WI0400587_Notification of Intent (NOI) – GW Remediation_20220903

WithersRavenel
1NIP Our People. Your Success.
September 1, 2022
Mr. Michael Rogers
DWR - UIC Program
1636 Mail Service Center
Raleigh, NC 27699
Subject: Notification of Intent to Construct or Operate Injection Wells
Doc's One Stop
215 National Highway
Thomasville, Davidson County, North Carolina
NCDEQ Incident No. 17393
Mr. Rogers:
Attached is a Notification of Intent to Construct or Operate Injection Wells for the State Lead
site Doc's One Stop. This site previously had a UIC permit associated with placement of a
Provectus Oxygen Releasing Substrate sock, Permit #WI0400417. Attached is a Notice of Intent
for injection of Trap and Treat® BOS200® activated carbon.
Sincerely,
WithersRavenel
Eliza betia A. Allyn, P.G.
Environmental Project Geologist II
115 MacKenan Drive I Cary, NC 27511
t: 919.469.3340 I f: 919.467.6008 I www.withersravenel.com I License No. F-1479
Cary I Greensboro I Pittsboro I Raleigh I Wilmington

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: September 1 , 20_22 PERMIT NO. (to be filled in by DWR)
A.
B.
C.
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) 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) X 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
STATUS OF WELL OWNER: State Government
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#17393); Attn: Sharon Ghiold
Mailing Address: 1646 Mail Service Center
City: Raleigh
State: NC Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8166
EMAIL Address:
[e-mail]
Cell No.: NA
Fax No.: 919-571-4718
Deemed Permitted GW Remediation NOI Rev. 1-06-2021
Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Sammy Zitawi
Company Name N/A
Mailing Address: 1408 Country Lake Drive
City: Greensboro State: NC Zip Code: 27406 County: Guilford
Day Tele No.: 336-655-8363 Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Elizabeth A. Allyn, P.G., Environmental Project Geologist II
Company Name WithersRavenel, Inc.
Mailing Address: 115 MacKenan Drive
City: Cary State: NC Zip Code:27511 County: Wake
Day Tele No.: 919-469-3340 Cell No.: 919-418-0279
EMAIL Address: [e-mail] Fax No.: 919-467-6008
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Doc's One Stop; 215 National Highway, NCDEQ Incident #17393
City: Thomasville County: Davidson Zip Code: 27350
(2) Geographic Coordinates: Latitude**: 35.891510°
Longitude**: -80.071460°
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: 680 square feet
Land surface area of inj. well network: —225 square feet ( 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated 100% (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: Elimination of 2B exceedances in groundwater at site
Scope: Characterization samples for injection calculations followed by injection of BOS 200 activated carbon
based in -situ remediation slurry into 9 injection points.
Goals: Significant reduction of source area contamination through removal of dissolved -phase petroleum
contamination with the aid of injections.
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).
Injectant: BOS 200
Volume of injectant: 630 lbs BOS 200 diluted in 315 gal water
Concentration at point of injection: — 2 lb BOS 200 / gal water
Percent if in a mixture with other injectants: 46.5% BOS 200
Injectant:
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: 9 (injection points, not wells) Proposed 0 Existing (provide GW-1s)
(2) For Proposed wells or Existing wells not having GW- 1s, 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.
1) 9 injection points will be advanced for direct injection of BOS 200 slurry with additives. No injection wells
will be installed during this process.
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.
1) Post -injection sampling of monitoring wells MW-1, MW-2, and MW-3 will be completed at the end of the
injection event.
2) Monitor site semi-annually until incident closed.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "7 hereby certi& 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."
*de/44_
Signature of Applicant
Elizabeth A. Allyn, PG, Environmental Project Geologist II, WithersRavenel
On behalf on NCDEQ-DWM, UST Section for Incident #17393
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

4110 WithersRavenel
Our People. Your Success.
FIGURES
Doc's One Stop - NCDEQ Incident #17393 WR Project # 02172214.60
Notice of Intent - UIC September 2022

sign / light pole
product li
possible gas or water main
CULBRETH AVE
01 unknown pipes (likely water)
J4341O
4. T 12
O 0 g'7.5'
MW-1
unknown pipe (found via GPR)
LLULNU:
SEWER LINE
WATER LINE
NATURAL GAS LINE
ELECTRIC LINE
UST SYSTEM PRODUCT LINE
UNKNOWN LINE
STORE I BUILDING
• Primary BOS 200 Injection Points
• Secondary BOS 200 Injection Points

ed by DHomans 03-30-2020
Drawing Path: Q:\4305\18\109a Docs One Stop\3_gw elevation.mxd pl
95
(94.89)
REFERENCE: 2018 AERIAL PHOTOGRAPH
GIS BASE LAYERS WERE OBTAINED FROM DAVIDSON COUNTY AND NC
ONEMAP. THIS MAP IS FOR INFORMATIONAL PURPOSES ONLY. ALL FEATURE
LOCATIONS DISPLAYED ARE APPROXIMATED. THEY ARE NOT BASED ON CIVIL
SURVEY INFORMATION, UNLESS STATED OTHERWISE.
CULBRETH-AVE
• �1
97.71 i)
(94.89) Relative Groundwater Elevation on 3/10/2020
® Type II Monitoring Well
Groundwater Flow Direction
Groundwater Contours (feet)
Project Parcel
GROUNDWATER ELEVATION MAP
DOC'S ONE STOP TF-17393
215 NATIONAL HIGHWAY
THOMASVILLE, DAVIDSON COUNTY, NORTH CAROLINA
SCALE:
1"=40'
DATE:
3-30-20
PROJECT NUMBER
4305-18-109A
FIGURE NO.
3
J

410 WithersRavenel
Our People. Your Success.
DIAGRAM OF TYPICAL INJECTION POINT
Doc's One Stop - NCDEQ Incident #17393 WR Project # 02172214.60
Notice of Intent - UIC September 2022

Boring # TBD
Date TBD
WR Rep TBD
WithersRavenel
1/ Engineers 1 Planners 1 Surveyors
TYPICAL INJECTION POINT - AREA B
Job Name Doc's One Stop (NCDEQ Inc. 17393) Job # 02172214.60
Site Loc. Thomasville, Davidson County, NC Easting NA
Driller TBD
Northing NA
Depth in Feet
(below land
surface)
From To
Soil Description
(Field USCS Classification)
Detail
0
4
Native Soils (TBD)
Injection Interval
DPT Injection Point
15 - 30 feet below land surface
4
10
DPT injection points extend to 30 feet below
land surface. Injection intervals for each point
are 4 to 10 feet below land surface. Following
completion of injections, each point will be
abandoned with bentonite and/or concrete to
match original surface grade.
Page 1 of 1
115 MacKenan Drive, Cory, North Carolina 27511 te1:919.469.3340 fax:[phone] www.withersravenel.com

410 WithersRavenel
Our People. Your Success.
BOSS 200 SAFETY DATA SHEET
Doc's One Stop - NCDEQ Incident #17393 WR Project # 02172214.60
Notice of Intent - UIC September 2022

TRAP & TREAT® BOS 200®
Safety Data Sheet
Calgo nCarbon®
Issued: 06/05/2015
Supersedes: 12/30/2011
Version: 1.0
SECTION 1: Identification of the Substance/Mixture and of the Company/Undertaking
1.1. Product identifier
Product name
Product form
Product code
Other means of identification
: Activated Carbon
: Mixture
: 3967
: Activated Carbon
1.2. Relevant identified uses of the substance or mixture and uses advised against
Use of the substance/mixture : Adsorbent
1.3. Details of the supplier of the safety data sheet
Calgon Carbon Corporation
P.O. Box 717
Pittsburgh, PA 15230
412-787-6700
1.4. Emergency telephone number
Emergency number
: CHEMTREC (24 HRS): 1-800-424-9300
SECTION 2: Hazards Identification
2.1. Classification of the substance or mixture
GHS-US classification
Combustible Dust H232
Not classified as a simple asphyxiant. Product does not displace oxygen in the ambient atmosphere, but slowly adsorbs oxygen from a confined
space when wet. Under conditions of anticipated and recommended use, product does not pose an asphyxiation hazard.
2.2. Label elements
GHS-US labeling
Signal word (GHS-US)
Hazard statements (GHS-US)
2.3. Other hazards
Other hazards not contributing to the
classification
2.4. Unknown acute toxicity (GHS-US)
No data available
Warning
: H232 - May form combustible dust concentrations in air
: Wet activated carbon can deplete oxygen from air in enclosed spaces. If use in an enclosed
space is required, procedures for work in an oxygen deficient environment should be followed.
SECTION 3: Composition/Information on Ingredients
3.1. Substance
Not applicable
3.2. Mixture
Name
Product identifier
%
Activated Carbon
(CAS No) 7440-44-0
>_ 80
Gypsum (Hydrated calcium sulfate)
(CAS No) 13397-24-5
< 20
SECTION 4: First Aid Measures
4.1. Description of first aid measures
First -aid measures general
First -aid measures after inhalation
First -aid measures after skin contact
First -aid measures after eye contact
First -aid measures after ingestion
If exposed or concerned, get medical attention/advice. Show this safety data sheet to the
doctor in attendance. Wash contaminated clothing before re -use. Never give anything to an
unconscious person.
IF INHALED: Remove to fresh air and keep at rest in a position comfortable for breathing.
IF ON SKIN (or clothing): Remove affected clothing and wash all exposed skin with water for at
least 15 minutes.
IF IN EYES: Immediately flush with plenty of water for at least 15 minutes. Remove contact
lenses if present and easy to do so. Continue rinsing.
IF SWALLOWED: Rinse mouth thoroughly. Do not induce vomiting without advice from poison
control center or medical professional. Get medical attention if you feel unwell.
06/05/2015
TRAP & TREAT® BOS 200®
3967
For Internal Use Only: PR#85 Page 1 of 7

Activated Carbon
Safety Data Sheet
4.2. Most important symptoms and effects, both acute and delayed
Symptoms/injuries
: Not expected to present a significant hazard under anticipated conditions of normal use.
However, dust may cause irritation and redness of the eyes, irritation of the skin and respiratory
system. The effects of long-term, low-level exposures to this product have not been
determined.
4.3. Indication of any immediate medical attention and special treatment needed
No additional information available
SECTION 5: Firefighting Measures
5.1. Extinguishing media
Suitable extinguishing media
Unsuitable extinguishing media
: Water spray. Carbon dioxide. Dry chemical. Foam. Sand.
: None known.
5.2. Special hazards arising from the substance or mixture
Fire hazard
Explosion hazard
Reactivity
5.3. Advice for firefighters
Firefighting instructions
: Dust may be combustible under specific conditions. May be ignited by heat, sparks or flames.
: Dust may form explosive mixture in air.
: No dangerous reactions known under normal conditions of use. Carbon oxides, ammonia, or
toxic halide fumes may be emitted upon combustion of the material.
: Wear NIOSH-approved self-contained breathing apparatus suitable for the surrounding fire.
Use water spray or fog for cooling exposed containers. Evacuate area.
SECTION 6: Accidental Release Measures
6.1. Personal precautions, protective equipment and emergency procedures
General measures : Evacuate area. Keep upwind. Ventilate area. Spill should be handled by trained clean-up crews
properly equipped with respiratory equipment and full chemical protective gear (see Section 8).
6.1.1. For non -emergency personnel
No additional information available
6.1.2. For emergency responders
No additional information available
6.2. Environmental precautions
Prevent entry to sewers and public waters. Avoid release to the environment. Product is not soluble, but can cause particulate emission of
discharged into waterways. Dike all entrances to sewers and drains to avoid introducing material to waterways. Notify authorities if product enters
sewers or public waters.
6.3. Methods and material for containment and cleaning up
For containment
Methods for cleaning up
6.4. Reference to other sections
No additional information available
: Sweep or shovel spills into appropriate container for disposal. Minimize generation of dust.
: Sweep or shovel spills into appropriate container for disposal. Minimize generation of dust.
Dispose of material in compliance with local, state, and federal regulations.
SECTION 7: Handling and Storage
7.1. Precautions for safe handling
Precautions for safe handling
Avoid dust formation. Avoid contact with skin, eyes and clothing. Do not handle until all safety
precautions have been read and understood. Wash hands and other exposed areas with mild
soap and water before eating, drinking or smoking and when leaving work. Keep away from
sources of ignition - No smoking.
7.2. Conditions for safe storage, including any incompatibilities
Storage conditions
: Keep container tightly closed in a cool, dry, and well -ventilated place. Keep away from ignition
sources.
SECTION 8: Exposure Controls/Personal Protection
8.1. Control parameters
Activated Carbon (7440-44-0)*
OSHA PEL (TWA) (mg/m3)
<_ 5 (Respirable Fraction)
<_ 15 (Total Dust)
06/05/2015
TRAP & TREAT® BOS 200®
3967
For Internal Use Only: PR#85
2/7

Activated Carbon
Safety Data Sheet
Gypsum (Hydrated calcium sulfate) (13397-24-5)*
OSHA PEL (TWA) (mg/m3)
<_ 5 (Respirable Fraction)
<_ 15 (Total Dust)
*Exposure limits are for inert or nuisance dust. No specific exposure limits have been established for this activated carbon product by OSHA or ACGIH.
8.2. Exposure controls
Appropriate engineering controls
Provide adequate general and local exhaust ventilation. Use process enclosures, local exhaust
ventilation, or other engineering controls to control airborne levels below recommended
exposure limits. Use explosion -proof equipment with flammable materials. Ensure adequate
ventilation, especially in confined areas. Wet activated carbon can deplete oxygen from air in
enclosed spaces. If use in an enclosed space is required, procedures for work in an oxygen
deficient environment should be followed.
Personal protective equipment : Gloves. Safety glasses. Insufficient ventilation: wear respiratory protection.
Hand protection
Eye protection
Skin and body protection
Respiratory protection
Gloves should be classified under Standard EN 374 or ASTM F1296. Suggested glove
materials are: Neoprene, Nitrile/butadiene rubber, Polyethylene, Ethyl vinyl alcohol laminate,
PVC or vinyl. Suitable gloves for this specific application can be recommended by the glove
supplier.
Use eye protection suitable to the environment. Avoid direct contact with eyes.
Wear long sleeves, and chemically impervious PPE/coveralls to minimize bodily exposure.
Use NIOSH-approved dust/particulate respirator. Where vapor, mist, or dust exceed PELs or
other applicable OELs, use NIOSH-approved respiratory protective equipment.
SECTION 9: Physical and Chemical Properties
9.1. Information on basic physical and chemical properties
Physical state
Appearance
Color
Odor
Odor threshold
pH
Relative evaporation rate (butylacetate=1)
Melting point
Freezing point
Boiling point
Flash point
Auto -ignition temperature
Decomposition temperature
Flammability (solid, gas)
Vapor pressure
Relative vapor density at 20 °C
Apparent density
Solubility
Log Pow
Log Kow
Viscosity, kinematic
Viscosity, dynamic
Explosive properties
Oxidizing properties
Explosive limits
9.2. Other information
No additional information available
Solid
Granular, powder, or pelletized substance
Black
Odorless
No data available
No data available
Not applicable
Not applicable
Not applicable
Not applicable
No data available
> 220 °C
No data available
> 220 °C
Not applicable
Not applicable
0.4 - 0.8 g/cc
Carbon and gypsum are insoluble; fertilizer components are soluble
Not applicable
Not applicable
Not applicable
Not applicable
No data available
No data available
No data available
06/05/2015 TRAP & TREAT® BOS 200® For Internal Use Only: PR#85 3/7
3967

Activated Carbon
Safety Data Sheet
SECTION 10: Stability and Reactivity
10.1. Reactivity
No dangerous reactions known under normal conditions of use.
10.2. Chemical stability
Stable under use and storage conditions as recommended in section 7.
10.3. Possibility of hazardous reactions
None known.
10.4. Conditions to avoid
Avoid dust formation. Heat. Ignition sources. Exposure to high concentrations of organic compounds may cause bed temperature to rise.
10.5. Incompatible materials
Alkali metals. Strong oxidizing agents.
10.6. Hazardous decomposition products
Carbon monoxide (CO), carbon dioxide (CO2). Ammonia. Toxic halide fumes.
SECTION 11: Toxicological Information
11.1.
Information on toxicological effects
Acute toxicity
: Not classified
Activated Carbon (7440-44-0)
LD50 oral rat
> 2000 mg/kg
Skin corrosion/irritation
Serious eye damage/irritation
Respiratory or skin sensitisation
Germ cell mutagenicity
Carcinogenicity
Not classified
Not classified
Not classified
Not classified
Not classified
Silica: Crystalline, quartz (14808-60-7)
IARC group
1 - Carcinogenic to humans
The International Agency for Research on Cancer (IARC) has classified "silica dust, crystalline, in the form of quartz or cristobalite" as carcinogenic
to humans (group 1). However these warnings refer to crystalline silica dusts and do not apply to solid activated carbon containing crystalline silica
as a naturally occuring, bound impurity. As such, we have not classified this product as a carcinogen in accordance with the US OSHA Hazard
Communication Standard (29 CFR §1910.1200) but recommmend that users avoid inhalation of product in a dust form.
Reproductive toxicity
Specific target organ toxicity (single exposure)
Specific target organ toxicity (repeated
exposure)
Aspiration hazard
Symptoms/injuries after inhalation
Sym ptoms/injuries
Not classified
Not classified
Not classified
Not classified
Not classified
Not expected to present a significant hazard under anticipated conditions of normal use.
However, dust may cause irritation and redness of the eyes, irritation of the skin and respiratory
system. The effects of long-term, low-level exposures to this product have not been
determined.
SECTION 12: Ecological information
12.1. Toxicity
No additional information available
12.2. Persistence and degradability
No additional information available
12.3. Bioaccumulative potential
No additional information available
12.4. Mobility in soil
No additional information available
12.5. Other adverse effects
No additional information available
06/05/2015 TRAP & TREAT® BOS 200® For Internal Use Only: PR#85 4/7
3967

Activated Carbon
Safety Data Sheet
SECTION 13: Disposal Considerations
13.1. Waste treatment methods
Waste treatment and disposal methods
Additional information
Vacuum or shovel material into a closed container. Dispose in a safe manner in accordance
with local/national regulations. Do not allow the product to be released into the environment.
Activated carbon is an adsorbent media; hazard classification is generally determined by the
adsorbate. Consult U.S. EPA guidelines listed in 40 CFR 261.3 for more information on
hazardous waste disposal.
SECTION 14: Transport Information
14.1. In accordance with DOT
Not classified as hazardous for domestic land transport
UN-No.(DOT)
DOT NA no.
Proper Shipping Name (DOT)
Department of Transportation (DOT) Hazard
Classes
Hazard labels (DOT)
Packing group (DOT)
DOT Quantity Limitations Passenger aircraft/rail
(49 CFR 173.27)
14.2. Transport by sea
Not classified as hazardous for water transport
IMO / IMDG
UN/NA Identification Number
UN- Proper Shipping Name
Transport Hazard Class
14.3. Air transport
Not classified as hazardous for air transport
ICAO / IATA
UN/NA No
UN- Proper Shipping Name
Transport Hazard Class
Packing Group
Marine Pollutant
14.4. Additional information
Other information
None on finished product
None on finished product
Not regulated
None on finished product
None on finished product
None on finished product
None on finished product
: None on finished product
: Not regulated
: None on finished product
: None on finished product
: Not regulated
: None on finished product
: None on finished product
: None on finished product
Under the UN classification for activated carbon, all activated carbons have been identified as a
class 4.2 product. However, this product type or an equivalent has been tested according to
the United Nations Transport of Dangerous Goods test protocol for a "self -heating substance"
(United Nations Transportation of Dangerous Goods, Manual of Tests and Criteria, Part 111,
Section 33.3.1.6 - Test N.4 - Test Method for Self Heating Substances) and it has been
specifically determined that this product type or an equivalent does not meet the definition of a
DOT self -heating substance (class 4.2) or any other hazard class.
SECTION 15: Regulatory Information
15.1. US Federal regulations
Activated Carbon Profile 85
All chemical substances in this product are listed in the EPA (Environment Protection Agency) TSCA (Toxic Substances Control Act) Inventory
or are exempt.
SARA Section 311/312 Hazard Classes Immediate (acute) health hazard
Cobalt (7440-48-4)*
Listed on the United States TSCA (Toxic Substances Control Act) inventory
Listed on United States SARA Section 313
SARA Section 313 - Emission Reporting 0.1 %
*Present below de minimis level
15.2. International regulations
No additional information available
06/05/2015
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Activated Carbon
Safety Data Sheet
15.3. US State regulations
California Proposition 65
WARNING: This product contains, or may contain, trace quantities of a substance(s) known to the state of California to cause cancer, birth defects,
or other reproductive harm.
Silica: Crystalline, quartz (14808-60-7)
U.S. - California -
Proposition 65 -
Carcinogens List
U.S. - California -
Proposition 65 -
Developmental Toxicity
U.S. - California -
Proposition 65 -
Reproductive Toxicity -
Female
U.S. - California -
Proposition 65 -
Reproductive Toxicity -
Male
No significance risk level
(NSRL)
Yes
No
No
No
NA
Cobalt (7440-48-4)
U.S. - California -
Proposition 65 -
Carcinogens List
U.S. - California -
Proposition 65 -
Developmental Toxicity
U.S. - California -
Proposition 65 -
Reproductive Toxicity -
Female
U.S. - California -
Proposition 65 -
Reproductive Toxicity -
Male
No significance risk level
(NSRL)
Yes
No
No
No
NA
Titanium dioxide (13463-67-7)
U.S. - California -
Proposition 65 -
Carcinogens List
U.S. - California -
Proposition 65 -
Developmental Toxicity
U.S. - California -
Proposition 65 -
Reproductive Toxicity -
Female
U.S. - California -
Proposition 65 -
Reproductive Toxicity -
Male
No significance risk level
(NSRL)
Yes
No
No
No
NA
Aluminum oxide (1344-28-1)
U.S. - New Jersey - Right to Know Hazardous Substance List
U.S. - Massachusetts - Right to Know List
U.S. - Pennsylvania - RTK (Right to Know) - Environmental Hazard List
Calcium sulfate (7778-18-9)
U.S. - Massachusetts - Right to Know List
U.S. - New Jersey - Right to Know Hazardous Substance List
U.S. - Pennsylvania - RTK (Right to Know) List
Silica: Crystalline, quartz (14808-60-7)
U.S. - New Jersey - Right to Know Hazardous Substance List
U.S. - Pennsylvania - RTK (Right to Know) List
U.S. - Massachusetts - Right to Know List
Gypsum (Hydrated calcium sulfate) (13397-24-5)
U.S. - New Jersey - Right to Know Hazardous Substance List
U.S. - Pennsylvania - RTK (Right to Know) List
Ammonium Nitrate (6484-52-2)
U.S. - New Jersey - Right to Know Hazardous Substance List
U.S. - Massachusetts - Right To Know List
U.S. - Pennsylvania - RTK (Right to Know) List
Limestone (1317-65-3)
U.S. - Massachusetts - Right To Know List
U.S. - New Jersey - Right to Know Hazardous Substance List
U.S. - Pennsylvania - RTK (Right to Know) List
SECTION 16: Other Information
Indication of changes
Revision Date
Other information
For internal use only
Revision 1.0: New SDS Created.
06/05/2015
Author: CJS.
PR #85
Prepared according to Federal Register / Vol. 77, No. 58 / Monday, March 26, 2012 / Rules and Regulations
06/05/2015 TRAP & TREAT® BOS 200® For Internal Use Only: PR#85 6/7
3967

Activated Carbon
Safety Data Sheet
NFPA health hazard : 0 - Exposure under fire conditions would offer no hazard
beyond that of ordinary combustible materials.
NFPA fire hazard : 1 - Must be preheated before ignition can occur.
NFPA reactivity : 0 - Normally stable, even under fire exposure conditions,
and are not reactive with water.
HMIS III Rating
Health : 0
Flammability : 1
Physical : 0
Personal Protection
This information is based on our current knowledge and is intended to describe the product for the purposes of health, safety and environmental
requirements only. It should not therefore be construed as guaranteeing any specific property of the product. The information is this document
applies to this specific material as supplied. It may not be valid if product is used in combination with other materials. It is the user's responsibility to
determine the suitability and completeness of this information for their particular use. While the information and recommendations set forth herein
are believed to be accurate as of the date hereof, Calgon Carbon Corporation makes no warranty with respect to the same, and disclaims all liability
for reliance thereon.
06/05/2015 TRAP & TREAT® BOS 200® For Internal Use Only: PR#85 7/7
3967

4110 WithersRavenel
Our People. Your Success.
AST ENVIRONMENTAL PROPOSAL
Doc's One Stop - NCDEQ Incident #17393 WR Project # 02172214.60
Notice of Intent - UIC September 2022

�T
Client Name
Withers Ravenel
Project Location
Docs One Stop - Thomasville, NC
Area A
MW-1
Site Information
Predominate Geology of Treatment Zone
Treatment Zone Area (ft^2)
225
Contamination Depth Start (ft bgs)
4.0
Contamination Depth End (ft bgs)
10.0
Treatment Volume (yd^3)
50.0
Triangular Grid Spacing (ft)
5.0
Number of Injection Points - Design
9
Injection Interval Distance (ft)
2.0
Number of Injection Intervals per Point - Design
3.5
Total Number of Injection Intervals
32
Effective Porosity
30%
Pore Volume (L)
11,470
Soil Density (Ib/ft^3)
110
Speciated COC Design Calculations
Contaminant of Concern
Benzene
Design Basis Soil (mg/kg) or Groundwater (mg/L)
Groundwater
Design Concentration
2.100
Design Endpoint
0.050
Contaminant of Concern Mass Loading (Ib/ft^3)
3.93E-05
BOS 200 per Injection Interval - Design (Ib)
20
BOS 200 Slurry Volume per Interval (gal)
10
Average BOS 200 per Injection Point (Ib)
70
BOS 200 Total (Ib)
630
TPH Design Calculations
TPH Groundwater Concentration (mg/L)
TPH Soil Concentration (mg/kg)
TPH Mass (Ib)
BOS 200 Total Demand (Ib)
Design Basis
Select Speciated or TPH
Speciated
Design BOS 200 Total per Area (Ib)
630
Trap & Treat Bacteria Calculations
Bacteria Concentrate (gal)
1
Sulfate Demand Calculations
Supplemental Gypsum per Interval - Design (Ib)
10
Total Supplemental Gypsum (Ib)
315
Slurry and Water Volumes
Slurry Volume per Interval (gal)
10
Estimated Water Volume (gal)
315
Summary
BOS 200 Total (Ib)
650
BOS 200 Unit Price ($, per RPI website)
$6.75
Bacteria Concentrate (gal)
5
Bacteria Concentrate Price ($, per RPI website)
$115.00
Supplemental Gypsum Total (Ib)
350
Gypsum Unit Price ($)
$0.45
Estimated Shipping and Tax ($/Ib)
$0.25
Total Material Price ($)
$5,283
Number of Field Days to Complete
2
Mobilization ($)
$2,000
Injection Location Markout ($)
Total Installation Price ($)
$13,400
Estimated Air Knife - 1-2 days ($)
$7,500
Total Estimated Price ($)
$26,183
Totals
225
50
9
32
650
650
5
350
315
1 day - $4,500
7/26/2022

ASSUMPTIONS
AST has made the following assumptions regarding this approach:
1. Pricing for products and services is valid for 180 days from the date of this proposal.
2. AST will support Withers Ravenel in preparing the UIC permit.
3. Pricing of the BOS 200° is based on the quantities outlined above. Should any of the
Proposed Injection Areas be removed from this design, pricing of the BOS 200° must be
adjusted to conform to the pricing structure shown at:
http://www.trapandtreat.com/products/quantity-pricing/
4. There will be adequate water onsite (25-gpm service) to prepare the BOS materials for
injection. The water service within 200' of all injection locations and fire hoses can be
placed and remain in -place for the duration of the injection. Shuttling of water is not
required. The water will be provided at no cost to AST. Hydrant permits and fees will be
provided by others.
5. The site stratigraphy allows for pushing up to 250 linear feet of 2.25" Geoprobe® rods per
day and injection of up to 500 lbs. of BOS 200° per day.
6. Work is performed during standard work week and hours (Monday -Saturday 7am-6pm)
7. Asphalt/concrete penetrations will be patched with like materials.
8. All utilities and underground appurtenances will be located prior to AST arriving on site.
AST will not be responsible for repairs to mis-marked or unmarked buried utilities and
other appurtenances.
9. Investigated derived waste will be drummed and staged on site for disposal by others.
10. Boring logs will be prepared by others during the injection effort.
11. The total depth throughout the area identified in the injection design will be accessible via
direct push utilizing a Geoprobe° 7000 series rig.
12. Traffic control will be provided by others if required.
13. The project is non -union and will not require prevailing wages.
14. After hours security will be provided by others at no cost to AST, if deemed necessary.
15. Withers Ravenel will provide a dumpster for general refuse such as empty paper bags,
pallets and other non -hazardous waste.
16. Cold Weather Protocol
a. All injection work is to be performed with overnight temperatures above 32 degrees
F. If injections are to be performed with overnight lows below 32 degrees F, the
installation price will be subject to an additional 25% charge to account for loss
time for additional shutdown/startup time for the injection system.
b. Injection work in temperatures below 20 degrees F is a health and safety concern
for the injection crew. If temperatures are not above 20 degrees F by 10 a.m., no
injection work will be performed that day. A daily stand by rate will be charged for
days lost due to cold weather.
Payment terms are full payment of product and shipping costs upon arrival. Payment of injection
services is not to exceed 60 calendar days from date of invoice. Interest will accrue at a monthly
rate of 1.5% for all outstanding balances including interest. The interest rate will be prorated for
partial months.

sign / light pole
product li
possible gas or water main
CULBRETH AVE
01 unknown pipes (likely water)
J4341O
4. T 12
O 0 g'7.5'
MW-1
unknown pipe (found via GPR)
LLULNU:
SEWER LINE
WATER LINE
NATURAL GAS LINE
ELECTRIC LINE
UST SYSTEM PRODUCT LINE
UNKNOWN LINE
STORE I BUILDING
• Primary BOS 200 Injection Points
• Secondary BOS 200 Injection Points

410 WithersRavenel
Our People. Your Success.
ACCESS AGREEMENT
Doc's One Stop - NCDEQ Incident #17393 WR Project # 02172214.60
Notice of Intent - UIC September 2022

Sharon Ghiold
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Ghiold:
RE: Site Access Agreement
Doc's One Stop Shop
215 National Highway
Thomasville, Davidson County, NC (WSRO)
STF #17393, Facility ID 0-001630
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 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 land owner.

Doc's One Stop
TF #17393
January 18, 2013
Page 2
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.
ox^
Signatufe
4VYtrt i4-/-4:1k/;
Type/Print Name of Owner or Agent
Phone Number
I V°g C; +r (k-e pry_
Address
Greeor%aara f r_ Z 79 0
City/State/Zip Code
t 26-13
Date