WI0400547_DEEMED FILES_20200706

Permit Number WI0400547
Program Category
Deemed Ground Water
Permit Type
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.sh restha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Mass General Store
Location Address
3565 NC Hwy 194 S
Sugar Grove
Owner
Owner Name
NC 28679
Ncdeq Dwm Ust Section Federal & State Lead Program
Dates/Events
Scheduled
Orig Issue
4/28/2020
App Received Draft Initiated Issuance
4/21/2020
Re g ulated Activities
Groundwater remediation
Outfall
Central Files: APS SWP
Permit Tracking Slip
Status
Active
Project Type
New Project
7/6/2020
· Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Watauga
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Herbert Berger
1646 Maile Service Ctr
Raleigh NC 27699
Public Notice Issue
4/28/2020
Re q uested /Received Events
Effective
4/28/2020
Expiration
Waterbody Name Streamlndex Number Current Class Subbasin
ATC
ENVIRONMENTAL • GEOTECHHICAL
BUILDING SCIENCES • MATERIALS TESTING
April 21, 2020
7606 Whitehall Executive Center Drive, Ste. 800
Charlotte, NC 28273
Tel: [phone]
Fax: [phone]
www. atcg rou pservices. 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
Mast General Store
3536 NC Highway 194 South
Sugar Grove, Watauga County, North Carolina 28679
Facility IDs: 0-001337
NCDEQ Incident No. 19273
Risk CIassification: High
Dear Ms. Shrestha:
ATC Group Services LLC (ATC) has prepared the enclosed Notice of Intent to operate a passive
ORS remedy in a previously -constructed groundwater monitoring well associated with the
referenced State Lead Trust Fund site.
If you have questions or require additional information, do not hesitate to contact me concerning at
704-529-3200 or at [e-mail].
Sincerely,
ATC Group Services LLC
Noelle A. France, LG
Project Manager
Attachments
NC DEQ/DWR
clECENED
APR 24 207A
Central Office

NC Department of Environmental Quality-Division of Water Resources (DWR)
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 (1 5A NCAC 02c .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION Cl SA NCAC 02c .0225) or TRACER WELLS OSA NCAC 02c .0229):
1) Passive Injection S vstems -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 is 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.
5) In-Situ Thermal Wells CT ST)-Used to 'heat' contaminated groundwater to enhance remediation
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE : __ ____,A=pr'""i"-'12=0a.:... -=2=02=0 PERMIT NO. IN ,U) 4-00 r 4--:/,-(to be filled in by DWR)
NOTE-If this NOi is being submitted as notification ofa modification ofa previously issued NOi for this site (e .g .,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needer' relevant information to assess and approve injection:
Permit No. WI~----------Issued Date: _________ _
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
(1)
(2)
(3)
(4)
(5)
(6)
___ Air Injection Well ....................................... Complete sections B through F , J, M
___ Aquifer Test Well ....................................... Complete sections B through F , J , M
X Passive Inj ection System .................... , .......... Complete sections B through F, H-M
___ Small-Scale Injection Operation ...................... Complete sections B through M
___ Pilot Test ................................................. Complete sections B through M
___ In-Situ Thermal (IST) Well ........................... Complete all sections except K
STATUS OF WELL OWNER: State Government
Deemed P ermitted GW Rem ediation NOi Rev . 2-14-2020
RECEIVED
APR 2 4 2020
NCOEQ/DWR
Central Office Page I
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): NCDE O. DWM. UST Section -State Lead Pro gram -Incident #19273 (Herb Berber)
Mailing Address: -----=1-=-64-'-6=-=M=a=il,....,S=e=rv-'--'i=c-=-e -=C=en=t=e=-r ___________________ _
City: Ralei eh State: NC Zip Code: __ ---=2_,_76=9'-"9_-=16'-'4-=-6 __ County:. ___ W~a=ke~
Day Tele No.: 919-707-8170 CellNo.: __________ _
EMAIL Address: [e-mail] Fax No.: __________ _
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: -----=J-=-o=hn==E"-. -=C-=-oo.=Jp~e=r-=-J=-=r. ______________________ _
Company Name --~M=a=st'-'G=e=n=e=ra=l-=S=to=r=e _____________________ _
Mailing Address: -----=-P-'-'.O=•c.=B=o=x=-7'-'1=-4,._____ ______________________ _
City: Valle Crucis State : NC Zip Code: 28691 County : Watauga
Day Tele No.: (828 ) 963-6511 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
F.
Name and Title: __ __,A""'l,_Ox.u=ar=le=s,...,. L=G=-.:_/-=S=e=m=·o-=--r -=-P=ro::;,,Lie=c"-"t -"'M~an=acoge=r'-----------------
Company Name __ __,A=T-=Cc...:.A..:,,s=s=o=ci=at=e=s -=-o.:..fN==o=-=rth=-..:,C=ar=o=l=in=a"-'. P~·=C'--'-. ______________ _
Mailing Address: __ ___,_7-=-60:..:6:...Wh..,_,__,,=it=e=ha=l"'--l E=xe=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.: (704 ) 529-3200 Cell No.: (803 ) 984-6764
EMAIL Address: al.guarles c@ atc gs.com Fax No.: __ ....;Na...:.=ot=-:Ac.:..:.;va=i=la=b=le"-----
PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Mast General Store . 3565 NC Hwv 194 South. Sugar Grove . NC 28679
City: __ _,S=u=<=e>=ar"--=G""'ro""v...:e'---______ County: Watau ga Zip Code: =28=6'-'-7-"---9 __ _
(2) Geographic Coordinates: Latitude**: ___ 0 __ __" or _....;3::..;6:a.a·=-2 =10=2~4=3_0
____ _
Longitude**: 0 " or ~__,-8=0'""". 7,._,8'-"l'--'-7=5-"-l 0
____ _
Reference Datum: ________ Accuracy: _______ _
Method of Collection:.--'G=o::.:o:c.;;!!=le=-=E=arth=.:.. ____________ _
**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 ofinj. well network: _______ square feet (:S 10 ,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated:. ____ (must be .'.:: 5% of plume for pilot test injections)
Deemed P ermitted GW Remediation NOI Rev . 2-14-2020 P age 2
H. INJECTION ZONE MAPS -Attach the following to the notification.
(I) 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 horiwntal 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.
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES AT THE SITE -Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
ATC will install Provectus ORS (oxvgen-releasing socks) in monitoring wells MW-IR and MW-2 to promote
accelerated petroleum compound biodegr adation in an effort to reduce dissolved concentrations. The socks
come in 3-foot sections and (2 ) socks will be installed in the well (6 feet per well). The socks are desi gn ed to
deliver controlled-release oxvgen into the groundwater for a pproximately six (6) months .
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 2 Proposed O Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS):.~6~t=o~1=2~(=MW~~-l=R=an=d~MW~~-2~-------------
(3) For Proposed wells or Existing wells not having OW-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
Note: A GW-1 s cannot be located for well MW-2, installed in 2007, total depth 12.4 feet, 2-inch diameter Sch
40 PVC, expected to be screened from approximately 3 to 12.4 feet.
K. INJECTION SUMMARY
NOTE: Onlv iniectants approved bv the e pidemiolog1 1 section o[the NC Division o f Public Health. De partment
o( Health and Human Services can be iniected. A pproved iniectants can be fo und online at
h ttp ://deg.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/e:round-water-
protectionl!n-ound-water-approved-in jectants . All other substances must be reviewed b v the DHHS prior to use.
Contact the UJC Program fo r more in fo i(you wish to get a pp roval fo r a di ffe rent additive. However. please
note it mav take 3 months or longer.
Injectant.~: --~P~r=o~ve=c=tus~O~R=S ____ Total Amt. to be injected (gal)/event.~: -~2=2~6=.2~in~.3~p=er~w=el=l __
Amt. Water to be injected (gal/event): -~O _______ _
Total Amt. to be injected (gal/event): -~O _______ _
No. of separate injection events_: l ___ Est. Total Amt. to be injected (gal):_--'O"-----------
Source of Water (if applicable)~: ~N~o~t=A=P ... P=lic=a=b=le~--------------------
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page3
L. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
it -violations of groundwater quality standards specified in Subchapter ;CI result from the injection activity.
Approximate semi-annual sampling; events in monitoring wells associated with the Incident will be performed.
During each sampling event. ATC will collect samples from all well for analysis of volatile organic compounds
VOCs) by EPA Method 6200B. ATC will also measure dissolved oxygen. conductivity._ temperature. pH. and
oxvcen reduction potential in the well durint sampling events. Data will be used to assess the effectiveness of
passive injection.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: `7 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 offines 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 5A NL'AC 02C 0200 Rules,"
on behalf of NCDEQ. DWM. UST Section' Al Quarles. Senior Project Manaver
Signature of Applicant Print or Type FulI Name and Title
Propert' Owner (ifthepropertr is not owned bs. the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to he 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 Access Ai reement between property owner and NCDEQ
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.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Progra m
1636 Mall Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Pernutted GW Remediation NOI Rey. 2-14-2020 Page 4

0 500 1 000
2 000
11
APPROXIMATE SCALE IN FEET
REFERENCE: USGS 7.6-MINUTE.MAP, VALLE CRUCIS, NORTH
CAROLINA. DATED 2016
LATITUDE' 36.21028° NORTH
LONOI"iUDE:-81.78173° WEST
TiTL£ FIGURE 1
SITE LOCATION MAP
MAST GENERAL STORE - NCDEO INCIDENT #19273
3565 NC HIGHWAY 194 SOUTH
VALLE CRUCIS, WATAUGA COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
Q lrIo1fl North Ceram 213273 1,70d0 5211-32130 FAX [phone]-
CAD FILE
MASTSM
PREP BY
AD
REV 6Y
AQ
SCALE
AS SHOWN
RATE
4.8.19
PROJECT NO
SLP1927303

\/\
WSW-2
FORMER
1, 000-GALLON
GASOLINE
UST
FORMER
550-GALLON
KEROSENE
UST
Source_ NC Geospatial Database
0 20 40
APPROXIMATE SCALE IN FEET
GRAVEL
PARKING
•MW-4
ia WSW-1
PAVED
PARKING
LEGEND
80 MONITORING WELL LOCATION
WATER SUPPLY WELL LOCATION
TITLE FIGURE
SITE MAP
MAST GENERAL
3565 NORTH
VALLE CRUCIS,
3
STORE - NCDEQ INCIDENT #19273
CAROLINA HIGHWAY 194 SOUTH
WATAUGA COUNTY, NORTH CAROUNA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
Cheri" North Corolla 28273 (704) 621)-3200 FAX 5ffi-ten
CAD FILE
MASTSM
PREP. BY
AD
REV. I3Y
AO
SCALE
AS SHOWN
DATE
4.8.19
PROJECT NO
SLP1 927303

I
WSW-2
1,O0C-GALLON
CiASCO"NE UST
550-GALLON
KER(3SEINE UST
LEGEND
Monitoring Well location
VAater Supply Weil location
91.18 Groundwater elevation in feet
- Groundwater elevation contour line
Groundwater Now direction
G 'l:
PARKING
93.0
93.51
M\'V-2
94,0 Z-----
92.0
MAST GENERAL STORE
95.U--4. ,1
/: MVV.-ItR _ r
95.6 •,, ^4.
�. .r, !�
V 4•
NaRT�
clik;;/- PAVED
FARILENG
j.
,y4
-ti
0
O 20 40 80
s — y
APPROXIMATE SCALE IN FEET
Note.
1. Depth to groundwater measured on O$/03119.
Tm-E FIGURE 4
GROUNDWATER ELEVATION CONTOUR MAP
MAST GENERAL STORE - NCDENR INCIDENT #19273
3565 NORTH CAROLINA HIGHWAY 194 SOUTH
VALLE CRUCIS, WATAUGA COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
Chariot* North Carobs 29273 (704) FAX 2
CAD FILE
MASTSM
PREP. BY
LB
REV BY
BC
SCALE
AS SHOWN
QAFt
09/13/19
PROJECT NO,
SLP1927304

WSW-2
EPA Method 6200E - VOCs AgiL
W-2
MW-2
EPA Method 6200E - VOCa Ag/L
Benzene 13.2
Naphthalene
21.9
FORMER
1.300•GALLO^t
r.;z,SOLINE DST --
550-GALLON
ICERCSEME LIST
•
Sample W
,21.Standard
GCL
$ettegnc 1
5,000
>' tillbatteene 600
83, Q0
NFij thibalene 6
6,000
Isotuutwlbemene 70
25.000
1,2,4-Trinrethyllenaem
100
2000
t,3.5-Tiimetbylberaore
400
ZS,Q011
Total Xylem
SIIO
>.5D0
ND
MW-4
Constituents not present in excess of 2L
standard
MAST GENERAL STORE
GRAVEL '
PARKING
wsw:1
EPA Method 6200B - VOCsjig L
ND
COMMERCIAL
ROPERTY
MW--1.R
ti
EPA Method 6200E - VOCs pa.
Benzene
129
Ethylben2ene
679
Total Xylenes
3511
Naphthalene
399
Isaprnpylbenaene
101
1,2,4-Triinethylbenmene
1480
1,3,5-Trime thy [benzene
547
LEGEND
Monitoring Well location
Water Supply Well location
0 20 40 B0
APPROXIMATE SCALE IN FEET
Notes:
1. Groundwater samples taken on 09/03119,
2. Concentrations exceeding 15A NCAC 2L
.0202 groundwater standards (2L Standard)
shown (micrograms per liter - ug/L)
3. GCL - Gross Contamination Level
TrTLE FIGURE 5
GROUNDWATER QUALITY MAP
MAST GENERAL STORE - NCDENR INCIDENT #19273
3565 NORTH CAROLINA HIGHWAY 194 SOUTH
VALLE CRUCIS, WATAUGA COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
ChariotN. North Caroler 26275 ❑O 52g-3200 PAX 00U 5 U272
CAD FILE
MASTSM
PREP.BY
LB
REV.HY
BC
SCALE
AS SHOWN
DATE'
09/13/19
PROJECT NO
SLP1927304

dam._,
e.
21
1. WELLCONTRACTORI
Keith A Seece
NONRESIDENTIAL W ELL CONSTRUCTION RECOIU)
worth Cimlina lkpartment of Ern ironment and Naiura! Resources- Division of Water Quiaiil+
WELL CONTRACTOR CERTIFICATION # 2856-r1
Welt Contractor (Individual) Name
Carolina Sail Investigations. LLC
Well Contractor Company Name
132 Gurney- Rd.
Steel Address
Olin N C.
26660
City or Town Stale ,Tip Code
(704 t 539-5279
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT
OTHER ASSr?GiATEO PERMITtf(itappalecote)
SITE WELL ID/Rif applicable) MW-1R
3, WELL USE (Cheek One Box) Monitoring a'f Munw pat/Public
Industnal/Commerelal [1 AgricuituraiD Recovery trajection J
Irnpalionc7 Other El last. use)
DATE DRILLED - - 04/22/201 5_
4. WELL LOCATION:
3565 NCI-Iwv 194 South
(Straet Name, NSitntiars. CQrMxMily. Subdivialon. Lvl No, Paree, Zip Code)
crrr: Valle Cruis - couNry Watauga
TOPOGRAPH1C 1 LAND SETTING: ;check appra),+ra ie uoxr
°Slope 'Valley eta' riRidge 'Other
LATITUDE 36 " DMS OR 36.21018 ❑D
LONGITUDE 81 DMS OR 8.1,7'8183 _ OD
Latitudeilongilude source- 60PS DTopographic map
(location of wall mast bl, snow) on a USGS rope map andstrec►red ro
fhrs form if not using GF'$1
B. FACILITY (Name sflhe business where the well is located )
Mast General Store.
Facltlty Name
9SE5 NC Hylnf 194 South
Street Address
VAMP GruiR NC
Facility 1E4 (If appllrable)
CityarTown State Zip Cade
Camino IRrpai-lnn t;'iilhersnnl
Contact Name
MS Whitehall Fxertitive Center Dr ,Silith ROO
Mailing Address
Charlotte NC 2R779
City or Town State Zip Code
f_)
Area code Phone number
G. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES
NO
c. WATER LEVEL Below Tap of Casing: S to FT.
(Use'+" if Above Too or Casing)
d. TOP OF CASING IS 0_ FT. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance In accordance with 15A NCAC 2C ,O118_
a. YIELD wpm): n/a METHOD OF TEST 1'i]a
f. DISINFECTION: Type TVA . Amount f/A
g. WATERZDNES (depth):
Top n1a Bottom n/a Top Bottom
Top Bottom �— Top Bottum
Top Bottom _ Top Bottom
Thakneasf
T. CASING: Depth Diameter Weight Materiel
Top.0. Bottom 3 FL 2" scll40 _}vc
Top 13otlom Ft.
Top. Bottom FL
8 GROUT- Depth Material Method
Top 0 Bottom 1 FL Portland DDur
top 1 Bottom 2 Ft. Bentonite tretnie-
Top Bottom FL
S. SCREEN: Depth Dtainetet Stat Size Material
Top - S Bottom_ 12 Fi 2N in. 010 m- pvO
Top _ _ Bottom Ft - - In. rn,
Top Bottom Ft.
1D SANDIGRAVEL PACK:
Depth Size Material
Top 2 Bottom 12 Ft. 10/30 silica sand
Top .. Bottom Ft.
Top . Bottom FL
11. DRILLING LOG
Top Bottom
_ t
1
12_ REMARKS:
Formation DeSaipLlpn
I no HEREar CERTire THRf THIO WELL VrAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC)C WELL CI!NSTRUCTIOM STAND- A r5, ANI3 THAT ACCPI OF THIS
q>-+'OASP. ee4P1O E G THE WF W'eR
34127C1.
SIGNATURE OF CERT1FTED DATE
Keith A. S aece.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NG 27699-161, Phone : [phone]
Form GW-'I b
Rev 21a9

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
-DIVISION OF WASTE MANAGEMENT
MICHAEL F. EASLEY, GOVERNOR
William G. Ross Jr., SECRETARY
Dexter R, Matthews, DIRECTOR
AVA
NCDENR
UNDERGROUND STORAGE TANK SECTION
Post-ir Fax Nola 7671
Herb Berger
Hydrogeologist
DWM UST Section
1637 Mail Service Or
Raleigh, NC 27699-1637
RE: Mast General Store
Hwy 194
Valle Crock, Watauga County, NC
DWM incident # 19273
Dear Mr, Berger:
NogTh Gwo.n+• D J rr,Knt Or
1 amiWe 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 113 contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of G.S. 1 43-
215.3ta)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 shalt have access to the site by the shortest
feasible route to the nearest public road. The Depariment 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 Genera! Statutes, Tort Claims Against State Deparunents and Agencies,
and as otherwise provided by law,
S. 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.
9ECEiVED
4PR 2 4 2020
Nc
cargDwri
ragcace
DMSlON OF WASTE MANAGEMENT/UST SECTION
1637 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA 27699-1637
PHONE [phone] FAX: [phone]
INTERNET: htin://www.WaStenot,enr.state.nc us
AN EQUAL OPpORTUNI Y/AFFIRMATIVE ACTION EMPLOYER - 50% RecrcuofjQ% POST-CONSLIMER PAPER

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.
Me agree not to interfere with, remove, or in any way damage the Department's well(s) or its
contractor's well(s) and equipmentyduring the investigation. i�
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—9146 Sign ire
Type/Print Name of 0 ner rir Agent
� -- q&?- 45,r
Phone Number
Address
Vedle _Cr cx s PC 2S )
City/State/Zip Code
RECENED
APR 2 4 NM