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Home My WebLink AboutWI0400544_DEEMED FILES_20200311Permit Number WI0400544 Program Category Deemed Ground Water Permit Type Injection Deemed Air Well Primary Reviewer shristi.shrestha Coastal SWRule Permitted Flow Facility Facility Name The Country STore Incident# 30792 Location Address 4807 NC Hwy 57n Semora Owner Owner Name Hatchgro LLC Dates/Events NC 27343 Scheduled Orig Issue 3/11/2020 App Received Draft Initiated Issuance 2/28/2020 Re g ulated Activities Groundwater remediation Outfall Central Files : APS SWP Permit Tracking Slip Status Active Project Type New Project 3/11/2020 Version 1.00 Permit Classification Individual Permit Contact Affiliation Major/Minor Minor Region Winston-Salem County Caswell Facility Contact Affiliation Owner Type Non-Government Owner Affiliation Brent W. Groce 103 Miranda Ln Roxboro NC 27574 Public Notice Issue 3/11/2020 Requested /Received Events Effective 3/11/2020 Expiration Waterbody Name Streamlndex Number Current Class Subbasin North Carolina Department of Environmental Quality -Division of Water Resources NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS The following are "permitted by rule" and do not require an individual permit when constructed in accordance with the rules of 15A NCAC 02C .0200 (NOTE: This form must be received at least 14 DAYS prior to injection) AQUIFER TEST WELLS C1 5A NCAC 02C .0220) These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics. IN SITU REMEDIATION (ISA NCAC 02C .022 5) or TRACER WELLS U SA NCAC 02C .0229): 1) Passive Injection S y 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 Injection O p erations -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. r--~ ,-• ·• ., ,,,,,., .. ,.,~ ,.Mtii;. ~ L r ._ 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 ~~ t~ 2020 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. -::-.... ·~, ... ,i-, ... ,...,....,.,~F--. .'.'r.l "'" ,1"""1,,. • l.i l. 4) Air Iniection 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 24 , 2020_ PERMIT NO. (A/1,0 'f-0 0 S lf t.J= (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 behalfof the business or agency: Name(s): ---=-N-'-C=D=-E=-"'O-'--'/D=-WM/U~~~S~T~S=ec~ti=·o=n/f~ru=st""F'""u=n=d-=B"""r=an=d=:-=In=c=i=de=n=t-=-M=a=n=a=g=er=---=L=in=d=a~B=lal=o=c=k'----- Mailing Address: --~l-=-6~4~6 -=-M=a=i~l =S=erv1~·c~e~C~e=n=t=er=·--------------------- City: ---~R=a=le=i=gh~-----State: NC Zip Code:=2~76=9..:.9 ____ County: ___ ~W~a=k=e- Day Tele No.: ---~9_1~9-_7_0 _7-_8_16~5 ___ _ Cell No.: __________ _ EMAIL Address:. ___ =L=in=d=a=.B=l=al=o=c=k @""'t=n=c=d=enr=.g;,.;o""'v'----Fax No.: ___________ _ Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page I D. PROPERTY OWNER(S) (if different than well owner/applicant) Name and Title: Brent W. Groce Company Name ---=H=a=tc=h=gr=o~L=L-=C ________________________ _ Mailing Address: ------=1=0=3~M=ir=an=d=a~L=an=e'------------------------- City: Roxboro State: _NC_Zip Code: 27574 County:~P~e=rs~o=n~--- Day Tele No.: ---~3~3~6-~5~97~-~22=0~7 ___ _ Cell No.: 336-592-1121 Fax No.: EMAIL Address:, _____________ _ ------------ E. PROJECT CONTACT (Typically Environmental Engineering Finn) Name and Title: --~L=y""'n~d=a=l =B~u=tl=er~------------------------ Company Name ---=S=&=ME=-I~n~c~. _________________________ _ Mailing Address: __ __,,_86_,,_4_,_,6"--W..:...:....;:e=st:....:M=ar=k=e-=---t =Str=e=e=t"-'S=m=·=te:....:1:....;:0=5 ________________ _ City: Greensboro State: _NC_ Zip Code: 27409 County: Guilford Day Tele No.: -----=3=3-=-6--=2=8....,8----'--7-=--18=--'0'-----Cell No.: 336-312-0276 EMAIL Address: __ ~l=b-=u=tl=er@'-'-'"s=m=e=i=n=c.=c=om~----Fax No.: ___________ _ F. PHYSICAL LOCATION OF WELL SITE (1) Facility Name & Address: Incident # 30792 Name: The Coun try Store 4807 NC Highway 57 N City: Semora County: Caswell Zip Code: 27343 (2) Geographic Coordinates: Latitude**: 0 " or 36.4993 ° ---- Longitude**: 0 __ " or -79.1530 ° ___ _ Reference Datum:, _______ ~Accuracy: _______ _ Method of Collection:----=D"'--e=L=o=rm=e-=®'--------------- **FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COO RD INA TES. G. TREATMENT AREA Land surface area of contaminant plume: ____ square feet Land surface area ofinj. 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. (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 Page2 I. J. 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. 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 h np ://deg.nc.gov/about/divisions/water- resources/water-resources-pennits/wastewater-branch/ ground-water-protection/ ground-water-approved-in jectants. All other substances must be reviewed by the DHHS prior to use . Contact the UIC Program for more info (919- 807-6496). lnjectant: Volume ofinjectant: ------------------------------ 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: lnjectant: ---------------------------------- Volume ofinjectant: _____________________________ _ Concentration at point of injection: Percent if in a mixture with other injectants: K. WELL CONSTRUCTION DATA (1) Number of injection wells: ---=-1 __ ---'Proposed __ _____,,l ___ E.xisting (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 pennanent, 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 ;_i result from the injection activity. N. SIGNATURE OF APPLICANT AND PROPERTY OWNER Well Owner/Applicant: "I hereby certify, under penalty of Iaw, 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 (applicable, abandon the injection well and all related appurtenances in accordance with the : i Rules." itla Signature of Applicant Print or Type Full Name and Title I.v ndal Butler. Environmental Scientist, S&ME, Inc. (Agent for NCDEO 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 wells) conform to the Well Construction Standards "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 A zreement 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 on this form. Please send I (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: (919) 807-6464 Deemed Permitted GW Remcdiation NO1 Rev. 3-2I-2018 Page 4 0 Ms. Linda Blalock DWM UST Section 163 7 Mail Service Ctr Raleigh, NC 27699-1637 Dear Ms. Blalock: RE: Site Access Agreement SEP 22 Pl-\ \: 5o The Country Store 4807 NC Hwy 57 N Semora, Caswell County Incident#: 30792 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 soil and groundwater under the authority of G.S. 143-2 l 5.3(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. DENR/WASTEMANAGEMENT UST SECTION ATTN: LINDA BLALOCK 1637 MAIL SERVICE CENTER RALEIGH NC 27699-1637 The Country Store Incident #: 30792 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. 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. Sincerely, Signature 6,2060 Type/Print Name of Owner or Agent Address Address get2 lo 4aI� 27$71 ity/Sta e/Zip Code 3: sf2 —#I2/4) 3i‘- s97- 220 &J) Phone Number 91i/zci a[e f WELL CONSTRUCTION DETAIL ` Well ID Project Name Project Number A - Proposed AS-1 30792-The Country Store 4305-19-034E W S&ME Staff Installation Date County City Weil Permit Number L Butler Scheduled 2/27/2020 Caswell Semora Not applicable Drilling Contractor License Number Drill Rig Well Type / Use Geologic Exploration, Inc. TBD Flush Monitor Well Water Level at FOB (0.01 ft- BTOC) Date/Time Northing (0.1 ft) Land Surface Elev. (0.01 ft) Drilling Method Hollow Stem Auger Depth to Water (0.01 ft- BTOC) Date/Time Easting (0.1 ft) Total Well Depth (0.1 ft-bgs Borehole Diameter (1 in) 55.0 8.25-inch 1 Pad Type 2' x 2' Concrete Protective Casing Flush Vault (8" diam) TOC Relative to Ground 025 ft 1/ Casing Material Depth Below Ground Surface (ft-bys' 2-in Sch 40 PVC Casing interval (0.1 ft-bgs) 0.25 to 49.8 Screen Type 2-in Sch 40 PVC (0.010) Screen Interval (0.1 ft-bgs) 49.8 to 54.8 Top of Seal - 45.0 0.1 ft-bgs4 % Grout Type Portland Cement T2 Top of Filter Pack 48.0 0.1 ft hgs Grout Interval (0.1 ft-bgs) 0.5 to 45.0 Top of Screen - 49.8 0.1 ft-bgs Seal Type 3/8 in. Holeplug Seal Interval (0 1 ft-bgs) 45.0 J to I 48-0 Screened Interval - 5.0 0.1 ft-bgs Filter Pack #2 Silica Sand Filter Pack Interval (0.1 ft•bgs) V 48-0 to ] 55.0 Bottom of Screen - 54.8 0.1 ft-bgs Development Bottom of Filter Pack - 55.0 0.1 ft-bgs Yes Cave In - 0.1 ft-bgs :§§, ,,,,i Development Volume (gal) Total Boring Depth - 55.0 0.1 ft-bgs - 1 Notes: BTOC - Below Top of Casing TBD - To Be Determined For lithologic information see attached boring log Form Revision Date: 9/1/17 2:10 PM