WI0400542_DEEMED FILES_20200228

Permit Number WI0400542
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Airport Exxon lncident#10022
Location Address
Formerly 3751 N Liberty St
Winston Salem
Owner
Owner Name
NC 27105
Ncdeq Owm Ust Section-Federal & State Lead Program
Dates/Events
Orig Issue
2/26/2020
App Received
2/26/2020
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
2/28/2020
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
Herbert Berger
1646 Maile Service Ctr
Raleigh
County
Forsyth
NC
Issue
2/26/2020
Effective
2/26/2020
27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasln
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 I5A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS i15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION 115A NCAC 02C .0225 y or TRACER WELLS 115A NCAC 02C .0229i:
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 trite 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: February 19 _.2020_
PERMIT NO. f 13.- 6O59'2.- (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
(1) x Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well Complete sections B through F, K, N
(3) 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
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): NCDEQIDWMIUST Section/Trust Fund Brand: Incident Manaier- Thomas Chapman
Maili5g 9,ddress: 1646 Mail Service Center,
� iv
City: Raleigh State: NC Zip Code:27699 _ County; Wake
FEB 2 (:13ZU le No.: 919-707-8170 Cell No.: -
EMAIL Address: IIerbert.Bergerct:ncdenr.zov Fax No.: -
t)eemtd rtiiatted•GNA—PRemediation NO1 Rev. 3-21-2018 Page i

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: --~M~a=rk~D~a~vt=·d=s=on=:~A=1~·rp..._o=rt~D-=i=re~c=to=r _________________ _
Company Nrune ____ 'F_o~rs~vt~h_C_o~un'---ry~------------------------
Mailing Address: ___ 3_80_1_N_. _L_ib_e_rty~S_tr_e_et~·---------------------
City: Winston-Salem State: _NC_ Zip Code: ___ 2_7_10_5_County:_F_o_rs_yth~---
Day Tele No.: ----=3-=--3--=---6---'-7-=-67"---=-63"""6"""'1'------Cell No.:
EMAIL Address:. _____________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ L_yn~d_a_l_B_u_tl_er ________________________ _
Company Nrune -------'S=&=M=E=-=I=nc=·-------------------------
Mailing Address: ----=-86"""4"-'6a....W-'-'--"e=st"""M=ar=k=e-"-t =Str=ee=t.,_S=ui=·=te'-'1"""0=5 ________________ _
City: Greensboro State: _NC_Zip Code:=2~74"-'0'""9 ____ County: Guilford
Day Tele No.: ----'-3-=-3-=--6-=2-=-88"--~7~18~0 ___ _
EMAIL Address: __ ~lb~u~t~le~r @._a-s~m~e~in~c~.c~o=m~----
F. PHYSICAL LOCATION OF WELL SITE
Cell No.: 336-312-0276
Fax No.:
( 1) Facility N rune & Address: ----=In=c=id=e=n"""t "'-#""10"""0=2=2--=-N""'a=m=e""":-=A=rrp=-· =o=rt-=--E=xx=o=n=---------
F ormerly 3751 N. Liberty Street (p arcel merged with Airp ort Authori ty pro peny
City: Winston-Salem County: Forsyth Zip Code: --=2~7--=---10~5'---
(2) Geographic Coordinates: Latitude**: ___ 0 ____ " or 36.136050° __ _
Longitude**: 0 __ " or -80.230058° __ _
Reference Datum: ________ Accuracy: _______ _
Method of Collection:_G--=-----=---oo=g=l~e=E=a=rt=h'------------
**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 contruninant 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) Contruninant 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 contrunination 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 Permitted GW Remediation NOi Rev. 3-21-2018 Page 2
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.
J. APPROVED INJECTANTS -Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at htt p://deg .nc.1wv/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ ground-water-protection/ ground-water-a pp roved-ini ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: --------------------------------
Volume of injectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants:
Injectant: ----------------------------------
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent ifin a mixture with other injectants:
K. WELL CONSTRUCTION DATA
Number of injection wells: --=2 ___ Proposed ______ .Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-1 s, 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.
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.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well 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 an 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 ajd all related appurtenances in accordance with the I5A_NCAC 02C 0200 Rules."
Lynda] Butler: Environmental Scientist. S&ME. Inc. (Agent for NCDEQ
ignature of Applicant Print or Type Full Name and Title
Propem. 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 .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 attached NCDEO Site Access Agreement
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 ofa signature an 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 GW Remodiation NOI Rev. 3-21-2018 Page 4

7fl In
UNDERGROUND STORAGE TANK SECTION
May 16, 2019
Mr. Thomas Chapman
Hydro geologist
DWM/UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Mr. Chapman
RE: Access Agreement
Airport Exxon
3751 North Liberty Street
Winston-Salem, Forsyth County, North Carolina
Incident Number: 10022
9 Pi; 3· 08
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 Environmental Quality (Department) or its contractor to enter upon said
property for the pmpose of conducting an assessment and/or remediation of the groundwater and/or soils
under the authority ofG.S. 143-215.940.
I am/We are granting permission to the lands we own or control 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 dam.age to the surrounding
lands. Any damages will be restored by the Department or its contractor to as close to the pre-work
condition as practicably possible.
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 will notify the land owners
48 hours prior to entry and 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. No representations or warranties, either expressed or implied, have been
made to melby the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed.
1/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
f^y�+VZx ►N•.7Fes.,
lire-f--i— V.>I4..tJ-=—
Type/Print Name of Owner or_t
?.6 —7 g 7- 6? C
Phone Number
Address N L z T I a S
ay
City/State/Zip Code
" / ?
Date
RE: Airport Exxon
3751 North Liberty Street
Winston-Salem, Forsyth County, North Carolina
Incident Number: 10022

COMPLETION REPORT OF WELL No. SPG-1
Sheet 1 of 1
PROJECT: Airport Exxon
PROJECT NO: 1584-03-005
PROJECT LOCATION: Winston-Salem, North Carolina
DRILLING CONTRACTOR: T. Miller
DRILLING METHOD: 4 1/4' H.S.A.
DATE DRILLED: 7/22104
WATER LEVEL:
LATITUDE:
LONGITUDE:
TOP OF CASING ELEVATION:
DATUM:
LOGGED BY: B. Ware
STRATA
DESCRIPTION
W
WELL
DETAILS
2
w
is
cc
W
h a kii gown Sandy .
SILT
pale to Medium
Brown Sandy BILT
10
-15
2
25.50
25.80
BSC
TD
WELL CONSTRUCTION DETAILS
PROTECTIVE CASING
Diameter:
Type:
Interval:
RISER CASING
Diameter. 2"
Type: PVC
Interval: 0.5-23.5
GROUT
Type: Neat Cement Grout
Interval: 1.0-19.5
SEAL
Type: Bentonite
Interval: 19.5-22.0
F1LTERPACK
Type: #2 Sand
Interval: 22.0-25.8
SCREEN
Diameter: 2"
Type: 0.010"
Interval: 23.5-25.5
LEGEND
E FILTER PACK
■ BENTONITE
Abl
CEMENT GROUT
CUTTINGS I BACKFILL
STATIC WATER LEVEL
Sala3718 Old Battleground Road
Greensboro, NC
TOC
GS
BS
FP
TSC
BSC
TOP OF CASING
GROUND SURFACE
BENTONITE SEAL
FILTER PACK
TOP OF SCREEN
BOTTOM OF SCREEN
TD TOTAL DEPTH
CG CEMENT GROUT
COMPLETION REPORT OF
WELL No. SPO-1
Sheet 1 of 1

COMPLETION REPORT OF WELL No, SPG-2
Sheet 1 of 1
PROJECT: Airport Exxon
PROJECT NO: 1584-03-005
PROJECT LOCATION: Winston-Salem, North Carolina
DRILLING CONTRACTOR: T. Miller
DRILLING METHOD: 41/4" H.S.A.
DATE DRILLED: 7122104
WATER LEVEL:
LATITUDE:
LONGITUDE:
TOP OF CASING ELEVATION:
DATUM:
LOGGED BY: B. Ware
STRATA
DESCRIPTION
odium Brown Sandy
SILT
te to Medium
Brown Sandy SILT
2
*sat
WELL
DETAILS
0.00
0.50
1,00
F
uJ
9
GS
TOC
CG
18.50 ! BS
22.00 FP
23.50 TSC
25.50 BSC
25.80 TD
3718 Old Battleground Road
Greensboro, NC
WELL CONSTRUCTION DETAILS
PROTECTIVE CASING
Diameter:
Type:
Interval:
RISER CASING
Diameter: 2"
Type: PVC
Interval: 0.5-23.5
GROUT
Type: Neat Cement Grout
Interval: 1.0-18.5
SEAL
Type: Bentonite
Interval: 18.5-22.0
FILTERPACK
Type: #2 Sand
Interval: 22.0-25.8
SCREEN
Diameter. 2"
Type: 0.010"
interval: 23.5-25.5
LEGEND
F- FILTER PACK
III BENTONITE
CEMENT GROUT
CUTTINGS 1 BACK FILL
x STATIC WATER LEVEL
TOC
GS
BS
FP
TSC
BSC
TD
CG
TOP OF CASING
GROUND SURFACE
BENTONITE SEAL
FILTER PACK
TOP OF SCREEN
BOTTOIN OF SCREEN
TOTAL DEPTH
CEMENT GROUT
COMPLETION REPORT OF
WELL No. SPG-2
Sheet 1 of 1

NORFLEET DRII/E
Drawing Path: (1\430512019119.128 - AIRPORT EXXON1$11-2CAAirpart Exxon Site Plan.dwg
NORTH LIBERTY STREET
MW-5
UW-1
f 1
I I MW-2 1 1
FORMER
DISPENSER
ISLANDS
RW-1
SPG-1
• MW-6
MW-7
KEY
* - MONITORING WELL LOCATION
• - MONITORING WELL PRESUMED DESTROYED
O - RECOVERY WELL LOCATION
• - AIR SPARGE WELL LOCATION
C J - FORMER UST LOCATION
RW-2
•
L___J
L__J
LJ
MW-1
FORMER
BUILDING
LOCATION
SPG-2
MW-9 (ATC)
4
MW-8
C47
45D
PAW-3
UST DATA TABLE
TANK ID
CAPACITY
CONTENTS
1
3,000 GALLONS
GASOLINE
2
6,000 GALLONS
GASOLINE
3
6,000 GALLONS
GASOLINE
4
550 GALLONS
FUEL OIL
5
550 GALLONS
WASTE OIL
MW-1
•
MW-9
30
GRAPHIC SCALE
60
(IN FEET)
SITE MAP
Site ID: 10022
AIRPORT EXXON
3751 NORTH LIBERTY STREET
WINSTON-SALEM: NORTH CAROLINA
SCALE:
AS SHOWN
DATE:
JAN. 2020
PROJECT NUMBER
4305-19-1 288
FIGURE NO,
2