WI0400572_Permit (Issuance)_20210726

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 injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection 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 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 (IST) — Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: , 20
PERMIT NO. (to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a 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 needed relevant information to assess and approve injection:
A.
B.
Permit No. WI Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well Complete sections B through F, J, M
(2) Aquifer Test Well Complete sections B through F, J, M
(3) x Passive Injection System Complete sections B through F, H-M
(4) Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (IST) Well Complete sections B through M
STATUS OF WELL OWNER: Choose an item.
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 1

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): NCDEQ, DWM, UST Section — Federal & State Lead Program (TF #44047)
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27511 County: Wake
Day Tele No.: 919-707-8263 Cell No.:
EMAIL Address: [e-mail] Fax No.: 919-715-0707
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Nicholas Walters (PropertyOwner)
Company Name Walters Motor Works
Mailing Address: 2817 Old US Highway 421E
City: Yadkinville State: NC Zip Code: 27055 County: Yadkin
Day Tele No.: 336-469-4037 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Elizabeth A. Allyn, Senior Project Manager
Company Name WithersRavenel
Mailing Address: 115 MacKenan Drive
City: Cary State: NC Zip Code: 27511 County: Wake
Day Tele No.: 919-418-0279 Cell No.: 919-418-0279
EMAIL Address: [e-mail] Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Former Center Station
2800 Center Road
City: Boonville
County: Yadkin
Zip Code: 27011
(2) Geographic Coordinates: Latitude**: " or 36 °. 183343
Longitude**: " or 80 °. 743593
Reference Datum: NAD83 Accuracy:
Method of Collection: Google Earth
**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 of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 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 — See attached for plume and contaminant concentration map
(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. — Cross -sections have not been completed
— See attached boring log for MW-1
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells. — See attached
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
WR will place one Provectus Oxygen Releasing Substrate (ORS) sleeve into monitoring well MW-1 impacted
by a UST release which was discovered in October 2012 to reduce contaminant concentrations by enhancing
biodegradation.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 1 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 27 feet
(3) For Proposed wells or Existing wells not having GW-1 s, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division of Public Health, Department
of Health and Human Services can be injected. Approved injectants can be found online at
http://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program for more info if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no injectants are to be used use N/A.
Injectant: Provectus ORS Total Amt. to be injected (gal)/event:1 sleeve (1.75 lbs of ORS/
sleeve)
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

Total Amt. to be injected (gal/event):
No. of separate injection events: Total Amt. to be injected (gal):
Source of Water (if applicable): Not Applicable
L. 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.
Annual monitoring of monitoring well MW-1 and the closest water supply well (WSW-1) will be
conducted. If effective, ORS sleeves will be replaced and the site will be re -sampled annually.
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 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 15A NCAC 02C 0200 Rules."
Elizabeth A. Allyn, Sr. PM, on behalf of NCDEQ-DWM UST Section (Inc. 44047)
Signa i f Applicant (f Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .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 for site access agreement
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu 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 Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 4

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411117
LEGEND
TYPE II MONITORING WELL LOCATION
0 WATER SUPPLY WELL LOCATION
NOTES:
1.) 2013 AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT.
MW-2
MW - 3
Anal tical Method
Sample ID
MW-1
MW-2
MW-3
MW-4
Date
Collected
8/5/2019
8/5/2019
8/5/2019
8/5/2019
NC 2L Standard
GCLs for Groundwater
Notes:
Result
Result
Result
67-64-1
32
11
16
6000
6.000,000
135-98-8
8.9
76
0.076
0.076
70
8,500
98-06-6
0.65
<0.088
<0.088
70
15,000
SUMMARY OF GROUNDWATER ANALYTICAL RESULTS
c
rID
� w
106-93-4
17
0.02
50
107-06-2
1.2
0.4
108-20-3
22
50
<0.050
- 0.050
70
400 70,000
0
G7
N
c
T
w
100-41-4
250
<0.061
<0.061
<0.061
600
84,500
EPA-602 / SM6200B
108-10-1
24
• 0.065
?.065
•
100
100,000
98-82-8
42
•54
<0.054
70
25,000
99-87-6
6.1
<0,
25
11,700
108-10-1
12
100
100,000
1634.04.4
330
20
20,000
91-20-3
330
6
6.000
103-65-1
92
87
087
70
3,000
108-88-3
3.1
<0.04_;
<0.5
600
260,000
1) All results provided in ug/L (micrograms per liter) or parts per billion.
2) Compounds analyzed for by laboratory but not listed were not detected above laboratory detection limits. See the laboratory report included in the Appendix for a full fist of constituents.
3) NC 2L Standard - North Carolina Groundwater Quality Standard as per NC Administrative Code 15A NCAC 02L.
4) GCLs for Groundwater - NCDENR UST Section Gross Contamination Levels for Groundwater.
= Result Exceeds Laboratory Detection Limits
= Result Exceeds NC 2L Standard for Groundwater
= Result Exceeds NC Gross Contaminant Level for Groundwater
FgRR/SROgOrAtc
SR 139i1
95-63-6
160
<0.054
<0.054
400
28.500
108-67-8
780
400
25,000
GRAPHIC SCALE
0 15 30
1 inch = 30 ft
1300
500
85,500
60
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1rWithersRavenel
Our
Well ID:
Date:
WR Rep:
People. Your Success.
WELL CONSTRUCTION LOG
MW-1 Job Name: Former Center Station Job #: 02171214.43
May 7, 2019 Site Loc.: Boonville, Yadkin County, NC TOC EL: NM
K.Buchanan Driller: Carolina Soils Investigations GW EL: NM
NC NAD83 Easting: 1485443.52 NC NAD83 Northing: 890165.59
Depth in
Soil Description
Well Construction
Feet
(Field USCS Classification)
0
Ground Surface
1
Dry, Orange CLAY (Conc. from 0.5-1)
I 0-1 ft
2
3
0-5 ft Concrete Grout
4
Moist, Orange Fine Sandy CLAY
1-7.5 ft
5
6
7
8
0-15 ft 2" Dia.
PVC Casing
9
Moist, Orange & White Fine Sandy
7.5-10 ft
SILT
5-13 ft Bentonite
10
11
12
13
Moist, Orange & Brown Fine Sandy
SILT
10-15 ft
14
15
16
17
18
19
20
Moist, Mottled, Red -Brown Fine SILT
15-24.8 ft
21
22
13-30 ft Clean -Washed Torpedo SAND
15-30 ft 2" Dia.
23
0.010-Slot PVC
24
Well Screen
25
26
Moist, Dark Brown/Gold Fine SILT
w/Mica
24.8-25 ft
27
28
Moist to Damp, Mottled Orange &
25-30 ft
29
Brown Fine SILT (Wet @ 26.5 ft)
30
31
32
Notes:
1.) Boring Terminated at 30' BLS
2.) BLS - Below Land Surface
3.) TOC - Top of Casing
= Groundwater Level (Measured Beneath TOC)
Page 1 of 1
115 MacKenan Drive Cary, North Caroiina 27511 te1.919.469.3340 fax.[phone] www.wither5ravenel.com

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LEGEND
TYPE II MONITORING WELL LOCATION
WATER SUPPLY WELL LOCATION
❑2.O91 GROUNDWATER ELEVATION (ft)
ns IMPLIED GROUNDWATER ELEVATION
INFERRED GROUNDWATER FLOW
NOTES:
t.} 2013 AERIAL OBTAINED FROM THE LOCAL COUNTY G1S DEPARTMENT.
GRAPHIC SCALE
10 20 40
•
4
1
4
-
MW-3
(71.12)
MW-2 (72.09)
u
J
O a °i
= a cv
HZri
Q W D
1-9
Z44
Q<
a
C
CU
ro
ry
17 E
End

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
Daniel Summers
Well Contractor Name
2579-A
NC Well Contractor Certification Number
Carolina Soil Investigations, LLC
Company Name
2. Well Construction Permit #:
List all applicable well permits (i.e. County, State, Variance, Injection, etc.)
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
❑ Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
Non -Water Supply Well:
❑� Monitoring
❑ Recovery
Injection Well:
❑ Aquifer Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
❑ Geothermal (Heating/Cooling Return)
❑ Groundwater Remediation
❑ Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑ Other (explain under #21 Remarks)
4. Date Well(s) Completed: 05-07-19 Well ID# MW-1 MW-2
5a. Well Location:
Facility/Owner Name Facility ID
2800 Center Road Boonville, NC
(if applicable)
Physical Address, City, and Zip
Yadkin
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.18339 N-80.74362
6. Is (are) the well(s): (]Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or ONo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. Number of wells constructed:
For multiple injection or non -water supply wells ONLY with the same construction, you can
submit one form.
2
9. Total well depth below land surface: 30 (ft.)
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: 25 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 8 (in.)
auger
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
15 ft•
30 ft*
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
15 ft.
2 in.
sch 40
pvc
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
15 ft.
30 ft.
2 in.
010
sch 40
pvc
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0 ft.
5 ft.
portland
mix & Pour
5 ft.
13 ft.
bentonite
tremie
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
13 ft•
30 ft.
10/30 silica sand
tremie
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
0 ft.
30 ft.
brown silt loam / brown silty clay / saprolite
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Contact Info:
Withers & Ravenel Kevin Buchanan [M] 919.422.1141
22. Certification:
c514111-11244-4--
05-07-19
Signature of Certified Well ntractor
Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this form within 30 days of completion of
well construction to the county health department of the county where
constructed.
Form GW-1
North Carolina Department of Environment an
Natural Resources - Division of Water Resources Revised August 2013

RECEIVED
DEC 31 2013
UNDERGROUND STORAGE TANK SECTION 'upertund Section
December 3, 2018
Mr. Thomas Chapman
Hydrogeologist
DWM/UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Mr. Chapman
RE: Access Agreement
Center Station
2800 Center Road
Boonville, Yadkin County, North Carolina
Incident Number: 44047
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 assessment and/or remediation of the groundwater
and/or soils under the authority of G.S. 143-215.94G.
I am/We are granting permission to the lands we own or control with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or
its contractor. The Department or its contractor shall protect and prevent damage to the surrounding
lands. Any damages will be restored by the Department or its contractor to as close to the pre -work
condition as practicably possible.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor will notify the land owners
48 hours prior to entry and may enter upon the land at reasonable times and have full right of access
during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31
of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and
Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and

is a public record, in accordance with G.S. 132-1.
6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the landowner. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed.
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Uoir---
Signature
/Vic Ldlo f/l/4/4 s
Type/Print Name of Owner or Agent
36-49- 6/037
Phone Number
o1cd is y 1-iLt E
Address
gkavi
N 2105s
City/State/Zip Code
121172cf7
Date
RE: Access Agreement
Center Station
2800 Center Road
Boonville, Yadkin County, North Carolina
Incident Number: 44047