WI0400532_DEEMED FILES_20191107

Permit Number
Program Category
Deemed Ground Water
Permit Type
., ,.
WI0400532
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Fonner Moore"s Exxon (Glendale Springs FD)
Location Address
7930 NC Hwy 16
Owner
Owner Name
Ncdeq State -Lead Program
Dates/Events
Orig Issue
11n/2019
App Received
10/21/2019
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28694
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
11/7/2019
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
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Herbert Berger
1646 Maile Service Ctr
Raleigh
Ashe
Issue
11n/2019
Effective
11n/2019
NC 27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
ATC
ENVIRUNIAENTAL • GEBTECHNICAL
BUILDING SCIENCES • MAIERIALS TESTING
October 16, 2019
7606 Whitehall Executive Center Drive, Ste. 800
Charlotte, NC 28273
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
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
Former Moore's Exxon
7390 NC Highway 16
Glendale Springs, Ashe County, North Carolina
Facility lD: WS-2669
NCDEQ Incident No. 6146
Risk Classification: Intermediate (1-180D)
Dear Ms. Shrestha:
ATC Group Services LLC (ATC) has prepared the enclosed Notice of Intent
operate an air sparging well for enhanced MMPE operations at the referenced
Fund site.
If you have questions or require additional information, do not hesitate to contact
704-529-3200.
Sincerely,
ATC Gr up Services LLC
Steven C F . bach, LG
Project Manager
Attachments
g 130
to construct and
State Lead Trust
me concerning at

Notice of Intent to Operate Injection Wells,
Former Moore's Exxon, Glendale Springs, North Carolina
NOTICE OF INTENT FORM
ATC
ENVIRONMENTAL • NENTECNNICAL
HOFLOINB SC3ENCES • MATERIALS TESTING

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 in jection)
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 OSA 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 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 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: October 16, 2012..... PERMIT NO. l;y J.-6 'f0 0 5°"'1 L (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
X 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
___ 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): --~N~C=D~E~O_-_S~t=a~te~L~e=a~d~P~ro=&=rr=am~-~In=c=id=en=t~#~6~1~4~6 ______________ _
Mailing Address: --~1~64~6~M=a=il~S~e~rvi~·~ce~C=en=t~er~-------------------
City: Ralei gh State: NC Zip Code:~27~6=9~9 ____ County:~W~ak=e ___ _
Day Tele No.: 919-791-4200 Cell No.: --~N_o~t~A~v~a~il~ab=l=e ___ _
EMAIL Address: herb.bergerr@ ncdenr.gov Fax No.: --~N~ot~A~v_a~i~la=b=le~---
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 1
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: ___ G~l~e=n_da~l~e ~S=pr=in=g=s~F~ir~e_D~e p~artm~=e=n~t ________________ _
Company Name --------------------------------
Mailing Address: --~73~9~0~N~C~H=ig=h~w~a_y~l~6 ______________ _
City: Glendale Springs State: NC Zip Code: 28694 County:.~A~s=h=e ______ _
Day Tele No .: [phone] Cell No.: __________ _
EMAIL Address: ____________ _ FaxNo.: __________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ S=t~ev~e_n_C~F~ra=m=b~a=ch=•-L_G~/~S~en=i=o~r ~Pr~o~je_c_t_M~an~a=ge~r ___________ _
Company Name --~A~T~C_G=r~o~u~p~S~er~v=ic=e=s~L_L~C~-------------------
Mailing Address: --~7=60~6~Whi~·t=eh=a=ll~E=x=e=c=u=ti~ve~C~en=t=er~D~ri=v~e-~S=t~e-~8~0~0 ___________ _
City: Charlotte State: NC Zip Code: 28273 County: Mecklenburg
Day Tele No .: 1 (704 ) 972 4080 Cell No.: __________ _
EMAIL Address: steven.frambach(w atc gs.com Fax No.: __________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Former Moore's Exxon (Glendale Sprin gs FD )
7390 NC Hi ghwav 16
City: --~G=l=en=d=a=le=-=Sp""'r""in""'g""s ______ County~: A~sh=e~ ______ .Zip Code: =2=86=9~4~--
(2) Geographic Coordinates: Latitude**: ___ 0 --__ " or 36 °. 345492
Longitude**: 0 __ "or -81 ° 380564
Reference Datum: _______ ---eAccuracy: _______ _
Method of Collection: Goo gle Earth Professional
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPIBC COO RD INA TES.
G. TREATMENT AREA
Land surface area of contaminant plume: ____ N~/_A __ square feet
Land surface area ofinj. well network: square feet (:S 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.
(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 ACTMTIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity . This should include the rate, volume, and duration
of injection over time.
NIA
J. APPROVED INJECT ANTS -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 h11p://deg.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-
80 7-6496).
Injectant: --"""N"'"IAe..:-_________________________ _
Volume ofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
Injectant: NIA
Volume ofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
Injectant: ---"'-N-"-/~A,___ _________________________ _
Volume ofinjectant: ___________________________ _
Concentration at point of injection:
Percent if in a mixture with other injectants: ___________________ _
K WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: --~ __ Proposed'---_____ E.xisting (provide GW-ls)
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, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
( c) Well contractor name and certification number
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The air spar inL-enhanced MMPE event is scheduled for November 4-8. 2019
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 comprehensive g oundwater sampline.event is scheduled for December 1. 2019.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby cert6, 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 opines 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 1 NCAC 02C 0200 Rules."
On Beha1 f of NCDEQ Steven C Frambach. on behalf of NCDEQ
Signature of App !cant Print or Type FuII Name and Title
Property Owner (if the property is not owned 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) conform to the Well Construction Standards
(15A NCAC 02C .020m "
"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 attached Access Agreement
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*4n access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of his NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted OW Remediation NO1 Rev. 3-21-2018 Page 4

Notice oflntent to Operate Injection Wells,
Former Moore's Exxon, Glendale Springs, North Carolina
ATTACHMENT A
INJECTION WELL CONSTRUCTION DETAILS
/~TC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES• MATERIALS TESTING
PLANNED AIR SPARGING WELL CONSTRUCTION ❑ETAILS
FLUSH -MOUNT MANHOLE
Installation Contractor: ENVIRONMENTAL DRILLING AND PROBING SERVICES (NC #3307)
LOCKABLE WELL CAP
Li = 0.25 FT.
L2 = 34.75 FT.
L3 = 5 FT.
L4 = 40 FT.
(NOT TO SCALE)
PROTECTIVE COVER AN❑
COVER MATERIAL
COVER DIAMETER
COVER LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
CONCRETE PAD
Steel
BACKFILL AROUND CASING
MATERIAL
THICKNESS
SEAL
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
DISTANCE ABOVE SCREEN
WELL SCREEN
SCREEN MATERIAL
❑IAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
DEPTH TO BOTTOM ❑F
BOREHOLE
DIAMETER OF BOREHOLE
8 inches
12 inches
2 feet x 2 feet
flush mounted
Sch 40 PVC
2 inches
flush threaded
34.75 feet
cement -sand grout
Varies
bentonite
2'
#2 silica sand
2`
Sch 40 PVC
2 inches
5 feet
0.010 inches
Varies
Varies
6-5 inches
INDICATES GROUNDWATER SURFACE
TITLE
TYPE -II AIR SPARGING WELL
CONSTRUCTION DIAGRAM
ATC
ENVIRONMENTAL • GEOTECIINICAL
BUILDING SCIENCES - MATERIALS TESTING
FILE
PREP. BY
DL
REV. BY
CD
DATE
PROJECT NO.

Notice of Intent to Operate Injection Wells,
Former Moore's Exxon, Glendale Springs, North Carolina
ATTACHMENT B
ACCESS AGREEMENT FROM PROPERTY OWNER
ETC
ENVIRONMENTAL • CELTECNNICAE
BUILDIRC SCIENCES • MATERIALSTfSTIN6

Herb Berger
Hydrogeologist
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
RE: Access Agreement
Former Moore's Exxon
7390 NC Hwy 16
Glendale Springs, Ashe County, North Carolina
Incident #6146
Dear Mr. Berger:
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 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 land owner.
I/We agree not to interfere with, remove, or any way damage the Department's wells) or its
contractor's well(s) and equipment during the investigation. (Former Moore's Exxon)
Sincerely,
4,). e/d04
Signature
Type/Pnnt Name of Owner or Agent
Phone Number
LA1,60A-*1/25
Address
L'LLI-g_ (GIj,JVQ
City/State/Zip Cdde
.�� 7 //
Date

6. The activities to be carried out by the Department or its contractor are for the primary beriefit 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 land owner.
1/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. (Former Moore's Exxon)
Sincerely,
I Signature
Type/Print Name of Owner or Agent
331E -9 z _25•2.
Phone Number
Mar Ck; 4 c, L.
Address
TL 5Oia Zepio
City/State/Zip Code
2-17•/1
Date