No.: --~N=o~t =A~v-"'a=il=ab=l=e ___ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ A_sh_l_e~y_M_._W_ink_e_lm_an_.~S_e_n_io_r_P_r_o~je_c_t _M_an_a_g_er ____________ _
Company Name ____ A_T_C_A_s _so_c_ia_t_es_o_f_N_ort_h _C_a_ro_l_in_a~._P_.C_. _______________ _
Mailing Address: -----=2-'---'72=5c___E=--c.c. M=il=lb=r-=-o=ok=R=o=ad=."""S"""u=it=e"""l""2"""1 ________________ _
City: Raleigh State: NC Zip Code:_2~7~6~0~4 ____ County:_W~ak=e ___ _
Day Tele No.: 919-871-0999 Cell No.: __ ~9~1~9~-8~3~0 ~-3~5~76~---
Fax No.: 737-207-8261 EMAIL Address: ashle y .winkelman@ atc gs.com ------------
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ----=-R=u=b_._y'"""s....;.M=1=·n=i =M=a=rt"'------------------
9118 NC High wav 62 South
City: Yanceyv ille County: Caswell Zip Code: __ 2~7~3~7~9 ____________ _
(2) Geographic Coordinates: Latitude**: 0 " or 36 °. 28676 ----------
Longitude**: 0 __ " or __ -7~9~0 • 36671
Reference Datum: __ ~W~G=S~8~4 __ ~Accuracy: ___ 1~0~-=m=e=te-=-r __ _
Method of Collection: DOQ -Acme Mapp er 2.2
**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: 1.810 square feet
Land surface area ofinj. well network: __ =1.=8-=-1-'---'0 ____ square feet~ 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: 100 (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. -Cross-sections were not identified in
previous reports submitted for 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 Page2
The following figures are included with this NOI package:
Figure 1— Site Topographic Map
Figure 2 — Site Map
Figure 3 — Potential Receptor Map
Figure 4 — Groundwater Elevation Map with hydraulic gradient
Figure S -- Groundwater Analytical Map
Figure 6 — Soil Analytical Map
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 t?ravit) feed Enviro-BAC into monitoring we11 MW-1 in order to aide in natural attenuation and reduce
compound concentrations to below the North Carolina Groundwater Quality Standards (2L Standards ). Based
on the most recent samp1in event performed in Jul\ 2018_the following compounds exceeded 2L Standards in
MW-1: benzene at 49.1 micrograms per liter j LJ, naphthalene at 98. jig/1... and 1.2-dichloroethane at 20
The iniectate. followed b\ 5 to 10 gallons of municipal water. will be poured into MW-I over up to a 3
hour time period.
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:l/deq.nc.gpv/abour/divisions/water-
resourceslwater-resources-permits/wastewater-hranchleround-water-proteetionleround-water-approved-iniectants.
All other substances must he reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
lnjectant: Enviro-BAC
Volume of injectant: 5 Gallons [2 kilograms of Enviro-SAC mixed with 5 callons of fresh water)
Concentration at point of injection: 8.8%
Percent if in a mixture with other injectants: 33% tconsiders 10 gallons of municipal water to
be poured in well followinc Enviro-BAC i
See Appendix A for MSDS information.
K. WELL CONSTRUCTION DATA
(1) Number of injection wells:
Proposed
1 Existing (provide GW-Is)
(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):
(a) Well type as permanent, GeoprobelDPT, 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 the well construction record for MW-1.
Deemed Permitted GW Remediation NOI Rev. 8-28-2U 17 Page 3

L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
A pp roximatel y two weeks after submitting the NOI, ATC will eravity feed Enviro-BAC into 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 Subcha pter 02L result from the injection activity.
ATC will collect a sam ple from MW-1 a pp roximatel y 30 days after the in jection event. A pp roximatel y 60 days
after the event. samples will be collected from all monitoring wells associated with the site. The sam ples will
be anal yzed for volatile organic com pounds bv EPA Method 6200B. The sam ples will be shi ed to SGS
Accustest in Scott, Louisiana. A TC will also measure dissolved oxvg en. conductivi ty. tem perature . pH . and
oxygen reduction potential in the sam pled wells durin g both events.
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 iriformation, 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
iriformation. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. " v:..--·--
Signature of Applicant
Ashley Winkelman. Senior Pro ject Manager. on behalf of Linda Blalock. NCDEO
(see Authorization to sign on next page)
Print or Type Full Name and Title
PROPERTY OWNER (if the pro perty is not owned b v the permit 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.
See App endix C Loftin Scott Aldridg e Jr.
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.
Submit TWO hard copies of the completed application package with an electronic version in CD or
USB Flash Drive to:
Deemed Permitted GW Remediation NOI Rev. 8-28-2017
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page 4
Liz Allyn
Subject: FW: NO1 Signature Authorization
From: Blalock, Linda[mailto:linda.blalock@ncdenrgovj
Sent: Tuesday, September 25, 2018 4:27 PM
To: Ashley Winkelman <[e-mail]>
Subject: NOI Signature Authorization
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 mare information, please let me know.
Linda Blalock
[e-mail]
fD.E
l r..eri b�w+�www+Mk
Linda Blalock
Environmental Engineer, Dtvitio+: of Waste Management
North Carolina DepartanenfofEnvironmental Quality
1646 Mail Service Center
Raleigh; irTC 27699-1646
919.707.8165 (Office)
1

Notice of Intent to Construct or Operate Injection Wells
Ruby's Mini Mart. Yanceyv ille, North Carolina
FIGURES
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EIIIIIIIIIEIITAl.•CEOTEl:HIICAL
BUILIIIIIS"CIENCE!• IIAIEIIILSl!nlll
The well ID is the last three numbers of the Parcel
Identification Number
Source: Caswell County NC GIS
P#014
500 Foot Radius
1,000 Foot Radius
Water Supply Well
Well Identification
N
ATC
E31WRl}IIAIEAAAI • CESTECHNICAl
BUILDIiifl SSiE ICES • MA1ECtAU ! Si NI
2725 E. Milibrook Road, Suite 121
Raleigh, NC 27604
[phone]
PROJECT NO: SLP 1982501
SCALE: As shown
above
FIGURE 3
POTENTIAL RECEPTOR MAP
RUBY'S MINI MART — INCIDENT #19825
9201 NC HIGHWAY 62 SOUTH
YANCEYVILLE, NORTH CAROLINA
REVIEWED BY: EA
DATE: 10/18/18

Notice of Intent to Construct or Operate Injection Wells
Rubv 's Mini Mart. Yanceyv ille . North Carolina
APPENDJXA
MSDSFORM
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[IJIRUIIIEIIIAl•IEaTfCIIIICll
IUILDllliSCIEIICES•IAlEIIUITESTlll
BID -CAT
Microbials
Form: Powder (SZE)
Safety Data Sheet
Section 1: Identification
Product Identifier:
Other Identifier:
Recommended Use:
Supplier Information:
EnviroBac
NONE
See Product Literature
689 Canterbury Rd
Shakopee. MN 55379
(p}952-445-4251 0) 952-445-7233
inFcCrbio-cat.comwww.bia-cci_co 1
Emergency Phone: [phone]am-4pm EST
Section 2: Hazard Identification
Hazard Classification;
Eye Damage/Irritation Category 2B
Skin Corrosion/Irritation Category 2
Signal Word: Warning
Hazard Statements:
H315
H320
Pictogram(s):
Precautionary Statement(s):
Wash face and hands thoroughly after handling.
Wear protective gloves/protective clothing/eye protection/face protection.
Causes skin irritation.
Causes eye irritation.
P264
P280
Response Statement(s):
P302/352 IF ON SKIN: Wash with plenty of water.
P305/351 /338 IF IN EYES: Rinse cautiously with water for several minutes. Remove contact
lenses, if present and easy to do. Continue rinsing. Immediately call a poison center/doctor
P308/311 IF exposed or concerned: call a poison center/doctor.
P332/313 If irritation occurs: get medical advice/attention.
P337/313 If eye irritation persists: get medical advice/attention.
P362/364 Take off contaminated clothing and wash it before reuse.
Hazards Not Otherwise Categorized:
Moderate Resniratory Irritant
Section 3: Composition/ Information on Ingredients
Name:
Name:
Name:
Inhalation:
Proprietary bacterial blend
Maltodextrin
Sodium chloride
CAS Number: NIA
CAS Number: 9050,36-3
CAS Number: 7647-114-5
% by weight: 3.5-6%
% by weight: 2-3.5%
%by weight: Remainder %
Section 4: Nrst-Aid Measures
tf inhaled remove from contaminated area to fresh air. Report the situation. Seek
medical attention if allergic response is exhibited,
Page 1 of 3

;11-
BUO-CAT
Microbials
Eye Contact:
Skin Contact:
Ingestion:
in case of contact with eyes, flush eyes with low pressure water for at least 15 minutes.
if irritation develops, seek medical attention.
In case of contact with skin, wash skin with soap and cold water. Remove
contaminated clothing and wash.
If swallowed, rinse mouth and throat thoroughly with tap water. Drink wafer.
Section 5: Fire -Fighting Measures
Suitable Extinguishing Media: Standard procedure for chemical fires. Foam. Water.
Non -Suitable Extinguishing Media: None
Specific Exposure Hazards: None
Protective Equipment: No special requirements
Personal precautions,
Emergency Procedures:
Containment methods:
Cleanup Procedures:
Section 6: Accidental Release Measures
Use only with adequate ventilation/personal protection. Avoid breathing
dust or spray mist. Avoid formation of dust and aerosols. (See section 8).
Prevent further leakage or spillage if safe to do so,
Contain and remove spilled product by mechanical means or with a
vacuum cleaner equipped with a high efficiency filter. Avoid formation
of aerosol.
Section 7: Handling and Storage
Safe Handling:
Storage:
Never handle powder without appropriate personal protective
equipment in accordance with Section 8. Avoid formation of dust.
Avoid splashing and high pressure washing. Ensure good ventilation of
the room when handling this product.
Keep container tightly closed in a cool, di v, well ventilated place.
Section 8: Exposure Controls/Personal Protection
Appropriate engineering controls: Adequate ventilation required for dusty conditions
Eye/face protection:
Skin protection:
Respiratory Protection:
Wear protective glosses or eye shield
Impermeable gloves recommended
Use NIOSH approved respiratory protection such as full face mask
Section 9: Physical and Chemical Properties
Appearance:
Odor:
Odor Threshold:
pH:
Melting point/freezing point:
Initial boiling point and boiling range:
Flash point:
Evaporation rate:
Flammability (solid, gas):
Upper/lower flammability or explosive
Vapor Pressure:
Vapor Density:
Relative Density:
Solubility:
Partition coefficient: n-octonol/water:
Auto -ignition temperature:
Decomposition temperature:
Viscosity:
Light to dark tan colored powder
Characteristic fermentation odor
Not available
Not available
Not available
Not available
Not available
Not available
Not available
limits: Not available
Not available
Not available
Not available
Soluble
Not available
Not available
Not available
Not available
Page 2 of 3

BIO-CAT
M i&robials
Section 10: Stability and Reactivity
Rea ctivity:
Chemical Stability:
Hazardous reactions:
Conditions to avoid:
Incompatible materials:
Hazardous Decomposition
Not available
Stable under normal storage conditions
Not available
Not available
Not available
Products: Not available
Section 11: Toxicological Information
Routes of Exposure:
Symptoms:
Immediate:
Delayed:
Acute toxicity:
Eye Irritation:
Skin Irritation:
Respiratory Irritation:
Sensitization towards product:
Germ cell mutageniclty:
Reproductive toxicity:
Carcinogenicity:
Ecotoxicity:
Persistence and degradability:
Bioaccumulative potential:
Mobility in soil:
Other adverse effects:
Eye contact, skin contact, ingestion, inhalation
May cause irritation to the eyes, skin. mucus membranes, and the
upper respiratory tract
Not available
Not available
May cause minor irritation
May cause minor irritation
May cause minor irritation
There is no evidence of sensitizing potential
Not available
Not expected to produce reproductive toxicity
Not classified as a carcinogen by IARC, OSHA, or NTP
Section 12: Ecological Information
Not available
Product is readily biodegradable
Not available
Not available
Not available
Section 13: Disposal Considerations
No special disposal method required, except that in accordance to all applicable federal, state, and
focal regulations.
Section 14: Transport Information
Harmonized Tariff Code:
UN Number:
UN Proper Shipping Name:
Transportation Hazard Class:
Pocking Group:
Transport Environmental Hazard:
Transport Special Precautions:
MARPOL:
3002.90.10 (for Microbials)
Not classified
Not classified
Not classified
Not classified
Not classified
Not classified
Not classified
JAN 1.9
r VIDn
Section 15: Regulatory Information
All components of this product ore listed or exempt from listing on the TSCA Inventory.
Section 16: Other Information
Revision History: Effective Date: 04/25/17 Supersedes: First Issue
GHS 2015 FORMAT
The information contained in this Safety Data Sheet, as of the issue date. is believed to be true and correct, However, the
accuracy or completeness of this information and any recommendations or suggestions are mode without warranty or
guarantee. Since the conditions of use are beyond the control of the company, it is the responsibility of the user to determine
the conditions of safe use of this product. The information does not represent analytical specifications. END OF 50S
Page 3 of 3

Notice of Intent to Construct or Operate Injection Wells
Rub y 's Mini Mart, Y ance vill e , North Carolina
APPENDIXB
MONITORING WELL CONSTRUCTION DETAILS
/4.TC
fJIWIRBNIEIIJAl•CiEIITECHIIIUI.
11111.DIHSCIEMCES•IIATEllAUrESTllllli
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2420
1. WELL CONTRACTOR:
MarkE. Ho.sler
Well Contractor (Individual) Name
Sensible Solutions Environmental Inc.
well Contractor Company Name
STREET ADDRESS 84Q Driftwood Drive
Qraham NC 27253
City or Town State Zip Code
( 336 )- 376-1253
Area code - Phone number
2. WELL INFORMATION:
SITE WELL ID* (if applicable) LYI 1'1" "l
STATE WELL PERMIT# (if applicable) NIA
DWQ or OTHER PERMIT #(it applicable} NIA
WELL USE (Check Apptcabte Box): Monitoring gi MunitipatPublic ❑
lndustriat/Commertial 0 Agncuiturai 0 Recovery 0 Injection ❑
Irrigation 0 Other 0 gist use)
DATE DRILLED 03/10/06
p PM n
y'aswell
TIME COMPLETED 3:30 AM
3. WELL LOCATION:
CITY: Yanceyville COUNTY
9118 NC Hfghw y L2 South
(Street Name, Numbers, Community, Ssibdlvislon,
TOPOGRAPHIC / LAND SETTING:
❑slope ❑ Valley ID Flat ❑ Ridge ❑
(check appropriate box)
LATITUDE 362,1Z 11"N
Lot No., Parcel, bp Code)
Other
May be in degrees,
minutes, seconds, or
is a decimal format.
LONGITUDE y90 � ,59" ,
Latitude/longitude source: 0 GPS ❑x Topographic meg
(location or well must be shown on a USGS topo map and
attached Pc this form if not using GPS)
4. FACILITY - is the rue ee er the nusinere wive use ea is locale's.
FACILTIY IDmt (if applicable) 0-007017
NAME OF FACILITY Ruby's Mini Mart
STREET ADDRESS 9118 NC Hwy. 62 S.
Yancevville NC 27379
City or Town State Zip Code
CONTACT PERSON Mr. J. T, .Jferson
MAILING ADDRESS 9068_,NC Hwy. 62 S.
Yanc_ville RC 27379
City or Town State Zip Code
( 336 )- 421-9248
Area code - Phone number
5. WELL DETAILS:
a TOTAL DEPTH- 25.0ft.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
C. WATER LEVEL Below Top of Casing: _ 18.92 FT
(Ilse "+" If Above Top of Casing)
d. TOP OF CASING IS - 0.30 FT Above Land Surface'
`Tap of casing terminated actor below land surface may require
a variance in accordance with 15A NCAC 2C .011 S.
e. YIELD (gpm). N/A METHOD OF TEST
IOTA
f. DISINFECTION: Type NIA Amount N/A
g. WATER ZONES (depth)::
From N/14 To From To
From To From To
From To From To
6. CASING: Thickness/
Depth Diameter Weight Material
From 0.3 To 25_Q Ft 0.154" PVC
From _ To Ft
From To Ft
7. GROUT: Depth Material Method
Frain 0.4 -To _ 4.O Ft #1 P_ortlgfld Poured
From 4-0 To 8.0 FL Bentonite Chips
From To Ft.
8. SCREEN: Depth Diameter Dot Size Material
From _10.0 To 25.0 FL 2 irr, 0.0101n Sch 40 PVC
From To _Ft in win
From To Ft in in.
9. SANDIGRAVEL PACK:
Depth Size Materiat
From 8.0 To 25.0 Ft #2 Qkartz Sand
From To Ft
From To Ft
10. DRILLING LOG
From To Formation Description
0.0 - 3.5 Brown and g er enzsh grsiy ,clightyv
micaceous. sligJu y f Idy SILT
3 5 - 25.0 Greenish -gray. slightty micaceous.
slightly silt} fine SAND.
11. REMARKS
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
155A NCAC 2C. WELI. CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD WAS BEEN PROVIDED TO THE WELL OWNER.
', dditt 03117106
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
Mark E. Hosier
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality with-ri 30 days. Attn: Information Mgt.,
1617 Mail Service Center - Raleigh, NC 27699-1617 Phone No. (919) 733 T015 ext 568.
Forni GW-ib
Rev. 7105

Notice of Intent to Construct or Operate Injection Wells
Rub y's Mini Mart, Yance yv ille , North Carolina
APPENDIXC
ACCESS AGREEMENT FROM SITE PROPERTY OWNER
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fllVIIDNIIEIITAI. • 1iEIITECHRlCAL
!UILDfKCSCIENCES•IATEIIAUtESTUII
Ms. Linda Blalock
DWM UST Section
1646 Mail Service Ctr
Raleigh, NC 27699-1646
Dear Ms. Blalock:
RE: Site Access Agreement
Ruby's Mini-Mart
9118 NC Hwy 62 SNanceyville/Caswell County
Incident#: 19825
NC Dept. of Environmental Quality
Div. Wa 5te Management-UST Section
Attn: Linda Blalock
l646 Mail Service Center
Raleigh, NC 27699-1646
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 investigation of the
groundwaters under the authority of G.S. 143-215.3(a)2.
I arn/W e are granting pennission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1 .
Ruby's Mini-MartfFTF-19825
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.
11We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
L6-71,-;r1
Type/Print Name of Dwnei or Agent
Y
. A 1-1 yw„._ p4
er r iJwy G s40'h r 12 :i)o ,4 ,2717 /
Address
74\4e--
Address
or e• U 7,4 4Y 0s ,27579
City/State/Zip Code
3 -5V'5 7
Phone Number
31/:6
Date

915000
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I eatures shown are not an authoritative location, nor are
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918250
921500
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924750
Figure 1 - Site Topographic Map
Ruby's Mini Mart (Incident #19825)
9118 NC Highway 62 South
Yanceyville, Caswell County, North Carolina
COORDINATE SYSTEM: PREP:
NAD 1983 StatePlane North Carolina FIPS 3200 Feat Robert.Sroda
Pc1h: S:.G L4_GPSProj cst_FeWcraVi CO E1: R Stec Lwd_L rods Ruaya Mini M.,1 F iearc t -Sire Tnpograpb is Mop - Ruby. M ini M ermxd
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REV:
AW
928000
931250
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ATC Associates of North Carolina, P.C. [phone]
Raleigh, North Carolina, 27604
DATE: 1/4/2017 1SCALE=1:24,000 PR❑ SLT 8O25D2
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923400
NOTES:
1. Features shown are not an authoritative location, nor are
Figure 2 - Site Map
Ruby's Mini Mart (Incident #19825)
9118 NC Highway 62 South
Yanceyvi.11e, Caswell County, North Carolina
COORDINATE SYSTEM: PREP:
NAl) 1983 StatePlane North Carolina FIPS 3200 Feet deremy.Aoh$ins
Path: S. di]S_GPSLProjcxi_FGtcrsN'CDENR Slat L ad_Lioda Siva119825 Miri M.e.Figi.r 2 - Sno M.0 - Rabya Mini Martmxd
'REV:
923600
i�
c
ATC Associates of North Carolina, P.C. [phone]
Raleigh, North Carolina, 27604
DATE:
EA 8/14/2018
SCALE: PROJECT NO.
1 ' = 41 " SLP 1982501

as
0
a
ou
v
0
a
N
0
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923400
NOTES:
1. Features shown are not an authoritative location, nor are they
presented to a state accuracy.
2. Mon -storing wells were gauged on 7/31/2018.
COORDINATE SYSTEM:
NAD 1983 StatePlane North Carolina FIPS 3200 Feet
Figure 4 - Groundwater Elevation Map
Ruby's Mini Mart (Incident #19825)
9118 NC Highway 62 South
Yanceyville, Caswell County, North Carolina
PREP:
Ieremy.Robbins
PN♦1: S:iGM_OPSNmjch_FaldcnPVWENR Slow Lead_Liada Sieea119825 - Robys Mioi MoMFigwed-GomadwaXv Flow Map Roils Mini Mari.mad
REV:
EA
DATE:
923600
ATC Associates of North Carolina, P.C. [phone]
Raleigh, North Carolina, 27604
8/14/2018
SCALE:
l"=41"
PROJECT NO.
SLP1982501

923400
923600
1
1
1
1
1
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0
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•
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NOTES:
1. Features shown are not an authoritative location, nor are
they presented to a stated accuracy.
2. Concentrations in bold equal or exceed the corresponding
NCDEQ Groundwater Quality 2L Standard (2L Standard).
3. NA = Not Analyzed
4. "<It or ND = Not detected at or above the laboratory
detection limit and/or laboratory reporting limit
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Figure 5 - Groundwater Analytical Map
Ruby's Mini Mart (Incident #19825)
9118 NC Highway 62 South
Yanceyville, Caswell County, North Carolina
ATC
ATC Associates of North Carolina, P.C. [phone]
Raleigh, North Carolina, 27604
COORDINATE SYSTEM:
NAD 1983 StatePlane North Carolina FIPS 3200 Feet
PREP:
Robert.Broda
REV:
EA
DATE:
9/24t2018
SCALE:
1'=50"
PROJECT NO.
SLP1982501
Path: S:LG]S IVProjrs _FoldrnNICDENR 91.Dc Lwd_LiadS Sfte115125 - Rubya M i M.rli1igum 5-Grmodw.ter Amlytial M.p - Ruby, Mini M.nmxd

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923600
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NOTES:
1. Features shown are not an authoritative location, nor are
they presented to a staled accuracy.
2. Bold indicates concentrations above the NCDEQ Action
Level or Soil -to -Groundwater MSCCs.
3. Italized indicates concentrations above Residential
Action Level.
4. Soil borings without a call out box did not exceed standards.
r
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Figure 6 - Soil Analytical Map
Ruby's Mini Mart (Incident #19825)
9118 NC Highway 62 South
Yanceyville, Caswell County, North Carolina
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ATC
ATC Associates of North Carolina, P.C. [phone]
Raleigh, North Carolina, 27604
CO
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CO
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Ca
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0
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COORDINATE SYSTEM:
NAD 1983 StatePlane North Carolina FIPS 3200 Feet
PREP:
Robert.Broda
REV:
AW
DATE:
1/13/2017
SCALE:
1'=50"
PROJECT NO.
SL1982502
Path; S;1G6 QPS7r9jcci eldrniNCDENR Sat¢ L Linda 5IcsL19625 - Rnhyr Mini MrN+igim4 . Soil Analyiipl Mac.- Rahss Mini Mart-mxd