WI0600163_DEEMED FILES_20150724

ol
Ro gers , Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael,
Jamie Honeycutt <[e-mail]>
Friday, July 24, 2015 11 :46 AM
Rogers, Michael; Osman, Hassan
Michael Pfeifer; Henson, Belinda; Allen, Trent; Palmer, Gwendolyn M
RE: NOi -Injection Well Operation-TF 10933 My Restaurant Site-Sampson Co WI0600163
TF 10933-My Rest. Injection Event Record signed.pdf
Attached is the completed Injection Event Record form for the above referenced site. Please give me a call if you have
any questions.
Thank you,
From: Rogers, Michael [mailto:michael.rogers @ncdenr.gov]
Sent: Wednesday, July 22, 2015 10:45 AM
To: Jamie Honeycutt <JHone ycutt @smeinc.com>; Osman, Hassan <hassan.osman @ncdenr.gov>
Cc: Michael Pfeifer <[e-mail]>; Henson, Belinda <belinda.henson @ncdenr.gov>; Allen, Trent
<trent.allen @ncdenr.gov>; Palmer, Gwendolyn M <[e-mail]>
Subject: RE: NOi -Injection Well Operation-TF 10933 My Restaurant Site-Sampson Co WI0600163
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for My Restaurant TF-
10933 located at 7223 Hobbton Hwy., Clinton, Sampson County, NC 28328. The Central Office of the WQROS received
your complete NOi electronically on July 17, 2015.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies
of the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If
well construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.rogers @ncdenr.gov , send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0600163. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re p ly to this email, as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hyd rogeo logist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
1
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wg/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Jamie Honeycutt [mailto:[e-mail]]
Sent: Friday, July 17, 2015 10:02 AM
To: Rogers, Michael
Cc: Michael pfeifer
Subject: NOI -Injection Well Operation-TF 10933 My Restaurant Site-Sampson Co
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10933 My Restaurant located at 7223 Hobbton Highway, Clinton
(Sampson County). I will also mail a hard copy of the NOi to you. We plan to install 0-SOXs at six exiting monitor wells
located at the site. If possible, I would like to perform the field work by the end of next week. Please give me a call on
my cell (910 977-7614) if you have any questions.
Thank you,
Jamie T. Honeycutt
Environmental Professional
.S&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
2
INJECTION.EVENT RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Resources
PermitNumber WI0600I63
1. Permit Information
S&ME. Inc.
Permittee
TF-1"0933 My Restaurant
Facility Name
7223 Hobbton H,vv, Clinton, NC
Facility Address
2. Injection Contractor Information
S&ME,Inc.
Injection Contractor I Company Name
Street Address 409 Chicago Drive # I 07
Fayetteville, NC 28306
City State Zip Code
l2!Q_j 977-7614
Area code -Phone number
3. Well Information
Number of wells used fot injection __ 6_· __ _
Well names MW-2. MW-3. MW-4. MW-9
MW-IO and MW-12
Were any new wells installed during this injection
event?
D Yes 5kNo
If yes, please provide the following information:
Numbe-r of Monitoring Wells _____ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored O Drilled O Direct-Push
0 Hand-Augured O Other (specify) __ _
Please include a copy of the G~f'-Jformfor each
well installed
Were any wells abandoned during this injection
event?
0 Yes Ill No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells _______ _
Please include a copy of the GW-30for each well
abandoned.
4. Injectant Information
0-SOX: Calcium Peroxide, Calcium Hydroxide
Injectant Type (Solid)
Concentration l 0-40 m g/L at inj ection p oint
If the injectant is diluted please indicate the source
dilution fluid. __ ~•=1,___ _______ _
Total Volume Injected 10 socks (2" x 3')
Volume Injected per well 2 socks at MW-2,3, 4 &IO
1 sock at MW -9 & 12
5. Injection History
Injection date(s)--'--'7-::.2..:::,4c.=.-2'"'0.LJJ .... 5,__ ______ _
Injection number (e.g. 3 of 5) _ ___._ ____ _
1s this the last injection at this site? (unknown)
0 Yes D 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.
/,l,py,£, ~-p_,,.. ;._Nf ,iiU, "'-'<>j ,.,{ }.Jcj)f.f._;R, _ _2J,lt,f u
5!GNATURE F JNJECTIONCO'J'.,Tlti\CT R D TE
Jamie T. Honey cutt (S&ME, Inc. -A gent for NCDEN )
PRl]'..TNAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: OTC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-'-IER
Rev. 8/5/2013
Central Files. APS SWP
7/2212015
Permit Number W10600163 Permit Tracking Slip
Program Category
Deemed Ground Water
Permit Type
injection Deemed in -situ Groundwater Remediation Well
Primary Reviewer
michael. rogers
Coastal SWRuIe
Permitted Flow
Facility
Status Project Type
Active New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Facility Name
My Restaurant TF-10933
Location Address
7223 Hobbton Hwy
Clinton NC 28328
Owner
Major/Minor Region
Minor Fayetteville
County
Sampson
Facility Contact Affiliation
Owner Name
NCDENR Vwm Ust State Lead
Dates/Events
Owner Type
Government - State
Owner Affiliation
Hassan Osman
1637 Mail Service Ceter
Raleigh NC 27699163
Orig Issue App Received Draft Initiated
7/22/2015 7/17/2015
Scheduled
Issuance Public Notice issue Effective Expiration
7/22/2015 7/22/2015
Reuulated Activities Requested (Received Events
Groundwater remediation
❑utfatt
Waterbody Name Streamindex Number Current Class 5ubbasin

Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Wednesday, July 22, 2015 10:45 AM
'Jamie Honeycutt'; Osman, Hassan
Cc: Michael Pfeifer; Henson, Belinda; Allen, Trent; Palmer, Gwendolyn M
Subject: RE: NOi -Injection Well Operation-TF 10933 My Restaurant Site-Sampson Co WI0600163
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for My Restaurant TF-
10933 located at 7223 Hobbton Hwy., Clinton, Sampson County, NC 28328. The Central Office of the WQROS received
your complete NOi electronically on July 17, 2015.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30} when completed. Please provide copies of
the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct push
or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-30). If well
construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael .ro gers @ncdenr.gov, send by fax to my attention at 919-
807 -6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WIOXXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0600163. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re p ly to this email. as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No . 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Jamie Honeycutt [mailto:[e-mail]]
Sent: Friday, July 17, 2015 10:02 AM
To: Rogers, Michael
1
Cc: Michael pfeifer
Subject: NOI -Injection Well Operation-TF 10933 My Restaurant Site-Sampson Co
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOi} to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10933 My Restaurant located at 7223 Hobbton Highway, Clinton
(Sampson County}. I will also mail a hard copy of the NOi to you. We plan to install 0-SOXs at six exiting monitor wells
located at the site. If possible, I would like to perform the field work by the end of next week. Please give me a call on
my cell (910 977-7614) if you have any questions.
Thank you,
Jamie T. Honeycutt
Environmental Professional
~S&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
2
Ro gers, Michael
From:
Sent:
To:
Subject:
Attachments:
Greetings-
Rogers, Michael
Wednesday , July 22, 2015 10 :34 AM
Henson, Belinda ; Allen, Trent
FW: NOi -Injection Well Operation-TF 10933 My Restaurant Site-Sampson Co WI0600163
NOI-TF 10933 My Restaurant Site, Sampson Co 2015-7-17.pdf
Please find attached a NOi for the above site. Please let me know as soon as possible if you wish to inspect the site
{optional for these deemed permitted sites) or otherwise have any issues. They want to insert the OSOX into some wells
by Friday if possible.
Thanks
From: Jamie Honeycutt [mailto:[e-mail]]
Sent: Friday, July 17, 2015 10:02 AM
To: Rogers, Michael
Cc: Michael Pfeifer
Subject: NOI -Injection Well Operation -TF 10933 My Restaurant Site-Sampson Co
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent {NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10933 My Restaurant located at 7223 Hobbton Highway, Clinton
{Sampson County). I will also mail a hard copy of the NOi to you. We plan to install O-SOXs at six exiting monitor wells
located at the site. If possible, I would like to perform the field work by the end of next week. Please give me a call on
my cell {910 977-7614) if you have any questions.
Thank you,
Jamie T. Honeycutt
Environmental Professional
*S&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile : [phone]
jhoneycutt@sme inc.com
www.smeinc.com
This electronic message is subject to the terms of use set forth at www .smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this ema il.
1
Rogers, Michael
From: Jamie Honeycutt [e-mail]>
Sent: Friday, July 17, 2015 10:02 AM
To: Rogers, Michael
Cc: Michael Pfeifer
Subject: NO - injection Well Operation-TF 10933 My Restaurant Site -Sampson Co
Attachments: NOl-TF 10933 My Restaurant Site, Sampson Co 2015-7-17.pdf
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOI) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10933 My Restaurant located at 7223 Hobbton Highway, Clinton
(Sampson County). I will also mail a hard copy of the NCl to you. We plan to install 0-5OXs at six exiting monitor wells
located at the site. If possible, I would like to perform the field work by the end of next week. Please give me a call on
my cell (910 977-7614) if you have any questions.
Thank you,
Jamie T. Honeycutt
Environmental Professional
ItS&IVIE
ENGINEERING INTEGRITY.
S&ME, lnc.
409 Chicago Drive, Suite 10
Fayettevi#le NC 28306
Ph' 910-323-1091
Fax: [phone]
Mobile: [phone]
hor}e_ycutt srrleinc.com
vwrw.smeinc.ccm
This electronic message is subject to the terms of use set forth at yrvrw smejric_carn/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.

♦S&ME
July 17, 2015
North Carolina Department of Environmental and Natural Resources
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Reference: NOI-TF 10933 My Restaurant Site, Sampson County
The enclosed report, NOI-TF 10933 My Restaurant Site, Sampson Co 2015-7-17, was been submitted
electronically to Mr. Michael Rogers, NCDENR, DWR, on July 17, 2015.
Regards,
S&ME, Inc.
°c::::f-?~
Environmental Administrator -Raleigh
RECElVED/DENRIDWR
JUL 2 2 2015
Water Quality
Permitting SectiOR
S&ME, Inc. I 3201 Spring Forest Road I Raleigh, NC 27616 I p 919.872.2660 If 919.876.3958 I www.smeinc.com
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT 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 NCA C 02C .0200. This form shall be submitted at least 2 weeks prior to iniection.
AQUIFER TEST WELLS (lSA NCAC OlC .OllO )
These wells are used to inject uncontaminated fluid into an aquifer to detennine aquifer hydraulic characteristics.
IN SITU REMEDIATION llSA 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.
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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: _,,_,Ju=ly,_1.,_,7 __ ___,, 2015 __ PERMIT NO. (,...J ( 0 fo 00 I & j (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
B.
(I} -----'Air Injection Well ...................................... Complete sections 8-F, K, N
(2) ___ .Aquifer Test Well ....................................... Complete sections 8-F, K, N
(3) X __ Passive Injection System ............................... Complete sections B-F, H-N
(4) ___ .Small-Scale Injection Operation ...................... Complete sections B-N
(5) __ .Pilot Test ................................................. Complete sections B-RECEIVEDJDENRJDWR
(6) ___ Tracer Injection Well ................................... Complete sections B-N
STATUS OF WELL OWNER: State Government
JUL 2 J £.u,J
Water Quality
Permlttfn9 Section
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Hassan Osman, NCDENR, DWM, UST Section
Mailing Address: 1637 Mail Service Center
City: Raleigh State: ~ Zip Code: 27699 County:_,W,_,__,,,,ak""e,___ _____ _
Day Tele No.: 919-707-8167 Celt No.: __________ _
EMAIL Address: hassan.osman @ncdenr.gov Fax No.: __________ _
UIC/Jn Situ Remed. Notification (Revised 3/2/2015) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: Bass Oil Com pan y (A.J. Bass, Jr.) {MW-2 . MW-3 . MW-4 , MW-9 and MW-12 )
Mailing Address: """P"-".O,a,:.•-=B::..;:o=x""'8=3.:::..5 ___________________ _
City: Clinton State:~ Zip Code:=2=83=2=9 ______ County: Sam pson
Day Tele No.: ________ _ Cell No.: _________ _
EMAIL Address: ____________ _ Fax No.: __________ _
D. PROPERTY OWNER (if different than well owner)
Name: NCDOT {Ken Batchelor) (MW-101
Mailing Address: =22_0-N~ort~h~B~lv...ad'---------------------
City: Clinton State: N.C._ Zip Code:28328 County: Sampson
DayTeleNo.: 910-592-6316 CellNo.: _________ _
EMAIL Address: kcbatchelor@ ncdot.gov Fax No.: __________ _
E. PROJECT CONT ACT -Person who can answer technical questions about the proposed injection project.
Name: Jamie Honeycutt (S&ME, Inc.)
Mailing Address: 409 Chica~o Drive. Suite I 07
City: Fa etteville State: ~ Zip Code: 28306 County: Cumberland
Day Tele No.: 910-323-1091 Cell No.:-=-9~10~-~97~7~-7~6"""1-'-4 _____ _
EMAIL Address: jhoneycutt@ smeinc.com Fax No.: _______ _
F. PHYSICAL LOCATION OF WELL SITE
(I) Physical Address: 7223 Hobbton H wy {MW-2 . MW-3 . MW-4 , MW-9 and MW-12 )
(2)
Physical Address: 7294 Hobbton Hwy (MW-10 ) County:-=S=a=m,...p=so=n-=---------
City: Clinton State: NC Zip Code:~2=8=32=8~---------
Geographic Coordinates: Latitude**: ___ 0 --__ ,, or 0
Longitude**: 0 __ "or 0
Reference Datum: ________ Accuracy: _______ _
Method of Collection: ________________ _
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY : A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMl1TED 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 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be~ 5% of plume for pilot test injections)
UICI In Situ Remcd. Notification (Revised 3/2/20 I 5) Page 2
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.
UICI In Situ Remed. Notification (Revised 3/2/2015) Page3
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.
A release of gasoline from an underg.round storage tank system located on the pro perty has im pacted
roundwater above the 15A NCAC 2L .0202 oroundwater ualit standards. Multi le rivate water su I wells
are located within 1,000 feet of the release. The use of O-SOX (Calcium peroxide or EHC-O chemical) usin g
six wells (MW-2 , MW-3 . MW-4. MW-9 , MW-10 and MW-12 ) is planned to enhance the de gradation of
petroleum contaminant levels in the groundwater to below the 2L Standards.
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http:/lportal.ncdenr.orglweblwqlapsl f!WJJro . All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program/or more info (919-807-6496).
Injectant: Calcium Peroxide in solid form b sock of chemical in monitor well for ox en
Volume of injectant: Varies , b diffusion. 1.75 lb EHC-O or 0.2625 lb Oxygen per well
Concentration at point of injection: __ ....,lc..::0;_-4..:..:0::;..m=g/"-'L=---------------
Percent if in a mixture with other injectants: Calcium peroxide >75%. Calcium H ydroxide <25%
lnjectant: --------------------------------
Volume of injectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
Injectant:
Volume of injectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: _____ Proposed ___ ___,6,__ __ Existing (MW-2, MW-3, MW4,
MW-9, MW-10 and MW-12)
(2) 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 sha11 include the following:
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
(c) well contractor name and certification number
UIC//n Situ Remed. Notification (Revised 3/2/2015) Page4
Well
Type
Grout
i ft-bls l
Screen
i ft-bus)
Casing
(ft-bls)
Well Contractor
Cert#
MW-2, 3,
and 4
Permanent
,
2-3
5-20
,
0,3-5.0
CTL Engineering
Raleieh
1350
MW-9,
MW-it7
Permanent
1-2
5-20
0.3-5.0
Special Testing Labs
of NC
1465
MW-12
Permanent
0-2
5-20
0,3-5.0
Special Testing Labs
ofNC
1468
_
Well Construction Records are Attached.
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Monitoring wells MW-2, MW-3 .MW4. MW-9, MW-10 and MW-12 were installed between November 16,
1993 and May 4, 1994. Passive oxygen releasing O-SOXs will be placed into the wells b► Jub 4, 2015.
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.
The injection of ox.ben is not expected to result in violations of the 2L Standards. Monitor wells will be sampled
on a regular basis and additional O-SOXs installed (as per NCDENR). This may be followed by post-
remediation sampling without oxen infusion to check for rebound of contaminant levels.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I herebycerttfy, under penalty oflaw, that Iam familiar with the information submitted in this
document and ail attachments thereto and that, based on my inquiry ofthose 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 154 NCAC 02C 0200 Rules."
Signature of Applicant � J Print or Type Full Name
PROPERTY OWNER (if the property is not owned bA the permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, 1 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
( 1 3 A NCAC 02C .020 0)."
"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 eement with AJ Bass. Jr. dated July 2010 and email from
NCDOT dated July 16, 2015
Signaturek of Property Owner (if different from applicant) Print or Type Full Name
* An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
U1C//n Sins Remed. Notification (Revised 3l212015) Page 5

Submit the completed notification package to:
UICI In Situ Rem ed. Notification (Revised 3/2/2015)
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page6
9 g��
MW-16
(97.09) 14.0
RMER AST
1 OIL CHANGE
EA
L
6 Mw::'t3 97.64)
a B M (97.55)
6 MW-8 (97.62)
(97.53)
9MW 7
(97.41
MY RESTAURANT - �MW.4
41,
(97.39) (97.36)
WI-12$ 6MW--11 4 MW 97.42
FORM UST : IN -' Iv
i (97.42)
.4297.fi MW •6 7)
NE STATION
MW4 (97.43)
a'�44 #r 4M 4
MW-15 (9776)
(98.09)
Pu
CO
6 M -10(97.37)
-1 1(97.38)
•
AST
ik
LEGEND
OP MONITOR WELL LOCATION
(97.42) GROUNDWATER ELEVATION
GROUNDWATER CONTOUR
GROUNDWATER MEASURED MARCH 5 & 6, 2015
IMAGE SOURCE: NC ONEMAP, DATED 2013
0 60 120
GRAPHFC SCALE (IN FEET)
A-5054
SCALE 1 ; 60'
DATE
APRIL 2015
DRAWN 8v
BTR
S&ME
COM
PROJECT N NC ENGINEER LICENSE #F-0176 KEENER, NORTH CAROLINA
4305-15-012 13201 SPRING FOREST R0, RALEIGH, NC 27B7h '
GROUNDWATER CONTOUR MAP
MY RESTAURANT TF-10933 - 7223 HOBBTON HWY
FIGURE NO.
4

r
,esto'
- >` * • ER AST A
1 OIL CHANGE
EA
FAL
�� tiillfT
ter•
ti •'•?'
Benzene
MW-8 uo1Ll
•
MW-7 ug/L
Benzene 116
1,2-Dichloroethane 0.58
Naphthalene 21.2
MY RESTAURANT -"
MW-12 uglL . PAW-12
Benzene 3.6
FORMER UST BASIN -
MW-18
MW-2
Benzene
Toluene
Ethylbenzene
Xylenes (total)
Naphthalene
Methylene chloride
n-Propyt-benzene
1,2,4Trtmethyl-benzene
uL
3,940
9,620
689
5,330
369
61.8
91.8
1,200
MW-4
MW-1
MW-15
MW-15
BDL
MW-2
MW-14
BDL
s -I
ER
: 9
LINE STATION
a
Ca MW 10
MW-9 ug/L
Benzene 9.6
Naphthalene 24.8
l�{
Yr
MW-6 ug/L
Naphthalene 9.2
■
MN
ASTS
Benzene
Toluene
Ethylbenzene
Xylenes (total)
Methyl Tert Butyl Ether
Naphthalene
Isopropyl -benzene
n-Propyl-benzene
1,2,4-Trimethyi-benzene
-10
PAW-6 MW-11
MW-5
BDL
-11
MW-1 ugfL
Benzene 378
Methylene chloride 21,3
Naphthalene 97.6
MW-5
<2L
MW-3
Benzene
Toluene
Ethylbenzene
Xylenes (total)
Naphthalene
n-Pnapyl-benzene
1,2,4-Trirnethyl-benzene
ug/L
471
7,060
1,260
5,670
428
123
947
924
2,410
1,080
4,540
22.3
304
182
165
1,200
ak
- AST
979
3,590
1,450
5,940
25.6
554
160
1,250
MW-4
Benzene
Toluene
Ethylbenzene
Xylenes (total)
Methylene chloride
Naphthalene
n-Propyl-benzene
1,2,4-Trimethyl-benzene
LEGEND
MONITOR WELL LOCATION
uglL - MICROGRAMS PER LITER
BDL - BELOW DETECTION LIMITS
60
SAMPLES COLLECTED MARCH 5 & 6, 2015 GRAPHIC SCALE
2L - CONSTITUENTS REPORTED BELOW 2L STANDARDS
ONLY CONSTITUENTS EXCEEDING 2L STANDARDS ARE SHOWN
IMAGE SOURCE: NC ONEMAP, DATED 2013
120
(IN FEET)
A-5055
SCALE 1" = 60'
DATE. APRIL 2015
DRA1Md HY BTR
PROJECT NO.
4305-15-012
$S&ME
WVVW.SMEINC_COM
NC ENGINEER LICENSE #F-0176
3201 SPRING FOREST RD. RALEIGH. NC 27616
GROUNDWATER CONSTITUENT MAP
MY RESTAURANT TF-10933 - 7223 HOBBTQN HWY
KEENER, NORTH CAROLINA
FIGURE NO_
5
1

Q 1PRMECT51201514305.15.0121CADL45056 dwo FtG6. 4111 /2015 4 27:27 PM
ER AST
I OIL CHANGE
f
{
EA
9 M1I
.SMW4
MW7
MY RESTAURANT -�
6MW
MW 12
®_!g MW-2
FORMER UST BASIN -
61i MW-15
LEGEND
09 MONITOR WELL LOCATION
uglL - MICROGRAMS PER LITER
BENZENE 2L STANDARD 1 uglL
SAMPLES COLLECTED MARCH 5 & 6, 2015
IMAGE SOURCE: NC ONEMAP, DATED 2013
0 60
120
GRAPHIC SCALE (IN FEET)
A-5056
SCALE 1 r� = 60,
DATE
APRIL 2015
DRAWN BY: BTR
pRO JECT NO:
4305-15-012
S&ME
NC ENGINEER LICENSE 4F-0176
3201 SPRING FOREST RD, RALEIGH, NC 27616
BENZENE ISOCONCENTRATION MAP
MY RESTAURANTTF-10933- 7223 HOBBTON HWY
KEENER, NORTH CAROLINA
FIGURE NO.
6

a
LL
n
0
0
a
a
BAST
OIL CHANGE AF EA
•
!Si MW-7
MY RESTAUR.AkT
,-- FORMER GASOLINE STATION
t
SMW
Mll-9
MW-129 ,, 09MW-1
MW 2 /
FORMER UST BASIN -- �MW-S
MW6
MW-16
MW-15
MW-14
LEGEND
MONITOR WELL LOCATION
ug/L - MICROGRAMS PER LITER
NAPHTHALENE 2L STANDARD 6 ug/L
SAMPLES COLLECTED MARCH 5 & 6, 2015
zPUI4�PS
jjf
co
Pi1MPS
fi 4T kai-
41 7
S o
r
-11
- AST
0 60 120
GRAPHIC SCALE (IN FEET)
IMAGE SOURCE: NC ONEMAP, DATED 2013 A-5057
SCALE- 1 dr 60
DATE. APRIL 2015
DRAMM.'U 6,: BTR
PROJECT
OJECT NO:
lksk•4305-15-012
S&ME
COM
NC ENGINEER LICENSE 01F-0176
3261 SPRING FOREST RD, RALEIGH, NC 27616
NAPHTHALENE
ISOCONCENTRATION MAP
MY RESTAURANT TF-10933 - 7223 HOBBTON HWY
KEENER, NORTH CAROLINA
FIGURE hO.
7
1

NORTH CAROLINA DEPARTMENTS UN 13EA1 !'ii t NI V 1KNMY,NT, AND NATURAL Rr.. ut0..15
DIVISION OP ENVIRONMWTAL MANAGE/4PNr . GROUNDWATER SECTION
PO. BOX 77687 • RALEIGH, NC 27elt, PHONE [phone]
WELL CONSTRUCTION RECORD
1DRILI11NG CONTRACTOR Special Tcstine Labs of NC
IDRILLER REGISTRATION NUMBER 1468
11, WELL LOCATION: Show :Latch of the location below)
Neatest Town: Clinton Canary: SAMPSON
FOR OFFICE USE ONLY
Quad No. Serial No.
Lai Long.
Minot Basin
Basin Code
STATE WELL CONSTRUCTION
PERMIT NUMBER: WELLS ON SITE
MW-12
Stab Hi)4w'at 701 South fNeentr Rd, intcrseciion, Depth_ Prillixltt Lae,
(Road, Community, or Subdivision and Lest too.) From To FCrmalton Description
2. OWNER Bass Gil Co. 0.06' 3.0' Topsoil with 000mic orditter
IADDRESS P. O. Box 835 3.0' 5.0' Brown silty fine to madiuA] sand
(Street or Rourc No.) SA' 7d1' Grav-browe, hoe.. tight sand
Clinton NC 28325
City or Town Srate ZIP Code 7.0' 9.0' Brown Guc•uiedium sandy sill
13. Date Drilled Ms 4, 199s USE OF WELL MOINITOR/NG 94' St.0' Grov-brown fee son.h silt
4. Total Depth 20.0 Feet Cuttings Collected? _ Yes X No SM.2' 130' Orange -dap. fiae•tnedium sand with light AIM' streaks
5. DOES WELL REPLACE EUSTING WELL Yu x No 13.0' 20.0' ❑mope -tan. Fine -medium rand
6. Static Water Level: NA ft. - above. X below top of rasing.
Top of casing is 0.3 0. ABOVE/BELOW Sand surlaec.
7. YIELD (gpm): NA METHOD OF TEST NA _
8. Water ZonCs (depth): 2'M
9. CHLORINATION: Typ; NA Astatmt NA
10. CASING:
] wail Tbickufss
Oilier ❑epdh Diameter or Weight/Ft Mate Sal
Proco NA To NA Ft. NA NA
Inner
From 0.3 la 5-0 R 2.4' Schedule 40 PVC
{
1. GROUT:
Depth Material Method
❑m 0.0 To 2.0 Fr. Rra.0. Mix Cement hand Pour
tam 2.0 To A0 _ Fr. Beatooire Chip.
12. SCREEN:
1 _Depth Diomelrr Slot Size Material
from 3.0 To 20.0 Ft 2 ie. 0.003 is PVC
From To F7. _ in. in.
d
Oat To FL in. in.
13, GRAVEL PACK
Depth Size Material
t{am 4.0 To 20.47 Ft Sand mesa Filter Sand
_tom To R.
:d. REMARKS: Mr Restaurant
1I additientai Spam is needed, usa back of farm.
LOCATION SiCETC3-1
HeNcnwhex-,vaK *g , wv Pe.fe' r*ns-ctA« .uxt+G.
1 ifYYf
diorce
r
I - I) 1 e '''P It \
m.c r�-re7'•
a .e
Mw•10
■
1 DO HERESY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 14 NCAC 2C, WELL CONSTRUCTION
RECORDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T '�i )W�
May 24, i944
- Signature of Ccatractor or Agen+
Date

NORTH CAROLINA DEPARTMENT OF HEALTH, ENWRONNEWT, AND NATURAL RESOURCES
❑1VISMON OF ENVIRONMENTAL MANAGEMENT • GROUNDWATER SECr1ON
P.R. BOX 27687 RALFSGH, NC 27611, PHONE (9I9) 783.5083
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR CTL Enkineennr. Inc. of NC
DRILLER REGISTRATION NUMBER ]35O
1. WELL LOCATION: (show sketch of Ibc locarioa below)
FOR OFFICE USE ONLY
Quad No. Serial No.
`• Long. -- - Pe
Minor Basin
Basin Code
STATE WELL CONSTRUCTION
PERMIT NUMBER: WFI l S ON SITE
f,�3res.tvtw-z,s MW-3
3lvatcse Tows'• Clinton County: SAMPSON
Stoic Hichwa,, 701. South
(Road, Community, or Subdivision and Lot No.)
{2 OWNER Bass oil Co.
Depth Drilling Log
From To Formation G:aa-iprion
0.00' 10.0' Dark brown One sand, hoer• day
ADDRESS RESS P. O. Boa F35 30.0' 13.0 Lt f`w has sandy oily
(Street or Route No.) 13.0' I6.O' Pinksarurared sa ,rolitc
Clialoa NC 28328
I City or To Stoic ZIP Cads 14.0' 20.0' Tan Gas wnt sand, Mat
'3. Date Drilled Havenlaer 36. 1943 USE OF WELL Mor,TTOIUNe
.d, Total Depth 20.0 Fcct Cuttings Collected? ^ Yes x No
IS. DOES WFLI REPLACE EXISTING WF.0 ? — Ye= 7ti No
6. Statir Water Level. HA fc _ above x ha/ow top of easing.
Top of casing is 0.3 ft. ABOVFJSEWW tacd curia cc.
7. YIELD (gym): NA METHOD OF TEST NA
8_ Water Zonrs ((epth): NA
1
9, CHLORINATION: Type NA Arnow NA
id,. CASING:
Outer Detach Diameter or Weight/Ft Maicrral
boom _ NA To NA FI NA NA
Lanni
?toes 03 To 5.0 Ft 2.0' Schedu}e iQ Y1 C
11. GROUT:
Wall Thickness
Depth MMereal Mcrbod
?rom 20 To 3.0 Pl. Rradv Mix Cement Haad four
From 3.0 To _4.0 P. 9celnuittCbira
,2. SCREEN!
Do}+rt Uiamerer Slot Sirs Malsriat
From 50 To 20.0 Et. 2 in. 6.Q110 in. PVC
roro To R is io.
.'ram To Fl. in. i4.
13. GRAVEL PACK:
Dcplh Sixc Material
rrnm 40 To 20.0 Fi. Sand Gran Filter Sind
From l'v Ft.
14. REMARKS. NI, Restareraer
{
Ill additional space IS ncedcd. use bQCK Of Iprri.
LOCATION SKETCH
PLEASE SEE F3OURE 5
1 DO HEREBY CERTIFY THAT 1 HiS WILL WAS CONSTRUCTED IN ACCOROANCI-,WITH 14 NCAC 2C, WELL CONSTRUCT ON
RE'CORDS, AND THAT A C'OFY c*'1 HIS RECORD 1-IAS BEEN PROVIDE() TO ye WELL Ov,""E.R.4.
w/moor 10. 1993
wit., of Cuerracrtsr to Agcar Dare

l3ORT"r' CAROUNA ❑EPARTMEwNT OF HEAL -T1'. ENV(1RONMENT, AND NATURAL RF_SOLURCFS
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROt7Nt]wATER SECTtoN
P.O. BOX 276S1 - RALEIGH, NC 27611, PHONE (919) 7E3-50♦ 3
WEI J. CONSTRUCTION RECORD
pRILLItNG CONTRACTOR CTL Enyiineerurz Inc. of NC
DRILLER REGISTRtATION NUMBER 1350
I_ WELL LOCATION: (S sketch of the tart=on below)
FOR OFFICE USE ONLY
Quad No. Seri21 No,
Eat Laeg. Pc
Fvfinat 132sin
Basin Code
STATE WELL CONSTRLIC"TION
PERMIT NUMBER. WELLS ON SITE
MW-4
Neaten Town: CSrntoe County: SAMPSON
State Fiuhwar 701 South
(Road, Cooanusaity, or Subdivision and Loll Ni
2 OWNER Bass oil Co.
Depth
From To
0.00• 0.2'
Drillina Lori
Formation Description
Asphalt
ADDRESS F. O. Box to 02' IA' Dark sandy day
(Street or Route No,) 1.0' 3.0' Dark black Erne suadl day
i Clinton NC 2&323
City ar Town Stets ZIP Cade 3.i1' S.0' l L icy mot fiat sandy clay
3. Bate Driiled Tiovccibc io1993 US OF WELL iMi4N1IiQRFNCr 5.0' f 1.0 U- tan rrcv One uudv day
4. Total Depth 20.0 Fast Cuttings Collected? iYes 1: No 11.0' 14.0• U. lac pink moist Dna sanely claw god saps4lise
;. DOES WELL REPLACE EXISTING WELL? Yei x Na 14.0' 20.o' Li. Lae sitar/ fine mods
Static Water Level NA ft _ abo' X below cop al c ,us.
Top of rasing is 0.3 ft. A30VE/BUOW lead mrranc,
7. YIELD Was); NA METHOD OF TEST NA
I$. Water Zones (dspiby- NA
4, CHLORINATION; Type NA Amount NA
tO. CASING:
If additioaat space is needed, use back of farm.
Wait Thickens
outer Depth Diameter cr Weight/Ft. Material LOCATION SKETCH
rats NA To NA Ft NA NA
lancr
Tram 93 To 5.0 T7. 2.0' Schedule 40 PVC
I
111. GROUT:
! Depth htatcriai Method
i0I 2.0 To 3.0 F1, Rea, Me, CCIIiep1 Heed Pcur PLEASE 5 E E F 1 G O K E S
Frain 10 Ta 4.0 F1. Bcatoaitt Clops
:2. SCREEN
i
I Depth Diameter Slot Sike Maicriel
From 5.0 To 20.0 Fs. 2 In. 0.010 iu. PVC
Yon+ To Ft in. in.
;toot To A. isr. la.
13. GRAVEL PACK
Depth Size Matefiai
_Irons 4.0 To 20.0 Ft. Sand Gran. Rim Sand 1
Rota To Fr.
I4. REMARKS: Mr k 4iivtato
1 i70 1-IEREDY CERTIFY THAT THIS WELL. WAS CON SftUCTED IN ACCORDANCJAViT1I 14 NCAC 2C. ' ELL CONSTI2UCI1ON
RECORDS. ANC THAT A COPY Or THIS RECORD I-1AS BEEN PROVIDED TOt '} . lz.LL OW
Iy 1 r
- !ziember 10.1993
nature a Coot! Or or 1larnt rjrtr

NORTH CAlisluNAueteuttsnorts vr-.
Dt VIS1ON OF FNVTRONM1=NrA1. MANAGEMENT - GROUNDWATER SECTION
P.O. SOX 27017 - PAS T1GII, NC 27011, PHONE (9W) 781•3083
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR Srtecial 'Testing Labs of NC
FOR ur'iviHL. uary vtts i
Quad Nn, _ Serial No.
La t. Lang
Mines Basin
Basin Code
Pc
STATE WELL CONSTRUCTION
DIULI.ER REGISTRATION NUMBER 1468 PERMIT NUMBER: WELLS ON SITE
1. WELL LOCATION: (show sketch of the laraiiott Mow}
Kearns/ Town: C3inroa
State Hjbv.a'• 701 Sows lKeener Rd intersection' Depth
(Road, Community, er Suhdi'..sicn and Lot Na.) From To
2. OWNER Sacs Oit co,
ADDRESS F. o. Bax Els
0.00' 34'
3.0' 4.0'
(Strut or Route No.) 4.0' 5.0'
Clinic NC 26328
City Of Town State ZIP Code SA' 0.0' Dk. brown brown and firer moist fmc siiirbtty ciavnv sands
3. Date Drilled Mnv 4 1994 USE OF WELL MONITORING 9.0' 11.0' Gray brawn elaret fine sands
4. Total Depth 20.0 Feel Cuttings Collected? Yes X Na 11.0' 13.0' Reddish eranrc rule 1 reed sands
5. DOES WELL REPLACE EXISTING WELL? _ yes x Na 13.0' 13.0 Brawn reddish fine to med. sands
G. Static Water Level: NA h. above X below tap of casing.
INw•9
Drilling Log
Formation Description
Topsail wish ar tapir: matter
Bra>,v dk. brown fine sands
13rown wl I>_ etc+ I•mc candy silt
Couniy: SAMPSON
Tap of coring is 0.3 it. ABOVE/BELOW /and surtarc.
7. YIELD (gpm): NA MEl'HOD OF TEST NA
8, Water Zories {depth]: NA
9. CHLORINATION: Type NA Amount Nil
10. CASING:
WeltTbiekncss
Outer L]9{,th Diameter or Weight/FY. Material
From NA To NA Fi. NA NA
Inner
From 0.3 To 3.0 FI. 2.0' Scbeduie 40 PVC
II. GROUT:
t]r1,il Malgrial 1/SctLod
NOW 1.0 To 2.0 Fr. Berta Mir, Cement Band Pour
From 2.0 TO 4.0 Ft. Bentonite Chips
11 SCREEN:
Drpld Diameter Slat Size Material
From _ 3.0 To 20.0 Ft. 2 ia, 0.010 tn. PVC
From To r. ia. ICI.
F7001 To Fl. i9_ n.
113. GRAVEL PACK:
]7cptb site Material
From 4.0 To 20.0 1-1, Sand Clean Fit u Saud
From To pt.
14. REMARKS' My Restaurant
I5.0' 20.0' Ten tlnr to mnd sands
11 additional opine is needed, usr back al form -
LOCATION SK1 TCii
.•11•:6,.e4' - n"% arm .w pra .-
l� /--
Mw-y I ri
/
4 k.w-.a.�. S S
--1--
,
/ -. - b
ae srtarr i'
er act
ay I(
ljff i r
L Lp
f p
r<ar
' Mw.tt
•
�._� Mir.r
ram]
*i w s!•1
.T.,q rf
At-
4.044
Mw.ip
•
I DO 1-IEREI3Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCQRDANC 14 N'QNSTRUCTION
RECORDS, AND THAT A COPY OF TIJIS RECORD 1IAS BEEN PROVIDED TO TI
Sig0yture of Couirnctor or Agsot
May 24, FM
Dale

Nortz N CAROLINA 1]t^YARI ryi.ply 4 Li, -
DIVISION OFEN1V'iRONMENTAL k'[ANAG GENT • GROUNDWATER SECTION
P.a. BOX 27687 - RALErIGI-I, NC 27011, PHONE [phone]
WELL CONSTRUCTION RECORD
RILLING CONTRACTOR Special Testinc Labs of NC
DRILLER REGISTRATION NUMBER 1468
1. WELL LOCATION: (Show sketch ei the lxarloa below).
Nearest Towo. C]ipioa
Staten Highway 701 South (F:seutr Rd intersection.
(Road. Community, or Subdivision and Los No.)
? OWNER Emu Oil Ca.
ADDRESS P. O. Sat 1535
(Slices or Route No.)
Clinton NC 28s2S
City or Towc Staten ZIP Coda
3. Date Drilled Mat 4. 1994 USE OF WELL. MCNIToiuNG
ti. Total Depth MO Fees Cuttings Collected? , Yes X No
5. DOES WELL REPLACE EXISTING WELL? _ Yes X Nu
5, Static Water Level: NA _ it.above X below top of casing"
Top of casing is 0"3 It. ASOVEI$E1.AW land surface.
17. YIELD (pm): Ni. METHOD OF TEST NA
.18. Watel Zones (depth): NA
19, CHLORINATION: Type NA
1[1 CASING:
QLL1CT Depth
Amount NA
Wall Thic stew
DLamm et or Weigh1/I-7"
Prom NA To NA R. NA
Inner
From 0..3
'11. GROUT:
NA
TO 5.0 Pi. 2.0' Sn3cda1e.40
Depth Material Method
From 1.0 To 2.0 Pi. Ready Mix Cammi Hand Pour
From 2.0 To i.0 Ft. Bentonite Chips
12. SCREEN:
} ❑cosh
From 10 _ To
From Tu
;From To R. in. in.
Material
PVC
Dumont 5101 Size Material
20.0 PI. 2 in. 0.010in. PVC
Fr. in. is
13. GRAVEL PACK:
Depth
; Frani 4 0 To 20.0 M. _ Sand
from To 11.
Size
34. REMARKS: Hsu Restaurant
Mn1etial
Clean filter Sand
Depth.
1,1nm To
moo: 0,2'
0.2' 0.6'
0.6' r.0'
1"0'
3.0'
$.0'
7.0'
3.0'
11"0'
11.0' 20.0'
•
•
• w ;ri'
MWt
.ever
nrr rrrer.'
11'UK U.*r iLL. Liar, trliL.e.
Quad No. Serial No.
IaL Zang.
himor Sisin
Sasiu Code
Pc
rin
STATE WELL CONSTRUCTION
PERMIT NUMRER 81-�169 WMI-1Jl11
Calmly: SAMPSONr
Drilling 1.a&
Formaliou Description
A;phali
Gravel
Red brown med sandy clay
Greenish arcv sand with traces of sill
Greaaiall prey sand will, xravei
Tin ornate fine TO mcd yapQy day
Tea ararre silty saaua
Tan of ;net With red inners silty sands
Ef addisional spare is needed, use hack of [atm.
LOCATION SKETCH
6fr,�/ylr(WA tilt SE'r pv
MW.9
M.w '4_
MW.10
■
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANL E «
RECORDS, ANO THAT A COPY OF THIS RECORD HAS BFFN PROVIDED TO
1 14 NCAC WVElCONSTRUC1'ION
Vt LLL� c �t
DC.Ieil Yl! •rl�'� i May 24. 1944
Signature of Contractor or Agcot

DENR
DIVISION OF WASTE MANAGEMNT
UST SECTION
1637 MAIL SERVICE CENTER
RALEIGH, NC 27699-1637
ATTN: Hassan Osman, Hydrogeologist
RE: Agreement for the Use of Property for A Groundwater Investigation at the
incident known My Restaurant, Highway 701, Keener, Sampson Co·unty,
Nm1h Carolina (Incident Number: 10933).
Dear Mr. Osman:
I am/We are the Owner(s)/Agent(s) of a parcel of property, located at or the incident in
question, and hereby permit the Department of Environment and Natural Resources
(Department) or its contractor(s) to enter upon said property for the purpose of
conducting an investigation of the groundwater under the authority of G. S. 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation will be conducted by the UST Section of the Department's Division
of Waste Management or its contractor(s). The investigation may include soil and
groundwater sampling, borehole drilling, and monitoring well installation.
2. The cost of site investigation and maintenance 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 assessment 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 Department 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.
Site Access Agreement (FTF # 10933 Continued)
Page 2 of 2
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 shalt 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 wells), or equipment during the on -going investigation.
Signature
ate
- l 17 _ i� J Bass rr
Type/Print Name of Owner or Agent
Date Type/Print Name of Owner or Agent
ro Soxgas NC S a$
Address
City/State/Zip Code
Address City/StatelZip Code
Telephone No. (Home) Telephone No. (Work)

Archived: Friday, July 17, 2015 9:28:36 AM
From: Batchelor, Kenneth
Sent: Thursday, July 16, 2015 3: 11 :07 PM
To: Jamie Honeycutt
Cc: Rhodes, Christopher E
Subject: Re: NCDENR Site-My Restaurant-Keener Community-Hwy 701 Right ofWay
Importance: Normal
Jamie,
I see no problems with you accessing the monitor wells located on NCDOT R/W as shown on the attached
map.
Kenny Batchelor, Jr.
NCDOT
Sent from my iPad
On Jul 16, 2015, at 12:12 PM, Jamie Honeycutt <[e-mail] > wrote:
Ken,
As discussed earlier, S&ME is a contractor for NCDENR, UST Section in Raleigh. We perform
assessment work for NCDENR at old underground storage tank release sites where the
responsible party is no longer viable and NCDENR has taken over assessment work. We have a
site identified as My Restaurant located at 7223 Hobbton Highway (Hwy 701) in the Keener
Community of Sampson County. In the early 1990s, several groundwater monitoring wells were
installed by others to assess groundwater contamination from former underground tanks at the
My Restaurant site. Two well (MW-10 and MW-11) are located across Hwy 701 from the My
Restaurant site within the DOT Right-of-Way. See the attached site map. To enhance the
biodegradation of the contamination in the groundwater, NCDENR has requested we install
O-SOXs in several of the wells (See attached brochure). The O-SOXs are smaller than 2"
diameter, three feet long and fit inside the wells. The O-SOXs contain Calcium Peroxide and
Calcium Hydroxide which releases oxygen over time into the groundwater to help with
biodegradation. We would like to install an O-SOX in MW-10 located within the DOT Right-of-
Way along with several wells located at our site. Before installing the O-SOXs, we must submit
the attached Notification Form to NCDENR Water Quality Section (see attached). The form
requires signature of the property owner where the well is located or some type of
documentation acknowledging the work. An email acknowledging the work will be fine.
If you have any questions, please give me a call on my cell at 910 977-7614.
thanks
Jamie T. Honeycutt
Environmental Professional
S&ME LoQo
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in
error please advise the sender by reply ar;ig delete this electronic message and any attachments. Please consider the
environment before printing this email.
<TF 10933 My Restaurant In Situ Remediation Notification-2015-7-1629.pdf>
<O-SOX Brochure.pdf>
<My Restaurant Site -Site Map-FIG2.pdf>
Email correspondence to and from this sender is subject to the N.C. Public Records Law and may be disclosed to third parties.
Site Access Agreement (FTF # 10933 Continued)
Page 2 of 2
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_
IIWe agree not to interfere with, remove, or any way damage the Department's well(s)
or its contractor's well(s), or equipment during the on -going investigation.
Sincere1 1
Signatu
Signature
o Rbx 3�
Address
ate Type/Print Name of Owner or Agent
Date Type/Print Name of Owner or Agent
C� ..�a.,�g3a,
City/State/Zip Code
Address City/State!Zip Code
Telephone No. (Horne) Telephone No. (Work)

Archived: Friday, July 17, 2015 9:28:36 AM
From: Batchelor, Kenneth
Sent: Thursday, July 16, 2015 3: 11 :07 PM
To: Jamie Honeycutt
Cc: Rhodes, Christopher E
Subject: Re: NCDENR Site-My Restaurant-Keener Community -Hwy 701 Right of Way
Importance: Normal
Jamie,
I see no problems with you accessing the monitor wells located on NCDOT R/W as shown on the attached
map.
Kenny Batchelor, Jr .
NCDOT
Sent from my iPad
On Jul 16, 2015, at 12:12 PM, Jamie Honeycutt <JHone y cutt @smeinc.com> wrote:
Ken,
As discussed earlier, S&ME is a contractor for NCDENR, UST Section in Raleigh. We perform
assessment work for NCDENR at old underground storage tank release sites where the
responsible party is no longer viable and NCDENR has taken over assessment work. We have a
site identified as My Restaurant located at 7223 Hobbton Highway (Hwy 701) in the Keener
Community of Sampson County. In the early 1990s, several groundwater monitoring wells were
installed by others to assess groundwater contamination from former underground tanks at the
My Restaurant site. Two well (MW-10 and MW-11) are located across Hwy 701 from the My
Restaurant site within the DOT Right-of-Way. See the attached site map. To enhance the
biodegradation of the contamination in the groundwater, NCDENR has requested we install
O-SOXs in several of the wells (See attached brochure). The O-SOXs are smaller than 2"
diameter, three feet long and fit inside the wells. The O-SOXs contain Calcium Peroxide and
Calcium Hydroxide which releases oxygen over time into the groundwater to help with
biodegradation. We would like to install an O-SOX in MW-10 located within the DOT Right-of-
Way along with several wells located at our site. Before installing the O-SOXs, we must submit
the attached Notification Form to NCDENR Water Quality Section (see attached). The form
requires signature of the property owner where the well is located or some type of
documentation acknowledging the work. An email acknowledging the work will be fine.
If you have any questions, please give me a call on my cell at 910 977-7614.
thanks
Jamie T. Honeycutt
Environmental Professional
S&ME LOQO
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile: [phone]
i [e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www .smeinc.com/email. If you received this message in
error please advise the sender by reply aQg delete this electronic message and any attachments. Please consider the
environment before printing this email.
<TF 10933 My Restaurant In Situ Remediation Notification-2015-7-1629.pdf>
<0-SOX Brochure.pdf>
<My Restaurant Site -Site Map-FIG2.pdf>
Email correspondence to and from this sender is subject to the N.C. Public Records Law and may be disclosed to third parties.
NORTH CAROLINA DEPARTMENT OF HEALTH, ENVIRONMENT, M'D NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SECTION
P.D. BOX 27637 - RALEIGH, NC 2761-1, PHONE (914) 7M-50IIi
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR CTLEneineerior Inc of NC
DRILLER REGISTRATION MIMBER I3SQ
L WELL LOCATION: (show sketci or lae locarioo blow)
NcarPa[TAwn: Clot lots
Srtse tifrhwa, 701 Souib
{Road, Commodity, or SubdGmision and bat No.)
2. OWNER Sass Oil Co.
ADDRESS P. O. Bar ffiS
(S1rcel at Route No.)
Clanton NC 2a 2S
City or Tows State Z1P Code
3. Date Drilled November 16, 1493 USE OF WFI1 MONITORING
i4_ Total Depth 20,0 Fxei Cuttings Collected? Yes x No
[5_ DOES WELL REPLACE EXISTING WELd.? Yes x No
6. Static Water Level: NA tr. aLOve X below top of rinsing.
Top of twins is 0.3 St. ABOVE/BELOW Lead surface.
1. YIELD (gpm). 1'IA METHOD OF TEST NA.
8. Water Zones (depth): NA
,9. CHLORINATION: Tvpr NA Amvpnt 1../A
i 0. CASING:
Wall Thickness
Omer Depth Diameter or Wm&ht/Ft. Matered
l ivm !VA To NA 11. NA \A
from To 5.(1 F: 2.0' Schedule 40 PVC
11. GROUT:
Depsh
Material Method
Death,
From To
0.00` 10.0'
10,0' 9A0'
13.0' i6A'
FOR OFFICE USE ONLY
Quad No. Serial No.
LaL long. Pe
Minot Basim
1�9iin Cock
STATE WELL CONSTRUcrioN
PERMIT NUMBER.: W LLS ON SITE
/
1r i,MW-'24 MW-3
Drilling Log
Formation Ocscriptiom
Dark hrowa $oe saa4 tram dam
11 pm Iine saadv dap
Pink sainrated saproiite
I4.0' 20.0a Tan Esac wct son ti day
County; SAMPSON
If adeGtiamal space is ortdedi use back of form.
LOCATION SKETCH
Fern 24 To 5.0 Ft. Ready ivfic Ccaeeo[ Viand Pour J PLEASE S E [' FIGURE 5
Prom 10 To 4.0 FI_ 1:'ceieaiic Cki is
:F2. SCREEN.:
Depth Diameter Skil Size M.icrl;l
Proar S 0 Tn 20.0 Ft 3 re. 0.010 io. PVC
tom To F in. in.
:FOPS T4 Fi.
13. GRAVEL PACK:
Driub Site Malcr 1
riaar 4.0 To 20.0 Ft. Sand Clean Fiber Sand
Frooe To F.
11. REMARYS:
M. R t7.Uraol
I DO HEREBY CI=RTIFY THAT I'f-iiS Wl LL WAS CONSTRUCfl 1D iN ACCQRDAN'CEWWITH 14 NCAC 2C, WELL CDNSTR UCL-iQN
RLC= RDS, AN1) THAT A COPY Or."1'I-1iS J CC)ttI) HAS BEEN PROVIDED TO 'nit WELL Of'lVi'ER/.
X LL {„ z; .r_m/r rmhre 10. 1913
sateen ni Chatraaen.nr Ageni hate

NDRTH CAROLINA DEPARTMeN T Ur R AL'1ti, rhlvtlkUNJ. NT, AND NA7•f.tRAL ltrNt2UHLf_'1
DIVISION OF EWVIRONME T1•AL MAMA ME)JT - GROUNDWATER .SECTION
P.O. SOX 17647 - RALF.tGH, 14C 27G1t, PHONE (919) 7E3.50133
WELL CONSTRTSCfION RECORD
DRILLING CONTRACTOR Svecial Testinc labs of NC
DRILLER REGISTRATION NUMBER 1468
WELL LOCATION: Oho Acta the hxatioa below,
*feared Town_ Clinton
Sum Rijihwav 701 South {keener Rd. iatersecian
(Road, Community, or Subdivisioc and Lai No,)
2. OWNER Bags Oi? Co.
3,
ADDRESS P. O. Box 835
Charon
Coy or Town
Date Drilled M:. t, ts't
(Street or Rouic No.)
NC ISM
State ZIP Code
USE OF WELL MONITORING
° 4. Total Depth 20,0 Foal Cuttings Collected? _ Yes x No
5. DOES WELL REPLACE H?CLSTLNG WELL? Yes x No
6 Static Water Level: NA ft *ewe X below tap of wtiaa.
Top a[ mein& is 0.5 f1" ABOVEIBEL.OW land surface
7" Y FJD Wu* _ NA METHOD OF TEST NA
8. Water Zones (depth); NA
9, CHLORINATION: Type NA Amount NA
10- CASING:
Wolf Mk/mess
Outer De pat Diameter or Weight/Ft.
From NA 'fa
Inner
From 03 I'u 5.0
11. GROUT-
Depth
?ram 0 h To
.From 2"0
Ft. IM CIA
Material.
Ft. 1.0' Schcdufc 40
PVC
Mate Fir I Method
2.0 P1, Re4e, o Cemcn. Hand Pore,
To 4.c Ft. Bentonite Claim
12- SCREEN-
-Depth Diauyslct Slol Szte Ma'crial
ions 5.0 To 20.0 FI, 2 1t7wale it. PVC
From To F. io ia.
am To
_3. GRAVEL PACK:
Depth Size Material
Tim 4.0 TB 20.0 Ft. Saud (loon Finer Sand
- rvm To
Ft.
_4, REMARKS: M- Rcstauraau
o epth
Prom To
0.00' 3.4'
3.17' 3.0'
3.0' 7.0'
7,0' 9.0'
9.0' 11.0'
11.0' 13.0'
13A' 20.0'
FOR OFFICE USE ONLY
Quad No. Seciat No.
La: Lb0L. Pc
W.raor Bask
Basin Cade
[T
i
STATE VVELL CONSTRUCTION
PERMIT NUMBER- WELLS S ON SITE
Mw•1_
County: SAMPSON
Driiliak Lug
POrwatioa Des tipeon
. utainil Willy organic oiflet
Brown silt'. bac To medium stud
Grant-bsowls. 6nc. rietrt sand
Brown Tam-vicdium sande sill
Cray -brown fins SAnd' silt
Oranes-tan, 6oc•mcdium sand with light era., streaks
Ctrapra.rat. fiv-meditm, 9120d
If additianat space is needed, uer back of form.
LOCkT1ON SKETCH
p! N" •8'
MW.9
•
v-, f µW,II t b ►rr• • r •
•
•
ce
•
1 DO HEREBY GERTlry ThAr THIS WELL WAS CONSTRUCTED TN ACCORDANCE \Valli ] 4 NCAC 2C, WELL CONS RucrION
RECORDS, AND THAT A COPY OF THIS RECORD] HAS BEEN PROV)DEI'') TO THZ140(W�R
Sipa:car of Contractor or AgCA1
May 24, 1994
Pale

NORTH CAROLINA DEPARTMENT OF HEALTH. ENVIRONMENT, AHD NATURAL RESOURCES
DIVISION OF ENVIRONMENTAL MANAGEMENT - GROUNDWATER SEGrIG''
P.O. BOX276E7 - RAL.EIGH, NC 2701I, PHONE (914j 783-3003
WELL CONSTRUCTION RECORD
aRELLING CONTRACTOR CTL Engineering Inc. of NC
DRILLER REGISTRATION NUMBER 1350
1. WEI.I. LOCATION: (Shorn sketchof tilt 30catioo below)
Nearest Tows: Crintos
Stale IiirMrcr 701 South
(Rosa, Cotcmmity, or Subdlvisioa and tat Ha.)
2. OWNER Eass Oil Ca.
ADDRESS P. O. Box ass
(antes et Rnme Nu.)
❑iatoa NC 7.8M
City or Towa State ZIP Code
S. Date Dri11ed November 16. Bashi USE OF WELL MONITORING
4. Total Depth 20.a Feet Cuttings Collected? `Yes a No
DOES WEEL REPLACE EXISTING WELL? Ycs X No
46. Static Water Level: NA IL above X below too o! easialr,
•
Top DI asivg i5 03 1c ABOVIJSEt OW land surface.
f7. YIELD (mot): NA METHOD OF TEST NA
8. Water Zones (dcpthy NA
9. CHLORINATION: Tjtpc NA Aatoml NA
10. CASING:
Wall Thiekaeti
I Outer Depth Diarge:er or Wei bt/R Ma les cal
�rarn NA Ta NA FL NA NA
:an./
Trott 9.3 To 3,0 FT. ^e.0' San: uk40 PVC
11. GROUT:
Deylh Material Method
'tool 2 To 30 I. Rec.& Mix Cc ncut Hand Pour
From 3.0 To 4.8 R. 8cotooitc Chills
12. SCREEN:
Froal
iron
641
Dula
3.0 To
To
To
Diameter SSni Size Maluial
20.0 F. 2 io. 0.010 io. PVC
13. GRAVEL PACK:
❑cplh
om 4.0 To
From To
PS. in. is
R. 14. io.
Size Altaic ryas
20.0 P Sand Oeau Pater Sand
14. REMARKS: my Res, cut Aryl
Quad No
LOtg. Pc
Mt= Basin
Basin Co&
FOR OFFICE USE ONLY
Lat.
Serial No.
STATE WELL CONSTRUCTION
PERMIT NUMBER: WE1r..LS ON SITE
MW4
Depth D rIlliu Log
Flom To Formation accipt cn
0.00' 0.1' Asphalt
0.2' 1.0' Dart ccodY day
1.1r 3.0' Dark blade Sac scats day
so•
11.0'
14.0-
20.0
County: SAMPSON
i.t�cX moat arm smut .char
l.r. Lan ircy 6nr sandy day
U ran nigh moils fine 1:11335. da, and lualitc
Li. tan glom Gee rands
If additional space is aesded, use bade of torn
LOCATION SKETCH
PLEASE SEE FIGURE 5
11)0 HEREBY CERTIFY TI-TAT THIS WELL, WAS c DNS FRUC'i'1 D IN ACCORDANcl ..V1TI1 34 NCAC 2C _LL CONS3'P UCION
RECORDS. ANO THAT A C.'OPY OP THIS RECORD HAS BEEN PROVIDE-:') TO 'f /ELL O\ -' •
a,.ere orCatrre 'iir or Agent Oat,

NORTH CARL/LU'iA.L7L•rAltr110r-t Jr - --
DIVISION OP ENVIRONMENTAL MANAC3EME T - GROUrWWATER SECTION
P.O. BOX 276$7 - RALFIGH. NC 27611. PHONE [phone]
WELL CONSTRUCTION RECORD
DRILLING CONTRACTOR Special 'festii u Tabs ❑f NC
'OH Uiri`' i uaL vn ..x
Qaad No. Scrlal No.
Lot Long -
.ylinor Basin
Basin Code
STATE WELL CONSTRUCTION
DRILLER REGlsI1tATZON NUMBER 3468 ,PERMTT NUMBER: WELLS ON S1T
I. WELL LOCATION: (Show sketch of the tomioa beloM'1
Nearest Town: [laloa
yIW"9
Coanry: SAMPSON
Mate Highway 701 South ; Itersrer Rd. intersection! D57111 Drilling Log
(Road C ramenity, or Subdivision and Let No.) Frog, To Furrunlion Description
2. OWNER Bsss ow Co. 000' 14' Torse is with °manic mailer
ADDRESS F O. Box ffi: 3.0' 4.0' Brown elk_ brown fine sands
(Stroll or Runic No.) 11.0' S.11' &owe Mt 1L mCY Gat ouch' sill
Chasm NC 28328
city or Town State ZIP Code S. 0.0' ilk brown brown and prey moist flan shrinks, ciaysw sands
3. Date Drilled Mav a, 199: USE OF WELL MONITORING RV ILO' firer brown. dercy line sands
4. Total Depth 20.0 Feel Cuttings Collected? Yai x Na ILA' 13.tr Reddish or'aaac Bee t aced scuds
5. DOES WELL REPLACE EXISTING WELL? - Yes _Na 13.0' 15.0' Brown tedcrah Goa to meet sands
6. Static Water LeveJ: hlA fl. above X below top of rig
Top of rasing is 03 ft. A.BOVEJBELOW land surface_
7. YIELD (spa NA METHOD OF TEST NA
8. Water 7,13re.s Nagai): NA
9_ CHLORINATION: Type NA Arnauar 1tiA
10. CASING:
13.0' 20.0" 'Tau Gar to mad. nods
1l additional spec it seeded 0.se back of Form.
Wall Thieknere
Outer Depth Dianteles or Weight/Pt. Matrrit,! LOGATFON S3C1 TCH
From NA To NA Pt. NA NA
Ionet
From 0 3 To :,0 Pt. 2.0' Sccedalc 40 PVC
I1. GROUT
Depth Mniertal 7.ieLod
From 1.0 To 2.0 FL lInner Mit Cc nmat 140n3 Pm.;
From 20 To 4.1) 'FL Bentonite Cbigs
32 SCREEN
Nab Dim:attar Slot Site ?vfateriaI
From 2.11 To 70.0 2 in. 0.030 in, PVC
From in FL io. ra-
From 10 ll. r. in..
13. GRAVEL PACK:
Orplh Size Matcri�1
From.. 4.0 To :0-0 1t. Saari Crean Filter Sand
• Frog:
11. REMAUKS: My Rt:taus eat
1
MW-1 j•01-
aycweav Wre ,.-riv., Pa, 3.`2, .. -
ti
•
Qy Asw-fd
DO HEREBY Y CERTIFY THAT TIUS WELL WAS CONSTRUCTED IN AC.C.ORDANCE WII ?4 N'Ch
RECORDS, AND TIiAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO T
NSTRUCTION
Ma, 24, toe:
.yilrail ac 0t Conttactar of Agrot Late

Kona CAROL.IMA 111d'Am cnruorr l tar Pe r...,..........»•.••• • -, . _ -'- _ -_ _ _
7]1V1�ON OF ENv[fnoNlr!£NTAL MANAGEMENT • GROUNDWATER SECTION
P.Q. BOX 27687 - RALEIGf3, NC 2761; PHONE (9f9) 783-5083
WELL CONSTRUCTION RECORD
ROVING CONTRACTOR 5: ec iol Testier Labs of NC
DRILLER REGISTRATION NUMBER 1468
i. WELL LOCATION: (saw shuch of the Mead= Wow),
Nearest Town: Ginty■
State HiiE bway 701 Saudi (Kw -net Rd. intersection
(Road Community, or Subdivision add Lei No.)
1. OWNER Bess Oil Co.
ADDRESS P. O. Box 631
C1inaaa
City or Tows
3. Date Dn71ed Ma. 4.1994
4. Total Depth 20,0 Fit
DOES WELL REPLACE
b. Static Water Leve.1: NA
S.
{Street or Route No.) 0.0' 1.0'
NC 2ICi28
Stine 21P Code 1.0' 30'
USE OF WELL moNITCRiNG 3.0' S.0'
Cuttings Colletxed? Yes x No S.V' 7.0'
EXISTING WET S..7 _ 'Yes x No
h.,_• above X below tip of easing.
Top of casing it 0.3 ft. ABOVE/BELOW land surfaac.
17. YIELD (gpea): NA METHOD OF TEST
$. Water lanes (depth): NA
'9. CHLORINATION: Tjpc N.►
1Q. CASING:
/worm[ NA
Wail Thickness
Oath Depth Diymercr or Weighlirt,
rost NA To NA Ft. f:A NA
ltrxu
Fran] 0.3 To 5.0 R. 2.0" Schsduic 40
li. GROUT.
striae M:ritrio1 Method
rProvi Z.0 Tv 2.0 Ft, ILwdy.Mi' Cr-4..31i F3xad Pour
Roue 2.6 Te 4.0 H. Bentooite Chips
►Austrial
PVC
12. SCREEN
Depth Diamdcr Slot Size Knietial
From 5.0 To 20.0 Pt. 2 i . 0.010 ia. PVC
From i'c F in. in_
Front To R. in. in
13. GRA'VEL FAC1'
Dep[E Size Material
From 4.0 Ta 20.0 Fr. Sand peon Fiber Sand
PrOoy
To Ft.
14. REMARKS_ Me Rcxlawant
7.0' 11.0'
11.0' 20.0'
f!
I
Depth
From To
o.00' 0.2'
1'UK UrI lt.l. yam. terta,a
Q uad No. Seriiaf No. _
Iat Luau Pe
Minor Basin
B. Code
STATE WELL CONSTRUCTION
Fir NUMBER: 81-0169-WM-D111
MW-10
County SAMPSON
Drilling Log
FormatiuY Demip[ion
Asoii nit
02' 0.6' Gravel
Red brown tiea ssady day
GreeMsh ern .sad with traces of tilt
GreenishRrc. rand with gravel
Tao oraere fine to mcd sand+ c14.
Tan maxim silty seeds
Tali Dina. With red lavers siir, eolith
U addidonai space is needed, um Each of form.
LOCATION SK1lr'ITCll
J
react MW-l7 Ll ink
L
•
ht
M91.11
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W 114 NCAC -9 uEI CONSTRUCTION
RECORDS, AND THAT A COPY OF THIS RF.COIdD 1-1AS BEEN PROVIDED TO •f k'I=LL
Sit,nature of Cnnuwoe or Agsat
may 24,19914
pain

DENR
DIVISION OF WASTE MANAGEMNT
UST SECTION
1637 MAIL SERVICE CENTER
RALEIGH, NC 27699-1637
ATTN: Hassan Osman, Hydrogeologist
RE: Agreement for the Use of Property for A Groundwater Investigation at the
incident known My Restaurant, Highway 701, Keener, Sampson C o·u~ty,
North Carolina (Incident Number: 10933).
Dear Mr. Osman:
I am/We are the Owner(s)/Agent(s) of a parcel of property, located at or the incident in
question, and hereby permit the Department of Environment and Natural Resources
(Department) or its contractor(s) to enter upon said property for the purpose of
conducting an investigation of the groundwater under the authority of G . S . 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation will be conducted by the UST Section of the Department's Division
of Waste Management or its contractor(s). The investigation may include soil and
groundwater sampling, borehole drilling, and monitoring well installation.
2. The cost of site investigation and maintenance shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the
surrounding lands.
3. Uniess 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 assessment 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 Department 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.