WI0400522_DEEMED FILES_20190716

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ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
July 10, 2019
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
2725 East Millbrook Road
Suite 121
Raleigh , NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
RECElVEO/NCDeQIDWR
.JUL 1 6 2019
Water Quality
Regio"al Operations Section
Division of Water Quality-Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Injection Event Record
Wheeler's Grocery
9385-A US Highway 158
Reidsville, Rockingham County, North Carolina
NCDEQ Incident #14897
Permit# WI0400522
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Wheeler's Grocery on behalf of the North Carolina Department of Environmental Quality State
Lead Program. The record documents the installation of Provect ORS sleeves in three monitoring
wells (MW-2, MW-3 , and MW-6) associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone] .
Sincerely,
ATC Associates of North Carolina, P.C.
Elizabeth A. Allyn
Project Manager
cc: Linda Blalock, Engineer for NCDEQ
Attachments
Ashley M. Winkelman, P .G.
Senior Project Manager
Injection Event Record
Wheeler's Grocery, Reidsville . North Carolina
INJECTION EVENT RECORD
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North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400522
1. Permit Information
NCDE O
Permittee
Wheeler's Grocery
Facility Name
9385-A US Hi ghway 158 , Reidsville, Rockingham
Counly
Facility Address (include County)
2. Injection Contractor Information
ATC Associates ofNC, P.C.
Injection Contractor/ Company Name
Street Address 2725 E. Millbrook Road, Ste 121
Raleigh NC 27604
City State Zip Code
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection_3 ____ _
Well IDs MW-2 MW-3 MW-6
Were any new wells installed during this injection
event?
D 'Yes IZ! No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy oftlte GW-1 fo rm for eaclt
well installed.
Were any wells abandoned during this injection
event?
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells" _______ _
Please include a copy oftlte GW-30 for eaclt well
abando11ed.
4. lnjectant Information
Provect ORS sleeve
Injectant(s) Type (can use separate additional sheets
if necessa1y
Concentration _ _,_7-=-5---=8=5-'-'%=----------
If the injectant is diluted please indicate the source
dilution fluid. Not A pp licable
Total Volume Injected (gal) 3.114 in3-sleeve vol.
Volume Injected per well (gal) 1,038 in 3-sleeve vol.
5. Injection History
Injection date(s)__;.J=u=ly_.5=, =20=1=9 _____ _
Injection number (e.g. 3 of5)"__.1=--=of"-'1,,,____ ___ _
Is this the last injection at this site?
D Yes igj 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 }1u /1cr
SIGNATURE OF INJECTION CONTRACTOR r 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
WI0400522
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
VI/heeler's Grocery
Location Address
8892 NC Hwy 158
Reidsville
Owner
Owner Name
Ncdeq Ust Section
Dates/Events
NC
Orig Issue
7/3/2019
App Received
6/20/2019
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27320
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
7/3/2019
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
Issue
7/3/2019
Effective
7/3/2019
County
Rockingham
NC 27699
Expiration
Re q uested /Received Events
Streamlndex Number Current Class Subbasln
ATC
ENVIRONMENIAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupeervices.com
tc1PoStuogus600 INV15tigineering License No. C-1598
part 'eieM
June 17, 2019
> AALIK20ONJLTzJu )3ly
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Wheeler's Grocery
9385-A US Highway 158
Reidsville, Rocldngham County, North Carolina
NCDEQ Incident #14897
ATC Project No. SLP1489704
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of the North Carolina Department of
Environmental Quality State Lead Program. The permit application covers the performance of
passive remediation in one monitoring well associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Elizabeth A. Allyn Ashley M. Winkelman, P.G.
Project Manager
cc: Linda Blalock, Engineer for NCDEQ
Attachments
Senior Project Manager

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

June 17, 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: Notice of Intent to Construct or Operate Injection Wells
Wheeler’s Grocery
9385-A US Highway 158
Reidsville, Rockingham County, North Carolina
NCDEQ Incident #14897
ATC Project No. SLP1489704

Dear Ms. Shrestha:

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

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

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

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

cc: Linda Blalock, Engineer for NCDEQ

Attachments
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ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
Notice of Intent to Construct or Operate Injection Wells
Wheeler’s Grocery, Reidsville, North Carolina

NOTICE OF INTENT FORM
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Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 1
North Carolina Department of Environmental Quality – Division of Water Resources

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

DATE: June 14 , 20__19__ PERMIT NO. (to be filled in by DWR)

A. WELL TYPE TO BE CONSTRUCTED OR OPERATED

(1) Air Injection Well……………………………..…Complete sections B through F, K, N
(2) Aquifer Test Well……………………….………..Complete sections B through F, K, N
(3) x Passive Injection System…………………..……..Complete sections B through F, H-N
(4) Small-Scale Injection Operation………………….Complete sections B through N
(5) Pilot Test………………………………………….Complete sections B through N
(6) Tracer Injection Well………………………….….Complete sections B through N

B. STATUS OF WELL OWNER: Choose an item.

C. WELL OWNER(S) – State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:

Name(s): Linda Blalock – Engineer, North Carolina Department of Environmental Quality
Mailing Address: 1646 Mail Service Center
City: Raleigh State: _NC_ Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8165 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: Not Available
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS

The following are “permitted by rule” and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This form shall be submitted at least 2 WEEKS prior to injection.

AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.

IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).

2) Small-Scale Injection Operations – Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.

3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.

4) Air Injection Wells - Used to inject ambient air to enhance in-situ treatment of soil or groundwater.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 2
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Ronald and Laura Prater
Company Name Not Applicable
Mailing Address: 8892 NC Highway 158
City: Reidsville State: _NC__ Zip Code: 27320 County: Rockingham
Day Tele No.: 336-349-7703 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available

E. PROJECT CONTACT (Typically Environmental Engineering Firm)

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

F. PHYSICAL LOCATION OF WELL SITE

(1) Facility Name & Address: Wheeler’s Grocery
8892 NC Highway 158
City: Reidsville County: Rockingham Zip Code: 27320
(2) Geographic Coordinates: Latitude**: o ′ ″ or 36 o. 289756
Longitude**: o ′ ″ or -79 o. 735085
Reference Datum: WGS84 Accuracy: 10-meter
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.

G. TREATMENT AREA

Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)

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

(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells. –Cross-sections were not identified in
previous work conducted at the site.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 3
See the following figures: Figure 1 – Site Topographic Map, Figure 2 – Site map, Figure 3 - Potential
Receptor Map, and Figure 4 – Groundwater Elevation Contour map, Figure 5 – Dissolved Benzene
Isoconcentration Contour Map, and Figure 6 – Additional Concentrations of Concern in Groundwater.

I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES – Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
ATC will install ORS sleeves in monitoring wells MW-2, MW-3, and MW-6 to facilitate a reduction in
contaminant concentrations at the site to below the North Carolina Groundwater Quality Standards (2L
Standards). Please see Table 1 for compounds that exceeded the 2L Standards. Note that due to water column
lengths, ATC will place three ORS sleeves in each well. ATC will install three 3-foot sections at the base of each
well, across the well screen. The sleeves will release oxidizing solids into the groundwater for approximately 6
months, at which point the chemicals in the sock will have depleted.

J. APPROVED INJECTANTS – Provide a MSDS for each injectant. Attach additional sheets if necessary.

NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-injectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).

Injectant: Provect ORS sleeves
Volume of injectant: 3,114 in3 – volume of socks
Concentration at point of injection: 75-85%
Percent if in a mixture with other injectants: Not Applicable

See Appendix A for MSDS information.

K. WELL CONSTRUCTION DATA

(1) Number of injection wells: Proposed 3 Existing (provide GW-1s)
(2) For Proposed wells or Existing wells not having GW-1s, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
See Appendix B for well construction details.
L. SCHEDULES – Briefly describe the schedule for well construction and injection activities.

Two weeks after submitting the NOI, ATC will install three Provect ORS sleeves each in monitoring wells MW-
2, MW-3, and MW-6.

M. MONITORING PLAN – Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
A TC will collect samples approximately 6 months after the installation of the Provect ORS sleeves in MW-2,
MW-3, and MW-6 (June 2019, with sampling to occur December 2019). During the sampling event, ATC will
collect samples from monitoring wells MW-2, MW-3, and MW-6 for analysis of volatile organic compounds by
EPA Method 6200B. The samples will be shipped to SGS North America Inc. in Scott, Louisiana. ATC will
also measure dissolved oxygen, conductivity, temperature, pH, and oxygen reduction potential in MW-2, MW-
3, and MW-6 during the December 2019 sampling event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
0----~---,
Signature of Applicant
Ashley Winkelman on behalf of Linda Blalock, NCDEQ
(see Authorization to sign on next page)
Print or Type Full Name and Title
PROPERTY OWNER (if the property is not owned by the permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to consh·uct 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
(J5A NCAC 02C .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See Appendix C Ronald E. Prater
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 Pe1mitted GW Remediation NOi Rev. 8-28-2017
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page 4
1
Liz Allyn
Subject:FW: NOI Signature Authorization

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

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

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

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

TABLE
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TABLE 1
Compounds that Exceed 2L Standards for Notice of Intent Monitoring Wells
WHEELER'S GROCERY
9385-A US HIGHWAY 158
REIDSVILLE, ROCKINGHAM COUNTY, NORTH CAROLINA
INCIDENT #14897
MW-2 2/26/2019 190 1,400 310 2,020 78 <12 300 100 37
MW-3 2/26/2019 3,100 9,700 1,100 7,800 380 1,100 1,800 540 180
MW-6 2/26/2019 3,200 3,200 500 1,740 310 170 190 49J 43J
1 600 600 500 6 20 400 400 70
Notes:
1. MTBE = Methyl Tertiary Butyl Ether
2. DIPE = Diisopropyl Ether
3. "<" or ND = Not detected at or above the laboratory detection limit
4. Concentrations are reported in micrograms per liter (ug/l) = parts per billion (ppb)
5. Concentrations in bold equal or exceed the corresponding NCDEQ Groundwater Quality 2L Standard (2L Standard)
6. GCL = Gross Contamination Limit
7. NE = Not established n-Propylbenzene8. J = Indicates constituent was detected above laboratory detection limit but below laboratory reporting limit
2L Standard
Analytical Method 6200B
WELL ID Date
Collected
BenzeneTolueneEthylbenzeneXylenes (Total)NaphthaleneMTBE1,2,4-Trimethylbenzene1,3,5-TrimethylbenzenePage 1 of 1
I
I
I I I I I I I I I I
Notice of Intent to Construct or Operate Injection Wells
Wheeler’s Grocery, Reidsville, North Carolina

FIGURES
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2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
[phone]
FIGURE 1
SITE TOPOGRAPHIC MAP
PROJECT NO: SLP1489703
REVIEWED BY: AW SCALE: 1:24000 DATE: 10/2017
WHEELER’S GROCERY –INCIDENT #14897
9385-A US HIGHWAY 158
REIDSVILLE, NORTH CAROLINA
Source: USGS Topographic Map, Reidsville 2010
N
Site
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ENVIRONMENTAL • GEDTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
t
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REID VILLE, NORTH CAROLJNA

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- GROUNDWATER FLOW DIRECTION
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• = TYPE II MONITORING WELL LOCATION
• = VERTICAL EXTENT WELL LOCATION
(70.41) = BENZENE ISOCONCENTRATION (ug/L)
= BENZENE ISOCONCENTRATION CONTOUR (DASHED WHERE APPROXIMATE)
(NS) = NOT SAMPLED
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7. GROUNDWATER SAMPLES COLLECTED 02/26/79

0
*
0 0 0 0 0 0 °
MW-11
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1.460
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220
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Notice of Intent to Construct or Operate Injection Wells
Wheeler’s Grocery, Reidsville, North Carolina

APPENDIX A

MSDS FORM
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MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 1 of 5
1.PRODUCT IDENTIFICATION:PROVECT-ORS
PRODUCT USE: Soil and water treatment.
MANUFACTURER: EMERGENCY PHONE:
PROVECTUS ENVIRONMENTAL USA: 1-[phone]
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide), Class 5.1, PG II, UN1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
CAS No. Percentage
1305-79-9 75%-85%
Ingredients Chemical Formula
Calcium Peroxide CaO2
Inorganic Nutrients 15%-25%
3. PHYSICAL DATA
Appearance White & brown granules
Physical state Solid
Odor threshold None
Bulk Density 500~650g/L
Solubility in Water Insoluble
pH ~11
Decomposition Temperature Self-accelerating decomposition with oxygen release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product contains <1% non-respirable crystalline
silica. The NTP and OSHA have not classified non-respirable crystalline silica as carcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (silicosis). ORS does not
contain respirable crystalline silica.
Potential Health Effects:
•General Irritating to mucous membrane and eyes.
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 2 of 5
•Inhalation Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
•Eye contact May cause irritation to the eyes; Risks of serious or permanent eye
lesions.
•Skin contact May cause skin irritation.
•Ingestion Irritation of the mouth and throat with nausea and vomiting.
5. FIRST AID MEASURES
•Inhalation Remove affected person to fresh air. Seek medical attention if effects
persist.
•Eye contact Flush eyes with running water for at least 15 minutes with eyelids
held open. Seek specialist advice.
•Skin contact Wash affected skin with soap and mild detergent and large amounts of
water.
•Ingestion If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Point
•Not applicable
Flammability
•Not applicable
Ignition Temperature
•Not applicable
Danger of Explosion
•Non-explosive
Extinguishing Media
•Water
Fire Hazards
•Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 3 of 5
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution. Pressurization if confined when heated or
decomposing. Containers may burst violently.
Fire Fighting Measures
•Evacuate all non-essential personnel
•Wear protective clothing and self-contained breathing apparatus.
•Remain upwind of fire to avoid hazardous vapors and decomposition products.
•Use water spray to cool fire- exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
•Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
•Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
•Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
•Do not touch or walk through spilled material. Keep away from combustibles (wood, paper, oils,
etc.). Do not return product to container because of risk of contamination.
8. HANDLING AND STORAGE
Storage
•Oxidizer. Store in a cool, well-ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
•Keep away from incompatible materials. Keep containers tightly closed. Do not store in
unlabeled or mislabeled containers.
•Protect from moisture. Do not store near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
•Store separately from organics and reducing materials. Avoid contamination that may lead to
decomposition.
Handling
•Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
•Do not swallow. Avoid breathing vapors, mists, or dust. Do not eat, drink, or smoke in work
area.
•Prevent contact with combustible or organic materials.
•Label containers and keep them tightly closed when not in use.
•Wash thoroughly after handling.
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 4 of 5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
•General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
•For many condition, no respiratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
•Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
•Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical-resistant (Recommended materials: PVC, neoprene or rubber)
Other Protective Equipment
•Eye-wash station
•Safety shower
•Impervious clothing
•Rubber boots
General Hygiene Considerations
•Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
•Stable under normal conditions
Condition to Avoid
•Water
•Acids
•Bases
•Salts of heavy metals
•Reducing agents
•Organic materials
•Flammable substances
Hazardous Decomposition Products
•Oxygen which supports combustion
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
•LD50 Oral: Min.2000 mg/kg, rat
•LD50 Dermal: Min. 2000mg/kg, rat
•LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological Information
•Hazards for the environment is limited due to the product properties of no bioaccumulation, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
•As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste Treatment
•Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations.
Package Treatment
•The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
•Proper Shipping Name: EHC-O
•Hazard Class: 5.1
•Labels: 5.1 (Oxidizer)
•Packing Group: II
15. REGULATORY INFORMATION
•SARA Section Yes
•SARA (313) Chemicals No
•EPA TSCA Inventory Appears
•Canadian WHMIS Classification C, D2B
•Canadian DSL Appears
•EINECS Inventory Appears
Notice of Intent to Construct or Operate Injection Wells
Wheeler’s Grocery, Reidsville, North Carolina

APPENDIX B

MONITORING WELL CONSTRUCTION DETAILS

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Pyramid Environmental & Engineering, P.C.
FIELD DRILLING RECORD
OCATION:
START DATE:
DR
L MET'
Wheeler's Grocery
2005-299
9385 US Highway 158
Monroeton, NC
12/20/05
JAD
3" H.S.A.
BORING/WELL #
BOIUNI
LOCA'T'
? SAMPLE MEI
ED
MW-2
In former 550-gallon
kerosene UST pit
12/20/05
Ransier
none
BO1ING..Di
DEPTH
In ft.)
5"
25 ft.
CASING D
Visual Manual Soil Classification
Color, texture, structure , cousin toncy,odor, etc
.
2"
25 ft.
PERC'sNT. RECOVERY
SLOW 'COUNTS
OVA REUL'S
0
10
Orange -red sand -gravel mixture (GP), slightly moist
to moist, moderate petroleum odor 5-10 ft, fill material
OVA =200 ppm
10
17
Orange -red sand -gravel mixture (GP), moist to wet
GW encountered at —15 feet BLS, moderate
Petroleum odor, fill material
OVA=150 ppm
17
25
Silt (MH), highly micaceous, phyllite/schist, saprolite
Saturated, strong petroleum odor
OVA=1000+ ppm
Well set at 25 feet BLS
MONITORING WELL INFORMATION (IF APPLICABLE)
RISER LENGTH(ft) 5 DEPTH(ft) 0 - 5 DIAMETER(in) 2
SCREEN LENGTH(ft) 20 DEPTH(ft)
DEPTH TO TOP OF SAND
DEPTH TO TOP SEAL
MATERIAL PVC
5 - 25 DIAMETER(in) 2 MATERIAL PVC
3 Feet BAGS OF SAND 2
1 Feet BENTONITE USED 1/4 Bag
BAGS OF CEMENT USED 1/4 bag

Pyramid Environmental & Engineering, P.C.
FIELD DRILLING RECORD
PROJECT NAME:
PROJECT NUMBER:
LOCATION;
START DATE:
GEOLOGIST:
DRILL METHOD:
Wheeler's Grocery
2005-299
9385 US Highway 158
Monroeton, NC
12/20/05
JAD
3" H.S.A.
ORLNG WELI
LOCATION:
AiV
MW-3
Immediately downgradient of
former 2K gal. gasoline UST
12/20/05
Ransier
none
BORING DIA.
5"
CABIN(
2"
TOTAL DEP
Co
25 ft.
CASING DEPTH:
Visual Manual Soil. Classification
c, texture, structure, consistency►,odor,
25 ft.
PERCENT RECOVERY
BLOW COUNTS
OVA RE'8IILTS
0
18
Red clayey silt (CL), micaceous, medium plasticity,
Moist 10-18, GW encountered at -15-16 feet, moderate
OVA= 800 ppm
Petroleum odor
18
25
Yellow -orange sandy silt (MH), highly micaceous,
Moist, strong petroleum odor, saprolite, phyllite
OVA=1000+ ppm
MONITORING WELL INFORMATION (IF APPLICABLE)
RISER LENGTH(ft) 5 DEPTH(ft) 0 - 5 DIAMETER(in) 2 MATERIAL PVC
SCREEN LENGTH(ft) 20 DEPTH(ft) 5 - 25 DIAMETER(in) 2 MATERIAL PVC
DEPTH TO TOP OF SAND 3 Feet BAGS OF SAND 2
DEPTH TO TOP SEAL 1 Feet BENTONITE USED 1/4 Bag
BAGS OF CEMENT USED 1/4 bag

North Carolina Department of Environment and Natural Resources- Division of Water Quality
Qu l
WELL CONTRACTOR CERTIFICATION ft 3580
YVtII^^ AA
f
1. WELL CONTRACTOR:
Bryan Vest
Well Contractor (Individual) Name
Ransier Environmental Drilling, Inc.
Well Contractor Company Name
PO Box 923
-Street-Address-
Whispering Pines
NC 28327
City or Town State Zip Code
(910 ) 690-6688
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#MW-6
OTHER ASSOCIATED PERMIT#(ifapplicable).
SITE WELL ID #(if applicable)
3. WELL USE (Check One Box) Monitoring I/Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED6123/11
4. WELL LOCATION:
9385-A Hwy 58
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Reidsville COUNTYRockingham
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valleylat ❑Ridge ❑Other
LATITUDE 36 0 *17 '22 ' DMS DD
LONGITUDE 79 0° 44 , 06 " DMS DD
Latitude/longitude source: fit PS Ejropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Wheeler's Grocery .
Facility Name
see above
Facility ID# (if applicable)
Street Address
see above
NC
City or Town
Kristin Beckwith
State Zip Code
Contact Name
PO Box 16265
Mailing Address
Greensboro
City or Town
336 ) 335-3174
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 25
NC 27416
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES ❑
NO V
c. WATER LEVEL Below Top of Casing: 15 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING Is -.25 FT. Above Land Surface`
"Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
g.-- WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING:. Depth Diameter Weight Material
Top -.25 Bottom 10 Ft. 2" Sch 40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top .5 Bottom 6 Ft. portiand tremmie
Top Bottom Ft:
Top Bottom Ft.
9. SCREEN: Depth Diameter Slot Size Material
Top 10 Bottom 25 Ft, 2" in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 8 Bottom 25 Ft. Med. Quartz
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom Formation Description
0 / 25 red/brown sl. clayey sandy silt
/
/
/
/
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
X 7/27/11
SIG URE'OF CERTIFIED WELL CONTRACTOR DATE
Bryan Vest
PRINTED NAME OF PERSON CONSTRUCTING THE -WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
Form GW-1 b
RPv 2In9

Notice of Intent to Construct or Operate Injection Wells
Wheeler’s Grocery, Reidsville, North Carolina

APPENDIX C

ACCESS AGREEMENT FROM SITE PROPERTY OWNER

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Ms. Linda Blalock
DWM UST Section
163 7 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Blalock:
RE: Site Access Agreement
Wheeler's Grocery
9385-A Hwy 158
Reidsville, Rockingham County
FTP#: 14897
r •
I•'
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 ofG.S. 143-
215.3(a)2.
I am/We are granting permission 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.
6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the landowner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation,
Sincerely,
9tv\allf Pti�
Signature
R001\d /; Pat4TkR-
Type/Print Name of Owner or Agent
8 '92 tibu y
Address
Address
(67.) ILL 2 73),
City/State/Zip Code
3%-3 f?-7703/nit( 3.h-3���I/5 -
Phone Number
J
71- Date