WI0400523_Application_20221005

AECOM
October 3, 2022
AECOM 919.461.1100 tel
5438 Wade Park Boulevard, Suite 200 919.461.1415 fax
Raleigh, NC 27607
Mr. Michael Rogers
North Carolina Department of Environmental Quality
Division of Water Resources, Groundwater Protection Section
Underground Injection Control Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Subject: Revised Application for Permit to Construct and/or Use a Well(s) for Injection
(Modification to Existing Permit #WI400523)
Former Salem Uniform Services Facility (Cintas Corporation)
4015 North Cherry Street, Winston-Salem, Forsyth County, North Carolina
#NONCD0002438
Dear Mr. Rogers,
AECOM Technical Services of North Carolina, Inc. (AECOM), on behalf of Cintas Corporation, is
submitting the attached Revised Application for Permit to Construct and/or Use a Well(s) for
Injection (modification to existing permit #WI400523) for proposed injection activities at the former
Salem Uniform Services facility located in Winston-Salem, North Carolina (NCDEQ Site ID #
NONCD0002438). Revisions to the application were requested in an email correspondence with
North Carolina Department of Environmental Quality (NCDEQ) dated September 21, 2022. The
revisions are summarized below:
Well construction records which include lithology information of the existing injection wells
have been included in Section 5 & Appendix B.
A description of the information used to select of injection and injectant concentrations are
included in Section 3.
A discussion of potential byproducts of the reductive dechlorination process stimulated by
the proposed injections is included in Section 3.4.
The proposed monitoring plan is included in Table 4 and discussed in Section 6.
Figures 3, 4, and 6 have been updated to include the injection zones based on estimated
radius of influence.
These injections are being conducted in accordance with the Remedial Action Plan previously
submitted by AECOM for the referenced site.
Please contact Beth Donovan at [phone] if you have any questions.
Yours sincerely,
Beth Donovan, PG
Project Manager

AECOM 2
Attachments: Revised Application for Permit to Construct and/or Use a Well(s) for Injection
Cc: Stephen Koehler — Cintas Corporation
Bob Wyrick — AECOM Technical Services of NC, Inc.

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Groundwater Remediation (15A NCAC 02C .0225)
Do not use this form for UIC wells Permitted by Rule (ref. 15A NCAC 02C .0217)
Permit Number (to be completed by DWR for new projects): WI
I. APPLICATION INFORMATION
1. Project is: [ ] New [X] Modification [ ] Renewal without modification [ ] Renewal with modification
2. If this application is being submitted for Renewal and/or Modification to an existing permit, provide:
Existing permit number WI400523 Issued Date: 11/8/19 & Expiration Date: 10/31/24
For all Renewals, attach an updated site map and status report including monitoring results of all injection activities
to date.
For Renewal without modification only, fill out sections I & II only, sign the certification on the last page of this form,
and obtain the property owner's signature to indicate consent (if the applicant is not the owner).
II. WELL OWNER(S)/PERMIT APPLICANT (generally the responsible party)
1. Name(s): Cintas Corporation, Stephen Koehler (Chemical/Environmental Engineer)
2. Signing Official's Name*: Title:
* Signing Official must be in accordance with instructions in Part XII.
3. Mailing address of Permittee/Applicant: 27 Whitney Drive
City: Milford State: OH Zip: 45150
4. Telephone number: 513-965-4906 Email: [e-mail]
5. Status (choose one): Individual X Business/Org. Federal State County Municipality
III. PROPERTY OWNER(S) (if different than well owners)
1. Name(s): Keith Kooken (K&V, LLC)
2. Mailing address: 227 W. 5th Street, #1
City: Winston-Salem
3. Telephone number: 336-407-8226
State: NC Zip: 27101
Email: [e-mail]
IV. PROJECT CONTACT — (generally the environmental/engineering consultant).
1. Name: Bethany Donovan, PG Title: Project Manager
2. Company: AECOM Technical Services of North Carolina, Inc
3. Address: 5438 Wade Park Boulevard, Suite 200
4. City: Raleigh State: NC Zip: 27607
5. Telephone number: 919-461-1560 Email: [e-mail]
Groundwater Remediation Application Rev. 2-17-2020 Page 1 of 9

V. FACILITY INFORMATION
1. Facility name: Former Salem Uniform Site Phone No. (if available):
2. Physical address: 4015 N. Cherry Street
City: Winston-Salem County: Forsyth Zip: 27015
3. Geographic Coordinates: Latitude: 872746.00 (Northing) Longitude: 1626889.72 (Easting)
Reference Datum: NAD 83 State Plane NC ft Accuracy: +/- 1 cm
Method of Collection (i.e., Google Earth, GPS, etc.): Site Survey
4. Brief description of business: Former industrial uniform cleaning and laundry facility
VI. INCIDENT DESCRIPTION
1. Source and date of contamination: Salem Uniform Services previously operated an industrial uniform
cleaning and laundry service at the Site from 1967 to 1983. In 1983, Cintas purchased the assets of Salem
Uniform (which ceased to exist as a business entity) and Cintas continued operating a uniform laundering and
services facility at the Site until 1986. Both Salem Uniform Services and Cintas were lease tenants at the Site;
neither firm owned the site property during their operations there. Data collected during previous investigations
suggest that surface releases or spills occurred close to the former building. The specific dates when the releases
occurred are unknown.
2. List all contaminants present in soils or groundwater at the site (contaminants may be listed in groups, e.g., gasoline,
diesel, jet fuel, fuel oil, chlorinated ethenes, chlorinated ethanes, metals, pesticides/herbicides, etc):
Chlorinated Volatile Organic Compounds- specifically PCE
3. Has LNAPL or DNAPL ever been observed at the site (even if outside the injection zone)?
[ ] Yes If yes, list maximum measured separate phase thickness: feet
[X] No If no, list maximum concentration of total VOCs observed at site: 80,246 ppb
4. Agency managing the contamination incident:
[ ] UST Section [ ] Superfund Section (including REC Program and DSCA sites)
[ ] DWR Aquifer Protection Section [ ] Solid Waste Section
[ ] Hazardous Waste Section [X] Other: IHSB DWM
5. Incident manager's name: Collin Day
Phone No.: 336-776-9675
6. Incident number or other incident mgmt. agency tracking number: NONCD0002438
Groundwater Remediation Application Rev. 2-17-2020 Page 2 of 9

VII. PERMITS
List all applicable permits or construction approvals issued for the facility or incident:
1. Previous or other UIC permits issued by DWR (e.g., NOIs) WI0400470
2. Other Non -Discharge or NPDES permit issued by DWR:
3. County or DEH subsurface wastewater disposal permits:
4. Hazardous waste management or other environmental permits required by state or federal law:
Groundwater Remediation Application Rev. 2-17-2020 Page 3 of 9

VIII. INJECTION SUMMARY
1. List all proposed injectants/additives.
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.
8 DPT Points
Injectant: ABC+ Mixture Total Amt. to be injected (gal)/event: Approx 10,000
Injectant: RTB-1® Total Amt. to be injected (liter)/event: Approx 40
Injectant: Magnesium Hydroxide Total Amt. to be injected (gal)/event: Approx 1,000
Barrier Wells (7 Permanent Wells)
Injectant: High Fructose Corn Syrup Sol'n Total Amt. to be injected (gal)/event: Approx 45,500
Injectant: Sodium Bicarbonate Total Amt. to be injected (lbs)/event: Approx 18,900
Total Amt. to be injected (gal/event): Approx 55,500 gallons
No. of separate injection events: 1 Total Amt. to be injected (gal): 55,500
Source of Water (if applicable): City of Winston Salem Water Supply
2. Estimated Injection rate per well: 6 gpm (DPT Points) and 3 gpm (barrier wells) GPM
3. Estimated Injection pressure: <200 pst (DPT Points) and <50 psi (barrier wells)pounds/square inch (PSI)
4. Temperature at point of injection: ambient air °F
5. Injection will be via:
Existing well(s)- Total No.: 7 ; Well Type (DPT, Permanent, etc.): permanent
Proposed well(s)- Total No.: 8 ; Well Type (DPT, Permanent, etc.): DPT Points
6. NC Certified Well Drilling Contractor's Name (if known): Rawlins Clarke
NC Well Contractor Certification No.: 4234-A
7. Date to be constructed if proposed: DPT to be constructed (attach well construction records [GW-ls] for
existing injection wells)
8. Screened interval/Injection interval of injection wells:
- DPT Points: Depth from _20_ to _70_ feet below land surface (BLS)
- Existing Injection Wells: Depth from _58 to_100_ft bls
9. Well casing (leave blank if Geoprobes®):
Type (PVC, stainless steel, other):
Casing depth: to ft. BLS
Type ❑PVC, stainless steel, other):
Casing depth: to ft. BLS
Groundwater Remediation Application Rev. 2-17-2020 Page 4 of 9

10. Grout (leave blank if Geoprobes):
Type (cement, bentonite, other):
Grout depth:
to ft. BLS
Type (cement, bentonite, other):
Grout depth: to
ft. BLS
IX. ATTACHMENTS — provide the following information in separate attachments. The attachments should be clearly
identified and presented in the order below to expedite review of the permit application package.
1. INJECTION ZONE — Per 15A NCAC 02C .0225(f)(3), specify the horizontal and vertical portion of the subsurface within
which the proposed injection activity will take place and beyond which no violations of groundwater quality standards shall
result from the injection as determined by an approved monitoring plan. The determination shall be based on the hydraulic
properties of the specified zone. Provide any supporting documentation in a separate attachment.
2. HYDROGEOLOGIC EVALUATION — Per 15A NCAC 02C .0225(f)(4), provide a hydrogeologic evaluation of the injection
zone that includes all of the following:
(A) Regional and local geology and hydrology;
(B) Changes in lithology underlying the facility;
(C) Depth to bedrock;
(D) Depth to the mean seasonal high water table;
(E) Hydraulic conductivity, transmissivity, and storativity, of the injection zone based on tests of site -specific material,
including a description of the test(s) used to determine these parameters;
(F) Rate and direction of groundwater flow as determined by predictive calculations or computer modeling;
(G) Lithostratigraphic and hydrostratigraphic logs of any existing test and injection wells; and
(H) For systems re -injecting treated on -site contaminated groundwater only- evaluation of infiltration galleries or
injection wells.
3. INJECTANT INFORMATION — Per 15A NCAC 02C .0225(0(6). provide information on each injectant as indicated below:
(A) MSDS, concentration at the point of injection, and percentage if present in a mixture with other injectants;
(B) The source of fluids used to dilute, carry, or otherwise distribute the injectant throughout the injection zone. If any
well within the area of review of the injection facility is to be used as the fluid source, then the following information
shall be submitted: location/ID number, depth of source, formation, rock/sediment type, and a chemical analysis
of the water from the source well, including analyses for all contaminants suspected or historically recognized in
soil or groundwater on the site;
(C) A description of the rationale for selecting the injectants and concentrations proposed for injection, including an
explanation or calculations of how the proposed injectant volumes and concentrations were determined;
(D) A description of the reactions between the injectants and the contaminants present including specific breakdown
products or intermediate compounds that may be formed by the injection;
(E) A summary of results if modeling or testing was performed to investigate the injectant's potential or susceptibility
for biological, chemical, or physical change in the subsurface; and
(F) An evaluation concerning the development of byproducts of the injection process, including increases in the
concentrations of naturally occurring substances. Such an evaluation shall include the identification of the specific
byproducts of the injection process, projected concentrations of byproducts, and areas of migration as determined
through modeling or other predictive calculations.
4. INJECTION PROCEDURE — Per 15A NCAC 02C .0225(f)(7), submit a table with a detailed description of the proposed
injection procedure that includes the following:
Groundwater Remediation Application Rev. 2-17-2020 Page 5 of 9

(A) The proposed average and maximum daily rate and quantity of injectant;
(B) The average maximum injection pressure expressed in units of pounds per square inch (psi); and
(C) The total or estimated total volume to be injected.
5. FRACTURING PLAN (if applicable) — Per 15A NCAC 02C .0225(0(9) submit a detailed description of the fracturing plan
that includes the following:
(A) Material Safety Data Sheets of fracturing media including information on any proppants used;
(B) a map of fracturing well locations relative to the known extent of groundwater contamination plus all buildings,
wells, septic systems, underground storage tanks, and underground utilities located within the Area of Review;
(C) a demonstration that buildings, wells, septic systems, underground storage tanks, and underground utilities will not
be adversely affected by the fracturing process;
(D) injection rate and volume;
(E) orientation of bedding planes, joints, and fracture sets of the fracture zone;
(F) performance monitoring plan for determining the fracture well radius of influence; and
(G) if conducted, the results of geophysical testing or pilot test of fracture behavior conducted in an uncontaminated
area of the site.
6. WELL CONSTRUCTION DETAILS — Per 15A NCAC 02C .0225(0(10), submit the following information in tabular or
schematic form as appropriate for each item:
(A) number and depth of injection wells;
(B) number and depth of borings if using multi -level or "nested" well systems;
(C) indication whether the injection wells are existing or proposed;
(D) depth and type of casing;
(E) depth and type of screen material;
(F) depth and type of grout;
(G) indication whether the injection wells are permanent or temporary "direct push" points; and
(H) plans and specifications of the surface and subsurface construction details.
7. MONITORING PLAN — Per 15A NCAC 02C .0225(fl(11). submit a monitoring plan that includes the following:
(A) target contaminants plus secondary or intermediate contaminants that may result from the injection;
(B) other parameters that may serve to indicate the progress of the intended reactions;
(C) a list of existing and proposed monitoring wells to be used; and
(D) a sampling schedule to monitor the proposed injection.
Monitoring wells shall be of sufficient quantity and location to detect any movement of injection fluids, injection process byproducts, or
formation fluids outside the injection zone. The monitoring schedule shall be consistent with the proposed injection schedule, pace of
the anticipated reactions, and rate of transport of the injectants and contaminants.
8. WELL DATA TABULATION — Per 15A NCAC 02C .0225(0(12), provide a tabulation of data on all existing or abandoned
wells within the area of review of the injection well(s) that penetrate the proposed injection zone, including monitoring
wells and wells proposed for use as injection wells. Such data shall include a description of each well's type, depth, and
record of construction or abandonment.
9. MAPS AND CROSS -SECTIONS — Per 15A NCAC 02C .0225(1)(13), provide scaled, site -specific site plans or maps
depicting the location, orientation, and relationship of facility components including the following:
(A) area map based on the most recent USGS 7.5' topographic map of the area, at a scale of 1:24,000 and showing the
location of the proposed injection site;
(B) topographic contour intervals showing all facility related structures, property boundaries, streams, springs, lakes,
ponds, and other surface drainage features;
(C) all existing or abandoned wells within the area of review of the wells listed in the well data tabulation that penetrate
the proposed injection zone;
(D) potentiometric surface map(s) that show the direction of groundwater movement, existing and proposed wells;
(E) contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the contaminant plume in
soil and groundwater, and existing and proposed wells;
(F) 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, major changes in lithology, and existing and proposed wells; and
Groundwater Remediation Application Rev. 2-17-2020 Page 6 of 9

(G) any existing sources of potential or known groundwater contamination, including waste storage, treatment, or
disposal systems within the area of review of the injection well or well system.
X. UIC SYSTEMS RE -INJECTING TREATED ON -SITE CONTAMINATED GROUNDWATER ONLY
1. FEES — Per 15A NCAC 02C .0225(m), submit/attach fees for new permits or modifications (refer to fee schedule
at https://deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/non-discharge-groundwater-remediation
2. SOILS EVALUATION - Per 15A NCAC 02C .0225(f)(2), for systems with proposed discharge within seven feet
of land surface and above the seasonal high water table, a soil evaluation of the disposal site shall be provided to the
Division by the applicant. If required by G.S. 89F, a soil scientist shall submit this evaluation. This evaluation shall be
presented in a report that includes the following information:
(A) Field description of soil profile. Based on examinations of excavation pits or auger borings, the following
parameters shall be described by individual horizons to a depth of seven feet below land surface or to bedrock:
thickness of the horizon; texture; color and other diagnostic features; structure; internal drainage; depth, thickness,
and type of restrictive horizons; pH; cation exchange capacity; and presence or absence of evidence of any seasonal
high water table. Applicants shall dig pits when necessary for evaluation of the soils at the site.
(B) Recommendations concerning annual and instantaneous loading rates of liquids, solids, other wastewater
constituents and amendments. Annual hydraulic loading rates shall be based on in -situ measurement of saturated
hydraulic conductivity in the most restrictive horizon.
3. ENGINEERING PLANNING DOCUMENTS — Per 15A NCAC 02C .0225(0(8), the following documents shall
be provided to the Division by the applicant (Note: if required by G.S. 89C, a professional engineer shall prepare
these documents):
(A) engineering plans for the entire system, including treatment, storage, application, and disposal facilities and
equipment, except those previously permitted unless they are directly tied into the new units or are critical to the
understanding of the complete process;
(B) specifications describing materials to be used, methods of construction, and means for ensuring quality and integrity
of the entire groundwater remediation system;
(C) plans that include construction details of recovery, injection, and monitoring wells and infiltration galleries;
(D) operating plans that include:
(i) the operating schedule including any periodic shut -down times;
(ii) required maintenance activities for all structural and mechanical elements;
(iii) a list of all consumable and waste materials with their intended source and disposal locations;
(iv) restrictions on access to the site and equipment;
(v) provisions to ensure the quality of the treated effluent and hydraulic control of the system at all times when
any portion of the system ceases to function, such as standby power capability, complete system -off status,
or duplicity of system components; and
(E) Completed, signed, and sealed Professional Engineer's Certification for new permit applications (form attached).
Groundwater Remediation Application Rev. 2-17-2020 Page 7 of 9

XII. CERTIFICATION (to be signed as required below or by that person's authorized agent*)
NCAC 15A 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or
ranking publicly elected official
4. for all others: by the well owner.
*If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the applicant
that names and authorizes their agent.
I hereby certi. under penalty of law that I have personally examined and am familiar with the information
submitted in this document and all attachments therein, 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 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(s)
and all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Typed or Printed Name and Title: Stephen Koehler, Manager Chemical/Environmental Engineering & Hygienically Clean
Signature:
Date: 7/20/2022
XIII. CONSENT OF PROPERTY OWNER (if the property is not owned by the permit applicant)
"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.
"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 . 0200). "
Typed or Printed Name and Title:
Signature: Date:
Submit TWO hard copies of the completed application package with an electronic version in CD or USB Flash
Drive to:
DIVISION OF WATER RESOURCES — UIC PROGRAM
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
Groundwater Remediation Application Rev. 2-17-2020 Page 8 of 9

XII. CERTIFICATION (to be signed as required below or by that person's authorized agent*)
requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or
ranking publicly elected official
4. for all others: by the well owner.
*If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the applicant
that names and authorizes their agent.
"I hereby cert under penalty of law that I have personally examined and am familiar with the information
submitted in this document and all attachments therein, 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 penalties, including the possibility offines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well(s)
and all related appurtenances in accordance with the approved specifications and conditions of the Permit."
Typed or Printed Name and Title:
Signature: Date:
XIII. CONSENT OF PROPERTY OWNER (if the property is not owned by the permit applicant)
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well is real
property and its constructionon land shall be deemed to vest ownership in the land owner, in the absence of contrary
agreement in writing.
"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
( ).
Typed or Printed Name and Title:
Signature:
Submit TWO hard copies of the completed application package with an electronic version in CD or USB Flash
Drive to:
DIVISION OF WATER RESOURCES — UIC PROGRAM
1636 MAIL SERVICE CENTER
RALEIGH, NORTH CAROLINA 27699-1636
TELEPHONE NUMBER: [phone]
Groundwater Remediation Application Rev. 2-17-2020
Page 8 of 9

Professional Engineer's Certification (for new permit application for UIC systems re -injecting treated on -site
contaminated groundwater only):
Permit No.: WI
Typed or Printed Name of Professional Engineer:
License Number:
Name of Engineering Firm (if applicable):
Mailing Address:
City: State: Zip:
Office Number: ( ) Mobile Number: ( )
Email Address:
attest that this application for
has been reviewed by me and is accurate and complete to the best of my knowledge. I further attest that to the best
of my knowledge the proposed design has been prepared in accordance with the applicable regulations. Although
certain portions of this submittal package may have been developed by other professionals, inclusion of these materials
under my signature and seal signifies that I have reviewed this material and have judged it to be consistent with the
proposed design.
North Carolina Professional Engineer's Seal, Signature, and Date:
Groundwater Remediation Application Rev. 2-17-2020 Page 9 of 9

A=COM
Delivering a
better world
Revised Application for Underground
Injection Control Permit WI0400523
Modification — Attachments
Former Salem Uniform
4015 North Cherry Street
Winston-Salem, North Carolina
60681957
October 2022
Cintas Corporation
Milford, OH

Application for Underground Injection Control 60681957
Permit — Attachments
Quality information
Prepared by
c.07Vdut441—
Casey Gilleland
Staff Geologist
Prepared for:
Cintas Corporation
Milford, Ohio
Prepared by:
AECOM
5438 Wade Park Boulevard, Suite 200
Raleigh, North Carolina 27607
USA
aecom.com
Copyright © 2022 by AECOM
Reviewed by Reviewed by
Beth Donovan, PG
Project Manager
Christopher Brownfield, PE
Senior Engineer
All rights reserved. No part of this copyrighted work may be reproduced, distributed, or transmitted in any form or by
any means without the prior written permission of AECOM.
Prepared for: Cintas Corporation, Milford, Ohio
AECOM

Application for Underground Injection Control 60681957
Permit - Attachments
Table of Contents
1. Injection Zone 1
2. Hydrogeologic Evaluation 1
2.1 Physiography 1
2.2 Regional Geology 1
2.3 Regional Hydrogeology and Hydrology 2
2.4 Site Geology 2
2.5 Site Hydrogeology 2
2.5.1 Aquifer Parameters 3
3. Injectant Information 3
3.1 Source Area and Off -site Downgradient Barrier ABC+ Injections 4
3.2 Downgradient Onsite and Off -site High Fructose Corn Syrup and Sodium Bicarbonate Barrier
Well Injections 4
3.3 Bioaugmentation 4
3.4 Byproducts of Stimulated Reductive Dechlorination Processes 5
4. Injection Procedure 5
5. Well Construction Details 5
6. Monitoring Plan 6
7. Well Data Tabulation 6
8. Maps and Cross Sections 6
9. References 7
Appendices
AppendixA Material Safety Data Sheets
Appendix B. Well Construction Records
Tables
Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Figures
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
Figure 8.
Proposed DPT and Injection Well Construction Details
Groundwater Elevation Data - May 2021
Summary of Proposed Injection Quantities
Proposed Phase II Enhanced Reductive Dechlorination Implementation Schedule
Existing Well Construction Details
Site Location Map
Site Plan with Area of Review
2021 PCE Isoconcentrations in Groundwater with Proposed Injection Points and Monitoring Well
Locations: Saprolite Unit Shallow Wells
2021 PCE Isoconcentrations in Groundwater with Injection Wells and with Monitoring Well Locations:
Transitional Unit Intermediate Wells
Cross Section Location Map A -A'
Cross Section A -A' with Proposed Injection Locations
Groundwater Potentiometric Map: Saprolite Unit Shallow Wells - May 2021
Groundwater Potentiometric Map: Transitional Unit Intermediate Wells - May 2021
Prepared for: Cintas Corporation, Milford, Ohio
AECOM

Application for Underground Injection Control 60681957
Permit — Attachments
Acronyms
ABC®
AECOM
bgs
DHC
DPT
ERD
ft/day
ft2/day
gpm
gpm/ft
HFCS
PCE
psi
PWR
RJRT
Site
TCE
VOC
ZVI
pg/L
Anaerobic BioChem
AECOM Technical Services of North Carolina, Inc.
Below ground surface
Dehalococcoides ethenopenes bacteria
Direct -push technology
Enhanced reductive dechlorination
Feet per day
Square feet per day
Gallons per minute
Gallons pr minute per foot
High fructose corn syrup
Tetrachloroethene
Pound -force per square inch
Partially weathered rock
R.J. Reynolds Tobacco Company
Former Salem Uniform facility
Trichloroethene
Volatile organic compounds
Zero valent iron
Micrograms per liter
Prepared for: Cintas Corporation, Milford, Ohio AECOM
iii

Application for Underground Injection Control 60681957
Permit — Attachments
1. Injection Zone
The former Salem Uniform facility (Site) located at 4015 North Cherry Street in Winston-Salem, North Carolina. The
Site is located at the southeast intersection of North Cherry Street and Polo Street in Winston-Salem, Forsyth County,
North Carolina (Figure 1).
The proposed enhanced reductive dechlorination (ERD) injection zone as stipulated in Title 15A North Carolina
Administrative Code 02C .0225(e)(2) coincides with the Area of Review that is shown in Figure 2. Source area
injections will take place directly upgradient of MW-17s in the area of the shallow groundwater plume that has
residual concentrations in excess of 1,000 micrograms per liter (pg/L) following the 2019 injections. Injections will be
administered by direct -push technology (DPT) into the shallow aquifer targeting a 50-foot interval at a depth of
approximately 20-70 feet below ground surface (bgs). Additionally, injections will be completed at three downgradient
barriers, including one onsite barrier and one off -site barrier each completed in partially weathered rock (PWR), and
one off -site barrier completed in saprolite. Injections will occur in the PWR barriers via permanent wells, and into the
saprolite barrier via DPT. Injections into the permanent wells will target a 40-foot interval in the PWR aquifer at a
general depth of 60-100 feet bgs. Injections in the saprolite barrier will target a 50-foot interval at a general depth of
20-70 feet bgs.
Figures 3 and 4 show the proposed injection locations with 2021 tetrachloroethene (PCE) data for shallow and
intermediate wells, respectively. Figure 5 is a cross section location map showing the plan view of the hydrogeologic
cross section shown on Figure 6. Figure 6 is hydrogeologic cross section that illustrates the interpreted water table
equipotential lines and PCE isoconcentrations at the Site with proposed injection locations. Table 1 summarizes
proposed injection intervals and existing injection well construction details.
2. Hydrogeologic Evaluation
2.1 Physiography
The Winston-Salem area is located within the western portion of the Piedmont Physiographic Province of North
Carolina. Both the regional and local landscape of the area are characterized by a broad, gently rolling uplands and
moderate to steep slopes common to the Piedmont. The drainage patterns in the area are classified as dendritic or
branching. The concave valleys are generally the result of weathering less resistant rock and soil units, which runoff
events serve as ephemeral streams. The convex areas are the result of more resistant rock, soil and direct rainfall to
the ephemeral streams. Generally, these types of drainage patterns reflect the weathering profiles, fractures, and
lithologic contact zones of subsurface soil and rock.
2.2 Regional Geology
Geologically, the Site is located in the Milton Belt litho -tectonic province of North Carolina (Brown, 1985). Bedrock in
this province is described as a metamorphic complex consisting of biotite gneiss and schist interlayered with mica,
amphibolite and granitic masses. Rocks of these compositions weather to form several distinct lithologic zones.
Overlying the competent bedrock are unconsolidated, granular and porous materials (regolith) that may consist of
alluvial deposits, soils and residual material formed from in -situ physical and chemical weathering of the parent rock.
The portion of the regolith that is derived from weathered rock, commonly referred to as saprolite, may retain the
fabric, texture, and structures of the original bedrock but it is has the consistency of dense soil (Heath, 1989).
Saprolite represents the most extreme weathered condition of the parent bedrock from which it is derived. A transition
zone of PWR is typically found between the saprolite zone and the lower competent bedrock. PWR is typically friable
bedrock that retains the parent rock structure, but it has undergone less weathering than saprolite. The PWR often is
highly fractured and permeable and contains fragments of unweathered rock. Bedrock in this area typically has
decreasing fracture density with depth (Heath, 1989).
Prepared for: Cintas Corporation, Milford, Ohio
AECOM
1

Application for Underground Injection Control 60681957
Permit — Attachments
2.3 Regional Hydrogeology and Hydrology
Aquifer systems in this part of the Piedmont region correspond with the geologic units present. The saprolite is
considered an unconfined or "water table" hydrostratigraphic unit of the regional aquifer. Saprolite and PWR acts as a
storage reservoir for groundwater that feeds the underlying fractured bedrock hydrostratigraphic unit. PWR and
bedrock units can exhibit unconfined, semi -confined, or even confined hydraulics. Most water supply wells in this
region tap the fractured bedrock unit. Supply wells installed in the bedrock aquifer of this region typically yield
between 15 and 20 gallons per minute (gpm) (Daniel and Payne, 1990). In groundwater recharge areas of the
Piedmont, the water table is usually closer to the ground surface during the winter and spring months, and is typically
deeper during the drier summer and autumn months.
2.4 Site Geology
In general, subsurface soils consist of silty clay residuum overlying clayey sand and silt saprolite, which coarsens with
depth. Typically, in the Piedmont of North Carolina, the saprolite serves as an unconfined storage aquifer that
transmits water downward (generally) to the lower semi -confined PWR unit and fractured confined metacrystalline
bedrock aquifer unit (Daniel and Payne, 1990). The saprolite originates from the underlying gneissic and schistose
bedrock and typically contains relict structures and fabric derived from the parent rock from which it was weathered.
The saprolite unit is generally described as a micaceous reddish -brown to yellow -brown mottled sandy silt to clayey
silt and silty sand. The mica and quartz sand content of the saprolite varies at different locations. Thickness of the
saprolite unit ranges from 55 feet near the center of the Site to 85 feet off -site near monitoring well MW-9(i). The
saprolite generally grades into PWR with depth. PWR often exhibits the same properties as deeper saprolitic soils,
but with higher occurrence of rock and rock fragments. PWR is approximately 35 feet thick in the middle of the Site
near well clusters MW-6 and MW-1, and it has a similar thickness at off -site well MW-9(i). At off -site well nests MW-3
and MW-10 the PWR is 12 feet thick or less. PWR at well MW-9(i) has alternating zones of highly weathered rock and
PWR. The zone of thick PWR observed at MW-9(i) and MW-6(d1) coincides with a possible linear trough or
depression in the bedrock surface that is highly weathered. This apparent bedrock structural feature appears to affect
the dimensions and migration of the dissolved off -site plume.
Bedrock composition varies from a dark gray, micaceous rock to a light gray and light brown, intermediate to felsic
rock. Depth to competent bedrock is approximately 90 feet bgs at onsite bedrock monitoring well MW-6(d1) and
increases downgradient to approximately 120 feet bgs at off -site monitoring well MW-9(i) located just north of the
R.J. Reynolds Tobacco Company (RJRT) property. Depth to competent bedrock decreases rapidly toward the RJRT
southwestern property boundary with bedrock approximately 23 feet bgs at MW-15(i). Southwest of the intersection of
North Cherry Street and Reynolds Boulevard, bedrock outcrops can be observed in Silas Creek.
2.5 Site Hydrogeology
Onsite groundwater is encountered at depths ranging from 13 to 33 feet bgs and the water table surface is found
primarily in the saprolite hydrostratigraphic unit. The depth to groundwater in off -site areas ranges from 11 to 45 feet
bgs. Depth to water measurements and groundwater elevations are summarized in Table 2. Shallow and
intermediate unit groundwater potentiometric maps for the Site during May 2021 are presented on Figures 7 and 8.
Figure 6 is a hydrogeologic cross section that illustrates the interpreted water table equipotential lines. Potentiometric
data indicate that shallow groundwater in the saprolitic hydrostratigraphic unit flows towards the south-southeast.
Potentiometric data indicate that groundwater flow in the transitional PWR aquifer is predominately towards the south,
with a slight flow component toward the southeast and southwest. Groundwater flow patterns indicate that
groundwater in both hydrostratigraphic units flows toward, and discharges into, the closest surface water body to the
Site; an unnamed tributary of Silas Creek. This tributary appears to have its headwaters along Polo Road northeast
and east of the Site, and it flows as a wet weather ditch and ephemeral stream through the wooded, commercial
Beroth Oil Company property east of the Site. South of McCanless Street the tributary has more perennial
characteristics beginning at a distance of approximately 130 feet from the southeast corner of the Site. A portion of
this stream runs through a concrete surface channel on residential properties and is then routed through subsurface
culvert pipes where it turns east to pass beneath May Street. Downstream of May Street, the unnamed stream has
open flow through the residential neighborhood south of the Site, where it then flows through a buried culvert pipe
under the RJRT manufacturing and packaging facility.
Prepared for: Cintas Corporation, Milford, Ohio
AECOM
2

Application for Underground Injection Control 60681957
Permit — Attachments
2.5.1 Aquifer Parameters
During the 2006 Comprehensive Site Assessment (ENSR, 2006) slug testing and single well pumping/recovery tests
were performed to evaluate aquifer parameters onsite. Transmissivity values for MW-3(i) ranged from 4.1 square feet
per day (ft2/day) to 26.2 ft2/day. The latter value, developed from specific capacity testing, is the most reasonable
value for this type of aquifer because the zone of water contribution during pumping (assumed to be equal to the
aquifer unit thickness) is largely unknown for a single well test and a partially penetrating well screen. The range of
transmissivity values at MW-8(i) was lower (2.5 ft2/day to 12.1 ft2/day). Again, the higher value calculated from a
specific capacity test is considered more reasonable for this type of aquifer due to the unknown aquifer thickness that
contributed to the yield when the well was pumped.
The parameter of transmissivity also was estimated by using hydraulic conductivity values derived from slug tests
multiplied by the well screen length at the test well. This estimation produced transmissivity values of 14.1 ft2/day at
well MW-1(s), 27.8 ft2/day at MW-4(s), and 65.8 ft2/day at well MW-7(s). These values are very similar to those
obtained from the specific capacity tests and they suggest that the entire saturated thickness of the saprolite/PWR
aquifer unit did not contribute water during the pumping tests.
The specific capacity varied from 0.008 gallons per minute per foot (gpm/ft) at MW-8(i) and 0.017 gpm/ft at well
MW-3(i). This range of values indicates a low -yielding PWR zone at the two locations that were tested. These results
also correlate well to the low water production observed in bedrock during drilling and the absence of major,
water -bearing fractures confirmed by borehole geophysical surveys.
Hydraulic conductivity values derived from slug testing varied from 1.26 feet per day (ft/day) at MW-1(s) to 4.1 ft/day
at MW-7(s). Measured values at the Site are reasonable for most Piedmont saprolitic soils derived from weathered
crystalline bedrock. Hydraulic conductivity also was calculated at MW-3(i) an MW-8(i) by using the maximum
transmissivity derived from specific capacity tests divided by the assumed aquifer thickness. Although the resultant
hydraulic conductivity values of 0.43 ft/day and 0.15 ft/day are feasible for a sandy silt saprolitic aquifer, these results
may be an order of magnitude too low due to the large aquifer thickness value used in the calculation.
3. Injectant Information
The proposed injectants described below were previously used during a pilot test event in September 2017
under UIC Permit #WI0400470 and the Phase I injections between November 2019 and January 2020 under
the original UIC Permit #WI0400523. During both injection events Anaerobic Biochem (ABC' ), zero valent iron
(ZVI), and magnesium hydroxide solutions (ABC+) were injected into the shallow saprolite groundwater
during both previous events to stimulate the reductive dech/orination of PCE in the on -site source area.
Additionally high fructose corn syrup (HFCS) and sodium bicarbonate solutions were injected into the
injection wells screened in the PWR zone.
The 2018 ABC+ and HFCS pilot injections showed promising decreasing trends of PCE as a result of the
stimulated ERD processes which lead to the proposal of additional injections in 2019. The Phase 12019
injections showed reductions of PCE ranging from 91-99% in both the on -site shallow groundwater and
within the intermediate PWR groundwater unit. More detailed results of the injections can be found in the
Quarterly Remediation Report (AECOM, 2019) and Full Scale ERD Injection Performance Report (AECOM,
2021) that were submitted to NCDEQ.
The injections described in the following sections were developed based on the success of the pilot and
Phase I injections using the same injectant solution and information gathered regarding the aquifer during
those events. An effective porosity of 0.25 and injection of approximate 5% of the effective pore volume was
assumed for the shallow saprolite DPT points, which equates to approximately 50 gallons per 2 ft depth
interval. The radius of influence (ROI) of the shallow saprolite DPT points was conservatively assumed to be
10ft. For the PWR well injections, an effective porosity of 0.1 and injection of approximately 20% of the
effective pore volume was assumed to develop the injection volume with an estimated ROI of 26ft.
Prepared for: Cintas Corporation, Milford, Ohio
AECOM
3

Application for Underground Injection Control 60681957
Permit — Attachments
3.1 Source Area and Off -site Downgradient Barrier ABC+ Injections
A dilute ABC®, ZVI, and magnesium hydroxide solution will be injected into 3 DPT locations near MW-17s (the source
area) and 5 DPT locations along McCanless Street immediately upgradient of PMW-5(s) to address the remaining
shallow groundwater impacts (PCE >1,000 pg/L). The proposed direct -push locations are shown in Figure 3, and
proposed injection intervals are summarized in Table 1. It is proposed that a total of 10,000 gallons of a dilute
ABC®/ZVI/magnesium hydroxide solution be injected into the points. The injections will be administered into the
shallow aquifer via DPT targeting a 50-foot interval (approximately 20-70 feet bgs). Approximately 20,000 pounds of
ABC+, 40 liters of RTB-1 (a Dehalococcoides ethenogenes bacteria [DHC] culture) and 1,000 pounds of magnesium
hydroxide will be injected in the 8 DPT locations into an estimated 200 intervals.
ABC+ is a mixturc ofABC® and ZVI. ABC+ will be injected to create anaerobic conditions and provide an electron
donor for dehalorespiring bacteria. ABC® coupled with ZVI provides a number of benefits for ERD. ABC® supports
anerobic bacteria growth by supplying short-term and long-term nutrients, which also assists in creating a reducing
environment. ZVI will aid in providing immediate reduction. ABC+ is comprised of lactates and fatty acids, as well as a
phosphate buffer. These elements work to maintain the pH in a range that is most suitable for microbial growth.
Magnesium hydroxide will also be used to buffer groundwater pH which is naturally low and also buffer groundwater
from production of metabolic acids from biodegradation ofABC+. Magnesium hydroxide provides an extended pH
buffering time relative to sodium bicarbonate.
The injection amendments will be mixed aboveground in a batch process with water sourced from a hydrant
connected to the city of Winston-Salem water supply system prior to subsurface delivery. The actual methodology will
depend on the capabilities of the selected injection subcontractor. Once mixed, this solution will be injected into eight
direct -push locations (FS-201 through FS-208) at multiple depth intervals. The solution will be injected using a
pneumatic double diaphragm pump. Proposed injection quantities are summarized in Table 3. Materials safety data
sheets for the injection amendments are included as Appendix A.
3.2 Downgradient Onsite and Off -site High Fructose Corn Syrup and Sodium
Bicarbonate Barrier Well Injections
A dilute high fructose corn syrup (HFCS) and sodium bicarbonate solution will be injected into PWR barriers (located
onsite and off -site) via permanent injection wells. The injectant will be administered via seven existing permanent
injection wells (IW-5, IW-6, IW-7, IW-9, IW-10, IW-11, and IW-12), which are located downgradient of the source area
injections in the southern end of the Site just upgradient of McCanless Street where HFCS was injected previously.
Injections into the permanent wells will target a 40-foot interval in the PWR aquifer at a general depth of 60-100 feet
bgs. A proposed injection volume of 6,500 gallons per well is estimated. A total of approximately 70,000 pounds of
HFCS and 18,900 pounds of sodium bicarbonate will be injected into the onsite and off -site wells.
HFCS yielded favorable results when injected into PWR during the pilot study and 2019 injections. HFCS will be
injected in the PWR barriers again to maintain anaerobic conditions and provide an electron donor for dehalorespiring
bacteria. Sodium bicarbonate will be injected to buffer the groundwater pH which is naturally low and to also buffer
groundwater from production of metabolic acids from biodegradation of the HFCS. Magnesium oxide has a relatively
low solubility and may clog well screens. Therefore, it cannot be used as a buffer in the PWR barrier injections. HFCS
will be injected to create anaerobic conditions and provide an electron donor for dehalorespiring bacteria. Sodium
bicarbonate will be injected to buffer the groundwater pH which is naturally low and to also buffer groundwater from
production of metabolic acids from biodegradation of the HFCS.
The injection amendments will be mixed aboveground in a batch process prior to subsurface delivery. The actual
methodology will depend on the capabilities of the selected injection subcontractor. Once mixed, this solution will be
injected into the permanent injection wells listed above. The solution will be injected using a pneumatic double
diaphragm pump. Proposed injection quantities are summarized in Table 3.
3.3 Bioaugmentation
Bioaugmentation will be completed using the RBT-1® bioaugmentation culture in the DPT injection locations. The
culture will contain an enriched dechlorinating culture, including DHC, capable of complete dechlorination of PCE and
Prepared for: Cintas Corporation, Milford, Ohio
AECOM
4

Application for Underground Injection Control 60681957
Permit — Attachments
its daughter products. Groundwater data at the Site indicates that native dechlorinating cultures, especially DHC,
were limited in some aquifer zones. Therefore, bioaugmentation will be used to enhance the natural population of
dechlorinating microbes in the ERD treatment areas. Each location will receive 1 liter of bioaugmentation culture per
10 vertical feet of treatment interval.
3.4 Byproducts of Stimulated Reductive Dechlorination Processes
The purpose of the injection of the fatty acid mixture and carbohydrate solution (ABC+ and HFCS
respectively) described in this document is to stimulate ERD processes to allow microbial bacteria to
dech/orinate PCE to harmless compounds such as ethene or carbon dioxide. Previous injections have
shown that the aquifer is conducive to the dech/orination of PCE and its daughter products. Introducing the
injection substrates, ABC® and HFCS (electron donors), stimulate natural microbe growth within the aquifer.
Those microbes in turn dech/orinate PCE to daughter products trichloroethene (TCE), cis-1,2-dichloroethene
(cis-1,2-DCE), vinyl chloride and eventually to ethene, ethane and carbon dioxide. During the sequential
dech/orination of PCE to its daughter products, hydrogen and chloride can be produced, though the
production of those compounds can be offset by the addition of bicarbonate. The fermentation of HFCS has
also been known to produce ketones such as acetone and butanone, which eventually oxidize to carbon
dioxide.
Results of the 2017 pilot test and 2019 Phase I injections have shown increases of the PCE daughter
products including ethene and carbon dioxide in monitoring wells within the injection zones indicating full
dech/orination of PCE is occurring in some areas on site as a result of previous ERD injections.
4. Injection Procedure
The proposed DPT locations and permanent injection wells (described in Section 5) will be used to facilitate the
proposed injections. The proposed injection activities are estimated to take approximately 17 days to complete.
Injection rates into the saprolite are expected to range from approximately 6 to 16 gpm, and injection rates into PWR
via permanent well and pneumatic pump are expected to range from 3 to 8 gpm. Injection pressures are expected to
range from 75 pound -force per square inch (psi) to 200 psi at DPT injection locations, and are expected to be less
than 50 psi at injection wells. However, the injection rate, amount and pressure will vary depending on field
conditions. A summary of injection quantities is provided in Tables 1 and 3.
5. Well Construction Details
Three (3) DPT points located near the source area and five (5) DPT points along McCanless Street have been
proposed for injections to address remaining shallow groundwater impacts (PCE>1,000 pg/L). Proposed DPT
injection locations are shown on Figure 3, and proposed injection intervals are summarized in Table 1.
DPT injections in the source area will include advancing a total of eight proposed temporary DPT injection points to
total depths ranging from approximately 20 to 70 feet bgs. DPT refusal depths were assumed based on previous site
drilling experience and may be modified according to field conditions. After DPT injection locations have been
completed, the borings will be abandoned using bentonite or cement grout.
HFCS injections will be conducted using existing injection wells that were installed prior to the 2019 injection event.
Injection wells IW-5, IW-6, IW-7, IW-9, IW-10, IW-11, and IW-12 were installed using a combination of hollow stem
auger and air rotary drilling techniques. They were constructed of schedule 40 polyvinyl chloride with 30-foot
0.010 inch screens. The total depth of these monitoring wells range from 88 feet bgs (IW-5 and IW-6) to 100 feet bgs
(IW-10, IW-11, and IW-12). Permanent well injection details are summarized on Table 1. Well construction records
including lithology information of the existing injection wells are included in Appendix B.
Prior to performing any invasive work, utilities will be marked by a private utility locator and surrounding public utilities
will be marked by a public utility locating service via 811 ticket. Additionally, each sampling location will be pre -cleared
using a stainless -steel hand auger to a depth of at least 5 feet bgs. Solid and liquid investigative derived waste will be
placed in drums, sampled, and properly manifested and transported off -site for disposal.
Prepared for: Cintas Corporation, Milford, Ohio
AECOM
5

Application for Underground Injection Control 60681957
Permit — Attachments
6. Monitoring Plan
Prior to injcction, Select existing injection and monitoring wells will bo were purged and sampled to establish baseline
conditions in June and August 2022. The sampling parameters to bo analyzed during the baseline sampling event
and that will be post -injection sampling will follow the tentative schedule/parameter list presented in Table 4. Based
on the results of previous injections fourteen monitoring wells within the injection zones and immediately
downgradient of have been selected for routine monitoring of field parameters, volatile organic compounds, electron
acceptors/degradation products, and microbial analysis for one year. In addition to the performance monitoring, a
site wide groundwater sampling event occurs each year in the spring (approximately 6-7 months following
the proposed injections) during which each site monitoring well is analyzed for volatile organic compounds
(VOCs).
Sampling frequency and parameters may be modified during the injection performance monitoring, based on
interpretation of the results.
7. Well Data Tabulation
See Table 5 for existing well construction details.
8. Maps and Cross Sections
See Figures 1-8
Prepared for: Cintas Corporation, Milford, Ohio
AECOM
6

Application for Underground Injection Control 60681957
Permit — Attachments
9. References
AECOM, 2019. Quarterly Remediation Report, February 2018 through November 2018, Former Salem Uniform
Facility. March 2019.
AECOM, 2021. Enhanced Reductive Dechlorination Injection Performance Report, Former Salem Uniform Facility.
AECOM North Carolina, Inc. October 2021.
Brown, P.M., 1985. Geologic Map of North Carolina. Prepared by NC Department of Natural Resources and
Community Development, Division of Land Resources.
Daniel, Charles and R.A. Payne, 1990. Hydrogeologic Unit Map of the Piedmont and Blue Ridge Provinces of North
Carolina. United State Geological Survey, Water -Resources Investigations Report 90-4035.
ENSR, 2006. Comprehensive Site Assessment Report— Former Salem Uniform Services Facility. June 28, 2006.
Heath, Ralph C., 1989. The Piedmont Ground -Water System. Presented in Ground Water in the Piedmont
Proceedings of a Conference on Ground Water in the Piedmont of the Eastern United States. October 16-
18, 1989. Published by Clemson University, Clemson, South Carolina.
Prepared for: Cintas Corporation, Milford, Ohio
AECOM
7

Application for Underground Injection Control 60681957
Permit — Attachments
Tables
Prepared for: Cintas Corporation, Milford, Ohio AECOM

Table 1
Proposed DPT and Injection Well Construction Details
Former Salem Uniform Facility
4015 N. Cherry Street, Winston Salem, North Carolina
Well ID
Proposed Injection
Well Status Install Date
DPT Points (Saprolite)
Well Type
Well
Construction
Well Well TOC
Install Diameter Elevatio
Method (inches) n
Screened/Injectio
n Interval
(ft bgs)
Total Well
Depth
(ft bgs)
FS-201
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
FS-202
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
FS-203
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
FS-204
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
FS-205
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
FS-206
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
FS-207
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
FS-208
Proposed
NE
Injection - Temporary
NA
DPT
1.5
NE
20 - 70
70
Existing In
ection Wells (PWR)
IW-5
Existing
Oct-19
Injection - Permanent
PVC
HSA/ARH
4
NS
58 - 88
88
IW-6
Existing
Oct-19
Injection - Permanent
PVC
HSA/ARH
4
NS
58 - 88
88
IW-7
Existing
Oct-19
Injection - Permanent
PVC
HSA/ARH
4
NS
58 - 88
88
IW-9
Existing
Oct-19
Injection - Permanent
PVC
HSA/ARH
2
NS
66 - 96
96
IW-10
Existing
Oct-19
Injection - Permanent
PVC
HSA
2
NS
70 - 100
100
IW-11
Existing
Oct-19
Injection - Permanent
PVC
HSA
2
NS
70 - 100
100
IW-12
Existing
Oct-19
Injection - Permanent
PVC
HSA
2
NS
70 - 100
100
Notes
ARH - Air Rotary/Air Hammer
DPT - Direct Push Technology
ft bgs - feet below ground surface
ft msl - feet mean sea level
HSA - Hollow Stem Auger
IW - Injection Well
NE - Not Established
NS - Not Surveyed
PVC - Polyvinyl Chloride
Total well depths for proposed DPT points are estimated and subject to change during installation.
Wells listed in the table above will be used to during this injection phase.
AECOM Page 1 of 1

Table 2
Groundwater Elevation Data - May 2021
Cintas - Former Salem Uniform Facility
4015 N. Cherry Street, Winston Salem, North Carolina
Well ID
MW-1(s)R
Initial Well MP
Elevation (ft msl)
970.60
Final Well MP
Elevation (ft msl)
970.60
Date
5/25/2021
Depth to Water
(ft bmp)°
14.30
Groundwater
Elevation (ft msl)'a
956.30
MW-1(i)`
971.17
971.17
5/25/2021
14.06
957.11
MW-2
979.91
979.91
5/25/2021
22.46
957.45
MW-3(s)
979.17
979.17
5/25/2021
22.20
956.97
MW-3(i)
978.91
978.91
5/25/2021
21.30
957.61
MW-4(s)
986.01
986.01
5/25/2021
27.75
958.26
MW-4(i)
986.32
986.32
5/25/2021
28.05
958.27
MW-5(s)
966.42
966.42
5/25/2021
11.33
955.09
MW-5(i)
965.61
965.61
5/25/2021
11.24
954.37
MW-6(s)
972.14
972.14
5/25/2021
16.23
955.91
MW-6(s)2
NA
971.80
5/25/2021
16.24
955.56
MW-6(i)
971.42
971.42
5/25/2021
16.00
955.42
MW-6(d1)'
968.71
971.77
5/25/2021
71.67
900.10
MW-7(s)
958.79
958.79
5/25/2021
10.24
948.55
MW-8(i)
957.80
957.80
5/25/2021
8.70
949.10
MW-10(i)
961.80
961.80
5/25/2021
43.19
918.61
MW-10(d1)'
963.30
961.63
5/25/2021
39.31
922.32
MW-11(s)
985.10
985.10
5/25/2021
26.53
958.57
MW-12(s)
NA
976.81
5/25/2021
20.13
956.68
MW-12(i)
NA
976.49
5/25/2021
19.64
956.85
MW-13(i)
NA
948.80
5/25/2021
25.40
923.40
MW-13(d)
NA
948.90
5/25/2021
26.88
922.02
MW-14(i)
NA
935.10
5/25/2021
NM
--
MW-15(i)
NA
910.90
5/25/2021
10.72
900.18
MW-16(i)
NA
964.60
5/25/2021
14.55
950.05
MW-16(d)
NA
964.50
5/25/2021
13.20
951.30
MW-17(s)
NA
NS
5/25/2021
14.38
--
MW-17(i)
NA
NS
5/25/2021
14.14
--
PMW-1(s)
NA
970.4
5/25/2021
12.00
958.40
PMW-1(i)
NA
970.1
5/25/2021
NM
--
PMW-2(s)
NA
971.1
5/25/2021
16.60
954.50
PMW-2(i)
NA
970.9
5/25/2021
15.20
955.70
PMW-3(s)
NA
970.4
5/25/2021
14.76
955.64
PMW-3(i)
NA
970.2
5/25/2021
14.59
955.61
PMW-4(i)
NA
965.6
5/25/2021
10.65
954.95
PMW-5(s)
NA
NS
5/25/2021
14.33
--
PMW-5(i)
NA
NS
5/25/2021
11.84
--
PMW-6(s)
NA
NS
5/25/2021
8.81
--
IW-1
NA
971.9
5/25/2021
NM
--
IW-2
NA
971.1
5/25/2021
15.41
955.7
IW-3
NA
NS
5/25/2021
17.82
--
IW-4
NA
NS
5/25/2021
16.92
--
IW-5
NA
NS
5/25/2021
16.57
--
IW-6
NA
NS
5/25/2021
16.51
--
IW-7
NA
NS
5/25/2021
14.49
--
IW-8
NA
NS
5/25/2021
17.95
--
IW-9
NA
NS
5/25/2021
13.17
--
IW-10
NA
NS
5/25/2021
11.22
--
IW-11
NA
NS
5/25/2021
9.31
--
IW-12
NA
NS
5/25/2021
8.38
--
IW-13
NA
NS
5/25/2021
7.23
--
Notes:
MP -measuring point
ft,nsl -feet rel stye to mean sea level
ft lamp- feet below measuring point
NM - not measured
NS - Not Surveyed
" MP eleretons on wells Mot-e01)and MW-10 (di) were mod,. on 1-10-05, corfected MP elev.).is shown
a Water level elevators (2002 through 10/20I2004) are .own for water level measurements referenced from "Intel Well MP Flevafron'"_ Water
collected after 1-19-05 use"Fnal Well MP Plevato. column values as reference
`Well MW-1(s)R Is a replacement well for MW-1(s), wfii cb was destroyed In October 20.
Well elevation surreys conduct. by RLS surveying (January 2004, October 2004 and February2000)

Table 3
Summary of Proposed Injection Quantities
Former Salem Uniform Facility
4015 N. Cherry Street, Winston Salem, North Carolina
Area
ABC®+
(LB)
Magnesium
Hydroxide
(LB)
RTB-1 (L)
Total
HFCS Bicarbonate Injection
(LB) (LB) Volume
(GAL)
Number
Injection
Points/Wells
Injection Volume
per Foot or Well
(GAL)
DPT Injections
Source Area
[FS-201 through FS-203]
Downgradient Offsite Barrier
[FS-204 through FS-208]
7,500
12,500
375
625
15
25
0
0
0
0
3,750
6,250
3
5
25
Injection Wells
Downgradient Onsite Barrier
[IW-5, IW-6, & IW-7]
Downgradient Offsite Barrier
[IW-9, IW-10, IW-11, & IW-12]
0
0
0
0
0
0
30,000
40,000
8,100
10,800
19,500
26,000
3
4
6,500
Notes:
ABC®+ - ABC® and ZVI
DPT - Direct Push Technology
GAL - Gallons
HFCS - High Fructose Corn Syrup
LB - Pounds
L - Liter
RTB-1 - Dehalospiring bacteria culture
ZVI -Zero Valent Iron
AECOM

Table 4
Proposed Phase II Enhanced Reductive Dechlorination Implementation Schedule
Former Salem Uniform Facility
4015 N. Cherry Street, Winston Salem, North Carolina
Baseline
Month 3
Month 6
Month 9
Well ID
PMW-1)s) PMW-2)s) PMW-5(s) PMW-6)s) MW-17)s) MW-6)i) MW-6)d1) MW-16)i) MW-16)d) PMW-2)i) PMW-4(i) PMW-5)i) IW-8 IW-13
Month 12
Field Parameters
TOC
VOC
EA
Microbial
Field Parameters
TOC
VOC
Field Parameters
TOC
VOC
MEE Only
Field Parameters
TOC
VOC
EA
Microbial
Field Parameters
TOC
VOC
EA
Microbial
Note
bgs - below ground surface
EA = Electron NcceptorsMegradafion Product/pH monibonng_ nitrate (EPA 353 2/300) sulfate (EPA 375 3/300) femc iron (EPA DDMD) manganese (EPA DDID) ferrous imn (EPA DDMD) nismlaed manganese (EPA DDID) sulfide
(EPA 276 2) carbon Monde (MOD EPA 381 D) hydrogen(AM2DGAX") ethene (RSK 175) ethane (RSK 175) methane (RSK 175) alkalinity (SM 2320) chloride (EPA 300 D)
EPA-Embronment3l Protector Agency
ERD -Enhanced Reductoee Dechlorinafion
Eleld -Eleld Parameters-DTVV DO pH ORP temperatureconductivity
Microbial - Dehalococcoides sp_ And Dehalobactersp_ and Census DNA bacA Reductase tceA Reductase Vino Chloride Reductase
TOG -Total Organic Carbon (EPA 415 1)
VOC -Volatile Organic Compounds (EPA 823013)
The proposed monitoring schedule is subject to change Additions and/or deletions to the proposed monitoring plan are expected

Table 5
Monitoring Well Construction Details
Cintas - Former Salem Uniform Services Facility (K&V, LLC Property)
Winston-Salem, North Carolina
WELL
CONSTRUCTION
DETAILS
AQUIFER
DATA
Well Number
MW-1(s)*
Date Installed
6/27/02
Well Construction
2 in Sch 40 PVC
Drilling
Method
HSA
Top of Casing
MP Elevation
(ft, msl)
971.19
Ground
Elevation
(ft, msl)
971.53
Well
Casing
Stickup
(ft, ags)
-0.34
Outer
Casing
Depth
(ft, bgs)
NA
Outer
Casing
Depth
(ft, msl)
NA
Screened
Interval
(ft, bgs)
19-29
Total Well
Depth
(ft, bgs)
29.0
Total Well
Depth
(ft, msl)
942.53
Aquifer Unit
Monitored
(see code)
sSAP
Depth to
Top of
Bedrock (ft)
NA
Top of
Bedrock
Elevation
(ft, msl)
MW-1(s)R*
12/5/07
2 in SS Casing/SS screen
HSA
970.60
971.50
-0.90
NA
NA
20-30
30.0
941.50
sSAP
NA
MW-1(i)
12/19/03
2 in PVC+SS casing/SS screen
HSA/MR
971.17
971.46
-0.29
NA
NA
70-80
80.0
891.46
T(PWR)
NA
<891.46
MW-2
11/26/02
2 in Sch 40 PVC
HSA
979.91
980.39
-0.48
NA
NA
30-40
40.0
940.39
sSAP/dSAP
NA
MW-3(s)
12/16/03
2 in Sch 40 PVC
HSA
979.17
979.62
-0.45
NA
NA
32-42
42.0
937.62
sSAP/dSAP
NA
MW-3(i)
12/17/03
2 in Sch 40 PVC
HSA/ARH
978.91
979.22
-0.31
NA
NA
75-85
85.0
894.22
T(PWR)
85.00
894.22
MW-4(s)
12/16/03
2 in Sch 40 PVC
HSA
986.01
986.36
-0.35
NA
NA
40-50
50.0
936.36
dSAP
NA
MW-4(i)
12/22/03
2 in PVC+SS casing/SS screen
HSA/MR
986.32
986.48
-0.16
NA
NA
70-80
80.0
906.48
T(PWR)
NA
MW-5(s)
12/16/03
2 in Sch 40 PVC
HSA
966.42
964.26
2.16
NA
NA
18-28
28.0
936.26
sSAP
NA
MW-5(i)
12/23/03
2 in PVC casing/SS screen
HSA/ARH
965.61
963.08
2.53
NA
NA
59-69
69.0
894.08
dSAP/T(PWR
NA
<894.08
MW-6(s)
10/1/04
2 in PVC+SS casing/SS screen
HSA
972.14
968.70
3.44
NA
NA
18-28
28.0
940.70
sSAP
NA
MW-6(s)2
7/31/2017
2" Sch 40 PVC
Roto-Sonic
971.8
969.5
2.30
NA
NA
40-50
50.0
921.8
dSAP
NA
NA
MW-6(i)
12/29/03
2 in PVC+SS casing/SS screen
HSA/ARH
971.42
968.39
3.03
NA
NA
70-80
80.0
888.39
T(PWR)
NA
MW-6(d1)
12/19/03-1/19/05
6 in PVC OC/2 in SS screen & riser;\A
HSA/ARH
971.77
967.75
4.02
93.0
874.75
106-121\A
121.0
846.75
sBR
91.00
876.75
MW-7(s)
12/16/03
2 in Sch 40 PVC
HSA
958.79
956.09
2.70
NA
NA
15-25
25.0
931.09
sSAP
NA
MW-8(i)
10/4/2004
2 in PVC casing/SS screen
ARH/MR
957.80
954.00
3.80
NA
NA
79-89
89.0
865.00
T(PWR)/sBR
87.00
867.00
MW-9(i)
9/28-29/04
2 in PVC casing/SS screen
HSA/ARH/MR
954.41
954.40
0.01
NA
NA
112-122
122.0
832.40
T(PWR)/sBR
120.00
834.40
MW-10(i)
9/28/04
2 in PVC casing/SS screen
HSA
961.80
961.80
0.00
NA
NA
52-62
62.0
899.80
T(PWR)
62.00
899.80
MW-10(d1)
9/27-10/5/04
6 in PVC OC;\B
HSA/ARH
961.63
961.50
0.13
69.0
892.50
69-172\B
172.0
789.50
sBR/iBr
62.00
899.50
MW-11(s)
09/10/09
2 in Sch 40 PVC
HSA
985.10
985.30
-0.20
NA
NA
45-55
55.0
930.30
dSAP
NA
MW-12(s)
2/20/13
2" SS Casing / SS screen
HSA
976.81
973.77
3.04
NA
NA
32-42
42.0
931.77
dSAP
NA
MW-12(i)
2/19/13
2" SS Casing / SS screen
HSA/ARH
976.49
973.52
2.97
NA
NA
67-77
77.0
896.52
PWR
NA
MW-13(i)
7/18/13
2" Sch 40 PVC
HSA
948.80
949.10
-0.30
NA
NA
55-65
65.0
884.10
dSAP
115.00
834.10
MW-13(d)
7/19/13
6" PVC OC / 2" PVC screen & riser
HSA/ARH
948.90
949.20
-0.30
119.0
830.20
135-145
145.0
804.20
BR
MW-14(i)
7/18/13
2" Sch 40 PVC
HSA
935.10
935.30
-0.20
NA
NA
27-37
37.0
898.30
dSAP
NA
MW-15(i)
7/18/13
2" Sch 40 PVC
HSA/ARH
910.90
911.10
-0.20
NA
NA
12-22
22.0
889.10
PWR
23.00
888.10
MW-16(i)
8/21/13
2" Sch 40 PVC
Roto-Sonic
964.60
964.80
-0.20
NA
NA
60-70
70.0
894.80
dSAP / PWR
92.00
872.80
MW-16(d)
8/22/13
6" PVC OC / 2" PVC screen & riser
Roto-Sonic
964.50
964.80
-0.30
97.0
867.8
110-120
120.0
844.80
BR
MW-17(s)
10/1/18
2" Sch 40 PVC
Roto-Sonic
NS
NS
NS
NA
NS
35-45
35.0
NS
dSAP
NA
NA
MW-17(i)
10/2/18
2" Sch 40 PVC
Roto-Sonic
NS
NS
NS
NA
NS
55-65
65.0
NS
T(PWR)/sBR
60.00
NS
IW-1
8/3/2017
4" Sch 40 PVC
Roto-Sonic
971.9
969.4
2.50
NA
NA
60-90
90.0
881.9
PWR
NA
NA
IW-2
8/1/2017
2" Sch 40 PVC
Roto-Sonic
971.1
968.8
2.30
NA
NA
60-90
90.0
881.1
PWR
NA
NA
IW-3
10/2019
4" Sch 40 PVC
HSA/ARH
NS
NS
NS
NA
NA
58-88
88.0
NS
PWR
NA
NA
IW-4
10/2019
4" Sch 40 PVC
HSA/ARH
NS
NS
NS
NA
NA
58-88
88.0
NS
PWR
NA
NA
IW-5
10/2019
4" Sch 40 PVC
HSA/ARH
NS
NS
NS
NA
NA
58-88
88.0
NS
PWR
NA
NA
IW-6
10/2019
4" Sch 40 PVC
HSA/ARH
NS
NS
NS
NA
NA
58-88
88.0
NS
PWR
NA
NA
IW-7
10/2019
4" Sch 40 PVC
HSA/ARH
NS
NS
NS
NA
NA
58-88
88.0
NS
PWR
NA
NA
IW-8
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
61-91
91.0
NS
PWR
NA
NA
IW-9
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
66-96
96.0
NS
PWR
NA
NA
IW-10
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
70-100
100.0
NS
PWR
NA
NA
IW-11
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
70-100
100.0
NS
PWR
NA
NA
IW-12
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
70-100
100.0
NS
PWR
NA
NA
IW-13
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
67-97
97.0
NS
PWR
NA
NA
PMW-1(s)
7/27/2017
2" Sch 40 PVC
Roto-Sonic
970.4
970.7
-0.30
NA
NA
25-45
45.0
925.4
dSAP
NA
NA
PMW-1(i)
7/28/2017
2" Sch 40 PVC
Roto-Sonic
970.1
970.6
-0.50
NA
NA
65-75
75.0
895.1
PWR
NA
NA
PMW-2(s)
7/28/2017
2" Sch 40 PVC
Roto-Sonic
971.1
968.9
2.20
NA
NA
25-45
45.0
926.1
dSAP
NA
NA
PMW-2(i)
8/5/2017
2" Sch 40 PVC
Roto-Sonic
970.9
968.8
2.10
NA
NA
80-90
90.0
880.9
PWR
NA
NA
PMW-3(s)
7/24/2017
2" Sch 40 PVC
Roto-Sonic
970.4
968.2
2.20
NA
NA
25-45
45.0
925.4
dSAP
NA
NA
PMW-3(i)
7/26/2017
2" Sch 40 PVC
Roto-Sonic
970.2
968.1
2.10
NA
NA
80-90
90.0
880.2
PWR
NA
NA
PMW-4(i)
8/4/2017
2" Sch 40 PVC
Roto-Sonic
965.6
963.5
2.10
NA
NA
80-90
90.0
875.6
PWR
NA
NA
PMW-5(s)
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
35-45
45.0
NS
SAP
NA
NA
PMW-5(i)
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
77-87
87.0
NS
PWR
NA
NA
PMW-6(s)
10/2019
2" Sch 40 PVC
HSA
NS
NS
NS
NA
NA
33-43
43.0
NS
SAP
NA
NA
Notes:
\A MW-6(d1) was temporarily constructed as open borehole in rock from 93-122.5 ft. bgs for initial sampling events. Well completed with screens & inner casing to depth of 121 ft. on 1-19-05. Well MP elevation is top of inner 2" SS casing.
\B Well MW-10(d1) is constructed as open borehole in rock from 69-172 feet. bgs. Well MP elevation is highest point on top of outer PVC casing, after completion in flush mount mahole and pad.
\C Well MW-9(i) was set in an aquifer zone of alternating partially weathered rock and more competent rock. The interface of continuous competent rock may not have been encountered above 122 ft. depth.
Well MW-1(s)R is a replacement well for MW-1(s), which was destroyed in October 2005.
Abbreviations:
ft = feet IW - Injection Well
MP = measuring point SS=stainless steel
NA = not applicable PVC=Polyvinyl chloride
NS = Not Surveyed HSA = Hollow stem auger
bgs = below ground surface ARH = Air Rotary/Air Hammer
ags = above ground surface MR = Mud Rotary
msl = mean sea level OC = Outer Casing
Aquifer Unit Codes:
sSAP = shallow saprolite
dSAP = deep saprolite
T(PWR) = transitional zone (partially weathered rock)
BR = bedrock
sBR = shallow competent bedrock
iBR = intermediate depth competent bedrock
AECOM

Application for Underground Injection Control 60681957
Permit — Attachments
Figures
Prepared for: Cintas Corporation, Milford, Ohio AECOM

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Map Location
Site Location Map
Cintas: Former Salem Uniform Services
4015 North Cherry Street
Winston-Salem, NC
0
2,000
4,000
May 2022
Feet
N
60681957
Figure 1
AECOM
AECOM
5438 Wade Park Blvd, Suite 200
Raleigh, NC 27607
Phone: [phone]
Fax: [phone]
www.aecom.com

ARCH D 24" x 36"
Checked: SP
Last Plotted: 2022-07-20
Last saved by: SPLAWNM(2022-07-15)
x—x
TRIB2(SW)-SW1
-tF \ x.
®RJR-G WO9
x
R J Reynolds
Corporation
Property
RJR-GWO7
— x-0
x
SILAS TRIB-SW02
� 0
Electrical
Substation
TRIB2(SW)-SW3
SILAS TRIB-SW01
North Cherry Street
Pool
Note:
This site plan was constructed from surveys by Slate Surveying Co., PA (October 2003 ) and Regional Land Surveyors, Inc. (January
2004, October 2004, February 2008, October 2008, March 2013, and September 2013) . Locations of roads and property lines were
digitiL d from property deed maps and aerial photos obtained from the Forsyth County, NC Tax Office and from the NC Department of
Transportation. This survey does not represent an accurate boundary survey and should not be used for such purposes.
x
x_
Wakefield Drive
Legend
—x
xx—
Wakefield Court
RJR-GW 04 Q
Boundary of K 0 V, LLC Property
( Former Salem Uniform )
Former Salem Uniform Building
Fence (Approx. Location )
Perennial Stream
Intermittent Stream
Wet Weather Drainage Ditch
1
RJR-GWO6 0
MW-10(d1)
x
MW-13(d)
MW-13(i)
RJR-GWO1
/Asphalt
Parking Lot
RJR-G WO2
r
Asphalt
Parking Lot
Culverted Perennial Stream
( Double )
Culverted Perennial Stream
( Single )
Storm Sewer / Reinforced
Concrete Pipe ( RCP )
Edge of Wooded Area
MW-10(i)
D
MW-1(s)
eMW-9(i)
G P-22 ®
El
Power Pole
Drop Inlet
Abandoned Water Supply Well
Water Supply Well ( inactive )
Abandoned Monitoring Well
Cross Section Transect A - A'
TRIB1(SE)-SW3
0
—x
MW-6(s)
6
MW-6(d 1)
North Cherry Street
MC-GWO2
Tributary Flows Into Concrete -Lined
Underground Culvert Ditch (03' Wide )
Pipe at This Point
May Street
TRIB1(SE)-SW2
Dalton Street
Shallow ( Saprolite Zone ) Monitoring Well
Intermediate ( Transitional / PWR Zone ) Monitoring Well
Deep ( Bedrock Zone ) Monitoring Well
Injection Well
MC-GWO1
IW-11
MW-16(d)
MW-16(i)
MW-7(s)
® MC-GWO3
MW-3(i)
MW-3(s)
Former Retaining Wall
Concrete
Pad
46-3
46-4
IMW-6(s)2 At
IW-5
MW-6(s) ' A
MW-6(i)
MW-6(d1)
PMW-2(i)
IW-1• PMW-4(i)
G W01-2012
IW-1
•
•
PMW-3(i)
t1
0, 0
kti-t
tts-i
\ MW-2� Former Salem
i Uniform Building
M�ni_1rs) L --
MW-1(s)R 1W-1(i)
PMW 1(i) PMW-1(s) MW-17(s) L �� —e MW 4(s)
Gr IW-7 a1 \MW12(i) MW-4(i)11
IW-1 MW-12(s)
PMW-2(s)
R,PMW-3(s)
• ' •
MW-50)Q MW-5(s)
Notes
1. WELL MW-1(s) WAS DESTROYED IN OCTOBER 2005 DURING BROWFIELDS PROGRAM SITE
WORK, AND COULD NOT BE LOCATED. A REPLACEMENT WELL, MW-1(s)R WAS INSTALLED BY
CINTAS IN DECEMBER 2007.
2. WELLS MW-17(i) AND MW-17(s) HAVE NOT BEEN SURVEYED, LOCATION IS APPROXIMATE.
100
0
—Asphalt
Parking Lot
0
SCALE IN FEET
1"=100'
100
N
s-
a
c
O
(0
U
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c• o ■'F _a)
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Date: 2022-07-15
Project No.: 60681957

z
0
7
a,
co
North Cherry Street
MW-7(s)
<1.00
May Street
PMW-5(s)
5,410
PMW-6(s)
8.92
Notes:
1. This figure is for conceptual purposes only. Proposed features are subject to change.
2. Injections are expected to be completed in a phased approach.
3. This site plan was constructed from surveys by Slate Surveying Co., PA ( October
2003) and Regional Land Surveyors, Inc. (Januar 2004, October 2004, February 2008,
October 2008, March 2013, and September 2013) . Locations of roads and property lines
were digitiLed from property deed maps and aerial photos obtained from the Forsyth
County, NC Tax Office and from the NC Department of Transportation. This survey does
not represent an accurate boundary survey and should not be used for such purposes.
PMW-3(s)
193
4.5 MW5(s)
0.676 J
MVV-17(s)
1,320
PMW-1(s)
12.2
MW-12(s)
6.45
MW-11(s)
172
aform Bui �4Wm
FS-201
FS-202
FS-203
Gravel
Saprolite Unit
MW-4(s)
184
0
00
0
0
o-
Legend
▪ Boundary of K O V, LLC Property
( Former Salem Uniform )
Former Salem Uniform Building
x Fence (Approx. Location )
Perennial Stream
Intermittent Stream
— Wet Weather Drainage Ditch
Culverted Perennial Stream ( Double )
C Culverted Perennial Stream ( Single )
Q FS-201
B MW-4(s)
m PMW-5(s)
1,350
Storm Sewer / Reinforced Concrete Pipe ( RCP )
Edge of Wooded Area
2022 Proposed DPT Injection Location with IZ ROI
Shallow ( Saprolite Zone) Monitoring Well
Performance Monitoring Well
PCE Concentration (pg/L)
PCE Concentration >1,000 pg/L
PCE Concentration 100 to 1,000 pg/L
PCE Concentration 1 to 100 pg/L
North Cherry Street
Abbreviations
PCE Perchloroethene (Tetrachloroethene )
pg/L micrograms per liter
DPT Direct Push Technology
IZ Injection Zone
ROI Radius of Influence (Approximate)
Notes
1. Well MW-1(s) was destroyed in October 2005 during
Brownfields Program site work, and could not be located.
A replacement well, MW-1(s)R, was installed by Cintas in
December 2007.
2. Samples were collected during March, May or October
2021 sampling events.
3. MW-17(s), PMW-5(s) and PMW-6(s) locations have
not been surveyed, locations are approximate.
4. OConcentrations collected during the May 2021
annual groundwater monitoring event.
80
0
80
SCALE IN FEET 1" = 80'
2021 PCE Isoconcentrations in Groundwater with
0,
0)
O N
0
2
-0 0
co w
cn ♦)
0
V 0
a) Q
• as
a)
0
0
L
a
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co
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oc
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c.)
N
y
a)
E
E a)
a)
L
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N Z
E
O O
NCDEQ ID No. #NONCD0002438
Date: 2022-07-15
Project No.: 60681957

2
ww
North Cherry Street
MW-16(i MW-16(d)
9,310 531
0
MW-8(i)
23
PMW-5(i)
24,100
May Street
Notes:
1. This figure is for conceptual purposes only. Proposed features are subject to change.
2. Injections are expected to be completed in a phased approach.
3. This site plan was constructed from surveys by Slate Surveying Co., PA ( October
2003) and Regional Land Surveyors, Inc. (Januar 2004, October 2004, February 2008,
October 2008, March 2013, and September 2013). Locations of roads and property lines
were digitiD:d from property deed maps and aerial photos obtained from the Forsyth
County, NC Tax Office and from the NC Department of Transportation. This survey does
not represent an accurate boundary survey and should not be used for such purposes.
IW-4
IW-8 0.796J
12.1 W-5
/<250-
<1,000 .,� 769
. IW7
*,.4 4 MW-6(d1 <500
1,510 PMW-1 (i)
� 129
W-1
IW-12 PM.00
.
W-2(i) 506
0.380J PMW-4(i)
<5
<1.00
IW-13/
<100 PMW-3(i)
0.306 J
• 1W-2
y 2.32
MW-5(i)e
5.2
MW\1(s)
M W-1(i)
1.53
e MW-12(i)
Former Salem Uniform Building
Former Concrete Slab
Former
Basement
Slab
Gravel Road
MWW-44(i) x
Legend
▪ Boundary of K ❑ V, LLC Property
( Former Salem Uniform )
— — — Former Salem Uniform Building
—■ — Fence (Approx. Location )
Perennial Stream
• — • — Intermittent Stream
— — Wet Weather Drainage Ditch
Culverted Perennial Stream ( Double )
Culverted Perennial Stream ( Single )
Storm Sewer/ Reinforced Concrete Pipe ( RCP )
Edge of Wooded Area
Power Pole
S MW-60) Intermediate ( Transitional / PWRZone )
Monitoring Well
MW-6(d1) Deep ( Bedrock Zone ) Monitoring Well
�IW-1
554
1
Injection Well with IZ ROI (Approximate)
PCE Concentration (pg/L )
PCE Concentration >10,000 pg/L
PCE Concentration 1,000 to 10,000 pg/L
PCE Concentration 100 to 1,000 pg/L
PCE Concentration 1 to 100 pg/L
Abbreviations
PCE
PWR
IZ
ROI
pg/L
<1.0
North Cherry Street
Perchloroethene ( Tetrachloroethene )
Partially Weathered Rock
Injection Zone
Radius of Influence
micrograms per liter
below laboratory detection limit
Note
1. Well MW-1(s) was destroyed in October 2005 during
Brownfields Program site work, and could not be located.
A replacement well, MW-1(s)R, was installed by Cintas in
December 2007.
2. Samples were collected during March, May or October
2021 sampling events.
3. MW-17(i), PMW-5(i) and IW-3 through IW-13
locations have not been surveyed, locations are
approximate.
80
0
80
SCALE IN FEET 1" = 80'
0
ppli
2022 UIC Permi
2021 PCE Isoconcentrations in Groundwater with
AN
W
0
0
4'
a
0
c.i
a)
a)
cn
0
L
a
0
Z
A �
d)
V �
LL
c
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v (n• v
C N
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co
o
cD O
u) 0
L-
E -c O
d O Z
• i`—
O
N Z w
u, p
U
U r Z
Transitional Unit Intermediate Wells
Date: 2022-07-15
Project No.: 60681957

ARCH D 24" x 36"
Checked: SP
Designer: SRF
Project Management Initials:
Last Plotted: 2022-07-18
SILAS TRIB-SW02
Electrical
Substation
TRIB2(SW)-SW3
SILAS TRIB-SW01
North Cherry Street
TRIB2(SW)-SW2
r//rim
Pool
Note:
This site plan was constructed from surveys by Slate Surveying Co., PA (October 2003 ) and Regional Land Surveyors, Inc. (January
2004, October 2004, February 2008, October 2008, March 2013, and September 2013) . Locations of roads and property lines were
digitiL d from property deed maps and aerial photos obtained from the Forsyth County, NC Tax Office and from the NC Department of
Transportation. This survey does not represent an accurate boundary survey and should not be used for such purposes.
TRIB2(SW)-SW1
RJR-GWO9
Legend
—x
xx—
RJR-G WO7
x—x-T_, x-
Wakefield Court
R J Reynolds
Corporation
Property
Boundary of K 0 V, LLC Property
( Former Salem Uniform )
Former Salem Uniform Building
Fence (Approx. Location )
Perennial Stream
Intermittent Stream
Wet Weather Drainage Ditch
Q RJR-GWO8
Culverted Perennial Stream
( Double )
Culverted Perennial Stream
( Single )
Storm Sewer / Reinforced
Concrete Pipe ( RCP )
Edge of Wooded Area
RJR-GWO5 Q
H
J
RJR-GWO6 Q
Power Pole
Drop Inlet
Abandoned Water Supply Well
Water Supply Well ( inactive )
Abandoned Monitoring Well
A A' Cross Section Transect A - A'
MW-10(d1)
MW-13(d)
MW-13(i)
RJR-GW01
/Asphalt
Parking Lot
RJR-G WO2
r
MW-14(i)
/Asphalt
Parking Lot
• MW-6(s)
S MW-6(i)
MW-6(d1)
yIW-1
Q GW01-2012
SILAS TRIB-SW01
MW-10(i)
MW-9(i)
Tributary Flows Into
Underground Culvert
Pipe at This Point
North Cherry Street
Concrete -Lined
Ditch (03' Wide )
-2
FS-2
FS-2
PMW-5(s)
PMW-5(i)
MC-G WO 1
MW-16(d)
MW-16(i)
MW-7(s) a5
Q MC-GWO3
PMW-6(s)
MW-3(i)
MW-3(s)
Former Retaining Wall
Concrete
Pad
MW-1(s)
MW-1(s)R
PMW-2(s
PMW-4(i)
GW01-2012 W-1
PMW-3(i)
MW-50)Q MW-5(s)
May Street
TRIB1(SE)-SW3
0
TRIB1(SE)-SW2
Dalton Street
t1
0, 0
tts-i
MW-11(s)
1
1
MW-1(i)
FS-2-0W-17(s)i •
FS-203 L — 7,4? MW-4(s)
MW-4(i)1
•
PMW-1(s) •
W-12(i)
MW-12(s)
MW-1(i)
Shallow (Saprolite Zone) Monitoring Well
Intermediate ( Transitional / PWR Zone) Monitoring Well
Deep ( Bedrock Zone) Monitoring Well
Injection Well
DPT Groundwater Sample Location (AECOM, Oct. 2012 )
Surface Water Sample Location (AECOM, 2009 - 2013 )
El
—x
x
x
x
O GP-22 DPT Groundwater Sample Location (CSA Report, AECOM, 2006 )
• FS-201 2022 Proposed DPT Injection Location
Notes
1. WELL MW-1(s) WAS DESTROYED IN OCTOBER 2005 DURING BROWFIELDS PROGRAM SITE
WORK, AND COULD NOT BE LOCATED. A REPLACEMENT WELL, MW-1(s)R WAS INSTALLED BY
CINTAS IN DECEMBER 2007.
2. WELLS MW-17(i) AND MW-17(s) HAVE NOT BEEN SURVEYED, LOCATION IS APPROXIMATE.
Gravel
100
0
0
Asphalt
Parking Lot
100
SCALE IN FEET
1"=100'
s_
O
■
0
J
O
a)
O
0
c
O
U
7O
z
co ■� _a)
F
i.. LL
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c'� cN
OTT; G) > O
'
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E a�U
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E c O
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ac o
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N _lo a
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N U. Z
Date: 2022-07-15
Project No.: 60681957

Approved: SGW ARCH D 24" x 36"
Checked: SGW
Designer: KLR
A ( South )
1,000 —
990 —
980 —
970 —
960 —
950 —
940 —
930 —
920 —
910 —
N
E
900 —
0
w 890 —
880 —
870 —
860 —
850 —
840 —
830 —
820 —
810 —
800 —
SILAS TRIB-SW02 - 20:13
Silas Creek
Alluvial Sediments
Bedrock Outcrop
in Silas Creek
4.3
North Cherr Street/ Re nolds Boulevard Intersection
Saprolite
PWR
Bedrock
RJR-GW15 - 2013
L()
900.18
CROSS SECTION A - A'
R J Reynolds Paved Drive
R J Reynolds
Corporation
Building
R J Reynolds
Entry Drive
2
2
Parking
Lot
Bedrock
N
i
N_
N
M
2
2
Parking
Lot
922.02
i
i
I
rn
RJR-GW01- 2012
as I = 2.7
c
0
U
a)
O�
< 1 = 49.6
a)
a)�
C
i
GP-22 - 2006
_ <5.0
174
wow
woo
woo
w
woo —
Gossett
Road
Residence
Saprolite
PWR
Bedrock
951.30
0
U
2
r
950.05
9,310
450
McCanless
Street
Residence
2
McCanless
Stree.�.� L
1' 000
531
imms ® ® ® Imo 100a ® ® ® ® mow
10
1
GW01-2012
Saprolite
955.91
955,42
900.10
1,510
CROSS SECTION A - A'
J
- 58.6 J
v
Small Wet Weather
Drainage Ditch
o-
12
• 956:68
6.45
0.965
503
,956.85
3.44
Former Salem Uniform Building
2
=11.6
Former
Walk -Out
Basement
Bedrock
PWR
A'(North )
— 1,000
Polo Road
958.57
— 990
— 980
— 970
— 960
950
940
930
920
— 910
))
E
— 900
0
a)
w
— 890
— 880
— 870
— 860
— 850
— 840
— 830
— 820
— 810
— 800
923.40
RJR-GW01- 2012
922.02 ' o
=
—2.7
l o
iU
a)
m
a)
—
1(f)=49.6
a)
•
•
•
`174
maim
Legend
Monitoring Well
Screened Interval
Permanent Injection
Well Location
Permanent Injection
Well Screen
Historic DPT Groundwater
Sample Location
Historic DPT Groundwater
Sample Interval
Proposed DPT
Injection Location
Proposed DPT
Injection Interval
4 Pore Water Sample Location
V Surface Water Sample Location
Lithologic Contact Line
( Dashed Where Inferred )
951.35 Groundwater Potentiometric Elevation
( ft. msl )
p Groundwater Equipotential Surface
( Dashed Where Inferred )
395 PCE Concentration (ug/L) in
Groundwater
PCE Isoconcentration (ug/L )
10 — — — ( Dashed Where Inferred )
General Direction of Vertical Hydraulic
Flow Gradients at Multi -Depth Well Clusters
Fence
Shallow Saprolite Injection Zone
Approximate Radius of Influence (ROI)
Intermediate PWR Injection Zone
Approximate Radius of Influence (ROI)
Lithology Legend
Saprolite
PWR
Bedrock
Sandy Silt to Clayey Silt Saprolite
Partially Weathered Rock ( PWR )
Competent Bedrock ( Biotite Gneiss and Schist )
Abbreviations
DPT Direct Push Technology
ft. msl Feet mean sea level
PCE Perchloroethene ( Tetrachloroethene )
ug/L Micrograms per Liter
Notes
1. Most recent PCE concentrations are shown for each well
on this cross section.
2. Data from DPT locations RJR-6W01 and GP-22 excluded
from PCE contouring.
3. MW-17(s), MW-17(i), and IW-10 locations have not been
surveyed. Ground surface elevation estimated.
VERTICAL SCALE : 1" = 20'
HORIZONTAL SCALE : 1" = 60'
VERTICAL EXAGGERATION : 3x
OL
Cross Section A -A'
njection Locations
with Proposed
Project No.: 60681957

Filename: \\NA.AECOMNET.COM\LFS\AMER\RALEIGH-USRAL3\DCS\PROJECTS\L-AECOM\GEOMATICS\CAD\PROJECTS\C\CINTAS 10287\WINSTON-SALEM NC\FORMER SALEM UNIFORM\2022 07 UIC\FIGURE 7_GW POTENTIOMETRIC MAP SAP SHALLOW. DWG
ARCH D 24" x 36"
Checked: SP
Designer: CC
Project Management Initials:
CO
Electrical
Substation
North Cherry Street
Pepsi Cola
PropertyBottling Co.
Ij
Pool
Note:
This site plan was constructed from surveys by Slate Surveying Co., PA (October 2003 ) and Regional Land Surveyors, Inc. (January
2004, October 2004, February 2008, October 2008, March 2013, and September 2013) . Locations of roads and property lines were
digitiL d from property deed maps and aerial photos obtained from the Forsyth County, NC Tax Office and from the NC Department of
Transportation. This survey does not represent an accurate boundary survey and should not be used for such purposes.
x—x
/ � 1
x
x
R J Reynolds
Corporation
Property
- x
x_ x— x-
Wakefield Drive
•
•
•
a
Wakefield Court
Aspen Court
J
/Asphalt
Parking Lot
Asphalt
Parking Lot
❑ ❑
El
—x
x
x
x
May Street
Dalton Street
North Cherry Street
/ MW-7(s) a5
948.55
■
x
'!
Boundary of K ❑ V, LLC Property
( Former Salem Uniform )
Former Salem Uniform Building
Fence (Approx. Location )
Perennial Stream
Intermittent Stream
Wet Weather Drainage Ditch
Culverted Perennial Stream
( Double )
Culverted Perennial Stream
( Single )
Storm Sewer / Reinforced
Concrete Pipe ( RCP )
Edge of Wooded Area
`a) Power Pole
x —
MW-6(s)
lvivv-1(s)
947.99
Shallow (Saprolite Zone )
Monitoring Well
Abandoned Monitoring Well
Injection Well
Groundwater Potentiometric
Elevation (ft., msl) on
Groundwater Equipotential
950 — — Contour (ft., msl )
Dashed where Inferred
411111111
NG
Not Gauged
Groundwater Flow Direction
MW-3(s)
956.97
MW-1(s)
MW-1(s)R
956.30
956.68
t1
0, 0
41, sle'
ttL $3
W-2
957.45
PMW-1(
NG
MW-12(s)
i7
❑n
Former .lem
Uniform : iding
MW-11(s)
958.57
Asphalt
Parking Lot
t
Notes
1. Well MW-1(s) was destroyed in October 2005 during Brownfields
Program site work, and could not be located. A replacement well,
MW-1(s)R, was installed by Cintas in December 2007.
2. Water level readings collected May 25, 2020.
2. Groundwater elevation for MW-2 not used in contouring
due to anomalous elevation value.
100 0
100
SCALE IN FEET
1"=100'
a
■ rri
E
O
•+.•
a)
0
s_
a)
-o
rri
a)
0
2
N
-
N
E
a)
■
c
O
U
_c
0
z
0
• — wi
QLL
Q
< G)
O •/
}▪ + W
E
C0 0
G
E
^G) G)
L co
CO
M
N
0 0
N LL

Filename: \\NA.AECOMNET.COM\LFS\AMER\RALEIGH-USRAL3\DCS\PROJECTS\L-AECOM\GEOMATICS\CAD\PROJECTS\C\CINTAS 10287\WINSTON-SALEM NC\FORMER SALEM UNIFORM\2022 07 UIC\FIGURE 8_GW POTENTIOMETRIC MAP TRANS INTERMEDIATE.DWG
ARCH D 24" x 36"
Checked: SP
Designer: CC
Project Management Initials:
Electrical
Substation
North Cherry Street
Pepsi Cola
PropertyBottling Co.
Pool
MW-15(i)
900.18
Note:
This site plan was constructed from surveys by Slate Surveying Co., PA (October 2003 ) and Regional Land Surveyors, Inc. (January
2004, October 2004, February 2008, October 2008, March 2013, and September 2013) . Locations of roads and property lines were
digitiL d from property deed maps and aerial photos obtained from the Forsyth County, NC Tax Office and from the NC Department of
Transportation. This survey does not represent an accurate boundary survey and should not be used for such purposes.
x
R J Reynolds
Corporation
Property
- x
x_ x- x- x- x- x-
Wakefield Drive
Wakefield Court
Aspen Court
J
MW-14(i)
NG
MW-9(i)
NG
x— —x
Asphalt
Parking Lo
/Asphalt
Parking Lot
MW-10(i)
918.61
MW-10(d 1)®
cZZ)
x
Legend
\ )1
x
North Cherry S eet
ay Street
Boundary of K ❑ V, LLC Property
( Former Salem Uniform )
Former Salem Uniform Building
—x x— Fence (Approx. Location)
Perennial Stream
Intermittent Stream
Wet Weather Drainage Ditch
Culverted Perennial Stream
( Double )
Culverted Perennial Stream
( Single )
Storm Sewer / Reinforced
Concrete Pipe ( RCP )
Edge of Wooded Area
Power Pole
MW-16(d)
MW-16(i)
950.05
920
MW-8(i)
949.10
x
MW-6(i)
947.83
Concrete
Pad
MW-6(d1)
MW-3(i)
957.61
� V
PMW-2(i)
NG
PMW-4(
NG
MW-5(i)
954.37
x
Intermediate ( Transitional /
PWR Zone) Monitoring Well
Deep ( Bedrock Zone )
Monitoring Well
Abandoned Monitoring Well
Injection Well
Groundwater Potentiometric
Elevation (ft., msl) on
Groundwater Equipotential
Contour (ft., msl) ( dashed where
inferred )
Groundwater Flow Direction
t1
0, 0
41, sle'
ttL $3
MW- i)
957.11
M 1(i)
G MW-12(i)
0956.85
PMW-3(i)
NG
•
Former Salem
Uniform Building
- -a _\
MW-1(s)— —
—T —
L__-�-�-f -�
MW-4(i)
958.27
Gravel
r-\
—Asphalt
Parking Lot
Notes
1. Well MW-1(s) was destroyed in October 2005 during Brownfields
Program site work, and could not be located. A replacement well,
MW-1(s)R, was installed by Cintas in December 2007.
2. Water level readings collected May 25, 2021.
3. NG - Not Gauged
100
0
100
SCALE IN FEET
1"=100'
■ •
Transitiona
c
0
0
_c
u W
co cow
Q ° co
N
O • a) > Q
�;
w
O p Z
E c o
^a wU Z
N E _lo a
CoO CoU
N U. Z
Date: 2021-07-08
Project No.: 60544093.3

Application for Underground Injection Control 60681957
Permit — Attachments
Appendix A
Material Safety Data Sheets
Prepared for: Cintas Corporation, Milford, Ohio AECOM

ABC -Ole January 2019
SAFETY DATA SHEET
ABC-01e
1. PRODUCT AND COMPANY IDENTIFICATION
PRODUCT NAME: ABC -Ole
GENERAL USE: Bioremediation of halogenated organics and metals
MANUFACTURER:
Redox Tech, LLC
200 Quade Drive
Cary, NC 27513
919-678-0140
EMERGENCY TELEPHONE:
Within USA and Canada: 1-800-424-9300
[phone] (collect calls accepted)
2. HAZARDS IDENTIFICATION
EMERGENCY OVERVIEW: Product is generally recognized as safe. May cause irritation
exposure to eyes. Long term contact to skin may cause some drying and minor irritation.
3. COMPOSITION INFORMATION ON INGREDIENTS
Proprietary mixture of fatty acids, glycerol, hydrolyzed vegetable oil, emulsifying agent and
dipotassium phosphate.
4. FIRST AID MEASURES
EYES: Immediately flush with water for up to 15 minutes. If irritation persists, seek medical
attention.
SKIN: Rinse with water. Irritation is unlikely, but if irritation occurs or persists, seek medical
attention.
INGESTION: Generally safe to ingest but not recommended.
INHALATION: No first aid required.
5. FIRE FIGHTING MEASURES
EXTINGUISHING MEDIA: Deluge with water
FIRE/EXPLOSION HAZARDS: Product is combustible only at temperatures above 600C

ABC -Ole January 2019
FIRE FIGHTING PROCEDURES: Use flooding with plenty of water, carbon dioxide or other
inert gasses. Wear full protective clothing and self-contained breathing apparatus. Deluging with
water is the best method to control combustion of the product.
FLAMMABILITY LIMITS: non-combustible
SENSITIVITY TO IMPACT: non -sensitive
SENSITIVITY TO STATIC DISCHARGE: non-senstive
6. ACCIDENTAL RELEASE MEASURES
Confine and collect spill. Transfer to an approved DOT container and properly dispose. Do not
dispose of or rinse material into sewer, stormwater or surface water. Discharge of product to
surface water could result in depressed dissolved oxygen levels and subsequent biological
impacts.
7. HANDLING AND STORAGE
HANDLING: Protective gloves and safety glasses are recommended.
STORAGE: Keep dry. Use first in, first out storage system. Keep container tightly closed when
not in use. Avoid contamination of opened product. Avoid contact with reducing agents.
S. EXPOSURE CONTROLS - PERSONAL PROTECTION
EXPOSURE LIMITS
Chemical Name
ABC
ACGIH
NA
OSHA
NA
NA
ENGINEERING CONTROLS: None are required
PERSONAL PROTECTIVE EQUIPMENT
EYES and FACE: Safety glasses recommended
RESPIRATOR: none -necessary
PROTECTIVE CLOTHING: None necessary
GLOVES: rubber, latex or neoprene recommended but not required
9. PHYSICAL AND CHEMICAL PROPERTIES
Odor:
Appearance:
Auto -ignition Temperature
Boiling Point
none to mild pleasant organic odor
milky
Non-combustible
>600 C

ABC -Ole January 2019
Melting Point NA
Density 0.90 gram/cc
Solubility infinite (miscible)
pH 6-8
10. STABILITY AND REACTIVITY
CONDITIONS TO AVOID: Do not contact with strong oxidizers
STABILITY: product is stable
POLYMERIZATION: will not occur
INCOMPATIBLE MATERIALS: strong oxidizers
HAZARDOUS DECOMPOSITION PRODUCTS:
11. TOXICOLOGICAL INFORMATION
Acute Toxicity
A: General Product Information
Acute exposure may cause mild skin and eye irritation.
B: Component Analysis - LD50/LC50
No information available.
B: Component Analysis - TDLo/LDLo
TDLo (Oral -Man) none
Carcinogenicity
A: General Product Information
No information available.
B: Component Carcinogenicity
Product is not listed by ACGIH, IARC, OSHA, NIOSH, or NTP.
Epidemiology
No information available.
Neurotoxicity
No information available.
12. ECOLOGICALATION
Ecotoxicity
Discharge to water may cause depressed dissolved oxygen and subsequent ecological stresses
Environmental Fate
No potential for food chain concentration

ABC-016 January 2019
13. DISPOSAL CONSIDERATIONS
DISPOSAL METHOD: Material is not considered hazardous, but consult with local, state and
federal agencies prior to disposal to ensure all applicable laws are met.
14. TRANSPORT INFORMATION
NOTE: The shipping classification information in this section (Section 14) is meant as a guide to the overall
classification of the product. However, transportation classifications may be subject to change with changes in
package size. Consult shipper requirements under I.M.O., LC.A.O. (I.A.T.A.) and 49 CFR to assure regulatory
compliance.
US DOT Information
Shipping Name: Not Regulated
Hazard Class: Not Classified
UN/NA #: Not Classified
Packing Group:None
Required Label(s):None
50thEdition International Air Transport Association (IATA):
Not hazardous and not regulated
INTERNATIONAL MARITIME DANGEROUS GOODS (IMDG)
Material is not regulated under IMDG
15. REGULATORY INFORMATION
UNITED STATES
SARA TITLE III
SECTION 311 No Hazard for Immediate health Hazard
SECTION 312 No Threshold Quanitity
SECTION 313 Not listed
CERCLA NOT REGULATED UNDER CERCLA
TSCA NOT REGULATED UNDER TSCA
CANADA (WHIMS): NOT REGULATED
16. OTHER INFORMATION
HMIS:
Health
0
Flammability
0
Physical Hazard
0
Personal Protection
E
E: Safety Glasses, gloves

Zero Valent Iron (ZV[)
June 2016
SAFETY DATA SHEET
Zero Valent Iron (ZVI)
Section I. PRODUCT AND COMPANY IDENTIFICATION
PRODUCT NAME:
GENERAL USE:
MANUFACTURER:
Redox Tech, LLC
200 Quade Drive
Cary, NC 27513
919-678-0140
zvI
Chemical reduction of halogenated organics and -or metals
EMERGENCY TELEPHONE:
Within USA and Canada: 1-800-424-9300
[phone] (collect calls accepted)
Section 2. HAZARDS IDENTIFICATION
Physical state
Emergency Overview
Routes of entry
Potential acute health effects
Eyes
Skin
Inhalation
Ingestion
Potential Chronic Effects:
Medical conditions
Solid (Powder)
Potential dust explosion. Avoid contact with oxidizing agents.
USE WITH CARE.
Follow good industrial hygiene practice
Demal contact. Eye contact. Inhalation. Ingestion.
May cause eye irritation.
No known significant effects or critical hazards
May cause respiratory tract irritation.
No known significant effects or critical hazards.
: Carcinogenic effects: Not classified or listed by IARC, NTP,
OSHA, EU AND ACGIH.
Mutagenic effects: Not available
: Teratogenic effects: Not Available
: Repeated exposure of the eyes to a low level of dust can
produce eye irritation
Section 3. COMPOSITION INFORMATION ON INGREDIENTS
Greater -than 98% Iron CASs 74 9-RO-6
Contains carbon, sulfur and other metal impurities.
Section 4. FIRST AID MEASURES
Eye contact
Skin contact
Inhalation
Check for and remove any contact lenses. In case of contact, immediately
flush eyes with plenty of water for at least 20 minutes. Get medical
attention if imitation occurs
Wash with soap and water. Get medical attention if irritation occurs.
Move person to fresh air. Get medical attention if breathing difficulty
persists

Zero Valent Iron (ZVI) June 2016
Ingestion Do not induce vomiting. Never give anything by mouth to an unconscious
person. Get medical attention if symptoms appear.
Notes to physician: No specific antidote. Material is used as an iron supplement in food and vitamins.
Treatment would be the same as for iron overdose.
Section 5. FIRE FIGHTING MEASURES
Flammability of the product
Fire -fighting media
Special protective
Equipment for fire-fighters
Special remarks on tire
Generally non-flammable but susceptible to dust explosion.
Use a fog nozzle to spray water.
Fire-fighters should wear appropriate protective equipment.
As with any finely granulated product, a risk of dust explosion
is present should the material be dispersed in air and
exposed to a source of ignition. Fine powder can form
flammable and explosive mixtures in air.
Section 6. ACCIDENTAL RELEASE MEASURES
In case of a significant release, take immediate efforts to minimize discharge to surface water
(storm drains, streams, lakes, rivers, etc). If the release occurs in a closed area, take steps to
improve ventilation. If improvement of ventilation is not possible, call the fire department. The
material can be swept up and placed into approved storage containers. Do not use a vacuum to
gather the material because this may result in dispersion of dust particles and increase the risk for
a dust explosion.
Section 7. HANDLING AND STORAGE
The material should be stored in a cool, dry, environment. It is not recomtended to store the material in
the proximity of oxidants. When handling the product, wear a dusk mask, eye protection and gloves. The
product should always be handled in a well ventilated environment.
Section 8. EXPOSURE CONTROLS — PERSONAL
PROTECTION
Engineering controls
Personal protection
Eyes
Respiratory
Hands
Use process enclosures, local exhaust ventilation or other engineering
controls to keep airborne levels below recommended exposure limits. If
user operations generate dust, fumes or mist, use ventilation to keep
exposure to airborne contaminants below the exposure limit.
Safety eyewear complying with an approved standard should be used and
selected based on the t ask being performed and the risks involved (avoid
exposure to liquid splashed, mists, gases or dusts).
Where there is a risk of exposure to high velocity particles safety glasses or face
shield complying with an approved standard should be used to protect against
impact. Where there is a risk of exposure to dusts, goggles should be used.
Recommended: Safety glasses.
Dusk mask or respirator is recommended.
Gloves are recommended

"Zero Valens Iron (ZVI) June 2016
Skin/Body Personal protective equipment for the body should be selected based on the task
being performed and the risks involved. Risk from dermal contact is minimal.
Section 9. PHYSICAL AND CHEMICAL PROPERTIES
Physical State Solid (Powder)
Color Gray
Melting/freezing point 1535°C (2795°F)
Specific gravity 7,88
Bulk density 2.4 to 3.2 g/cm'
Solubility Insoluble in water
Section 10. STABILITY AND REACTIVITY
The product is reactive with oxidizers. Precautions should be taken not to store or contact the
product with oxidizers.
Fine particles of this product (not widely found in this grade) have a potential for a dust
explosion. The product should be handled in a well ventilated area where dust generation is
minitnized.
Section 11. TOXICOLOGICAL INFORMATION
Acute Effects
Eyes May cause eye irritation.
Skin No known significant effects or critical hazards.
Inhalation May cause respiratory tract irritation.
Ingestion No known significant effects or critical hazards.
Chronic Health Effects: Carcinogenic effects: Not classified or listed by IARC, NTP,
OSHA, EU and ACGIH
Section 12. ECOLOGICAL INFORMATION
Will reduce dissolved oxygen levels in aquatic ecosystems. Direct discharge to surface water should be avoided.
Section 13. DISPOSAL CONSIDERATIONS
The generation of waste should be avoided or minimized to the extent practical. Disposal of this product, solutions
and any by-products should be completed in an environmentally responsible manner brat courpties with-a1Hocal,
state and federal laws.
Section 14. TRANSPORT INFORMATION
Classification:
AND/ADR/TDG/DOT/IMDG/IATA: Not regulated.

Zero Valent Iron (ZVI) June 2016
Section 15. REGULATORY INFORMATION
This product is not regulated in the United States and Canada. The user should ensure this
product is not regulated where used.
Section 16. OTHER INFORMATION
Health
0
Fire Hazard
2
Reactivity
1
Personal Protection
C

MG Ingredients
401 N Parsons Ave, STE 107B
Brandon, FL 33511
__(
`
0Ph: [phone] Fax: [phone]
Date: 10/07/2015
SECTION 1: Identification
Product Identifier
Substance name:
CAS No.:
Molecular weight:
Synonyms:
Use of the substance/mixture:
Supplier:
Phone:
Email:
Emergency number:
Product form: Substance
Guar gum
900030-0
1-2 X 106 DALTONS
Guar Cyamopsis, Guar Flour
Thickener, Stabilizer and Emulsifier
MG Ingredients
401 N parsons Ave. STE 10713
Brandon, FL 33510
1-813-661-7048
[e-mail]
1-813-817-5899
SECTION 2: Hazards identification
Classification of the substance
GHS-US classification:
label elements
GHS-US labeling:
Hazard pictograms (GHS-US):
Signal word (GHS-US):
Hazard statements (GHS-US):
Precautionary statements (GHS-US):
NFPA RATING
Not Classified
Not required
Not required
No signal word
Not applicable
If in Eyes:
If swallowed:
If on skin:
If inhaled:
Rinse cautiously with water for several minutes.
Remove contact lenses, if present, Continue rinsing.
Call a doctor if you feel unwell.
Wash with plenty of water.
Move to fresh air and seek medical advice.
HMIS Classification
HEALTH
1
FLAMMABILITY
1
REACTIVITY
0
PERSONAL PROTECTION
E
wwtv,mgingredients.com

MG Ingredients
401 N Parsons Ave, STE 107E
Brandon, FL 33511
Ph: [phone] Fax: [phone]
ECTION 3: Composition/information on ingredients
Component Name
Product Identifier
Weight %
Guar Gum
(CAS No. 9000-30-0)
(EINECS No. 232-536-5)
100
SECTION 4: First aid measures
Description of first aid measures
First -aid measures general: No Special precaution needed
First -aid measures after inhalation: If large quantities of dust are inhaled, keep the airway open. Move
immediately to fresh air and seek Medical advice.
First -aid measures after skin contact: After contact with skin, wash with warm soapy water, If any irritation
persists, seek medical advice
First -aid measures after eye contact: After contact with eyes, flush immediately with plenty of water. If
irritation develops, seek medical advice.
First -aid measures after ingestion: If Guar gum powder is swallowed, seek medical attention may cause
gastrointestinal blockage. Do not give laxatives. Do not induce vomiting unless directed to do so by medical
personnel.
Most important symptoms and effects, both acute and delayed
Symptoms/injuries: Eye irritation.
Symptoms/injuries after inhalation: Coughing, Sore throat, Nasal Congestion, Sneezing and shortness of
breath.
Symptoms/injuries after ingestion: Irritation of the digestive tract, choking, suffocation.
SECTION 5: Firefighting measures
Extinguishing media
Suitable extinguishing media: Water, foam or CO2 extinguishers may be used on fires involving Guar Gum.
Unsuitable extinguishing media: Do not use streams of water as dust dispersed by water streams can explode.
Special hazards arising from the substance or mixture
Fire hazard: Carbon oxides
Explosion hazard: - There is a risk of dust explosion if fine particles mix with air.
Advice for firefighters
Firefighting instructions: Guar gum will burn when in contact with flame but self -extinguishes when the flame
is removed. Promptly isolate the scene by removing all persons from the vicinity of the incident if there is a fire.
No action shall be taken involving any personal risk or without suitable training. Move containers form fire area
if this can be done without risk. Use water spray to keep fire -exposed containers cool.
Protection during firefighting: Fire-fighters should wear appropriate protective equipment and self-contained
breathing apparatus (SCBA) with a full face -piece operated in positive pressure mode.
www.mgingredients.com

MG Ingredients
401 N Parsons Ave, STE 107B
Brandon, FL 33511
Ph: [phone] Fax: [phone]
SECTION 6: Accidental release measures
Personal precautions, protective equipment and emergency procedures
Spilled material may cause a slipping hazard. Avoid dust formation. Keep unnecessary and unprotected
personnel from entering the area. For additional information, refer to section-8: Exposure controls and
personal protection.
Environmental precautions
There is a risk of dust explosion if fine particles mix with air. Prevent from entering into soil, ditches, sewers,
waterways and/or ground water. For additional information, refer to section-12: Ecological information.
Methods and material for containment and cleaning up
For containment: Clean up spills immediately, sweep up or vacuum, then place in to a suitable clean, dry and
properly labeled closed container for disposal. Do not flush affected area with water unless absolutely
necessary. Wetted surfaces can become extremely slippery. If wetted, flush thoroughly with water until all
products is removed.
Methods for cleaning up: Recover dry product by vacuum or brush and shovel.
SECTION 7: Handling and storage
Precautions for safe handling:
Handling: No smoking, open flames or sources of ignition in handling and storage area. Wear appropriate
personal protective equipment. Minimize dust generation and accumulation. Avoid contact with eyes, skin, and
clothing. Keep container tightly closed. Avoid ingestion and inhalation. Ensure adequate ventilation.
Conditions for safe storage, including any incompatibilities:
Storage conditions: Store in a dry, cool and well -ventilated place. Keep container closed when not in use.
incompatible with: Strong -oxidizing agents
SECTION 8: Exposure controls/personal protection
Exposure Limits: Contains no substances with occupational exposure limit
Exposure controls
Appropriate engineering controls : Facilities storing or utilizing this material should be equipped with an
eyewash facility and a safety shower. Use adequate ventilation to keep airborne concentrations
low.
Hand protection
Eye protection
concentrations.
Skin and body protection
Respiratory protection
generates concentrations of dust
: Not normally necessary but standard work gloves recommended.
The use of goggles is recommended if there are heavy dust
Wear appropriate protective clothing to prevent skin exposure.
. A dust respirator is recommended if handling the product
SECTION 9: P sica an. c emica +ro.erties
Information on
Physical state
Appearance
Color
Odor
pH
Melting point
Freezing point
Boiling point
Flash Point
basic physical and chemical properties
Solid
Powder
White to Creamy white
Slight.
A 1% aqueous solution is approx neutral
Decomposed
Not applicable
Not applicable
No data available
ww w.mgingredients.com

MG Ingredients
401 N Parsons Ave, STE 107B
Brandon, FL 33511
�' Ph: [phone] Fax: [phone]
Auto -ignition temperature
Decomposition Temperature
Flammability (solid, gas)
Vapor pressure
Vapor density
Density
Solubility
Viscosity
Other information
No additional information available
>200u C
No data available
No data available
Not applicable
Not applicable
550-850 kg/m3 (depending upon grade)
Soluble but forms very viscous solutions, which become
pasty at concentrations greater than 5%.
Forms viscous solutions with water
SECTION 10: Stability and reactivity
Reactivity
Chemical Stability
Possibility Of Hazardous Polymerization: Will not occur
Conditions To Avoid: Dust Generation
Incompatible Materials: Strong -oxidizing agents.
Hazardous Decomposition Products: Thermal decomposition may produce carbon monoxide and dioxide.
No data available.
Guar gum is stable if stored under cool, dry conditions.
SECTION 11: Toxicological information
Guar gum is natural food additive. Guar gum is widely used in food and in pet food as a thickener, stabilizer and
emulsifier
Information on toxicological effects
Acute toxicity
LD50 oral
LD50 dermal
LC50 inhalation (mg/m3)
>5000 mg/kg (rat)
No data available
No data available
Skin corrosion/irritation: Repeated contact may cause flaking and softening of skin
Eye irritation: The dry powder may cause foreign body irritation in the eyes of some individuals. Corneal injury is
unlikely.
Germ cell mutagenicity: No Data
Available
Carcinogenicity: Not classified
Reproductive toxicity: Not classified
Specific target organ toxicity (single exposure): May cause respiratory sensitization.
Specific target organ toxicity (repeated exposure): Excessive inhalation of dust may cause slight irritation and
can impede respiration owing to the hydrophilic nature of the gum, which can form a gel in the airway.
Aspiration hazard: Not classified
Symptoms/injuries after inhalation: Coughing, Sore throat, Nasal Congestion, Sneezing and shortness of breath.
Symptoms/injuries after eye contact: eye irritation.
Symptoms/injuries after ingestion: Irritation of the digestive tract, choking, suffocation.
ECTION 12: Ecological information
Eco Toxicity
Guar Gum is not expected to be harmful to the ecology.
Persistence and degradability
'vww.nigingredients.com

MG Ingredients
401 N Parsons Ave, STE 107E
Brandon, FL 33511
Ph: [phone] Fax: [phone]
Guar gum is biodegradable in waste treatment facilities when well diluted.
Bio accumulative potential
No data available
Mobility in soil
No data available
SECTION 13: Disposal considerations
Waste treatment methods: Guar gum does not meet the criteria of a hazardous waste if discarded in its
purchased form. Under RCRA, it is the responsibility of the user of the product to determine at the time of
disposal, whether the product meet RCRA criteria for hazardous waste. This is because product user,
transformations, mixtures, processes etc., may render the resulting materials hazardous.
Empty containers retain residues. All labeled precautions must be observed.
Waste disposal recommendations: Dispose of in a permitted industrial landfill. Ensure that containers are
empty prior to disposal in a permitted industrial landfill. Do not dump down in sewers or drainage as this may
cause blockage.
SECTION 14: Transport information
Not regulated as hazardous material No special requirements and no restrictions on transportation by land, sea or air.
U.S. Department of Transportation (DOT): Not Regulated
IMDG CODE: Not Regulated
IATA: Not Regulated
SECTION 15: Regulatory information
Guar gum is an EC permitted Food Additive (E-412).
Guar gum is approved as a direct food additive by WHO/FAO and in the United States by FDA regulation 121.104 -
"Generally Recognized as Safe" (GRAS)
TSCA Inventory status : All ingredients are listed on the TSCA inventory.
DSCL (EEC) : All ingredients are listed on the DSCL Inventory.
California Propusition65 : Not listed
: Not listed
Not listed
: Not listed
: Not listed
: Not listed
SARA 302
SARA 311
SARA 312
SARA 313
WHMIS Canada
SECTION 16: Other information
Creation Date: 15/05/2015
Revision/Review-Date:-No-previous revision/review. -
Disclaimer: The information and recommendations contained in this Safety Data Sheet have been
compiled from sources believed to be reliable and to represent the most reasonable current opinion
on the subject when the SDS was prepared. No warranty, guaranty or representation is made as to the
correctness or sufficiency of the information, The user of this product must decide what safety
measures are necessary to safety use this product, either alone or in combination with other products,
and determine its environmental regulatory compliance obligations under any applicable federal or
state laws.
W<vw.urgingred ienis. com

MG Ingredients
401 N Parsons Ave, STE 107E
Brandon, FL 33511
Ph: [phone] Fax: [phone]
Abbreviations:
CAS Chemical Abstract Service
GHS Globally Harmonized System of Classification and Labeling of Chemicals
NFPA National Fire Protection Association
HMIS Hazardous Material Information System
LD50 Lethal Dose expected to cause death in 50% of the test animals
FDA United States Food and Drug Administration
WHO World Health Organization
FAO Food and Agriculture Organization of the United Nations
IATA International Air Transport Association
EINECS European Inventory of Existing Commercial Chemical Substances
OSHA U.S. Department of Labor, Occupational safety and health administration
IMDG International Maritime Dangerous Goods.
RCRA Resource Conservation and Recovery Act
www.mgingredients.com

EnviroBlend
Metal Waste Treatment, ,r,;, w uecra. ,E
Issue Date 01-Dec-2014
Revision Date 12-April-2017
SAFETY DATA SHEET
Version 1
1. IDENTIFICATION OF THE SUBSTANCE/PREPARATION AND OF THE COMPANY/UNDERTAKING
Product identifier
Product Name
ENVIROBLEND® 93 HR 325
Other means of identification
Product Code ENVIROBLEND® 93 HR 325
Synonyms Light Burned Magnesium Oxide, Caustic Calcined Magnesia, MgO, Magnesium Oxide,
Recommended use of the chemical and restrictions on use
Recommended Use Heavy metals remediation product.
Uses advised against No information available
Details of the supplier of the safety data sheet
Manufacturer Address
Premier Magnesia, LLC, 75 Giles Place, Waynesville, NC 28786
Emergency telephone number
Company Phone Number 828-452-4784
24 Hour Emergency Phone Number Chemtrec 1-800-424-9300
Emergency Telephone Chemtrec 1-800-424-9300
2. HAZARDS IDENTIFICATION
Classification
OSHA Regulatory Status
Product dust is classified as a "nuisance particulate, not otherwise regulated" as specified by ACGHI and OSHA. The excessive,
long-term inhalation of mineral dusts may contribute to the development of industrial bronchitis, reduced breathing capacity, and
may lead to the increased susceptibility to lung disease. This chemical is not considered hazardous by the 2012 OSHA Hazard
Communication Standard (29 CFR 1910.122)
Not a dangerous substance or mixture according to the Globally Harmonized System (GHS)
Label elements
Emergency Overview
The product contains no substances which at their given concentration, are considered to be hazardous to health
Appearance Fine Powder
Physical state Solid Odor Odorless
Causes mild irritation to the eyes
Low toxicity by skin contact.
Chronic overexposure by inhalation of airborne particulate may irritate upper respiratory system as well as the throat.
Ingestiomis ans.rnlikeiy rQute_of exposure. If ingested in large amounts it may cause irritation, nausea, vomiting, diarrhea,
abdominal pain, black stool, pink urine, coma and possibly death.
Hazards not otherwise classified (HNOC)
Other Information
Unknown Acute Toxicity
100% of the mixture consists of ingredient(s) of unknown toxicity
3. COMPOSITIONIINFORMATION ON INGREDIENTS
Page 1 f 7

ENVIROBLEND® 93 HR 325
Revision Date 12-April-2017
Common name
Synonyms
Magnesium Oxide # 1309-48-4.
Light Burned Magnesium Oxide, Caustic Calcined Magnesia, MgO, Magnesium Oxide,
Chemical Name
Magnesium Oxide
CAS No.
1309-48-4
Weight-%
100
Trade Secret
4. FIRST AID MEASURES
First aid measures
Eye contact
Skin Contact
Inhalation
Ingestion
Rinse thoroughly with plenty of water, also under the eyelids. (Get medical attention
immediately if irritation persists.).
Wash skin with soap and water.
Remove to fresh air. If breathing has stopped, give artificial respiration. Get medical
attention immediately.
Not an expected route of exposure. Drink 1 or 2 glasses of water. Never give anything by
mouth to an unconscious person. Do not induce vomiting without medical advice.
Immediate medical attention is required.
Most important symptoms and effects, both acute and delayed
Symptoms No information available.
Indication of any immediate medical attention and special treatment needed
Note to physicians Treat symptomatically.
5. FIRE -FIGHTING MEASURES
Suitable extinguishing media
Use extinguishing measures that are appropriate to local circumstances and the surrounding environment.
Unsuitable extinguishing media Water reacts with magnesium oxide producing magnesium hydroxide and heat. Do not
allow water to get inside containers: reaction with water will cause product to swell,
generate heat, and burst its container. If contact is unavoidable, use sufficient water to
safely absorb the heat that may be generated.
Specific hazards arising from the chemical
No information available.
Explosion data
Sensitivity to Mechanical Impact None.
Sensitivity to Static Discharge None.
Protective equipment and precautions for firefighters
As in any fire, wear self-contained breathing apparatus pressure -demand, MSHA/NIOSH (approved or equivalent) and full
protective gear.
6. ACCIDENTAL RELEASE MEASURES
Personal precautions, protective equipment and emergency procedures
Personal precautions
Environmental precautions
Ensure adequate ventilation, especially in confined areas.
Page 217

ENVIROBLEND a 93 FIR 325
Revision Date 12-April-2017
Environmental precautions See Section 12 for additional ecological information.
Methods and material for containment and cleaning up
Methods for containment Prevent further leakage or spillage if safe to do so.
Methods for cleaning up
Carefully clean up and place material into a suitable container, being careful to avoid
creating excessive dust. If conditions warrant, clean up personnel should wear approved
respiratory protection, gloves and goggles to prevent irritation from contact and/or
inhalation.
7. HANDLING AND STORAGE
Precautions for safe handling
Advice on safe handling
Use personal protective equipment as required.
Conditions for safe storage, including any incompatibilities
Storage Conditions Keep container tightly closed in a dry and well -ventilated place. Avoid generation of dust.
Do not allow contact with water.
Incompatible materials
Interhalogens, bromine pentacuoride, chlorine trifluoride. Contact with aluminum metal may
release hydrogen gas. Incandescent reaction wtih phosphorus pentachloride. Water will
react with magnesium oxide to form magnesium hydroxide and release heat and steam.
8. EXPOSURE CONTROLS/PERSONAL PROTECTION
Control parameters
Exposure Guidelines
Chemical Name
Magnesium Oxide
1309-48-4
This product, as supplied, does not contain any hazardous materials with occupational
ex osure limits established b the re ion s ecific re.ulato bodies.
ACGIH TLV
TWA: 10 mg/m3 inhalable fraction
OSHA PEL
TWA: 15 mgim3 fume, total
particulate
(vacated) TWA: 10 mglm3 fume
and total particulate
NIOSH IDLH
IDLH: 750 mglm3 fume
NIOSH IDLH Provide workers wth NIOSH approved respirators in accordance with requirements of 29 CFR 1910. 134 for level of
exposure incurred.
Appropriate engineering controls
Engineering Controls Provide sufficient ventilation, in both volume and air flow patterns to control mist/dust
concentrations below allowable exposure limits. Showers. Eyewash stations.
Individual protection measures. such as personal protective equipment
Eye/face protection
Skin and body protection
Respiratory protection
Avoid contact with eyes. The use of eye protection is recommended.
The use of eye protection, gloves and long sleeve clothing Is recommended.
Provide workers with NIOSH approved respirators in accordance with requirements of 2
CFR 1910. 134 for level of exposure incurred.
General Hygiene Considerations Wash hands thoroughly after handling.
9. PHYSICAL AND CHEMICAL PROPERTIES
Information on basic physical and chemical properties
Page 3/7

ENVIROBLEND® 93 HR 325 Revision Date 12-April-2017
Physical state
Appearance
Color
Property
pH
Melting point/freezing point
Boiling point/ boiling range
Flash point
Evaporation rate
Flammability (solid, gas)
Flammability Limit in Air
Upper flammability limit:
Lower flammability limit:
Vapor pressure
Vapor density
Specific Gravity
Water solubility
Solubility in other solvents
Partition coefficient
Autoignition temperature
Decomposition temperature
Kinematic viscosity
Dynamic viscosity
Explosive properties
Oxidizing properties
Other Information
Softening point
Molecular weight
VOC Content (%)
Density
Bulk density
Solid
Fine Powder
Brownish
Values
10-11
>2100 °C >3600 °F
No information available
No information available
Not Applicable
No information available
No information available
No information available
No information available
No information available
3.56
Slight <1%
No information available
No information available
No information available
No information available
No information available
No information available
No information available
No information available
No information available
No information available
No information available
No information available
40-60 Ib/ft3
Odor
Odor threshold
Re ma r k s
Odorless
No information available
• Met hod
10. STABILITY AND REACTIVITY
Reactivity
No data available
Chemical stability
Stable under recommended storage conditions.
Possibility of Hazardous Reactions
None under normal processing.
Hazardous polymerization Hazardous polymerization does not occur.
Conditions to avoid
Extremes of temperature and direct sunlight.
Incompatible materials
Interhalogens, bromine pentafluoride, chlorine trifluoride. Contact with aluminum metal may release hydrogen gas. Incandescent
reaction wtih phosphorus pentachloride. Water will react with magnesium oxide to form magnesium hydroxide and release heat
and steam.
Hazardous Decomposition Products
Heat and steam,
11. TOXICOLOGICAL INFORMATION
Page 4 / 7

ENVIROBLEND® 93 HR 325 Revision Date 12-April-2017
Information on likely routes of exposure
Product Information Magnesium Oxide # 1309-48-4
Inhalation Inhalation of fume (not Mg0 dust particulate) produced upon decomposition of magnesium
compounds can produce a febrile reaction and leukocytosis in humans.
Eye contact
Skin Contact
Ingestion
No data available.
No data available.
No data available
Information on toxicological effects
Symptoms No information available.
Delayed and immediate effects as well as chronic effects from short and long-term exposure
Sensitization
Germ cell mutagenicity
Carcinogenicity
Reproductive toxicity
STOT - single exposure
STOT - repeated exposure
Aspiration hazard
Numerical measures of toxicity
Unknown Acute Toxicity
No information available.
No information available.
No information available.
No information available.
No information available.
No information available.
No information available
- Product Information
100% of the mixture consists of ingredient(s) of unknown toxicity
12. ECOLOGICAL INFORMATION
Ecotoxicitv
No data available on any adverse effects of this material on the environment
100% of the mixture consists of components(s) of unknown hazards to the aquatic environment
Persistence and degradability
No information available.
Eioaccumulation
No information available.
Other adverse effects
No information available
13. DISPOSAL CONSIDERATIONS
Waste treatment methods
Disposal of wastes
This produce does not exhibit any characteristics of a hazardous waste. The product is
suitable for landfill disposal once the free water component is evaporated or absorbed by a
suitable absorbent (earth). Follow all applicable federal, state and local regulations for safe
disposal.
Contaminated packaging Do not reuse container.
Page 5 17

ENVIROBLEND® 93 HR 325
Revision Date 12-April-2017
14. TRANSPORT INFORMATION
DOT
Not regulated Not regulated by DOT as a hazardous material No hazard class, label or
placard required, no UN or NA number assigned.
15. REGULATORY INFORMATION
International Inventories
TSCA
Complies
Chemical Name
TSCA
DSLINDSL
EINECSIELINCS
ENCS
IECSC
KECL
PICCS
A1CS
X - Listed
Magnesium Oxide
Complies
Complies
Complies
Complies
Complies
Complies
Complies
TSCA - United States Toxic Substances Control Act Section 8(b) Inventory
DSLINDSL - Canadian Domestic Substances List/Non-Domestic Substances List
EINECSIELINCS - European Inventory of Existing Chemical Substances/European List of Notified Chemical Substances
ENCS - Japan Existing and New Chemical Substances
IECSC - China Inventory of Existing Chemical Substances
KECL - Korean Existing and Evaluated Chemical Substances
PICCS - Philippines Inventory of Chemicals and Chemical Substances
AICS - Australian Inventory of Chemical Substances
US Federal Regulations
SARA 313
This product does not contain any substances reportable under Sections 302, 304 or 313. Sections 311 and 312 do apply. (Routine
Reporting and Chemical Inventories)
SARA 3111312 Hazard Categories
Acute health hazard No
Chronic Health Hazard No
Fire hazard No
Sudden retease_of.pressure _hazard No
Reactive Hazard No
CWA (Clean Water Act)
This product does not contain any substances regulated as pollutants pursuant to the Clean Water Act (40 CFR 122.21 and 40
CFR 122.42)
Page 61 7

ENVIROBLEND® 93 HR 325 Revision Date 12-April-2017
CERCLA
This material, as supplied, does not contain any substances regulated as hazardous substances under the Comprehensive
Environmental Response Compensation and Liability Act (CERCLA) (40 CFR 302) or the Superfund Amendments and
Reauthorization Act (SARA) (40 CFR 355). There may be specific reporting requirements at the local, regional, or state level
pertaining to releases of this material
US State Regulations
California Proposition 65
This product does not contain chemicals known to the State of California to cause cancer, birthdefects or other reproductive toxins.
U.S. State Right -to -Know Regulations
Chemical Name
Magnesium Oxide
1309-48-4
U.S. EPA Label Information
EPA Pesticide Registration Number Not Applicable
New Jerse
X
Massachusetts
X
Penns Ivania
X
16. OTHER INFORMATION
NFPA
HMIS
Issue Date
Revision Date
Revision Note
No information available
Disclaimer
The information provided in this Safety Data Sheet is correct to the best of our knowledge, information and belief
at the date of its publication. The information given is designed only as a guidance for safe handling, use, processing,
storage, transportation, disposal and release and is not to be considered a warranty or quality specification. The
information relates only to the specific material designated and may not be valid for such material used in combination
with any other materials or in any process, unless specified in the text.
End of Safety Data Sheet
Health hazards 1 Flammability 0
Health hazards 0
Instability 0
Flammability 0 Physical hazards 0
Physical and Chemical
Properties -
Personal protection X
01-Dec-2014
12-April-2017
Page 7 f 7

SAFETY DATA SHEET
Cargill
1. Identification
Product identifier
Other means of identification
Synonyms
Recommended use
Recommended restrictions
High Fructose Corn Syrup
Not available.
HFCS/sweetener blends
Not available.
None known.
Manufacturer/Importer/Supplier/Distributor information
Company name Cargill, Incorporated
Address Minneapolis, MN 55440
US
Telephone General Information:
E-mail Not available.
Emergency phone number
2. Hazard(s) identification
Physical hazards
Health hazards
OSHA defined hazards
Label elements
Hazard symbol
Signal word
Hazard statement
Precautionary statement
Prevention
Response
Storage
Disposal
Hazard(s) not otherwise
classified (HNOC)
Supplemental information
Not applicable.
1-800-370-7386
24 Hour Emergency: 1-800-424-9300
Not classified.
Not classified.
Not classified.
None.
None.
The mixture does not meet the criteria for classification.
Observe good industrial hygiene practices.
Wash hands after handling.
Store away from incompatible materials.
Dispose of waste and residues in accordance with local authority requirements.
None known.
3. Composition/information on ingredients
Mixtures
Chemical name
CAS number
0/0
High fructose corn syrup
977042-84-4
100
4. First -aid measures
Inhalation
Skin contact
Eye contact
Ingestion
Most important
symptoms/effects, acute and
delayed
Move to fresh air. Call a physician if symptoms develop or persist.
Wash off with soap and water. Get medical attention if irritation develops and persists.
Rinse with water. Get medical attention if irritation develops and persists.
Rinse mouth. Get medical attention if symptoms occur.
Direct contact with eyes may cause temporary irritation.
High Fructose Corn Syrup
920718 Version #: 01 Revision date: - Issue date: 19-June-2014
SDS US
1/5

Indication of immediate
medical attention and special
treatment needed
Treat symptomatically.
General information
5. Fire -fighting measures
Suitable extinguishing media
Unsuitable extinguishing
media
Specific hazards arising from
the chemical
Special protective equipment
and precautions for firefighters
Fire -fighting
equipment/instructions
Specific methods
Ensure that medical personnel are aware of the material(s) involved, and take precautions to
protect themselves.
Water fog. Foam. Dry chemical powder. Carbon dioxide (CO2).
None known.
During fire, gases hazardous to health may be formed.
Self-contained breathing apparatus and full protective clothing must be worn in case of fire.
In the event of fire, cool tanks with water spray.
Cool containers exposed to flames with water until well after the fire is out.
6. Accidental release measures
Personal precautions,
protective equipment and
emergency procedures
Methods and materials for
containment and cleaning up
Environmental precautions
7. Handling and storage
Precautions for safe handling
Conditions for safe storage,
including any incompatibilities
Keep unnecessary personnel away. Wear appropriate personal protective equipment. Ensure
adequate ventilation.
Large Spills: Stop the flow of material, if this is without risk. Dike the spilled material, where this is
possible. Absorb in vermiculite, dry sand or earth and place into containers. Following product
recovery, flush area with water.
Small Spills: Wipe up with absorbent material (e.g. cloth, fleece). Clean surface thoroughly to
remove residual contamination.
Avoid discharge into drains, water courses or onto the ground.
Use with adequate ventilation. Wear appropriate personal protective equipment. Avoid direct
contact with eyes.
Keep container tightly closed. Store in a well -ventilated place. Store away from incompatible
materials (see Section 10 of the SDS).
8. Exposure controls/personal protection
Occupational exposure limits
Biological limit values
Appropriate engineering
controls
No exposure limits noted for ingredient(s).
No biological exposure limits noted for the ingredient(s).
General ventilation normally adequate.
Individual protection measures, such as personal protective equipment
Eye/face protection If contact is likely, safety glasses with side shields are recommended.
Skin protection
Hand protection
Other
Respiratory protection
Thermal hazards
General hygiene
considerations
Wear suitable gloves.
Wear suitable protective clothing.
In case of insufficient ventilation, wear suitable respiratory equipment.
Wear appropriate thermal protective clothing, when necessary.
Always observe good personal hygiene measures, such as washing after handling the material
and before eating, drinking, and/or smoking. Routinely wash work clothing and protective
equipment to remove contaminants.
9. Physical and chemical properties
Appearance
Physical state
Form
Color
Odor
Colorless to slightly yellow liquid.
Liquid.
Syrupy liquid.
Colorless to slightly yellow.
Odorless.
High Fructose Corn Syrup
920718 Version #: 01 Revision date: - Issue date: 19-June-2014
SDS US
2/5

Odor threshold Not available.
pH Not available.
Melting point/freezing point Not available.
Initial boiling point and boiling 230 °F (110 °C)
range
Flash point Not available.
Evaporation rate Not available.
Flammability (solid, gas) Not available.
Upper/lower flammability or explosive limits
Flammability limit - lower Not available.
(0/0 )
Flammability limit - upper Not available.
(%)
Explosive limit - lower (%) Not available.
Explosive limit - upper (%) Not available.
Vapor pressure Not available.
Vapor density Not available.
Relative density 1.35
Solubility(ies)
Solubility (water) Complete
Partition coefficient Not available.
(n-octanol/water)
Auto -ignition temperature Not available.
Decomposition temperature Not available.
Viscosity Not available.
10. Stability and reactivity
Reactivity
The product is stable and non -reactive under normal conditions of use, storage and transport.
Chemical stability Material is stable under normal conditions.
Possibility of hazardous
reactions
Conditions to avoid
Incompatible materials
Hazardous decomposition
products
No dangerous reaction known under conditions of normal use.
Contact with incompatible materials.
Strong oxidizing agents.
No hazardous decomposition products are known.
11. Toxicological information
Information on likely routes of exposure
Ingestion Ingestion may cause irritation and malaise.
Inhalation No adverse effects due to inhalation are expected.
Skin contact May cause skin irritation.
Eye contact May cause eye irritation.
Symptoms related to the Irritant effects.
physical, chemical and
toxicological characteristics
Information on toxicological effects
Acute toxicity
Skin corrosion/irritation
Serious eye damage/eye
irritation
Respiratory or skin sensitization
Respiratory sensitization
Skin sensitization
Occupational exposure to the substance or mixture may cause adverse effects.
Prolonged skin contact may cause temporary irritation.
Direct contact with eyes may cause temporary irritation.
No data available.
No data available.
High Fructose Corn Syrup
920718 Version #: 01 Revision date: - Issue date: 19-June-2014
SDS US
3/5

Germ cell mutagenicity No data available to indicate product or any components present at greater than 0.1 % are
mutagenic or genotoxic.
Carcinogenicity This product is not considered to be a carcinogen by IARC, ACGIH, NTP, or OSHA.
Reproductive toxicity No data available.
Specific target organ toxicity - No data available.
single exposure
Specific target organ toxicity - No data available.
repeated exposure
Aspiration hazard No data available.
12. Ecological information
Ecotoxicity Not expected to be harmful to aquatic organisms.
Persistence and degradability No data is available on the degradability of this product.
Bioaccumulative potential No data available for this product.
Mobility in soil No data available.
Other adverse effects No other adverse environmental effects (e.g. ozone depletion, photochemical ozone creation
potential, endocrine disruption, global warming potential) are expected from this component.
13. Disposal considerations
Disposal instructions Collect and reclaim or dispose in sealed containers at licensed waste disposal site.
Hazardous waste code
Waste from residues / unused
products
Contaminated packaging
The waste code should be assigned in discussion between the user, the producer and the waste
disposal company.
Dispose of in accordance with local regulations. Empty containers or liners may retain some
product residues. This material and its container must be disposed of in a safe manner (see:
Disposal instructions).
Since emptied containers may retain product residue, follow label warnings even after container is
emptied.
14. Transport information
DOT
Not regulated as dangerous goods.
IATA
Not regulated as dangerous goods.
IMDG
Not regulated as dangerous goods.
Transport in bulk according to Not established.
Annex II of MARPOL 73/78 and
the IBC Code
15. Regulatory information
US federal regulations This material is not listed on the US TSCA 8(b) Inventory, therefore it may only be used for TSCA
Exempt purposes such as R&D or Food, Drug or Cosmetic use.
TSCA Section 12(b) Export Notification (40 CFR 707, Subpt. D)
Not regulated.
US. OSHA Specifically Regulated Substances (29 CFR 1910.1001-1050)
Not listed.
CERCLA Hazardous Substance List (40 CFR 302.4)
Not listed.
Superfund Amendments and Reauthorization Act of 1986 (SARA)
Hazard categories Immediate Hazard - No
Delayed Hazard - No
Fire Hazard - No
Pressure Hazard - No
Reactivity Hazard - No
SARA 302 Extremely hazardous substance
Not listed.
SARA 311/312 Hazardous No
chemical
High Fructose Corn Syrup
920718 Version #: 01 Revision date: - Issue date: 19-June-2014
SDS US
4/5

SARA 313 (TRI reporting)
Not regulated.
Other federal regulations
Clean Air Act (CAA) Section 112 Hazardous Air Pollutants (HAPs) List
Not regulated.
Clean Air Act (CAA) Section 112(r) Accidental Release Prevention (40 CFR 68.130)
Not regulated.
Safe Drinking Water Act Not regulated.
(SDWA)
US state regulations
US. Massachusetts RTK - Substance List
Not regulated.
US. New Jersey Worker and Community Right -to -Know Act
Not listed.
US. Pennsylvania Worker and Community Right -to -Know Law
Not listed.
US. Rhode Island RTK
Not regulated.
US. California Proposition 65
US - California Proposition 65 - Carcinogens & Reproductive Toxicity (CRT): Listed substance
Not listed.
International Inventories
Country(s) or region Inventory name On inventory (yes/no)*
Australia Australian Inventory of Chemical Substances (AICS) No
Canada Domestic Substances List (DSL) No
Canada Non -Domestic Substances List (NDSL) No
China Inventory of Existing Chemical Substances in China (IECSC) No
Europe European Inventory of Existing Commercial Chemical No
Substances (EINECS)
Europe European List of Notified Chemical Substances (ELINCS) No
Japan Inventory of Existing and New Chemical Substances (ENCS) No
Korea Existing Chemicals List (ECL) No
New Zealand New Zealand Inventory No
Philippines Philippine Inventory of Chemicals and Chemical Substances No
(PICCS)
United States & Puerto Rico Toxic Substances Control Act (TSCA) Inventory No
"A "Yes" indicates this product complies with the inventory requirements administered by the governing country(s).
A "No" indicates that one or more components of the product are not listed or exempt from listing on the inventory administered by the governing
country(s).
16. Other information, including date of preparation or last revision
Issue date 19-June-2014
Revision date -
Version # 01
Disclaimer The information contained herein is believed to be true and accurate. However, all statements,
recommendations or suggestions are made without any guarantee, representation or warranty,
express or implied, on our part. Therefore, no warranty is made or to be implied that the
information set out in this document is accurate or complete, and we accordingly exclude all
liability in connection with the use of this information or the products referred to herein. All such
risks are assumed by the purchaser/user. For the avoidance of doubt, however, nothing in this
document excludes or limits our liability for death or personal injury caused by our negligence or
for fraudulent misrepresentation.
High Fructose Corn Syrup
920718 Version #: 01 Revision date: - Issue date: 19-June-2014
SDS US
5/5

SIGMA-ALDRICH
Material Safety Data Sheet
Version 3.0
Revision Date 06/26/2007
Print Date 08/31/2009
1. PRODUCT AND COMPANY IDENTIFICATION
Product name : Sodium bicarbonate
Product Number : S6014
Brand : Sigma -Aldrich
Company : Sigma -Aldrich
3050 Spruce Street
SAINT LOUIS MO 63103
USA
Telephone : [phone]
Fax : [phone]
Emergency Phone # : [phone]
2. COMPOSITION/INFORMATION
ON INGREDIENTS
Synonyms : Natron
Sodium hydrogen carbonate
Formula : NaHCO3
Molecular Weight : 84.01 g/mol
CAS -No. EC -No. Index -No. Concentration [%]
Sodium hydrogencarbonate
144-55-8 205-633-8 - -
3. HAZARDS IDENTIFICATION
Emergency Overview
OSHA Hazards
No OSHA Hazards
HMIS Classification
Health Hazard: 1
Flammability: 0
Physical hazards: 0
NFPA Rating
Health Hazard: 0
Fire 0
Reactivity Hazard 0
Potential Health Effects
Inhalation May be harmful if inhaled. May cause respiratory tract irritation.
Skin May be harmful if absorbed through skin. May cause skin irritation.
Sigma -Aldrich Corporation
Sigma -Aldrich - S6014 www.sigma-aldrich.com Page 1 of 5

Eyes May cause eye irritation.
Ingestion May be harmful if swallowed.
4. FIRST AID MEASURES
If inhaled
If breathed in, move person into fresh air. If not breathing give artificial respiration
In case of skin contact
Wash off with soap and plenty of water.
In case of eye contact
Flush eyes with water as a precaution.
If swallowed
Never give anything by mouth to an unconscious person. Rinse mouth with water.
5. FIRE -FIGHTING MEASURES
Flammable properties
Flash point no data available
Ignition temperature no data available
Suitable extinguishing media
Use extinguishing measures that are appropriate to local circumstances and the surrounding environment.
Special protective equipment for fire-fighters
Wear self contained breathing apparatus for fire fighting if necessary.
Further information
The product itself does not burn.
6. ACCIDENTAL RELEASE MEASURES
Personal precautions
Avoid dust formation.
Environmental precautions
Do not let product enter drains.
Methods for cleaning up
Sweep up and shovel. Keep in suitable, closed containers for disposal.
7. HANDLING AND STORAGE
Handling
Provide appropriate exhaust ventilation at places where dust is formed.
Storage
Keep container tightly closed in a dry and well -ventilated place.
8. EXPOSURE CONTROLS / PERSONAL PROTECTION
Contains no substances with occupational exposure limit values.
Personal protective equipment
Respiratory protection
Respiratory protection is not required. Where protection from nuisance levels of dusts are desired, use type N95
(US) or type P1 (EN 143) dust masks. Use respirators and components tested and approved under appropriate
government standards such as NIOSH (US) or CEN (EU).
Hand protection
For prolonged or repeated contact use protective gloves.
Sigma -Aldrich Corporation
Sigma -Aldrich - S6014 www.sigma-aldrich.com Page 2 of 5

Eye protection
Safety glasses
Hygiene measures
General industrial hygiene practice.
9. PHYSICAL AND CHEMICAL PROPERTIES
Appearance
Form solid
Colour no data available
Safety data
pH no data available
Melting point 300 °C (572 °F)
Boiling point no data available
Flash point no data available
Ignition temperature no data available
Lower explosion limit no data available
Upper explosion limit no data available
Density 2.160 g/cm3
Water solubility no data available
10. STABILITY AND REACTIVITY
Storage stability
Stable under recommended storage conditions.
Conditions to avoid
Avoid moisture.
Materials to avoid
Strong acids, Strong oxidizing agents
Hazardous decomposition products
Hazardous decomposition products formed under fire conditions.
Carbon oxides, Sodium oxides
11. TOXICOLOGICAL INFORMATION
Acute toxicity
LD50 Oral - rat - 4,220 mg/kg
Irritation and corrosion
Skin - Human - Mild skin irritation - 3 d
Eyes - rabbit - Mild eye irritation - 30 s
Sensitisation
no data available
Chronic exposure
no data available
Sigma -Aldrich Corporation
Sigma -Aldrich - S6014 www.sigma-aldrich.com
Page 3 of 5

Signs and Symptoms of Exposure
Exposure to large amounts can cause:, Gastrointestinal disturbance, Heavy or prolonged skin exposure may result in
the absorption of harmful amounts of material.
Potential Health Effects
Inhalation May be harmful if inhaled. May cause respiratory tract irritation.
Skin May be harmful if absorbed through skin. May cause skin irritation.
Eyes May cause eye irritation.
Ingestion May be harmful if swallowed.
12. ECOLOGICAL INFORMATION
Elimination information (persistence and degradability)
no data available
Ecotoxicity effects
no data available
Further information on ecology
no data available
13. DISPOSAL CONSIDERATIONS
Product
Observe all federal, state, and local environmental regulations.
Contaminated packaging
Dispose of as unused product.
14. TRANSPORT INFORMATION
DOT (US)
Not dangerous goods
IMDG
Not dangerous goods
IATA
Not dangerous goods
15. REGULATORY INFORMATION
OSHA Hazards
No OSHA Hazards
TSCA Status
On TSCA Inventory
DSL Status
All components of this product are on the Canadian DSL list.
SARA 302 Components
SARA 302: No chemicals in this material are subject to the reporting requirements of SARA Title III, Section 302.
SARA 313 Components
SARA 313: This material does not contain any chemical components with known CAS numbers that exceed the
threshold (De Minimis) reporting levels established by SARA Title III, Section 313.
SARA 311/312 Hazards
Acute Health Hazard
Sigma -Aldrich - S6014
Sigma -Aldrich Corporation
www.sigma-aldrich.com
Page 4 of 5

Massachusetts Right To Know Components
No Components Listed
Pennsylvania Right To Know Components
Sodium hydrogencarbonate
New Jersey Right To Know Components
Sodium hydrogencarbonate
California Prop. 65 Components
This product does not contain any chemicals known to State of California to cause cancer, birth, or any other
reproductive defects.
CAS -No.
144-55-8
Revision Date
Revision Date
CAS -No.
144-55-8
16. OTHER INFORMATION
Further information
Copyright 2007 Sigma -Aldrich Co. License granted to make unlimited paper copies for internal use only., The above
information is believed to be correct but does not purport to be all inclusive and shall be used only as a guide. The
information in this document is based on the present state of our knowledge and is applicable to the product with
regard to appropriate safety precautions. It does not represent any guarantee of the properties of the product. Sigma -
Aldrich Co., shall not be held liable for any damage resulting from handling or from contact with the above product.
See reverse side of invoice or packing slip for additional terms and conditions of sale.
Sigma -Aldrich - S6014
Sigma -Aldrich Corporation
www.sigma-aldrich.com
Page 5 of 5

SIGMA-ALDRICH
Material Safety Data Sheet
Version 3.0
Revision Date 06/26/2007
Print Date 08/31/2009
1. PRODUCT AND COMPANY IDENTIFICATION
Product name : Sodium bicarbonate
Product Number : S6014
Brand : Sigma -Aldrich
Company : Sigma -Aldrich
3050 Spruce Street
SAINT LOUIS MO 63103
USA
Telephone : [phone]
Fax : [phone]
Emergency Phone # : [phone]
2. COMPOSITION/INFORMATION
ON INGREDIENTS
Synonyms : Natron
Sodium hydrogen carbonate
Formula : NaHCO3
Molecular Weight : 84.01 g/mol
CAS -No. EC -No. Index -No. Concentration [%]
Sodium hydrogencarbonate
144-55-8 205-633-8 - -
3. HAZARDS IDENTIFICATION
Emergency Overview
OSHA Hazards
No OSHA Hazards
HMIS Classification
Health Hazard: 1
Flammability: 0
Physical hazards: 0
NFPA Rating
Health Hazard: 0
Fire 0
Reactivity Hazard 0
Potential Health Effects
Inhalation May be harmful if inhaled. May cause respiratory tract irritation.
Skin May be harmful if absorbed through skin. May cause skin irritation.
Sigma -Aldrich Corporation
Sigma -Aldrich - S6014 www.sigma-aldrich.com Page 1 of 5

Eyes May cause eye irritation.
Ingestion May be harmful if swallowed.
4. FIRST AID MEASURES
If inhaled
If breathed in, move person into fresh air. If not breathing give artificial respiration
In case of skin contact
Wash off with soap and plenty of water.
In case of eye contact
Flush eyes with water as a precaution.
If swallowed
Never give anything by mouth to an unconscious person. Rinse mouth with water.
5. FIRE -FIGHTING MEASURES
Flammable properties
Flash point no data available
Ignition temperature no data available
Suitable extinguishing media
Use extinguishing measures that are appropriate to local circumstances and the surrounding environment.
Special protective equipment for fire-fighters
Wear self contained breathing apparatus for fire fighting if necessary.
Further information
The product itself does not burn.
6. ACCIDENTAL RELEASE MEASURES
Personal precautions
Avoid dust formation.
Environmental precautions
Do not let product enter drains.
Methods for cleaning up
Sweep up and shovel. Keep in suitable, closed containers for disposal.
7. HANDLING AND STORAGE
Handling
Provide appropriate exhaust ventilation at places where dust is formed.
Storage
Keep container tightly closed in a dry and well -ventilated place.
8. EXPOSURE CONTROLS / PERSONAL PROTECTION
Contains no substances with occupational exposure limit values.
Personal protective equipment
Respiratory protection
Respiratory protection is not required. Where protection from nuisance levels of dusts are desired, use type N95
(US) or type P1 (EN 143) dust masks. Use respirators and components tested and approved under appropriate
government standards such as NIOSH (US) or CEN (EU).
Hand protection
For prolonged or repeated contact use protective gloves.
Sigma -Aldrich Corporation
Sigma -Aldrich - S6014 www.sigma-aldrich.com Page 2 of 5

Eye protection
Safety glasses
Hygiene measures
General industrial hygiene practice.
9. PHYSICAL AND CHEMICAL PROPERTIES
Appearance
Form solid
Colour no data available
Safety data
pH no data available
Melting point 300 °C (572 °F)
Boiling point no data available
Flash point no data available
Ignition temperature no data available
Lower explosion limit no data available
Upper explosion limit no data available
Density 2.160 g/cm3
Water solubility no data available
10. STABILITY AND REACTIVITY
Storage stability
Stable under recommended storage conditions.
Conditions to avoid
Avoid moisture.
Materials to avoid
Strong acids, Strong oxidizing agents
Hazardous decomposition products
Hazardous decomposition products formed under fire conditions.
Carbon oxides, Sodium oxides
11. TOXICOLOGICAL INFORMATION
Acute toxicity
LD50 Oral - rat - 4,220 mg/kg
Irritation and corrosion
Skin - Human - Mild skin irritation - 3 d
Eyes - rabbit - Mild eye irritation - 30 s
Sensitisation
no data available
Chronic exposure
no data available
Sigma -Aldrich Corporation
Sigma -Aldrich - S6014 www.sigma-aldrich.com
Page 3 of 5

Signs and Symptoms of Exposure
Exposure to large amounts can cause:, Gastrointestinal disturbance, Heavy or prolonged skin exposure may result in
the absorption of harmful amounts of material.
Potential Health Effects
Inhalation May be harmful if inhaled. May cause respiratory tract irritation.
Skin May be harmful if absorbed through skin. May cause skin irritation.
Eyes May cause eye irritation.
Ingestion May be harmful if swallowed.
12. ECOLOGICAL INFORMATION
Elimination information (persistence and degradability)
no data available
Ecotoxicity effects
no data available
Further information on ecology
no data available
13. DISPOSAL CONSIDERATIONS
Product
Observe all federal, state, and local environmental regulations.
Contaminated packaging
Dispose of as unused product.
14. TRANSPORT INFORMATION
DOT (US)
Not dangerous goods
IMDG
Not dangerous goods
IATA
Not dangerous goods
15. REGULATORY INFORMATION
OSHA Hazards
No OSHA Hazards
TSCA Status
On TSCA Inventory
DSL Status
All components of this product are on the Canadian DSL list.
SARA 302 Components
SARA 302: No chemicals in this material are subject to the reporting requirements of SARA Title III, Section 302.
SARA 313 Components
SARA 313: This material does not contain any chemical components with known CAS numbers that exceed the
threshold (De Minimis) reporting levels established by SARA Title III, Section 313.
SARA 311/312 Hazards
Acute Health Hazard
Sigma -Aldrich - S6014
Sigma -Aldrich Corporation
www.sigma-aldrich.com
Page 4 of 5

Massachusetts Right To Know Components
No Components Listed
Pennsylvania Right To Know Components
Sodium hydrogencarbonate
New Jersey Right To Know Components
Sodium hydrogencarbonate
California Prop. 65 Components
This product does not contain any chemicals known to State of California to cause cancer, birth, or any other
reproductive defects.
CAS -No.
144-55-8
Revision Date
Revision Date
CAS -No.
144-55-8
16. OTHER INFORMATION
Further information
Copyright 2007 Sigma -Aldrich Co. License granted to make unlimited paper copies for internal use only., The above
information is believed to be correct but does not purport to be all inclusive and shall be used only as a guide. The
information in this document is based on the present state of our knowledge and is applicable to the product with
regard to appropriate safety precautions. It does not represent any guarantee of the properties of the product. Sigma -
Aldrich Co., shall not be held liable for any damage resulting from handling or from contact with the above product.
See reverse side of invoice or packing slip for additional terms and conditions of sale.
Sigma -Aldrich - S6014
Sigma -Aldrich Corporation
www.sigma-aldrich.com
Page 5 of 5

Safety Data Sheet
Shaw Environmental, Inc.
17 PRINCESS ROAD
LAWRENCEVILLE, N.J. 08648
[phone]
SECTION 1 - MATERIAL IDENTIFICATION AND INFORMATION
Material Name: DHC microbial consortium (RTB-1 SDC-9) MSDS #: ENV
1033
Date Prepared: 10/06/2003 CAS #: N/A (Not Applicable)
Prepared By: Simon Vainberg Formula #: N/A
Material Description: Non -hazardous, naturally occurring non -altered anaerobic
microbes and enzymes in a water -based medium.
24 HOUR EMERGENCY RESPONSE PHONE NUMBER [phone]
SECTION 2 - INGREDIENTS
Components % OSHA ACGIH OTHER
PEL TLV LIMITS
Non -Hazardous Ingredients 100 N/A N/A N/A
SECTION 3 - PHYSICAL/CHEMICAL CHARACTERISTICS
Boiling Point: 100.. C (water) Specific Gravity (H20 = 1): 0.9 - 1.1
Vapor Pressure @ 25" C: 24 mm Hg (water) Melting Point: 0" C (water)
Vapor Density: N/A Evaporation Rate (H20 = 1): 0.9 - 1.1
Solubility in Water: Soluble Water Reactive: No
pH: 6.0 - 8.0
Appearance and Odor: Murky, yellow water. Musty odor.

MATERIAL SAFETY DATA SHEET FOR DHC consortium (RTB-1)
PAGE 2 OF 4
October 6, 2003
SECTION 4 - FIRE AND EXPLOSION HAZARD DATA
Flash Point: N/A
Flammable Limits: N/A
Extinguishing Media: Foam, carbon dioxide, water
Special Fire Fighting Procedures: None
Unusual Fire and Explosion Hazards: None
SECTION 5 - REACTIVITY DATA
Stability: Stable
Conditions to Avoid: None
Incompatibility (Materials to Avoid): Water -reactive materials
Hazardous Decomposition Byproducts: None
SECTION 6 - HEALTH HAZARD DATA
HEALTH EFFECTS
The effects of exposure to this material have not been determined. Safe handling of
this material on a long-term basis will avoid any possible effect from repetitive acute
exposures. Below are possible health effects based on information from similar
materials. Individuals hyper allergic to enzymes or other related proteins should not
handle.
Ingestion: Ingestion of large quantities may result in abdominal discomfort including
nausea, vomiting, cramps, diarrhea, and fever.
Inhalation: Hypersensitive individuals may experience breathing difficulties after
inhalation of aerosols.
Skin Absorption: N/A

MATERIAL SAFETY DATA SHEET FOR DHC consortium (RTB-1)
PAGE 3 OF 4
October 6, 2003
Skin Contact: May cause skin irritation. Hypersensitive individuals may experience
allergic reactions to enzymes.
Eye Contact: May cause eye irritation.
FIRST AID
Ingestion: Get medical attention if allergic symptoms develop (observe for 48 hours).
Never give anything by mouth to an unconscious or convulsing person.
Inhalation: Get medical attention if allergic symptoms develop.
Skin Absorption: N/A
Skin Contact: Wash affected area with soap and water. Get medical attention if
allergic symptoms develop.
Eye Contact: Flush eyes with plenty of water for at least 15 minutes using an eyewash
fountain, if available. Get medical attention if irritation occurs.
NOTE TO PHYSICIANS: All treatments should be based on observed signs and
symptoms of distress in the patient. Consideration should be given to the possibility
that overexposure to materials other than this material may have occurred.
SECTION 7 - SPILL AND LEAK PROCEDURES
Reportable quantities (in Ibs of EPA Hazardous Substances): N/A
Steps to be taken in case of spill or release: No emergency results from spillage.
However, spills should be cleaned up promptly. All personnel involved in the cleanup
must wear protective clothing and avoid skin contact. Absorb spilled material or
vacuum into a container. After clean-up, disinfect all cleaning materials and storage
containers that come in contact with the spilled liquid.
Waste Disposal Method: No special disposal methods are required. The material may
be sewered, and is compatible with all known biological treatment methods. To reduce
odors and permanently inactivate microorganisms, mix 100 parts (by volume) of DHC
consortium with 1 part (by volume) of bleach. Dispose of in accordance with local, state
and federal regulations.

MATERIAL SAFETY DATA SHEET FOR DHC consortium (RTB-1)
PAGE 4 OF 4
October 6, 2003
SECTION 8 - HANDLING AND STORAGE
Hand Protection: Rubber gloves.
Eye Protection: Safety goggles with side splash shields.
Protective Clothing: Use adequate clothing to prevent skin contact.
Respiratory Protection: Surgical mask.
Ventilation: Provide adequate ventilation to remove odors.
Storage & Handling:
Material may be stored for up to 3 weeks at 2-4.. C without aeration.
Other Precautions: An eyewash station in the work area is recommended.
While the information and recommendations set forth herein are believed to be
accurate as of the date hereof, Shaw Environmental, Inc. MAKES NO WARRANTY
WITH RESPECT HERETO AND DISCLAIMS ALL LIABILITY FROM RELIANCE
THEREON.

Application for Underground Injection Control 60681957
Permit — Attachments
Appendix B
Well Construction Records
Prepared for: Cintas Corporation, Milford, Ohio AECOM

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Fur Internal Use ONLY
1. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A - 4121
NC We'1 Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
Lisr a8 applicable well cansrracrian pernars (i.r. Cathay Snare, Variance, ere )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ lndustrial/Commerc ial
❑ Irrigation
Non -Water Supply Well:
❑ Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑ Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Date Well(s) Completed: 10/28/19
5a. Well Location:
C I NTAS
Sr7Groundwaler Remedtation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well 1D#
IW-3
Facility 'Ow•ner Name Facility 1 D. (if applicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address, City and Zip
FORSYTH
County Parcel Menu ficauon No. (PIN)
56. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lei:Iong is sufficient)
36° 08' 27.85" N 80° 15' 49.40" W
6. Is (are) the well(s): RIPermanent or OTemporary
7. Is this a repair to an existing well: . Yes or 121No
IJ rhos is a repair fill out known well Conlin, lion information and explain the nature rJ the
repent under .21 remarks set time or on the hack oJ'this farm.
8. Number of wells constructed: 1
1.1e' rgrrhtple infection ar nave -water supp. s wells ONLY with the same construction. you can
Inferno one farm.
9. Total well depth below land surface: 88•0 (ft.)
roe nndnple u•e.s hsr au depths eel th/ferent (example. 38 200' and 2 r(100'1
10. Static water level below top of casing: 20.0 (ft.)
f'warer level es above lasing. use -. -
I1. Borehole diameter: 12.0/7.875 (in.)
12. Well construction method: AUGER/AIR
pse auger, rotary. cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. 1 ield (gpm)
Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
rt.
R.
ft.
rt.
IS. OUTER CASING (for multi -eased wells) OR LINER (if op livable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
ft.
rt.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 rt.
58.0 ft.
4.0 In.
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
58.0 r'•
88.0 ft.
4.0 i'
.010
SCH 40
PVC
rt.
rt.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 °•
53.0 fl.
PORTWeaaEMTOwTE
SLURRY
D.
R.
ft.
Ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
56.0 ft.
88.0 rt'
20-40
FINE SILICA SAND
rt.
rt.
20. DRILLING
LOG (attach additional sheers if necessary)
FROM
TO
DESCRIPTION (valor, hardness, sail/reck type, grain size, err.)
0.0 r'•
15.0 rt.
BROWN SANDY SILT
15.0 ft•
35.0 ft•
RED CLAYEY SILT
35.0 rt•
50.0 ft.
RED SANDY SILT
50.0 fr•
60.0 ft.
BROWN SANDY SILT
60.0 ft.
74.0 ft.
PWR
74.0 ft-
86.0 ft-
WEATHERED ROCK
86.0 r'•
88.0 rt•
ROCK
21. REMARKS
BENTONITE SEAL FROM 53.0 TO 56.0 FEET
22. Certification:
,eayt,
Signature ofCertified Well Contractor
11/25/19
Date
N!'swung llas form, I hereby 'o1 f' rhar the sell/) was (were) constructed ire accordance
with I5A N('A(' 02C 0100 or 15,4 NCA(' 02C .0201 Well Construction Standards and rhea u
copy rJ olds record has been prorieled to the hell 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 Weill: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lniection Wells: 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 Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above.. also submit one copy of this form within 30 days of
completion of well construction to the county health department of the count).
where constructed.
Form GW-I
Nonh Carolina Department of En,. ronment and Nation. Resources Division of Water Quality Revised kui 20I

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A- 4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit 8:
1.isr all applicable well construction permits Me. ('mint'. State. Variance. ere'.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Healing/Cooling Supply)
Olndustrial/Commercial
❑Irrigalton
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection WeII:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
4. Dale Well(s) Completed:
5a. Nell Location:
C I NTAS
®Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
OTracer
❑Other (explain under #2I Remarks)
10/25/19 Well MN
Facility/Owner Name
IW-4
Facility ID'. ( fapplicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address, City, and Zip
FORSYTH
County Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one Iatilong is sufficient)
36° 08' 27.85" N 80° 15' 49.40"
6. Is (are) the well(s): l2tPermanent or ❑Temporary.
W
7. Is this a repair to an existing well: ❑Yes or ErlNo
lidos is a repair. Jill our known well construction information and explain Mr nrvrirc of the
repair under a21 remarks .seeIio n or on the hack of this fiirnr.
S. Number of wells constructed: 1
For multiple injeciiao or non -water sty.r.I' hells ONLY ...th rh, Name el instructiern. tut. z aft
submit one firrvn.
9. Total well depth below land surface: 90'0 (ft.)
1•irr nimrhiple wells list all depths if dig rend (example- 3Fi:'lei' and 1@ l (N7•}
10. Static water level below top of casing: 20' 0 (ft.)
lj halt r leiel is ahem; casing, use "_
11. Borehole diameter: 12.0/7.875 (in,)
12. Well construction method: AUGER/AIR
(i c. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. field (gpm) Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
rt.
ft.
IS. OUTER CASING (for multi -cased wells) OR LINER (If ap Iieable)
FROMTHICKNESS MATERIAL
TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loopy
FROM
TO
DIAMETER
TIIICKNESS
MATERIAL
0.0 ft.
60.0 rr.
4.0
in.
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
60.0 n.
90.0 re.
4.0 in,
.010
SCH 40
PVC
n.
n.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & A1+IOUNr
0.0 rt.
55.0 fl'
PO"TWAa0MTOMIE
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (If applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
58.0 rt.
90.0 rt.
20-40
FINE SILICA SAND
rt.
rt.
20. DRILLING LOG (attach additional sheet if necessary)
FROM
TO
DESCRIPTION teaktr, hardness, saiLtrock type, Brain sire, etc I
0.0 n.
15.0 n•
15.0 ft.
35.0 n.
BROWN SANDY SILT
RED CLAYEY SILT
35.0 rt.
50.0 n•
RED SANDY SILT
50.0 n•
60.0 n.
BROWN SANDY SILT
60.0 n,
78.0 rt,
PWR
78.0 IL
88.0 D'
WEATHERED ROCK
88.0 n.
90.0 n•
ROCK
21. REMARKS
BENTONITE SEAL FROM 55.0 TO 58.0 FEET
22. Certification:
,/e/14-^
11 /25/19
Signature of Certified Well Contractor Date
Hy signing this frrnr. 1 hereby certify Mai the well(s) was (were) constructed in accordance
with 15A N('.4(' 01(' 0100 or 15A N( A(' 02(' 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 ',tse the back of this page to provide additional well site details or +veil
construction details. You may also attach additional pages if'necessary
SUBMITTALINSTUCTIONS
24a. Fur All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: 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 Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, 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 OW. t
North Carolina Department of Environment and Natural Resources Division of Water Quality Revised Jan. 20I'+

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY
I. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Nome
A-4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. WeII Construction Permit N:
Lin all applicable well e'rrmrtrnc'Iioii permits (i.e. ('aunty. Stare. Variance. arc'.)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
()Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑Aqua er Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (HeatingiCooling Return)
IZIGroundwater Remediatton
❑Salinity Barrier
❑Stormwater Drainage
❑ Subsidence Control
❑ Tracer
❑Other (explain under 821 Remarks)
4. Date Well(s) Completed: 10/23/19 Well 1DN
5a. Well Location:
CINTAS
IW-5
Facility/Owner Nanie Facility IDt (if applicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address, City, and Zip
FORSYTH
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell Feld, one Wong. is sufficient)
36° 08' 27.85" N 80° 15' 49.40"
6. Is (are) the well(s): (7IPermanent or ❑Temporary
W
7, Is this a repair to an existing well: ❑Yes or EINo
If this is a repair, fill ma known irell cwrstrunian nrrprmarian and explain the nature of the
repair carder e21 remarks section or an the back of this firm.
8. Number of wells constructed:
!'or nrnhiple d fecnan or parr -haler supply wells ONI.Y with the same construction. YOU can
submit one film
9. Total well depth below land surface: 88'0 (ft.)
or multiple rrc!!s '.rt all rkpeke if dii/rrenr (example- 3@2W' and 2@I00')
PkStatir water level below top of casing: 20.0 (ft.)
r} rater k rel ix able caring, use "
I I. Borehole diameter: 12.0/7.875 (in.)
12. Well construction method: AUGER/AIR
e auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of lest:
13b. Disinfection type: Amount:
1.1. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
R.
ft.
IS. OUTER CASING (for multi -cased wells) OR LINER (if appllivable)
FROM
TO
DIAMETER
THICKNESS MATERIAL
rt.
rt.
in.
[
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
58.0 f6
4.0 i"
SCH 40
PVC
ft.
rt.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
58.0 ft'
88.0 f•
4.0 i"'
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD &AsIOUN'r
0.0 It
53.0 ft-
PORTwtliacRrone
SLURRY
ft.
ft.
ft.
rt.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
56.0 f"
88.0 f"
20-40
FINE SILICA SAND
ft.
re.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, sail/roek type, grain size, etc.)
0.0 ft'
15.0 ft'
BROWN SANDY SILT
15.0 ft•
35.0 f'•
RED CLAYEY SILT
35.0 ft,
50.0 f"
RED SANDY SILT
50.0 f'•
60.0 R.
BROWN SANDY SILT
60.0 f•
70.0 '
PWR
70.0 11-
86.0 f'•
WEATHERED ROCK
86.0 f •
88.0 f'•
ROCK
2f. REMARKS
BENTONITE SEAL FROM 53.0 TO 56.0 FEET
22, Certification:
Signature of Certified Well Contractor
11/25/19
Date
Hy signing this firrni, 1 hereby certify dun the "'e!l(s) bras (here{ consirucied rn arc ar,/rur:x'
with 1.5A N('A(' 02(' .d101) or i5A N('A(' 02(' ,11200 Wei/ (instruction Standards curl dun a
copy of this record has been prarided ra Ilia argil! miner.
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 Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lnieetion Wells: In addition to sending the form to the address in 24a
above, also submit a cop} of this form with_n 30 days of completion of well
construction to the following
Division of Water Quality, Underground injection C'onlrol Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water SuoDIv & Injection Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
completion of well constriction 10 the county health department of the counl.k
where constructed
Form OW-1
North Carolina Department of Enerrannteni an
d Natural Resources Divis.on of Water Quality Revised lair ?:UI x

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
For Internal Use ONLY
I. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A-4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Nome
2. Well Construction Permit if:
List all applicable well construction permits (i.e. County STare, Variance, etc.)
3. Well Use (check well use):
]Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑ Irrigation
Non -Wider Supply Well:
❑Monitoring
❑Municipal/Public
❑ Residential Water Supply (single)
❑ Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
o Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
®Groundwater Remediation
❑Salinity Barrier
OStormwater Drainage
❑Subsidence Control
❑Tracer
❑ Other (explain under N21 Remarks)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
f1.
IS. OUTER CASING {for multi -cased wells} OR LINER (if ap legible)
FROM THICKNESS MATERIAL
TO
R.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal dosed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
58.0 rt.
4.0
in.
SCH 40
PVC
n.
n.
in.
17. SCREEN
FROM
58.0 °'
TO
88.0 fI.
DIAMETER
4.0 in.
SLOT SIZE
.010
THICKNESS
SCH 40
MATERIAL.
PVC
rt.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
53.0 ft'
PORMNa9ENTp0TE
SLURRY
re.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
56.0 f.
88.0
20-40
FINE SILICA SAND
n.
n.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft.
TO
15.0 ft
DESCRIPTION (solar, hardness, soil/rock type, grain sine, etc.}
BROWN SANDY SILT
4. Date Well(s) Completed: 1 OI22r'19 Well IDN
Sa. Well Location:
CINTAS
IW-6
Factlity'Owner Name Facility ION (if applicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address. City and Zip
FORSYTH
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° 08' 27.85" N 80° 15' 49.40"
6. Is (are} the well(s): tOPermanent or ❑Temporary
W
7. Is this a repair to an existing well: L1Yes or ElNo
If dos is a repair, fill out known well construction kfrmarian and csplain the nature in' the
repair under 21 remarks .s.etion or on the back ,.f this fermi.
8. Number of wells constructed: 1
For multiple infechon r,r rum-lrarer supply •cells ONLY with the same construction, you can
xahntit one. farm
9. Total well depth below land surface:
Fier multiple wells list all depths of dith,rent rexanplc- 3@200• and 2©I(N.t
88.0
(ft.)
ID. Static water level below top of casing: 20'0 (ft.)
if wafer keel rr shot c caxlrrk, DSC .. ..
11. Borehole diameter:
12.0/7.875 (in.)
12. Well construction method: AUGER/AIR
(Le auger rotary, cable. direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. ] ietd (gpm) Method of test:
13b. Disinfection type: Amount:
15.0 ft
35.0 fr.
RED CLAYEY SILT
35.0 ft.
50.0 ft
RED SANDY SILT
50.0 R•
60.0
BROWN SANDY SILT
60.0 ft.
70.0 ft.
PWR
70.0 ff.
86.0 ft.
WEATHERED ROCK
86.0 °'
88.0 n•
ROCK
21. REMARKS
BENTONITE SEAL FROM 53.0 TO 56.0 FEET
22. Certification:
Signature of Certified Well Contractor
11/25/19
Dale
By signing tlus fisrnr, I hereby certify that the trel!(ti) was (were) constructed in aC.anhume
with 15A N(il (' 024' ,0100 or 15A MA(' 02(' 0200 Well ('orrstnavian Standards end rloo r+
copy ill 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. Fur All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
I617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: 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 Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Infection Wells: In addition to sending the form to
the address(es) above, 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
d Natural Resources - Division of Water Quality Res iscd kin 201

WELL CONSTRUCTION RECORD
This farm can he used for single or multiple wells
For Internal Use ONLY.
1. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A- 4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
1 rst all applicable irell constructor ',erodes (i.e. County, Scale, Variance, ere)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
Olndustnal/Commerc la!
°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 d2l Remarks)
4. Date Well(s) Completed: 10/21/19
Sa. Well Location:
C I NTAS
Well ID#
IW-7
FacilityfOwner Name Facility ID# (if applicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address, City, and Zip
FORSYTH
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one tat/long is sufficient)
36° 08' 27.85" N 80° 15' 49.40"
6. Is (are) the well(s): ©Permanent or °Tempuras)
W
. Is this a repair to an existing well: O1'es or DNo
l f tltc Ls a repair. fill our kuau'n urr construction urfnrrnaran and explran the murure of the
repair under :.21 remarks section ur-rm the had of obis frirri.
R. Number of wells constructed: 1
1•ar multiple infection or tun-watermrpply axles ONLY rrifli ohs same construction. Jai, ten
Tabour are form.
9. Total well depth below land surface: 90.0 (ft.)
i•ar multiple hells het all depths if ...Oren( (v.. ample- 3 tr 200' and i@11x', 1
10. Static water level below top of casing: 20'0 (ft.)
yl'irarerlevel is ahore caving. use -.
11. Borehole diameter: 12.0/7.875 (in.)
12. Well construction method: AUGER/AIR
(i e. anger, rotary, cable, direct push. etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:....
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15, OUTER CASING (for multi -cased wells) OR LINER (if ap icable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft'
60.0 R.
4.0 in'
SCH 40
PVC
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
60.0 ft.
90.0 f'-
4.0 ft'
.010
SCH 40
PVC
ff.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD &AMOLNT
0.0 ft.
55.0 re.
PoenANoaeerormr
SLURRY
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
58.0 rt
90.0 ft-
20-40
FINE SILICA SAND
R.
R.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION Kolar, hardness, soiVroek type, grain size, err.)
0.0 ft'
15.0 re.
BROWN SANDY SILT
15.0 ft.
35.0 It
RED CLAYEY SILT
35.0 ft.
50.0 ft
RED SANDY SILT
50.0 ft-
60.0 r''
BROWN SILT
60.0 R-
88.0 ft
PWR
88.0 rt.
90.0 r'•
ROCK
ft.
R.
21. REMARKS
BENTONITE SEAL FROM 55.0 TO 58.0 FEET
22. Certification:
/e/142.--"
11/25/19
Signature of Certified Well Contractor Date
fly signing ilia fore. 1 hereby certify that the weft tear (lure/ constructed in uccorrkui.:
with 15.4 IV( 'A( 1.12(' .01(l0 or IJA N('Ar 02(' 020(1 Well f'nitctrucror Standurdc urid that
rri(rt' of this record lac 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 %yell
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 follow;ng.
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: 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 fo-lowing
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the c0un1)
where constructed
Form GW-I
North Carolina Department of Environment and Natural Resource s - Ui, is ii i or Water Quality Revised JOB : ,1'

WELL CONSTRUCTION RECORD
This form can be used for single or mWtiple wells
For Internal Use ONLY
I. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A - 4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applcable well construction permits (i.e. ('aunty, State, Variance. etc.)
3. Well Use (check well use):
Vi'ater Supply Well:
❑Agricultural
❑ Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
❑ Monitoring
❑ Municipal/Public
j Rcsldenllal Water Supply (single)
Residential Water Supply (shared)
rJ Recovery
Injection Well:
❑Ayuiter Recharge
❑Ayuiter Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
❑ Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
®Groundwater Remedial ton
❑Salinity Barrier
❑Stormwater Drainage
°Subsidence Control
❑Tracer
❑tither (explain under 0021 Remarks)
4. Date Well(s) Completed: 10/30119 Well ID#
5a. Well Location:
C I NTAS
IW-8
Facility/Owner Name Facility IDF Of applicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Ph).; ...ill .Address. !'icy, 0.0 Zip
FORSYTH
Ccairn.. Parcel Idenoftcauon No. (PIN)
5b. 1 atitude and Longitude in degrees/minutes/seconds or decimal degrees:
if well Geld. one . it/long i.; si_ffcient)
36° 08' 27.85"
80° 15' 49.40"
6. Is (are) the well(s): (Permanent or ❑Temporary
W
7. Is this a repair 10 an existing well: OYes or IZINo
the r rs ri repair, r:0 ton krwtrn well construction information and explain the irenurc a(the
rcpnrr under 21 remark, ...worm or an the bark of this furor.
8. Number of wells constructed: 1
multiple injection ar iron -water supply wr4's ONLY with the sane canrtructkm, you can
.submit ant' firrnr.
9. Total well depth below land surface: 91.0
l•nr n,idt.;ple hells hi.' all ;,kruhs rfiI jf rent (example- 3 ,2000 • and 2 l00)
(ft.)
10. Static water level below top of casing: 20.0 (ft.)
11 "ewer km/ rsalxm..catrog, rare •• ,.
I1. Borehole diameter: 8'0 (in.)
12. Well construction method: AUGER
li.e anger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
rt.
15. OUTER CASING (for multi -eased wells) OR LINER (if ap livable)
FROM THICKNESS 1 MATERIAL
TO
rt.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 n.
61.0 R.
2.0
in.
SCH 40
PVC
ft.
rt.
in.
17, SCREEN
FROM
TO
DIAMETER
SLOTSIZR
THICKNESS
MATERIAL
61.0 rt.
91.0 fe.
2.0 is
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPIACEMENTMETHOD & AMIN NT
0.0 rr.
56.0 It-
PORTLAND BENTONITE
SLURRY
ft.
ft.
ft.
R.
19. SANDIGRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
59.0 f'
91.0 rt.
20-40
FINE SILICA SAND
R.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft-
20.0 H.
TO
20.0 rt.
60.0 fL
DESCRIPTION (color, hardness, soillrock type, Cram sae, etr I
RED CLAY
BROWN CLAYEY SILT
60.0 f'
72.0 rr.
BROWN SILT
72.0 r'
91.0 n.
PWR
ft.
rt.
fl.
It.
R.
ft.
21. REMARKS
BENTONITE SEAL FROM 56.0 TO 59.0 FEET
22. Certification:
Signature of Certified Well Contractor
11/25/19
Dote
By signing dos form, 1 hereby ceniJy that the wilts) was (were) CORsirrrn sl ni accordance
with 15A N('A(' 02C 0100 or 15,4 N(A(' 02(' 0200 Well ('nnrtrnctiorr tatrdants and that a
copy of this rec-ord has been prnrided to the well owner
23. Site diagram or additional well details:
You may use the back of this page 10 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 Quality, Information Processing Utlit,
1617 Mail Service Censer, Raleigh, NC 27699-1617
24b. For Iniection Wells: 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 Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction 10 the county health department of the count
where constructed
Form G W-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised but 201 ;

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A-4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit if:
Liss all applicable well construction permits (i.e. ('aunty. Store. Variance. etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Dlrrigation
Non -Water Supply Well:
❑Monitoring
❑MunicipaUPublic
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
❑Geothermal (Heating/Cooling Return)
h7Groundwaler Remediatlon
❑Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under N21 Remarks)
For Internal Use ONLY:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
D.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap livable)
FROM THICKNESS 1 MATERIAL
TO
ft.
re.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
66.0 ft.
2.0
in.
SCH 40
PVC
rt.
ri.
in,
17. SCREEN
FROM
66.0 ft'
TO
96.0 f'
DIAM ETER
2.0 in.
SLOT SIZE
.010
THICKNESS
SCH 40
MATERIAL
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL.
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
61.0 R•
voanrWoaEwTa.TE
SLURRY
ft.
It.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
64.0 ft-
96.0 D'
20-40
FINE SILICA SAND
ft.
R.
20. DRILLING LOG (attach additional sheeh if necessary)
FROM
TO
DESCRIPTION (rotor, hardness, soWroek type, train sire. etc )
0.0 n.
20.0 ft.
RED CLAY
4. Date %►ell(s) Completed: 10/30/19 Well ID#
5a. Well Location:
CINTAS
I W-9
Facility/Owner Name Facility IDth inapplicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address. City, and Zip
FORSYTH
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one Iattlong is sufficient)
36° 08' 27.85" N 80° 15' 49.40"
6. Is (are) the well(s): 121Permanent or ❑Temporary
W
'r. Is this a repair to an existing well: ❑Yes or DNo
rf rlhrs It a riykrrr. fill am known hell einistrucnon rnliunmrimr and explain the nrnnre rJ the
rpwr under ?1 remarks section or an she hack cJ7his tome.
8. Number of wells constructed: 1
r or multiple infection or rum -water supply u'el.i tlNL 1' with the same donsfrucrian, you can
.shnnrone form.
96.0
9. Total well depth below land surface: (ft.)
For multiple wells list all depths J'd ereru (example- 3@2i70' and 1!r'.100,)
10. Static water level below top of casing: 20"0 (f1.)
r1 heater keel Ai obore casing, use -•
11. Borehole diameter: 8'0 (in.)
12. Well construction method: AUGER
lie auger rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. field (gpm)
Method of test:
13b. Disinfection type:
Amount:
20.0 ft.
60.0 !'•
BROWN CLAYEY SILT
60.0 ft•
72.0 re.
BROWN SILT
72.0 f•
96.0 re.
PWR
re.
ft.
ft.,
ft.
ft.
rt.
21, REMARKS
BENTONITE SEAL FROM 61.0 TO 64.0 FEET
22. Certification:
Signature of Certified Well Contractor
11/25/19
Date
Hy signing this Dorm, 1 hereby certify that the well(s) was (were) conrrrncted or accordance
with 15A MCA" 01(' .0100 or ISA MCA(' 02(' U100 Well Construction Srandarch and rhea it
crept' al this recapd has been provided to rle 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 veil
construction to the following.
Division of Water Quality, Information Processing Unit,
1617 Mail Service Censer, Raleigh, NC 27699-1617
24b. For Iniection Wells: 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 Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of This form %vithin 30 days of
completion of well construction to the county health department of the count'.
where constructed
Form OW-1
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan 201

WELL CONSTRUCTION RECORD
This form can be used for single or entiltiple wells
For Internal Use ONLY
1, Well Contractor Information:
NICHOLAS HAYES
Well CtovBctor Name
A - 4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable irell co nstrue:um permits (i.e. ('runny, State. Variance. ate f
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural DMunicipal. Public
❑Geothermal (Heating/Cooling Supply) ❑Residential Water Supply (single)
❑lndustrial/Commercial ❑Residential Water Supply (shared)
❑Irrigation
Non -Water Supply Well:
°Monitoring ❑Recovery
Injection Well:
DAqutkr Recharge ❑Groundwater Remediation
❑ Aquifer Storage and Recovery ❑Salinity Barrier
°Aquifer Test DStormwater Drainage
❑Experimental Technology ❑Subsidence Control
°Geothermal (Closed Loop) ❑Tracer
❑ Geothermal (Healing/Cooling Return) ❑Other (explain under #21 Remarks)
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
rt.
rt.
IS. OUTER CASING (tor multi -cased wells) OR LINER (if ap livable)
FROM THICKNESS MATERIAL
TO
ft.
f1.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 n.
rt.
70.0 ft.
R.
2.0
in.
in.
SCH 40
PVC
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL.
70.0 ft•
100.0 ft
2.0 in.
.010
SCH 40
PVC
R.
ft.
in.
18. GROUT
FROM
0.0 ft.
TO
65.0 (1.
MATERIAL
vonrwroernrennE
EMPLACEMENT M ETHOD & AMOUNT
SLURRY
ft.
ft.
ft.
ft.
19. SANDIGRA V EL PACK Inapplicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
68.0 f•
100.o R•
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 R•
TO
20.0 IL
DESCRIPTION (color, hardness. soitrrvck type. Brain sire, etc.)
RED CLAY
4. Dale Well(s) Completed: 10/29/19
5a. %fell Location:
CINTAS
Well ID#
IW-10
FaciliiylOwner Name Facility ID" Inapplicable
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physic:il .;;I,L rs, City, and Zip
FORSYTH
County Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one Ialllong is sufficient)
36° 08' 27.85" N
80° 15' 49.40"
6. Is (are) the well(s): I2IPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or LJNo
if this is a repair, Jill out known well construction it frrnrarian and explain the nature of Me
repair tinder 21 remarks seciian or on the hack if this form.
S. Number of wells constructed: 1
For nrnhipk injection or tarn-water.ntpplr wells ONI.Y with the same construction. you can
submit one form.
9. Total well depth below land surface: 100.0 (ft.)
....or multiple swells list ail 4,prhs if different (esanrple- 3 rr 200 and 2 l00')
ID. Static water level below top of easing: 20•0 (ft)
Ji'warer level rs above casing! use " "
11. Borehole diameter: 8•0 (in.)
12. Well construction method: AUGER
Ire. auger, rolary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
20.0 n•
60.0 ft.
BROWN CLAYEY SILT
60.0 ft'
72.0 ft.
BROWN SILT
72.0 n.
100.0 f'•
PWR
n.
R.
ft.
R.
ft.
re.
21. REMARKS
BENTONITE SEAL FROM 65.0 TO 68.0 FEET
22. Certification:
,/ez14-"
Signature of Certified Well Contractor
11/25/19
Date
By signing this Jornt. 1 hereby certify that the well(s) was (irere) constructed or accordance
with 1 SA N('A(' 01(' 0100 or 15A NI A(' 01(' 0200 Well Construction Standards and rluo if
copy aphis record has been provided to fife 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 Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For lnieclion Wells: 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 Quality, Underground Injection Control Program,
1636,Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & lnieclion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the count)
where constructed.
Form O W- I
North Carolina Department of Environment and Natural Resources - Division of Wales Quality Re%ised Jan 2013

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A - 4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
Liss all applicable a'e/l carts/memo permits (Le. Counrl .hare. Nararnc'e, ea')
3. Well Use (check well use):
Water Supply Well:
❑ Agricultural
❑Geothermal (Heating/Cooling Supply)
❑Industrial/Commercial
❑Irrigation
Non -Water Supply Well:
❑ Monitoring
❑MunictpalfPubl Ic
°Residential Water Supply (single)
❑Residential Water Supply (shared)
❑ Recvvery
Injection Well:
❑Aquifer Recharge
❑ Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
4. Date Wells) Completed: 11/01/19
5a. Well Location:
C I NTAS
❑Groundwater Remedial ion
❑Salinity Barrier
❑ Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑Other (explain under #2 1 Remarks)
Well ID#
IW-11
FaciLiy/Owner Name Facility IDA' Of applicable:.
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address. City and Zip
FORSYTH
Count, Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(dwell field, one lalltong is sufficient)
36° 08' 27.85" N 80° 15' 49.40" "r
6. is (are) the well(s): tr7Permanent or ❑Temporary
7. Is this a repair to an existing well: DYes or IDNo
(phi% is a repair. fill our known well construction infirrnmrian and explain lire mature of sire
ATOP" Wader 21 remarks seerlrm ar on the back al this form.
8. Number of wells constructed: 1
Far ximlipl inlu son or tam -water supply wells On)" mirth the same construction 3 o9 co
sr,h.... one farm.
9. Total well depth below land surface: 100,0 (ft.)
,w ....Maple wells list all depths if different !example- 3 a 200 and 2 rr l00)
10. Static water level below top of casing: 20.0 (ft.)
fJ oar. r level is alum•, casing. arse "
11. Borehole diameter: 8•0 (in.)
12. Well construction method: AUGER
lie anger, rotary. cable. direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
13a. 1 ield (gpm) _ _ Method of test:
13b. Disinfection type: Amount:
For Internal Use ONLY'
H. WATER ZONES
FROM
TO
DESCRIPTION
D.
rt.
ft.
rt.
15. OUTER CASING (for multi -cased wells) OR LINER (Hap icable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER
CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 1t.
70.0 D•
2.0 in.
SCH 40
PVC
ft.
n.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
70.0 11.
100.0 ft.
2.0 'n•
.010
SCH 40
PVC
ft.
fl.
in.
r 18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 1t•
65.0 ft'
PORT rirN'oaiTI
SLURRY
ft.
ft,
rt.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
68.0 f'•
100.0 1t•
20-40
FINE SILICA SAND
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness. soil/rack type. grain size, etc.)
0.0 ft'
20.0 n'
RED CLAY
20.0 ft.
60.0 1t'
BROWN CLAYEY SILT
60.0 ft,
65.0 ft.
BROWN SILT
65.0 ft.
100.0 D•
PWR
ft.
n.
ft.
rt.
ft.
f.
21. REMARKS
BENTONITE SEAL FROM 65.0 TO 68.0 FEET
22. Certification:
11/25/19
Signature of Certified Well Contractor Dale
By signing this frnm, 1 hereby certify that the u•efl(n) was (mere) constructed rn accardanc r
with 15A MAC 02C 0100 ar 15A MAC 02C 0200 Well Construction Standards nosy rent n
copy of dins recent has been prorated m 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 we
construction details. You may also attach additional pages if necessary
SUBMITTAL 1NSTUCTIONS
24a. Fur All Wells: Submit this form within 30 days of completion of well
construction to the following
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: 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 wel
construction to the following
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, 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 CW-I
North Carolina Department of Environment and Natural Rexmrces - Dlv_sion of Water Quality Revised Jan 2(.117.

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
Fo: Internal Use ONLY
1. Well Contractor Information:
NICHOLAS HAYES
Well Contractor Name
A- 4121
NC Well Contractor Cerlification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable mull construction permits (i.e. Colony. State. Variance. etc )
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Irrigation
OMunicipal/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)
1Ground++ tier Remedtation
{]Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
14. WATER ZONES
FROM
TO
DESCRIPTION
rl.
ft.
rt.
ft.
15. OUTER CASING (for multi -eased wells) OR LINER (if ap Ucable)
FROM THICKNESS 5 MATERIAL
TO
ft.
ft.
DIAMETER
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0.0 ft.
70.0 it.
2.0
in.
SCH 40
Pvc
ft.
rt.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
70.0 ft.
100.0 rl.
2.0 in.
.010
SCH 40
PVC
rt.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
0.0 ft.
65.0 ft.
Pann.ANDBENTtriTE
SLURRY
rt.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
68.0 ft-
100.0 ft
20-40
FINE SILICA SAND
ft.
rt.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
0.0 ft.
TO
20.0 ft.
DESCRIPTION (color, hardness, soilirock type, train size. etc.)
RED CLAY
4. Date Well(s) Completed: 11/05119
Sa. Well Location:
C I NTAS
Well ID#
IW-12
Facility/Owner Name Facility IDlf (if applicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address, City, and hip
FORSYTH
County Parcel identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
Orwell field, one Iatilong is sufficient)
36` 08' 27.85" N 80* 15' 49.40" NI.
6. Is (are) the well(s): 12IPermanent or ❑Temporary
7. Is this a repair to an existing well: ❑Yes or IZINo
if tine IN a repair, Jill Ora known well construction hrformatian and ecplahr the nature of the
repair under e21 remarks section or on the hack of this form.
8. Number of wells constructed: 1
For multiple injection or run -water supply wells ONLY with the same construction., you can
submit one firm.
9. Total well depth below land surface: 100.0 (ft.)
For multiple wells list a0 depths iJri flireut (example- 3 u 200' and 2©1(N1)
10. Static water level below lop of casing: 15'0 (ft.)
ll water level iv above casing. use - • ..
II. Borehole diameter: 10.0/6.0 (in.)
12. Well construction method: AUGER/AIR
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
I3b. Disinfection type: Amount:
20.0 rr.
60.0 ft
BROWN CLAYEY SILT
60.0 ft-
65.0 n.
BROWN SILT
65.0 ft•
100.0 a
PWR
ft.
ft.
rt.
ft.
ft.
ft.
21. REMARKS
BENTONITE SEAL FROM 65.0 TO 68.0 FEET
22. Certification:
,e/hyt,
Signature of Certified Well Contractor
11/25/19
Date
Hy .signing this firm, 1 hereby certify that the wre'll's) wax (wen) c'orr.structed m accordance
with 13A A'( A(' 02(' 0100 or 15A N('A(' 112('.0200 Well Construction. Standards and that u
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 Quality, Information Processing Unit,
1617 Mail Service Censer, Raleigh, NC 27699-1617
24b. For lnjgction Wells: 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 Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the count).
where constructed.
Form CiW-I
Noah Carolina Depanntem of Environment and Natural Resources -Division of Water Quality Revised Jan 2013

WELL CONSTRUCTION RECORD
This form can be used for single or muluple wells
For internal Use ONLY
1. Well Contractor Information:
NICHOLAS HAYES
Well Contraclor Name
A- 4121
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
tut all applicable well construction permits (i.e County. Variance. etc)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑irrigation
Non -Water Supply Well:
❑Monitoring
❑Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
❑Aquifer Test
❑Experimental Technology
❑Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
4. Date Wells) Completed: 11/04/19
5a. R'ell Location:
CINTAS
❑Groundwater Remediation
❑Salinity Barrier
❑Stormwater Drainage
DSubsidence Control
❑Tracer
❑Other (explain under #21 Remarks)
Well MN
IW-13
FacilitylOwner Name Facility ID# (if applicable)
4015 NORTH CHERRY STREET WINSTON SALEM 27106
Physical Address, City, and Zip
FORSYTH
County
Parcel Identification No (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field. one latllong is sufficient)
36° 08' 27.85" N 80° 15' 49.40"
6. Is (are) the well(s): 121Permanent or ❑Temporary
w
7. Is this a repair to an existing well: ❑Yes or DNo
If dais is a repair, Jill not know; well construction nefini atmrr and explaun the nature r f the
repair under .21 remarks .section ar on the hack of this forms.
8. Number of wells constructed: 1
1,irr multiple injection or ram -water supply wells ()NI,Y irilh the same Construction, you can
submit one fixm.
9. Total well depth below land surface: 97'0 (ft.)
For multiple wells list all depths if'different (example- 3 rr 21xl' and 2 a Nil')
10. Static water level below top of casing: 15.0 (ft.)
If water level is above caring, ore "
11. Borehole diameter: 10'�16'� (in.)
12. Well construction method: AUGER/AIR
(i.e. auger, rotary, cable, direct push, etc )
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test:
I3b. Disinfection type:
Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
D.
ft.
15. OUTER CASING {for multi -cased wells) OR LINER (if ap livable)
FROM THICKNESS MATERIAL
TO
ft.
ft.
DIAM ETER
in.
16, INNER CASING OR TUBING (geothermal cloaed-loop)
FROM
TO
DIAM ETER
THICKNESS
MATERIAL
0.0 n.
67.0 ft•
2.0
in.
SCH 40
PVC
rt.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
67.0 ft.
97.0 r''
2.0 in.
.010
SCH 40
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLAC EM ENT METHOD & AMOUNT
0.0 D.
62.0 ft.
POMU.ThDBtNTOMre
SLURRY
ft.
R.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
65.0 r'•
97.0 ft.
20-40
FINE SILICA SAND
rr.
rr.
20. DRILLING LOG (attach additional aborts if note nary)
FROM
0.0 ft.
20.0 ft.
TO
20.0 h.
60.0 It.
DESCRIPTION (rotor, hardness, soil/neck type, plain size, tit 1
RED CLAY
BROWN CLAYEY SILT
60.0 ft•
75.0 ft•
BROWN SILT
72.0 r'•
97.0 '•
PWR
ft.
ft.
ft.
ft.
n.
ft.
21. REMARKS
BENTONITE SEAL FROM 62.0 TO 65.0 FEET
22. Certification:
/e,th-"
Signature ofCertifiied Well Contractor
11/25/19
Date
By signing this farm I hereby cerrifj- char the well(s) was (here) constructed in accordance
srnh 15,4 N( A(' 02(', 0100 or 15,1 N( A(' 02(' 0200 Well ('onsrruction Standards and that a
copy r fdris record has kV, 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 INSTUCI'IONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Quality, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Iniection Wells: 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 Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form .within 30 days or
completion of well construction to the county health department of the county
where constructed
Form G W-
North Carolina Department of Environment and Natural Resources - Division of Water Quality Revised Jan 201

Application for Underground Injection Control 60681957
Permit — Attachments
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