WI0400626_Notification of Intent (NOI) – GW Remediation_20240529

NC Department of Environmental Quality—Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule"and do not require an individual permit when constructed in accordance
with the rules of I5A NCAC 02C.0200(NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS(15A NCAC 02C.0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION(15A NCAC 02C.0225) or TRACER WELLS(15A NCAC 02C.0229):
1) Passive Injection Systems - In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks,iSOC systems,and other gas infusion methods(Note: Injection Event Records(IER)do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small-Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation,and where the
surface area of the injection zone wells is located within an area that does not exceed five percent of the land surface
above the known extent of groundwater contamination. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
5) In-Situ Thermal Wells(IST)—Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: May 29, 2024 PERMIT NO. to be filled in by DWR)
NOTE-If this NOI is being submitted as notification of a modification of a previously issued NOI for this site(e.g.,
different injection wells,plume,additives,etc.)and still meets the deemed permitted by rule criteria,provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
Permit No.WI Issued Date:
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well....................................... Complete sections B through F,J,M
(2) Aquifer Test Well....................................... Complete sections B through F,J,M
(3) Passive Injection System............................... Complete sections B through F,H-M
(4) Small-Scale Injection Operation...................... Complete sections B through M
(5) X Pilot Test................................................. Complete sections B through M
(6) Tracer Injection Well................................... Complete sections B through M
(7) In-Situ Thermal(IST)Well........................... Complete sections B through M
B. STATUS OF WELL OWNER: Business/Organization
Deemed Permitted GW Remediation NOI Rev.2-17-2020 Page 1

C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): Sam Kramer- Speedway,LLC
Mailing Address: 500 Speedway Drive, Ste 200
City: Enon State: OH Zip Code: 45323 County: Clark
Day Tele No.: 937-864-3000 Cell No.:
EMAIL Address: samuel.kramer(&7-1 Lcom Fax No.: N/A
D. PROPERTY OWNER(S)(if different than well owner/applicant)
Name and Title:
Company Name
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT(Typically Environmental Consulting/Engineering Firm)
Name and Title: Brett Schaefer
Company Name AECOM
Mailing Address: 6000 Fairview Rd,Ste 200
City: Charlotte State: NC Zip Code: 28210 County:Mecklenburg
Day Tele No.: 704-208-5508 Cell No.:
EMAIL Address: Brett.SchaeferAaecom.com Fax No.: N/A
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name&Address: Speedway Store—6933 Winston-Salem
2420 South Stratford Road
City: Winston-Salem County.Forsyth Zip Code: 27103
(2) Geographic Coordinates: Latitude": 0 "or 36.05392°N
Longitude": 0 "or 80.32133 °W
Reference Datum: NAD83 Accuracy: +/-5 ft
Method of Collection: Goo,gle Earth
"FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: 8,130 square feet
Land surface area of inj.well network: 125 square feet(< 10,000 W for small-scale injections)
Percent of contaminant plume area to be treated: 1.5 %(must be<5%of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev.2-17-2020 Page 2

H. INJECTION ZONE MAPS—Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s)to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells,and existing and proposed injection wells.
(3) Potentiometric surface map(s)indicating the rate and direction of groundwater movement,plus existing
and proposed wells.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination,and purpose, scope,goals of the proposed injection activity:
The Site, Speedway#6933,formerly operated as a WilcoHess convenience store with,gasoline and diesel sales.
The Site is currently in use as a convenience store and retail petroleum dispensingfty and operates three
8,000- albgasoline underground storage tanks (UST), one 8,000-,gallon diesel UST and one 8,000- ag Ilan
kerosene UST.The current Incident#30467 was initiated in 2004,when a monitoring,system alarm was activated
for one of the 8,000-gallon capacity gasoline USTs. Precision Tank Services was contracted to perform a tank
tightness test for the number 4 Regular Unleaded(RUL) gasoline UST in question. The test was performed on
September 3, 2004, with non-passing results. The tank was repaired and placed back into service. Incident
#30467 was opened.
The purpose of this project is to perform a Mobile Multi-Phase Extraction(MMPE)with Surfactant Injection on
monitoring wells exhibiting a measurable apparent LNAPL thickness greater than 0.01 feet(MW-1, and MW-
6)and monitoring wells exhibiting a benzene concentration greater than the Gross Contamination Limit of 5,000
ug/L(MW-8,and MW-14,).The proposed MMPE/Injection event will run from Monda. through Thursday. On
Monday AECOM's subcontractor will run the MMPE event for approximately 20 hours. Then breakdown the
MMPE system on Tuesday and immediately startup the Injection system and operate for approximately 8-12
hours. Approximately 1,700 gallons of injection solution(4% solution) will be injected into 4 impacted wells.
Following the injection period,the subcontractor will allow overnight down time for the injection to take effect.
On Wednesday the subcontractor will re-setup the MMPE system to operate for approximately 24-hours and
shutdown on Thursday.Following this procedure, groundwater sampling will take place 30 days after the event,
aiming to remediate the level of petroleum hydrocarbons in the groundwater.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 4 Proposed MW-1,MW-6,MW-8,and MW-14
Existing(provide NC Well Construction Record(GW-1)for each well)
(2) Appx. injection depths(BLS): 14-35 feet
(3) For Proposed wells or Existing wells not having GW-Is,provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following(indicate if construction is proposed or as-built): See Attachment A
(a) Well type as permanent, Geoprobe/DPT,or subsurface distribution infiltration gallery
Deemed Permitted GW Remediation NOI Rev.2-17-2020 Page 3

(b) Depth below land surface of casing, each grout type and depth, screen,and sand pack
(c) Well contractor name and certification number
Well ID Well Type Well Contractor Certification Notes
Construction Number
Data
K. INJECTION SUMMARY
NOTE. Only injectants approved by the epidemiology section of the NC Division of Public Health.Department
of Health and Human Services can be infected. Approved injectants can be found online at
http:Hdeg.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 Prozram for more info i1you wish to get approval for a different additive. However,please
note it may take 3 months or lonzer. If no injectants are to be used use N/A.
Injectant: Ivey-Sol#103 at 4%solution with water Total Amt.to be injected(gal)/event: 1,700
Injectant: Total Amt.to be injected(gal)/event:
Injectant: Total Amt.to be injected(gal)/event:
Injectant: Total Amt.to be injected(gal)/event:
Injectant: Total Amt.to be injected(gal)/event:
Total Amt.to be injected(gal/event): 1,700
No.of separate injection events: 0 Total Amt.to be injected(gal): 1,700
Source of Water(if applicable): On-site potable water.
L. MONITORING PLAN—Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
Approximately 30 days after completion of the Surfactant Enhanced MMPE event,AECOM will mobilize to the site
to perform a comprehensive groundwater monitoring event to evaluate the effectiveness of the Limited
Iniection/MMPE event. Prior to sampling, groundwater levels will be measured at all on-site monitoring wells. The
groundwater samples will be collected using a dedicated bailer and a minimum of three well volumes will be purged
prior to sampling The groundwater samples will be shipped to a North Carolina certified laboratory via overnight
courier and analyzed by EPA Method SM6200 for benzene, toluene, ethylbenzene, xylenes (BTEX), 1,2-
dichloroethane (1,2-DCA), ethylene dibromide (EDB), isopropyl ether (IPE), methyl tert-butyl ether (MTBE),
naphthalene,and oxygenates.
Deemed Permitted GW Remediation NOI Rev.2-17-2020 Page 4

M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: `I hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Samuel J. Kramer Manager,Environmental Services
Signature of Applicant Print or Type Full Name and Title
Property Owner(if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s)are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(I5A NCAC 0 2 C.0200)."
"Owner"means any person who holds the fee or other property rights in the well being constructed.A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
Signature*of Property Owner(if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two(2)weeks prior to injection to:
DWR—UIC Program
1636 Mail Service Center
Raleigh,NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev.2-17-2020 Page 5

ATTACHMENT A
INJECTION ZONE MAPS
(SECTION H)

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N�
Speedway, LLC.
Speedway Store#6933 SITE LOCATION MAP FIGURE 1
g 2420 South Stratford Road Source:Topo USGS 7.5 Minute Topographic Map
Quadrangle:Winston-Salem W,NC
Winston-Salem, North Carolina Copyright:2022 U.S.Geological Survey AECOM
U
DATE: NOVEMBER 2022 DRAWN BY: I.LAZAR REVIEWED BY: N.PINSKER PROJECT NO.: 60690898

Creek
(Approx. 400' North)
ifs
Hillcrest Properties, LLC
MW-18
•
-$ MW-19 _
. - -- Ditch - -
- _
MW-20
MW-17�-
MW-13
MW-12�-
VW 1.4
yid
Wooded Area
g I MW-9 MW, -8 I
MW_7
MW-1
Speedway
I I Store#6933
MW-4
Building I MW-3 / �
�.. MW-10 MW`6 \I of
�-` ank Field
*MW-3D i
�+, IElNm ®O I Bobotsiares Property
Canopy& ��
� III II 2414 S. Stratford Road
j I Dispenser
16 Islands �' __III
LL --------------
M `1- \Road I MW-2 I C I � O
-------
IIt -
MW-11 O® El MW-16
' --oH off w---oH/w- -oH/ off/w---OH/w---o w--- ---OH/MW_-0H/ -- OH/w- -off/w---off/w---off/w---o
- - - - - - - -
3
WM
3
Stratford Road
U
E
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a
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b
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Z
w O 1 • • • •• • O 1 O • • •
5
W LEGEND
v
N —••— Approximate Property Boundary Underground Storage Tank Monitoring Well
Railroad Tracks -oHiW-- Overhead Wire Deep Monitoring Well
Treeline c01) Utility Pole/ Power Pole + Sump Sample Location
N s1001 Ground Elevation Contour ;o; Light Post/Traffic Light IveySol#103 Injection ROI (-10 ft)
Olo Product Dispenser ❑ Catch Basin /Stormwater Inlet
E
v
U
g SCALE IN FEET: Speedway, LLC.
Speedway Store#6933 IveySol#103 Injection FIGURE 1
40 0 40 2420 South Stratford Road Zone Map
8 NOTE: ALL MAP FEATURES ARE APPROXIMATE Winston-Salem, North Carolina AECOM
IN SCALE AND LOCATION.
DATE. OCTOBER 2022 DRAWN BY: I.DUMITRU REVIEWED BY: N.PINSKER PROJECT No.: 60690898

� f
N
Creek
(Approx. 400' North)
Hillcrest Properties, LLC
MW-18
MW-19
Regraded
\\ \ Area
— — Ditch
MW-20
MW-17
MW-13�
I MW-12
I I
MW-14
I I -0-
I �
I _ Wooded Area
I I �
I �
I , 1
I
I I I �MW-8 I
I I I I
MW-15
L J \ MW-
I I Speedway
1 1 Store#6933 MW-4 ti \
Building MW-3
I
MW 10 Tank Field =1
I MW-3D � O® I MW 6 I
Bobotsiares Property
Canopy& 1 5�)I 2414 S. Stratford Road
I Dispenser MN-1
Islands ___II
10 0 01 #3�)I
MW-2 �c�#2�1� = I O\ Road
I �
MW-11 O® O® I ILA#1�J MW-16
I
--OH OH W---OH/W- -OH/ OH/W---OH/W---O W--- --
---OH/W---OH/ -- OH/W- -OH - OH/W---OH/W---03
_ — - - - - - - MW-5 — — — - -
Stratford Road
a
w
a
3
E
y
3
--OH/W —)OH/W---OH/W---OH/W---OH/W---OH/W-C�OJH/W---OH/W---OH/W---OH/W---OH/W---OH/W-CBI/W--
r
C
LEGEND
—••— Approximate Property Boundary `__i Underground Storage Tank � Monitoring Well #1 8,000-Gal. Diesel
#2 8,000-Gal. Kerosene
Railroad Tracks --OH/W-- Overhead Wire 9 Well (Destroyed)
Monitoring Y ) #3 8,000-Gal. RUL Gasoline
Treeline c_a) Utility Pole/Power Pole Deep Monitoring Well #4 8,000-Gal. RUL Gasoline
E 1 001 Ground Elevation Contour ;o, Light Post/Traffic Light - Sump Sample Location #5 8,000-Gal. PUL Gasoline
OIO Product Dispenser ❑�+ Catch Basin /Stormwater Inlet
SCALE IN FEET: Speedway, LLC.
FIGURE 2
Speedway Store#6933
40 0 40 2420 South Stratford Road SITE PLAN
NOTE: ALL MAP FEATURES ARE APPROXIMATE Winston-Salem, North Carolina AEC'OM
o IN SCALE AND LOCATION.
? DATE: NOVEMBER 2022 DRAWN BY: I.LAZAR REVIEWED BY: N.PINSKER PROJECT NO.: 60690898
z

*,IV
\ Creek
(Approx. 400' North)
Hillcrest Properties, LLC
MW-18
NG // MW-19
NG
- _ Ditch
MW-20
NG
MW-17 �ti
NG
O � ^h
o- - - — - - coP —
\ 00 — — —
MW-13 �" 816
69.59�j 818 -
MW-12
I 69.99 �_�,`p� 820 -
MW-14 I 0 822 -
6979�
Wooded Area I ,�O
�<0
I / AN
MW-9 MW-8
I
70.22 I
7034
OS I r MW-15 $
O MW-7 71.87
70.27
\ i I Speedway
\ Store#6933 MW-4
70.51 I \
Building I MW-3 Tank Field 7�S
MW-10 70.51 \ ,I
70.85 I / MW-3D ElO1 MW-6
_70.74*
�� Ali i Bobotsiares
Canopy& — o Property
Dispenser MW-1* ji�—�Ij 2414
Islands ®O ° U85� S. Stratford Road
71 00- -
70.96
o� O I �� �J -�� MW-16 \
MW-11 MW-5 71.45
--oH off w---oH/w- -oH/ OH/71.07OH/W---o W--- --��71.44-OH/ � � -- off/W- -uH w---off/w-\)H/W_--
o ff
O�
Stratford Road
0
a
o"
0
a
a
3 /
E
N
OH/WE QDOH/W---OH/W---OH/W-- H/W---OH/W6ii/W---OH/W---OH/W---OH/W---OH/W---OH/W—C-�/W—
E
LEGEND
—••— Approximate Property Boundary Utility Pole/ Power Pole Groundwater Elevation Contour (Ft)
Dashed Where Inferred
_ Railroad Tracks :o, Light Post/Traffic Light
Treeline 0 Catch Basin /Stormwater Inlet /� Approximate Groundwater
Z �100l Ground Elevation Contour -4 Monitoring Well Flow Direction
W NG Not Gauged
Oho Product Dispenser Deep Monitoring Well 9
i Underground Storage Tank Sump Sample Location Groundwater Elevation Not Used in Contouring
--- Light Non-Aqueous Phase Liquid
--off/W-- Overhead Wire 70.96 Groundwater Elevation (Ft) Observed in Well
0
SCALE IN FEET: Speedway, LLC.
W Speedway Store#6933 GROUNDWATER ELEVATION MAP FIGURE 4
aMEEli
ao o ao 2420 South Stratford Road NOVEMBER 21, 2023
NOTE: ALL MAP FEATURES ARE APPROXIMATE Winston-Salem, North Carolina AECOM
IN SCALE AND LOCATION.
DATE: JANUARY 2024 DRAWN BY: D.OLTEANU REVIEWED BY: E.RIEGEL PROJECT NO.. 60690898
U

� f
Creek
(Approx. 400' North)
Hillcrest Properties, LLC
(Re-graded Property)
MW-18
MW-19
\\\ Regraded
\� \ Area
Former Ditch
(Filled in During grading activities)
M\AI
Regraded
MW-17 Area
MW-13
_0_
MW-12 NS
I NS �5,000— I
r MNS4 �\ I
I i Remediation
Building \
1 NQ, Woodlined Area
_ I
M -8
�A -g _0!12,600
r"
IND MNS15
I I
I J MW-
I Spee y 65.7 J
I I I Store#69 MW-4
I I 328
w -J
Building MWD3
I
01
MW-1110 Tank Field =
a I MW-3D ❑ ®OI MW 6 �I
C & r
LNA L Bobotsiares Property
Canopy II 5 II(0.01 ft) i
ano 2414 S. Stratford Road
N I Dispenser M -1 — 1
1,310 I #a
EIslands 10 OI #3J)I
o I
— —10® ❑ O® I — —�IL A#2M��WJI �\II J
I _ -OH/W-OH/WMW-2 C ov,
ND #1 — MW-16MW-11 - OH
-OHLIJOH W---OH/W- -OH/ OH/W---OH/W---O --- ---OH/W---OH /W---OH/W-
- O �
-5 0
6.3 J
N
Q
H
M
r Stratford Road
0
Y
K
O_
N
m
0
E
v
N
O
3
m
0
--OH/WFeL3OH/W---OH/W---OH/W---OH/W---OH/W-C-aO-I/W---OH/W---OH/W---OH/W---OH/W---OH/W-CeOd/W-
U
o
LEGEND
n
—••— Approximate Property Boundary ;o; Light Post/Traffic Light 13,100 Benzene Isoconcentration (pg/L)
Railroad Tracks ❑+++ Catch Basin /Stormwater Inlet FP Free Product Observed in Well
y Treeline Monitoring Well Ns Not Sampled
U
O Ic Product Dispenser Monitoring Well (Destroyed) ND Not detected at or above laboratory's
= Underground Storage Tank # Deep Monitoring Well practical quantitation limit
orl�w-- Overhead Wire 1,000, Benzene Isoconcentration Contour
Sump Sample Location in pg/L(Dashed Where Inferred)
COL) Utility Pole/ Power Pole
Uo
E
d
U
SCALE IN FEET: Speedway, LLC.
s DISSOLVED BENZENE FIGURE 4
Emmli Speedway Store#6933 ISO-CONCENTRATION MAP
40 o ao 2420 South Stratford Road
E NOTE: ALL MAP FEATURES ARE APPROXIMATE Winston-Salem, North Carolina OCTOBER 2022 /��COM
8 /'1�
IN SCALE AND LOCATION.
16
DATE: OCTOBER 2023 DRAWN BY: B.SCHAEFER REVIEWED BY: E.RIEGEL PROJECT NO.: 60690898

N CREEK
\ B (APPROXIMATE) \
/
/
HILLCREST PROPERTIES, LLC / \
/ MW-19
WOOD / \
OPEN FIELD /
A
MW-18
s% / \
\ / / ♦ WOODED \
\/' WOODED / \
' MW-13
/ W-20 /
/ / ♦ OODLINE \
/ ♦ MW-12
/ ♦ WOODED MW-14 ♦ Mw-1
ia MW-17 / ♦ \
WOODED
Gl \\1 M -7 \
\/ _ BOBOTSWRES PROPERTY
\ 2414 S. STRATFC D ROAD
♦
\ ♦ ♦ A
OODUNE Mw- ♦ Q�QP9
O��PO
MW-9 ` Q
\ ♦ WILCO 111 MW-60
\ ♦ ♦ 1+IW-16
\ 0
`e. O 0
♦ MW-3 0 0
\ �iP ♦ O O ♦
�y0 MW-31) Mw-1 0 0 Mw-
\ Z `, CANOPY B,
A T O
\ MW-10 /
/
\ BUILDING C
MW-2
\\ ♦ /
♦ MW-11 ORD
\ /d
/a
\ /a
/a
LEGEND a
/a
0 MW-1 MONITORING WELL LOCATION a/
0 MW-3D DEEP MONITORING WELL LOCATION a/
RAILROADS a/
PROPERTY BOUNDARY a/
—w—o+—�— D.O.T. RIGHT-OF-WAY /
CONCRETE /a
/a
GEOLOGIC CROSS-SECTION LOCATION /d 0 40'
A A' (SEE DRAWINGS 5.2 THROUGH 5.4)
a/ SCALE: 1"= 40'
DRAWN DATE: NOVEMBER 2012
GEOLOGIC CROSS-SECTION BY:
lof,II]-ATLANTIC LOCATION MAP DRAFTING CHECK JOB N0: 00OR1536.07
WILCO 1 1 1 BY:
ASSOCIATES, INC. 2420 S. STRATFORD ROAD ENGINEER CHECK\ CAD # 01-153619-07
Engineering & Environmental Solutions WINSTON-SALEM, NORTH CAROLINA APPROVED
BY: DWG NO: 5.1
REFERENCE: GOGGLE EARTH AERIAL AND FORSYTH COUNTY GIS WEBSITE.

N I-
WILCOHESS #111 MW-3 . O
4 STORE MW-2 A' NN cD I
N� O
MW-8 MW-3D1):f of100' 100' W ( N
m O � u7
:2 O
W O I
A O _
MW-12 MW-14 A — — — Z O O
L Li
90' ///// 90' Q m 0 CD
0 0 0
DIT H A
MW-20 y U
U W
W =
80' 80' V U
B B Z W O
o_r
a .. a .. C� .. IL ..
v B om om Wm am
Z MW-18
0 B
a 70' v 70'
Lu ~ ? Q Z
Lu
I J
/5,000 Lu
Z O Q
/ O Of O
/ F-
0 =
60' \ 60' W D' �
(n
QO
V) O Of
0 w
vi Q
U_ V)
50' o _ — — ? 50' O O Z
N
O
J F-
O N cn
W Z
C.0 �
C
40' 40'
In
U ti
O
30' 30' W
O
O �
W
LEGEND ^ ,'-g) W
SCREENED INTERVAL Z
4X W
Z WATER LEVEL 10/8/12 A BROWN SLIGHTLY MICACEOUS SANDY AND SILTY CLAY (CL) VERTICAL EXAGGERATION= of
( 9/ ) B BROWN AND GRAY SLIGHTLY MICACEOUS SANDY AND CLAYEY SILT (ML) 0 40' bA W
5,000 ESTIMATED BENZENE ISOCONCENTRATION CONTOUR FOR THE GCL u L C COMPETENT ROCK (APPEARS GRANITIC) W
GASOLINE FREE PRODUCT HORIZONTAL SCALE: 1'- 40' �1

O O
B B' oN I
MW-7 MW-4 MW-1 MW-5
100' 100' W rr-K
►`�
Q] O u"1 tf)
:2 O
L A j O I
UST OZ p O O
BASIN ? Z Z
MW-13
90' ' 90 W U
O0 U
A B CC
l.i
B y Y
U U
W W
80, A / 80' v v
� o
CREEK i Z w o
MW-19 z z
o B
70' v ? 70'
J Q
W ? T B m Z
I J
w 00
5`,000� CD Oa Q
ZO Of U
0 _
60' ? ? W. W p Of
._ LL- O
O
c V) w
vi Q
U_ N
50' 50' (' Z
o N O
W Z
O
40' 40'
� U
30' 30' W fi
O
O fi
LEGEND W
SCREENED INTERVAL U Z
VERTICAL EXAGGERATION=4X W
L WATER LEVEL 10/8/12 0 40 Of
W
5.000 ESTIMATED BENZENE ISOCONCENTRATION CONTOUR FOR THE GCL (ug/L) A BROWN SLIGHTLY MICACEOUS SANDY AND SILTY CLAY (CL) LL-
W
GASOLINE FREE PRODUCT B BROWN AND GRAY SLIGHTLY MICACEOUS SANDY AND CLAYEY SILT (ML) HORIZONTAL SCALE: 1"= 40'

C MW-10 MW-31) MW-4 MW-15 C,
100' 100'
A A
go, A gp
B ?
B
60' ? 80'
F 70' - 70'
F 60'
60'
w
Ir
50' ?- - - - ?
50'
C
40' 40'
LEGEND
SCREENED INTERVAL
WATER LEVEL 10/8/12 VERTICAL EXAGGERATION=1.5
A BROWN SLIGHTLY MICACEOUS SANDY AND SILTY CLAY (CL)
5,000 ESTIMATED BENZENE ISOCONCENTRATION CONTOUR FOR THE GCL (ug/L) B BROWN AND GRAY SLIGHTLY MICACEOUS SANDY AND CLAYEY SILT (ML)p%-_0
GASOLINE FREE PRODUCT C COMPETENT ROCK (APPEARS GRANITIC) HORIZONTAL SCALE: 1'= 30'
GEOLOGIC CROSS—SECTION
111 C—C' DRAWN
II]-ATLANTIC BY: DATE: NOVEMBER 2012
M
ASSOCIATES, INC. 2420 S. STRATFORD ROAD DRAFT J06 No: 00OR1536.07
CHECK:
Engineering & Environmental Solutions WINSTON—SALEM, NORTH CAROLINA ENG
CHECK: M CAD NO: 01-153622-07
REFERENCE: APPROVAL: DWG NO: 5.4

ATTACHMENT C
WELL CONSTRUCTION INFORMATION
(SECTION J)

WELL CONSTRUCTION RECORD
North Carolina-Department of Environment and Natural Resources-Division of Water Quality-Groundwater Section
WELL CONTRACTOR(INDIVIDUAL)NAME (prbrt) Tommy Solyard CERTIFICATION#3307
WELL CONTRACTOR COMPANY NAME Environmental Orllllng&Probing Services,LLC(EDPS) PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# NA ASSOCIATED WQ PERMIT# NA
(if applicable) (if applicable)
1, WELL USE(Check Applicable Box):Residential ❑ Municipal/Public.❑ Industrial ❑ Agricultural ❑
Monitoring 19 Recovery ❑ Heat Pump Water Injection ❑ Other❑ If Other,List Use
2, WELL LOCATION: Topographic/Land setting
Neatest Town: Winston-Salem County Forsyth ❑Ridge ❑Slope ❑Valley ®Flat
2420 South Stratford Road,Winston-Salem,North Carollna 27103 (check appropriate box)
(Street Name,Numbers,Community,Subdivision,Lot No.,Zip Code) Latitude/longitude of wel I location
N3605'59"W80014'40"
3. OWNER: WilcoHess Service Station#111 (degreeslminuteslseconds)
Address 2420 South Stratford Road Latitude/longitude source:®GPS❑Topographic map
(Street cr Rotae No.) (check box)
Winston-Salem NC 27103 DEPTH DRILLING LOCI
City or Town State Zip Code From To Formation Description
Area code-Phone number
4. DATE DRILLED 3.3-05
5, TOTAL DEPTH: 35'
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
7. STATIC WATER LEVEL Below Top of Casing: NA FT,
(Use"+"if Above Top of Casing)
8. TOP OF CASING IS 0 FT,Above Land Surface"
"Top of easing terminated at/or below land surface requires a
variance in accordance with ISA NCAC 2C,0118,
9, YIELD(gpm): NA METHOD OF TEST NA
10. WATER ZONES(depth): NA
NA LOCATION SKETCH
11, DISINFECTION:Type NA Amount NA Show direction and distance in miles from at least
12. CASING: Wall Thickness two State Roads or County Roads.Include the road
Depth Diameter or Weight/Ft. Material numbers and common road names.
From 20. To 0 Ft. V sch.40 PVC
From TO Ft.
From To Ft.
13. GROUT: Depth Material Method
From 18 To 16 Ft. Bentonite tremie
From 16 To 0 Ft. Grout tremie
14. SCREEN: Depth Diameter Slot Size Material S,r
From 35 To 20 Ft.__2" in, 0.01 in, PVC
_Ft. ^—in. in.
15. SAND/GRAVEL PACK:
Depth Size Material
From 35 To 18 Ft, #2,med Sand S i
From To Ft,
16. REMARKS: Well No: MW-1
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE ITH ISA NCAC 2C,WELL.
CONSTRUCTION STANDARDS,AND Tl�T A COPY OF THIS .ECORD HAS BEE OVIDED TO THE WFLL OW L•R
�� GNATUR S QK<ON:
?
TIN TI , WELL D "E
Submit the original to the Division of Water Quality,Groundwater Section,1636 Mail Service Center-Raleigh,NC
27699-1636 Phone No.[phone],within 30 days. GW-1 REV.07/2001

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR C'ERT11ICATTON9 3576
1.WELL CONTRACTOR: d, TOP OF CASING IS o FT.Above Land Surface*
Stefan Smith "Top of casing terminated at/or below land surface may require
Well Contractor(€ndlvMdual)Name a variance in accordance with 15A NCAC 2C.0118,
SAEDACCO Inc e. YIELD(9pm): METHOD OF TEST
Well Contractor Company Name f. DISINFECTION:Type Amount
STREET ADDRESS 9088 NORTHFIELD DR g. WATER ZONES(depth):
_.._ From To From To
FORTMILL Sc 29707 From TO From To
City or Town State Zip Code
704-622-6920 From To_ From_To,—_v,,,_
Area code- Phone number 6. CASING: Thickness/
2.WELL INFORMATION: Depth Diameter Weight Material
SITE WELL ID#(if applicable) _6 From 0 To 20 Ft, 2 SCH40 PVC
STATE WELL PE RMIT#(If applicable) From_______ To Ft.
DW'VQ or OTHER PERMIT#(If applicable) Frarn To Ft.
WELL USE(Check Applicable Box)Monitoring Q Municipal/Public❑ 7, GROUT: Depth Material Method
Industriat/Commercial L Agricultural L'7 Recovery ID Injection Cl From o -fo 16 Ft PORTLAND POURED
Irrigatlono Other D (list use) From To Ft, ..
DATE DRILLED 3-2-2011 From To, "'Ft.
•TIME COMPLETED 12:3 o AM O PM 8, SCREEN: Depth Diameter Slot Size Material
1 WELL LOCATION: From 20 T035 Ft,2- --- in. 010 in. . PVC
CITY; WINSTON SALEM COUNTY FORSYTH From Tq Fk,.__�._._—in. in,
_- From To Ft. in. in.
2420S.STRATFORD RD
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) S' SANptG PACK:
Depth
Size Material
TOPOGRAPHIC/LAND SETTING: From 18 To 35 Ft. #2 SAND
OSlope LValfey KIFlat ORIdge C_i Other " '"' �`� ®'
From—To Ft.
(check appropriate box) —�---�
May be in degrms, From To—Ft.
LATITUL7E 36.3504 - -----• minutes,seconds or
10.DRILLING LOG
LONGITUDE 80.32109 —_m __ in a decimal tarmat From To Formation Description
Latttl deflongitude source: sI GPS LI Opographic inap 0 2 RED SILT
(facation of weli must be shom7 on a USGS topo•map and 20 35 SAPROLITE
attached to this form!f not using GPS)
4.FACILITY-Is the name of the busfness where the well is located.
FACILITY ID*(if applicable)_MW=6_...___--_
NAME OF FACILITY WILCO-HESS #111
STREET ADDRESS 2420 S STRATFORD RD
WINSTON SALEM NC 27103 35 -
City or Town State Zip Code
CONTACT PERSON GARY FISHER W
MAILING ADDRESS 409 ROGERS VIEW COURT --
RALIEGH NC 27610 11.REMARKS:
City or Town State Zip Code
800 )- 486-7568
Area code« Phone number
DO HEREBY CERAFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE NTH
!r WELL DETAILS: 11 NCAC 2C,WELL CONSTRUC RION STANDARDS,AND THAT A COPY OF THIS
d. TOTAL DEPTH: 35 RECORD HAS BEEN PROVIDED TO THE WELL OWNER-
I3-2-2011
b, DOES WELL REPLACE EXISTING WELL? YES I-] NOy.€ GNATURE OF CERTIFIED WELL CONTRACTOR � DATE
c. WATER LEVEL Below Top of Casing: 29 FT, Stefan Smith
(Use"+"If Above Tap of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the[division of Water Quality within 30 days. Attn: Information Mgt., Form Gw-1b
1617 Mail Service Center—Raleigh,INC 27699-1017 Phone No.[phone] ext$68. Rev.7105
i

NON RESIDENTIAL WELL CONSTRUCTION.RECORD
' Notth Carolina Department of Environment and Natural ReS'Ources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION# 3576
"grihtF'r-
1.WELL CONTRACTOR: d, TOP OF CASING IS o FT.Above Land Surface'
Stefan Smith *Top of casing terminated atlor below land surface may require
Well Contractor(Individual)Name a variance In accordance with 18A NCAC 2C.0118.
SAEDACCO Inc e. YIELD(gpm): METHOD OF TEST_
Well Contractor Company Name f. DISINFECTION:Type _ Amount
STREET ADDRESS -9088 NORTHFIELD DR g. WATER ZONES(depth);
From To— From To
FORTMILL Sc 29707 From To From To
City or Town State Zip Code
From Tq From-To ,_.
704-622-6920
Area code- Phone number 6, CASING: Thickness/
2.WELL INFORMATION: Depth Diameter Weight Material
SITE WELL ID#(if appflsable)MW-8 From 0 _--To 20 Ft, 2 SCH40 PVC
STATE WELL PERMIT#(if applicable) From Tc Ft,
From Tc Ft
DWW or OTHER PERMIT#(if applicable) 7, GROUT: Depth Material Method
WELL USE(Check Applicable Box)Monitoring K Municipal/Public GI
IndustriallOommercial L7 Agricultural L� Recovery LI Injection[I From a To 16 Ft PORTLAND POURED
Irrigationp Other n (list use) From To Ft,
DATE DRILLED
3-1-2011 FromTo_Ft.�
8, SCREEN: Depth Diameter $lot Size Material
TIME COMPLETED 3:30 AM O PM
From 2o To35 Fi,2 in. -.ono_ in. __-PVC_.
3,WELL LOCATION, —
frcm To Ft.,, in. — in..
CITY: WINSTON-__SALEM ---- _ COUNTY FORSYTH From To Ft, in. In.
2420S.STRATFORD RD
8. SANDIGRA1fEL PACK*
(Street Name,Numbers„Cemmunity,SLlbdivlslon,Lot No.,Parcel,Zip Co-de) Depth Size Material
TOPOGRAPHIC I LAND SETTING: From 18 To 35 Ft. #2 SAND
O Slope o Valley iC Flat 0 Ridge El Other __
_._ Fram ,To Ft.
(check appropriate box)
LATITUDE 36,3504 may bohidegr , From To Ft.
minutes,Seconds or 10.DRILLING LOG
LONGITUDE 90,32109 in adecimal format From TO Formation Description
l,atitudeflongitudesource: MOPS 1j7bpographi.e nap 0 20 RED SILT
{location of well mast be shown on a USGS topo reap and 20 35 SAPROLITE
attached to this form if act using GPS)
4.FACILITY.Is the rnsme or t97e buslness whafa the well Is located.
FACILITY 10#(If appllcablo)MW-8 �^ _
NAME OF FACILITY wilco-HEss #111
STREET ADDRESS 2420 S STRATFORD RD
WINSTON SALEM NC 27103 35
City or Town State Zip Code
CONTACT PERSON GARY FISHER
MAILING ADDRESS 409 ROGERS VIEW COURT
RALIECH NC 27610 11.REMARKS:
City or Town Stale Zip Code
800 )- 486-7568
Area code» Phone numbor
S.WELL DETAILS: I DO HF=PEB?CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCOROANCE WITH
15A NCAG 2C,WELL CONSTRUCTION STANDARDS,AND TFIAT A GOPY CF THIS
a. TOTAL DEPT6I: 35 RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
V{t� -z3/! 3-1-2011
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOS] -
FENATURE OF CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: 29 FT.
Stefan smith
(Use"+"if Above Top of Casing)
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form GW 1b
1617 Mail Service Center—Raleigh,NC 276,99-1617 phone No.[phone] ext 668, Rev.7105

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SABDACCO Inc Y. ft,p"UPli'1 ' I TFi
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2420 S. Stratford Road A. l lGR VEi p}i`K:+
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{fk`aF?Arap. to •Flti„
IaTtJE1Iw. 36.0534 IbIA �7S it#xiit± .• M .�^----
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L6IVC3IrlUDE..80.32-109 ah(feclkr�{)k:i'Urir t- Frt1EIt THY Qti718t10n l r~ rani in
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-
+t,�i0.CELi't`Y
NAME' F`;FAFL1 T`>
)kft�- 2420 S. Stratfozd Road
Winston Salem N.C. 27103 �
(; IJ1;f T"PRi�Mid- Atlantic (Trey Marchant) _. .__.M ,w„_..............a.,,_., ,._ ,,.,..._
MA UN :ADC AE 3 409 Rogers View Court
Raleigh N.C. 27610 �
ity:tir'Trnp/il',; 5t'rltg ZPp - 2' bentonite seal from 121 to 14
8 0 0 486-7569_. ..
Area code. Ph'm6;6un bi§.r.
I t3C7 MEFtFB� CEfiTIFY Tt~1AT'rHI%VVELL WAS 9t4 ACg0. 9DAN(,E WITH
a.WE=LLDETAIL ' 1$t+NCAC20 V%%�E�klL.CpN$TRE)OTIONSTANI)ARI'lb A 4.11fikTAt0Y&THISa. '
R HAu PRt11+IDEti ttl TI]E SN�LL OVYNt'
TOTAL CSEzE*i°t i 2 6'
3-12-12
n. E)OP.S WRL4!ItPLACK iwgMtIKG WELL? YES NO—M
l VATUF3�#31^ f f : fi'I D VNirt L G NTRACT R. DATE
C, WATEFt LEVEL,Beitiv; o rd€Casih -. F. Robert Miller
(tile"+ k Ab °Pe a }
PRINT t NO THE,,WELL
igubmit tha or[lg nal:t. tlia(iviai6n.ofF �r OU8111ty within d—m Ekttrt.lnfortnatliain MOt.,,
i81.7 tV1a 13ervi e.Gdt t r`-ilA1, No I?689'-ml i?h(p-q No.ts.IS)"7;.'3
i