WI0400589_Notification of Intent (NOI) – GW Remediation_20220919

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 individualpermit when constructed in accordance
with the rules of 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to infection)
AQUIFER TEST WELLS (15A NCAC 02C .02201
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 .02291:
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: September 19 , 2022 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:
Permit No. WI
Issued Date:
A. 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
B. STATUS OF WELL OWNER: State Government
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 State Lead Program - Thomas Chapman
Mailing Address: 127 Cardinal Drive
City: Wilmington State: NC_ Zip Code: 28405 County: New Hanover
Day Tele No.: 910-796-7215 Cell No.: 910-796-7406
EMAIL Address: thomas.chapman0-ncdenr.Qov Fax No.: 910-350-2004
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Nancy G. Hooper
Company Name
Mailing Address: 752 A
City: Burlington State: NC_ Zip Code: 27217 County: Alamance
Day Tele No.: 336-584-6707 Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Adam Lee, PG, Senior Staff Geologist
Company Name Terracon Consultants, Inc
Mailing Address: 2401 Brentwood Road, Suite 107
City: Raleigh State: NC_ Zip Code: 27604 County: Wake
Day Tele No.: 919-436-2965 Cell No.: 919-669-3638
EMAIL Address: adam.lee&terracon.com Fax No.: 919-876-9555
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: White Rock Service Station Store — 11601 NC-86 South
City: Prospect Hill County: Caswell Zip Code: 27314
(2) Geographic Coordinates: Latitude**: 36 ° 17 ' 55.917" or °
Longitude**: 79 ° 12_' 51.576" or °
Reference Datum: Accuracy:
Method of Collection: Google Maps
**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 fe 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
(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.
L 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:
Two 1.000 gallon gasoline USTs_ two 1.000 gallon orahan USTs_ one 550 gallon kerosene UST. and one 550
gallon diesel UST were the cause of a release at unknown date prior to June 1, 1989. Petroleum based compounds
were detected in two monitoring wells exceeding 2L water quality standards. Based on most recent data
presented in the semiannual report (July. 2022) it is recommended to deploy oxygen compound releasing socks
in MW-11. MW-12, and MW-13 followed by groundwater sampling event of these monitoring wells three
months after oxygen compound is deployed to evaluate effectiveness of treatment.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 0 Proposed 3 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 33 ft
(3) For Proposed wells or Existing wells not having GW-Is, 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 iniectants annroved by the enidemiologv section of the NC Division ofPublic Health. Denartment
of Health and Human Services can be injected. Approved iniectants can be found online at
hllp://deg.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 iniectants are to be used use N/A.
Injectant: Oxygen Release Compound (ORC) Total Amt. to be injected (gal)/event: 6 pounds
Injectant: Total Amt. to be injected (gal
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Total Amt. to be injected (gal/event): 6 pounds
No. of separate injection events: 1 Total Amt. to be injected (gal): 6 pounds
Source of Water (if applicable): NA
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.
Groundwater will be sambled three months following the installation of the ORC socks. Following the 3-month
event, we plan to conduct groundwater monitoring activities using low -flow sampling techniques on a semi-
annual basis. We will collect groundwater samples from thirteen wells (MW-1 through MW-6. MW-8, MW-I I
through MW-13. RW-1. RW-2, and RW-4). Pace Analytical Services. LLC, in West Columbia, South Carolina
will analyze the samples for VOCs by USEPA Method 6200B including methyl tert-butyl ether, ethylene
dibromide, and di isopropyl ether. We will contact NCDEQ SLP Program Manager, Thomas Chapman, of
violations of groundwater aualitv standards and/or if the violations_ are believed to be a result of the miection
activities.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I 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 I5A NCAC 02C 0200 Rules. "
Adam A. Lee, PG, Senior Staff
Geologist
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
(I5A NCAC 02C C. 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.
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.
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 4

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 5

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Well ID: MW-11 through MW-13
Project No.: 70217276
Site Location: White Rock Service Station (IN#15111) n
Field Personnel: NA EX.P'""""'-h
Date: NA 2401 Brentwood Road Suite 107
Location: 11601 NC-86 S, Propsect Hill, NC Raleigh, NC 27604
Drilling Method: NA 919.873.2211
Driller: NA
Monitoring Well Construction Diagram
Land Surface I Death Below Land Surface (ft)
Riser Pipe Concrete 3
Diameter 2"
Material PVC
Length 18'
Bottom of Grout 14
Bottom of Bentonite Seal 16
Sand Pack ------------------------ Top of Screen 18
Sand Size #2
Well Screen ------------------------ ---
Diameter 2"
Length 15' Bottom of Screen 33
Slot Size 0.01 Bottom of Tail Pipe 33
Material PVC Bottom of Borehole 33
4.25 Borehole Diameter (inches)
Note: Not to scale

WN
MH t3
5� �+3
` 13 UNDERGROUND STORAGE TANK SECTION
May 20, 2020
Mr. Thomas Chapman
Hydrogeologist
DWM/UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Mr. Chapman
RE: Access Agreement
White Rock Service Station
11601 Hwy 86 South
Prospect Hills, Caswell County, North Carolina
Incident Number: 15111
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 Environmental Quality (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:
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,
Signature
Type/Print N me of Owner or Agent
Phone Number
15 �r
Address
Y-`'i C . lL 1
City/State/Zi ode
Date
RE: White Rock Service Station
11601 Hwy 86 South
Prospect Hills, Caswell County, North Carolina
Incident Number: 15111

is a puffs c WcOr ante with G.S. 132-1.
. activities to be =rk d out
by the �artm t or its Wutmctor ate for the
prima , fitment and of Ile State of I:.rth Car Una. _may benefits ry
atxruiug tc3 ttte ownerare inci� dt� e
"he Jepartm'-1 t or its Oontractor is not and shall not bcconsftued to be an a n em I
cc Uador of the landowner. No representations or Rramn#ie�s, either expressed or implied, have been
oyecor
made to me/bY the Department, the State of North Carolina, or its' h� contsecr a
results that may be obtained or the quality of work to be € r(s)'�ar� thee
Performed.
IlWe agree not to interfere with, remove or any Ways damage the Department's
welks) or its
c"ntractor's wells) and equipment ;luring the investigation.
Sincerely,
Si�4tt+�ae
cck' G V GL
h
TY�t Naane r3f Own or Agent
?t Y — 351- 7Y V l
Phone Number
ICE $ L O-ke l�o
Address
U/S 64o AIG -2,75
City/Staterzip'.Lot
DW3
RE. ate Rock
11601 Hwy s6 South
Pr"PW HSI&, Caswell County, North Carelirta
lncideutNumber.15111

is a public record, in accordmee with G.S.132-1.
6. The activities to be carried out by the Departt=t or its COMM& are fbr 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 Df the landowner- No representations or warranties,either expiased or implied, have been
wade to radby the Department, the State of North Carolina, or iWffieir contractors) regarding the
results that may be obtained or the quality of work to be perf�ed.
I/We agree not to interfere with, remove or any ways damage the Department's wells) or its
contractor's wells) and equipment during the investigation.
Sincerely,
1
Tit Name ofOwner or Agent
536 - 03-6 950
Rhone Nmber
/ag &LmIdodi) A W
Address
,BllRz✓n/6roN, n/6 a%2)s
City/stawe Zip Code �r--- --
6�A/P-Ip
Date
RE; White Rock Se mec Station
11601 Hwy 86 South
Prospect raids, CSsweii COuss(N North Ca vN=
incident Number:15111

is a public record, in accordance with O.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 melby 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.
1/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,
Signature
Type/Print Name of Owner or Agent
5,C-213— 9 `fC
Phone Number
/ Z- Y � C j /%J <..
Address
City/State/Zip Code
'S Z�'zc�
Date
IRE: White Rock Service Station
11601 Hwy 86 South
Prospect Hills, Caswell County, North Carolina
Incident Number:15111