WI0400577_Permit (Issuance)_20211025

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (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 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: October 12 , 2021
by DWR)
PERMIT NO. (to be filled in
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) X Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well Complete sections B through F, K, N
(3) Passive Injection System Complete sections B through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through N
(6) Tracer Injection Well Complete sections B through N
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): NCDEQ-DWM, UST Section, Federal & State Lead Program (TF#24248); Attn: Herb Berger
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8170 Cell No.: NA
EMAIL Address: [e-mail] Fax No.:
Deemed Permitted GW Remediation NOI Rev. 1-06-2021
Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title:
Company Name
Mailing Address:
Shaikh Amjad Masoud on behalf of Masoud Abid
225 Westridge Drive
City: Burlington State: NC Zip Code: 27215 County: Alamance
Day Tele No.: 336-512-2044 Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: G. Matthew James, P.G., Project Manager
Company Name WithersRavenel, Inc.
Mailing Address: 115 MacKenan Drive
City: Cary State: NC Zip Code: 27511 County: Wake
Day Tele No.: 919-238-0335 Cell No.:
EMAIL Address: [e-mail] Fax No.: 919-467-6008
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Country Cupboard; 9681 NC HWY 700; Incident #24248
City: Pelham County: Rockingham Zip Code: 27311
(2) Geographic Coordinates: Latitude**: 36.517283°
Longitude**: -79.547515°
Reference Datum: Google Earth Accuracy: +/- 5m
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)
H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 2

DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
Purpose:
Scope:
Goals:
J. APPROVED INJECTANTS — Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-inj ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Inj ectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Inj ectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Inj ectant:
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: 0 Proposed 2 Existing (provide GW-1 s)
(2) For Proposed wells or Existing wells not having GW-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):
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "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."
04,,z&44,„yz__
G.Matthew James, PG, Project Manager, WithersRavenel
On behalf of NCDEQ-DWM, UST Section for NCDEQ Incident # 24248
Signature of Applicant 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 NCDEQ STATE -LEAD ACCESS AGREEMENT FOR PROPERTY
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 his NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 4

RESID
0
SUMMARY OF GROUNDWATER ANALYTICAL RESULTS
COUNTRY CUPBOARD
9681 NC-700
PELHAM, ROCKINGHAM COUNTY, NC
INCIDENT # 24248
Analytical Method
6200B - Volatile Organic Compounds
Ca lc
504.1
6020B
Date
Benzene
Butylbenzene, n-
Butylbenzene, sec-
Ethylbenzene
Isopropyl Ether
Isopropylbenzene
(Cumene)
Isopropyltoluene, 4-
Methyl-tert-Butyl Ether
a)
Propylbenzene, n-
Trimethylbenzene,
1,2,4-
Trimethylbenzene,
1,3,5-
Xylenes, total
1,2-Dibromoethane
Sample ID
Collected
a
m
L_
a)
_
L
a_
j
-a
(0
z
1-
71-43-2
104-51-8
135-98-8
100-41-4
108-20-3
98-82-8
99-87-6
1634-04-4
91-20-3
103-65-1
108-88-3
95-63-6
108-67-8
1330-20-7
106-93-4
7439-92-1
MW-1
3/5/2021
Not Sampled due to LNAPL ;
MW-2
3/5/2021
1160
55.3
<`
1610
75.2
130
<50.0
884
419
416
1620
3390
1070
7530
NA
MW-3
3/5/2021
2080
<50.0
<`
2490
146
<50.0
<100
719
417
7190
3390
957
15600
NA
MW-5
3/5/2021
233
231
88.6
803
192
50.8
<100
481
745
1360
4510
1520
7190
NA
MW-12
3/5/2021
22300
<50.0
<
4160
161
<50.0
<100
795
478
47500
3230
835
19300
NA
SS-1
3/5/2021
35300
<500
<
5870
662
<500
<500
<1000
3500
987
76200
7600
1870
34400
NA
NC 2L Standard
1
70
70
600
70
70
25
20
6
70
600
400
400
500
0.02
15
GCLsforGroundwater
5,000
5,900
8,800
80,000
70,000
30,500
11,700
20,000
6,000
26,100
260,000
28,500
24,100
50000
50
15000
Notes:
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 list of constituents.
3) NC 2L Standard - North Carolina Groundwater Quality Standard as per NC Administrative Code 15A NCAC 02L.
4)
GCLs for Groundwater - NCDEQ UST Section Gross Contamination Levels for Groundwater.
NL
= No Regulatory Level Established
Result
= Result Exceeds Laboratory Detection Limits
Result
= Result Exceeds NC 2L Standard for Groundwater
Result
= Result Exceeds NC Gross Contaminant Level for Groundwater
LEGEND
BENZENE GCL ISOCONTOUR (5,000 ug/L)
BENZENE 2L STANDARD ISOCONTOUR (1 ug/L)
FORMER UST LOCATION
J LIMIT OF 2001 EXCAVATION
r___1 LIMIT OF 2008 EXCAVATION
WATER SUPPLY WELL LOCATION
TYPE II MONITORING WELL LOCATION
SPARGE WELL LOCATION
NOTES:
1.) LOCATIONS AND SIZES ARE APPROXIMATE AND NOT EXACT.
2.) ISOCONTOUR LINES ARE DASHED WHERE INFERRED.
INSTALL THREE - 4-INCH DIAMETER SVE WELLS TO ASSIST IN THE REMOVAI
PETROLEUM MASS BETWEEN 10 FT BGS AND 30 FT BGS
ESTIMATED RADIUS OF INFLUENCE 15 FT SHOWN BY DASHED CIRCLE
AMW-6
FORMER
DISPENSER
ISLAND
MW-4
ARD
SITE
MMW}-13
,MW-2
MW-3
,MW-5
i
GRAPHIC SCALE
0 10 20
40
1 inch = 20 ft.
0 .
Z
0
N
}
Z a
3
0
Z
0
0
APPROVED BY
02172214.08
03/31/2021
cc
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0

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
A7 'A
NCDENR
NORTH CAROLINA DEPARTMENT OF
FuvlranuINFNT ANn Neri mei RFsrn IRrFe
UNDERGROUND STORAGE TANK SECTION
Herb Berger
Hydrogeologist
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
RE: State Lead Referral Notification
Former Country Cupboard
9681 NC Highway 700
Pelham, NC 27311, Rockingham County, NC
DWM Incident # c2 `t a 1/4.1.St
Dear Mr. Berger:
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and hereby
permit the Department of Environment and Natural Resources (Department) or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of G.S. 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and is
a public record, in accordance with North Carolina G.S. 132-1.
DIVISION OF WASTE MANAGEMENT/UST SECTION
1637 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA 27699-1637
PHONE: [phone] FAX: [phone]
INTERNET: http://www.wastenot.enr.state.nc.us
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/1 O% POST -CONSUMER 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 land owner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
/1JA p-/'lASocl Z
Type/Print Name of Owner or Agent
3 3 - 53 9 — 6/4 E
336 — 372-- . yy ._ c' LLE:,�
Phone Number
Address _ ( , /S"
%zJ,f1.Ti`1� re is( 27m?IS--
City/State/Zip Code
Date

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2907
1. WELL CONTRACTOR:
Thomas Whitehead
Well Contractor (Individual) Name
S&ME. Inc.
Well Contractor Company Name
3201 SDrina Forest Road
Street Address
Raleiah NC 27616
City or Town State Zip Code
(919 ) 872-2660
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# N/A
OTHER ASSOCIATED PERMIT#(if applicable) N/A
SITE WELL ID #(f applicable) AS-1
3. WELL USE (Check One Box) Monitoring 6/Municipal/Public 0
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection 0
Irrigation❑ Other 0 (list use)
DATE DRILLED 7/1 8/14
4. WELL LOCATION:
9681 Hiahwav 700
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Pelham COUNTY Rockingham
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley QrFlat ❑Ridge ❑Other
LATITUDE 36 " 51 ' 7,290.0000 " DMS OR 3X-X)0000000( DD
LONGITUDE 79 " 54 ' 7,500.0000 " DMS OR 7X.X)0o00000( DD
Latitude/longitude source: UPS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Former Country Cunhnard
Facility Name Facility ID# (if applicable)
9RR1 Hinhwav 70(1
Street Address
Pelham NC 27311
City or Town State Zip Code
Ahid Masnud
Contact Name
225 West Ridge Drive
Malting Address
6urlinatan NC 27215
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 55 feet
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO pi
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 50 Ft.� sch 4Q PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material Method
Top 0 Bottom 45 Ft. portland Pour
Top 45 Bottom 48 Ft. bentonite Pour
Top Bottom Ft.
9. SCREEN: Depth
Diameter Slot Size
Top 50 Bottom 55 Ft. 2 in. .010 in.
Top Bottom Ft. in. In.
Top Bottom Ft. in. In.
10. SAND/GRAVEL PACK:
Depth
Top 48 Bottom 55
Top Bottom
Top Bottom
11. DRILLING LOG
Top Bottom
0 1
10 / 39
0
39 / 40
/
/
/
/
12. REMARKS:
Ft.
Ft.
Ft.
Material
sch40 Dvc
Size Material
Coarse Sand
Formation Description
Red Fill
Oranae Silt
Oranae Sandy Silt
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2WELL CONSTRUCTION STANDAFj,DS, AND THAT A COPY OF THIS
RECORD EEN PROVIDED TO TWELL ER.
GNATURE OF CERTIFIED WELL CONTRACTOR
4
DA E/1/1L
Thomas Whitehead
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09

COMPLETION REPORT OF WELL No. AS-1
Sheet 1 of 1
PROJECT: Country Cupboard
PROJECT NO:
PROJECT LOCATION: Pelham, Rockingham County, NC
DRILLING CONTRACTOR: T. Whitehead
DRILLING METHOD: 41/4" H.S.A.
DATE COMPLETED: 7/17/14
WATER LEVEL:
LATITUDE:
LONGITUDE:
TOP OF CASING ELEVATION: 99.36
DATUM:
LOGGED BY: L. Butler
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STRATA
WELL
DETAILS
DEPTH
(ft-)
LEGEND
ELEVATION
(ft.)
WELL CONSTRUCTION DETAILS
DESCRIPTION
SYMBOL
DEPTH
(ft.)
0.00
GS
99.62
PROTECTIVE
Diameter:
RISER
Diameter:
GROUT
SEAL
FIL
SCREEN
Diameter:
LEGEND
■
X
4 7-
••`
y
CASING
Type:
Interval:
CASING
2-inch
Type: SCH 40 PVC
Interval: 0.26-50.0
Type: cement grout
Interval: 0.75-45.0
Type: Bentonite
Interval: 45.0-49.0
ERPACK
Type: #2 Sand
Interval: 49.0-55.2
2-inch
Type: 0.010
Interval: 50.0-55.0
FILTER PACK TOC TOP OF CASING
BENTONITE GS GROUND SURFACE
BS BENTONITE SEAL
CEMENT GROUT BOC BASE OF OUTER CASING
TSC TOP OF SCREEN
CUTTINGS / BACKFILL BSC BOTTOM OF SCREEN
STATIC WATER LEVEL TD TOTAL DEPTH
CG CEMENT GROUT
I
0.26
0.75
45.00
49.00
50.00
55.00
55.20
TOC
CG
BS
TSC
BSC
TD
99.36
98.87
54.62
50.62
49.62
44.62
44.42
T L
0
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-
FILL: FINE SANDY
brown orange, dry
- 5
FILL: CLAYEY SILT
-
gray green, moist, with
rock fragments and
debris, fuel
organic odor?
Z
orange tan, damp,
oxidation staining; fuel
odor
= 10
-
_ 15
- 20
SANDY SILT
25
-30
gray tan, moist
-35
SANDY SILT
4o
- 45
gray tan, moist, difficult
drilling at 52 feet
-50
_
- - 55
r---
E -- COMPLETION REPORT OF
- WELL No. AS-1
ENGINEERING
NVRO ENMENIA• L TESTING Sheet 1 of 1