Press Alt + R to read the document text or Alt + P to download or print.
This document contains no pages.
HomeMy WebLinkAboutWI0500707_GW-1_20250120 TERRA iuest
i�����
ENVIRONMENTAL CONSULTANTS,P.C.
January 20, 2025
Blake Butcher VIA EMAIL
NCDEQ Groundwater Resources Branch-UIC Program
blake.butcher@deg.nc.gov
Re: W10500707 Permit Update
Bunn Exxon, 300 Main Street, Bunn, NC
NCDWM-UST Incident No. 18013// Terraquest Project No. 00997
Dear Mr. Butcher,
On behalf of the permitee and petroleum leak responsible party, Bunn Exxon, Terraquest
Environmental Consultants, P.C. hereby submits this letter to amend conditions of the
W10500707 "permit" that was issued as a response to Terraquest's original Notice of Intent
submittal for a permit-by-rule situation.
The original NOI for this site focused on air sparge wells that are present as part of an active
treatment system. That work continues. Terraquest subsequently received approval from the
subject's regulator, the NCDEQ's DWW-UST, for placement of Oxygen Biochem (OBC) and/or
DualOx at the site. Terraquest has attached safety data sheets for those compounds.
Attached are Figures 1, 2, and 3 that show the site's location, vicinity, and layout including the
remediation system. Figure 4 is provided to show the site in geologic cross-sectional view. Figure
5 provides recent groundwater analytical quality data.
The regulations regarding the petroleum release incident at this site mandate that groundwater
contamination above the Gross Contamination Levels be removed. At last check, that has
happened. Due to contaminant rebound with groundwater table fluctuations, Terraquest
requested and received permission to apply DualOx and OBC. We are going with DualOx to start.
DualOx is a mixture of 7.9% by weight hydrogen peroxide and Epsom salts. It will cause in-situ
chemical oxidation of the contamination and will also promote ongoing degradation via natural
processes via the addition of oxygen and sulfates that will act as respiratory electron acceptors
in aerobic and anaerobic conditions. Wells with prior GCL violations will be the target. Those
wells include MW6, MW12, and MW19. Both DualOx and OBC would be applied to the wells in
passive manner by pouring the mixtures into the well from the surface. Approximately five
gallons of injectant will be applied to each well during an injection event. Well construction
records for the subject wells are enclosed.
As always, thank you for your help and please reach out if you have any questions. Thanks so
much!
100 East Ruffin Street, Mebane, North Carolina 27302
Telephone (919) 563-9091 -Facsimile (919) 563-9095
www.terraquestpc.com
Page 2 of 2
W10500707
#18013 Bunn Exxon
Terraquest Environmental Consultants, P.C.
1/20/25
Sincerely,
TERRAQUEST ENVIRONMENTAL CONSULTANTS, P.C.
4,�>)(41v-�
Ryan D. Kerins
Project Manager
Enclosures
cc: Bunn Exxon, Ken Pearce
NCDWM-UST, Craig McIntosh
100 East Ruffin Street, Mebane, North Carolina 27302
Telephone (919) 563-9091 -Facsimile (919) 563-9095
www.terraquestpc.com
u t Crolap
n
��.li 1. •'S' �J
Cern
or Cern
Bullrl
F'
!
�.�u.'„"'. %' �'�_ "'vvi�� •� . . _ram - y
f I 7' r �'� / �� fate
I ( "' `� Cerra::• `V;sue` `�
I-. . i� �' `¢ i ..:�� '��✓ ,.� �•� ICY_�_. _ ��� j,'
Ti'nk
MAP SOURCES: USGS 7.5 MINUTE TOPOGRAPHIC MAPS OF BUNN EAST AND WEST, NC
GRAPHIC SCALE
iiiii
0' 2,000' 4,000'
SITE LOCATION MAP
ue EXXON
300 MAIN STREET
BUNN EXXON BUNN, NC
ENVIRONMENTAL CONSULTANTS, P.C. PROJECT NO. 00997 DRAWN BY: RDK I DATE: 1/20/25
SCALE: 1" = 2,000' 1 CHECKED BY: MJB FIGURE NO. 1
PW30
R-10
PW25
22
�j PW21
O�
PW23 Z OPT
�sl
o � �
PW29�i
15 �y PW20
Aoq FT Q�
�8
9 O9
CC �JPW W6 SAE. R�VAE 6
PW12 26 (3 �06 �9s R-10
W1 oj
(3PW11 PW3 7418 9496 PW7 T
R-10 PW1 Ps 77 IT
7119
PW13 PW1 JF
PW14 `SO CC
PW18
PW 1 6
9B P PW24
P W 17
� J
00,
00
S� R-10 PW27 CC
o,
C� JF PW28
yyP�
LEGEND
QI!) NON-POTABLE IRRIGATION WELL
ABANDONED WATER SUPPLY WELL
DISCONNECTED WATER SUPPLY WELL NO ACTIVE POTABLE WATER SUPPLY
R-10 RESIDENTIAL WELLS WITHIN 1,500 FEET OF SITE GRAPHIC SCALE
CC CENTRAL COMMERCIAL
ZONING BOUNDARY ol
1895 LAST FOUR DIGITS OF FRANKLIN 200' 400 800
COUNTY PIN NUMBERS. 1 = 400'
uest SITE VICINITY MAP
wm BUNN EXXON
300 MAIN STREET
BUNN, INC 27508
BUNN EXXON BUNN INC
ENVIRONMENTAL CONSULTANTS,P.C. PROJECT NO. 00997 DRAWN BY: JAK DATE: 1/20/25
SCALE: 1" = 400' CHECKED BY: MJB FIGURE NO. 2
c�
z
z
z
LEGEND m
Type II Monitoring Well
Type III Monitoring Well
AUTOMAx ll� Air sparge wells
Soil vapor extraction wells
Q Y
\ W n,
W m
\\ -D �z m
O
\IW9 _ �
z
QI �
+MW4 \ J O m m m
LLJ
6 ® \ LL) O U
5 _
W <
4 o Gj \ (f) o
0 0 o SVE�i SVE4 ��� AAS2
o SVE1 0 SVE6 \ � O
SVE \ 6
T AS1 \ U.S. POST 0 ^II
3 sr OFFICE O
a � \ Z
Nmn* T2 it SVE7 V OX O
Q 1 \ X z
W H
NATIONWIDE U
E8 INSURANCE z w w
SV)=9 a ASS �9\ Z O Q
O 4 MW12 \ m d !n
0 NWi _ EECTRicn'- - \ 1 VIW1 6
�}
SVE1 \
MW5* 8 AS4 \
FM *WWI
�AS6+MWJ +MW10 AS11 \
+MW13
7 g
i YYY"'
*MW2 /
12 /
GP MW AS14 /
*MW17 /
/ UST LEGEND
/ T1 2,000—GALLON GASOLINE — CLOSED
/ T2 5,000—GALLON GASOLINE — CLOSED
/ T3 1,000—GALLON GASOLINE — CLOSED
/ T4 1,000—GALLON GASOLINE — CLOSED T
*M`4'4 / T5 1,000—GALLON DIESEL — CLOSED
/ T6 9,000/6,000—GALLON GASOLINE b
/ AST 1,000—GALLON DIESEL a
/ AST2 1,000—NON—HIGHWAY DIESEL
AST3 1,000—GALLON USED OIL I
MW18 / AST4 500—GALLON KEROSENE I
/ AST5 250—GALLON WASTE OIL z
/ o
/ , U
/ J
F
Z
uj
/ GRAPHIC SCALE I z
i >
0' 20' 40' 80' w
/ 1" = 40'
z
AUTO— Z On
Z N
AA A •• mo 9
290.00' 1:
�� 2L STANDARD VIOUITIDN PLUME �
Z
MW4 MW1 MW2 MW5 MW11 MW6 MW18 Ts s w
CD
280.00 B2, ' . �a' ez� �y� z o
z sT U
(9 10) T2 � .p us_aosr U
77
OFFICE Z
Q
270.00 B20) (1B10
3) �'.� c a Pw`� NEoLAMM
B13 ( W m J
11 13 B6 0 � 0
0�— B Zw � 7' F—
( ) (�
(10-12) B - X O
260.00 , OF X
250.00 U m 0 L, LLJ
o
(� UL-j <
i i i i i i i i i �MwT Z
240.00LLJ
CD
0
cj�
LEGEND Z/? Q
GRAPHIC SCALE Elevations are from a professional survey conducted by Tim ? \ z
Newcomb Land Surveyors. Al �•% X
HORIZONTAL: 1" = 40' Lean Clay (CL) w
20' — A detailed discussion of site geology along with boring logs Mostly medium stiff to stiff, orange/tan
VERTICAL: 1" — 20' w
are included in the CSA Report. clay, with some fine and coarse grained z O w
sand. Q
VERTICAL This drawing is a fence diagram. The distances between Z IY U
wells do not correlate with a straight line between the first Clayey Sand (SC) m a- un
10' EXAGERATION X 2 and last well of the cross section. ® Mostly medium dense, fine and coarse
grained sand with medium stiff tan clay.
20' 40' SAPROLITE HISTORICAL GROUNDWATER
soprolite Mostly medium stiff, ton/gray
with characteristics of clay. QUALITY DATA USED TO �■
B ❑ Estimated Extent of stg—MSCC Violation. 9 GENERATE THIS MAP
1
290.00'
MW8 MW3 T5 MW5 MW11 MW10 MW13 SOUTH MAIN ST. MW16
280.00' B3
(3-5) SOIL BORING WITH LOCATION OF BURIED UTILITIES
B4 SAMPLE LOCATION WELL ID '
s \ GROUND SURFACE d
POTENTIOMETRIC SURFACE �I Z
2 7 0.0 0 M 51M\
(12-14
(TYPE II MONITORING WELL I z
SCREEN
260.00 ,� i� �� i� ,�,� �� ���� ,� , EXTENT OF SOIL CONTAMINATION�� ��e U)
i i�,��� ��ii�,��� ��i ��,�i i�,��� i �� ABOVE SOIL TO GROUNDWATER ��� i Z
O
CONCENTRATION U
OUTER CASING ESTIMATED EXTENT OF J
2L STANDARD VIOLATION Q
250.00' z
SCREEN Z
LU
ESTIMATED EXTENT OF
GCL VIOLATION
240.00' ,
O
TYPE III MONITORING WELL d'
c�
Contami nant of Concern z
u'
o
Z
LEGEND m L
3.
£ o E c - m 4 n
x
e w o £ s m o �Type II Monitoring Well \
Datolm w _ R F
Well ID Col leetW 0 z R
MW1 11/7/24 20B 2,690 412 2980 <4.40 <14.8 362 <4.60 96.1 <14.2 119 195 <15.2 <14.0 25 Type III NanitO rin Well
�� W
MW5 11/7/24 4,470 1960 1,920 6,680 23.8 432 533 <2.30 163 75 492 370 956 <7.00 102 Yp g .
MW6 11/7/24 4,710 12,400 2,060 8960 955 1,630 854 <11.5 224 <35.5 402 500 <38.0 <35.0 981 CL
W CL
H MW10 11/7/24 1,010 7,060 788 6A (-D40 142 239 1,020 6.71 312 <17.8 299 496 <19.0 <17.5 69b � Q _
MW11 11/7/24 564 5,190 921 4,570 <4.40 <37.0 526 <4.60 146 <14.2 25 219 <15.2 <14.0 592 W
MW12 11/7/24 3,500 14,800 1,100 7,060 <11.0 331 749 <11.5 200 <35.5 20A 261 <38.0 <35.0 479 AUTOMAX J
MW13 11/7/24 412 81.2 395 571 324 91.0 308 <0.460 110 2.05 27J 168 025 396 40A
MW18 11/7/24 110 1.02 21.6 17.4 22 107 19 <0.230 <0.560 <0.710 430 15.8 <0,760 <0.700 292 /n
MW19 11/7/24 1,030 1,090 109 2,150 111 611 347 30 112 <3.55 6.61 123 <3.80 <3.50 131 V) Y
MW20 11/7/24 838 236 656 1,350 <0.440 348 347 1.08 <1.12 2.04 20 195 775 23 631 LLJ
OW'
11 24 853 4,550 351 2,100 494 64 265 <4.60 858 414.2 410.6 132 <15.2 <14.0 202 �/ LLJ W m n,
2L Standard 1 600 600 500 20 70 400 0.02 400 25 7D 6 70 70 70 � - \
Gross Contamination Level 5,000 260,000 80,000 50,000 20,000 70,000 28,500 50 24,100 11,700 30,500 6,000 5,900 8,800 26,100 Select ground Water analytical results for the J Z m
MW9 11/7/24 sampling event are provided in ug/L. D
zz
U Qz�P A complete summary of groundwater analytical g z }
+MW4 results is provided as Table 5 and the full \ o m m m
6 analytical report is provided in Appendix E of the -J C) Y z
® c$� Mw1 1 1/2024 CAPR. w a
0 o 0 y
�
000 w
G 9 AW' - V�
7 ,c� U.S. POST
T T3 \`� U OFFICE z O
ST
Nmn* T2 o
Q ' X
NATIONWIDE \ W U
o INSURANCE z w
n I � Q
u MW12 m d (I)
+MW2 O MW2 F y MW16
MW5* �
Q° +MW19
_MW11 1 MW10
Y +MW13
1•
YA MW20
\
Ql W
i GP
i MW6*
*Mw17 UST LEGEND
T1 2,000-GALLON GASOLINE - CLOSED
T2 5,000-GALLON GASOLINE - CLOSED
T3 1,000-GALLON GASOLINE - CLOSED Jim
T4 1,000-GALLON GASOLINE - CLOSED if,
0 GCL *M 4 T5 1,000-GALLON DIESEL - CLOSED
T6 9,000/6,000-GALLON GASOLINE b
AST 1,000-GALLON DIESEL o_
AST2 1,000-NON-HIGHWAY DIESEL I z
VIOLATIONS . AST3 1,000-GALLON USED OIL I <
Mwis AST4 500-GALLON KEROSENE I
AST5 250-GALLON WASTE OIL z
0
Uj
J
Q
H
Z
GRAPHIC SCALE I z
0
0 20' 40' 80 >
1" = 40'
DualOx 2024
SAFETY DATA SHEET
DualOxTM
1. PRODUCT AND COMPANY IDENTIFICATION
PRODUCT NAME: DualOxTM
GENERAL USE: Chemical and biological oxidation of petroleum products
MANUFACTURER: EMERGENCY TELEPHONE:
Redox Tech,LLC Within USA and Canada: 1-800-424-9300
200 Quade Drive +1 703-527-3887 (collect calls accepted)
Cary,NC 27513
919-678-0140
2. HAZARDS IDENTIFICATION
EMERGENCY OVERVIEW: May have a slight sulfur odor. Non-hazardous liquid
May react in the presence of a reducing agent and water to produce hydrogen sulfide.
Contact with eyes will likely cause irritation and should be rinsed immediately.
Should be no irritation upon contact with skin.
Ingestion may cause diarrhea
3. COMPOSITION INFORMATION ON INGREDIENTS
All components are non-hazardous (Dilute hydrogen peroxide, magnesium sulfate heptahydrate
and citric acid)
4. FIRST AID MEASURES
EYES: Immediately flush with water for 15 minutes. See a medical doctor if irritation persists.
SKIN: Rinse with water. Irritation is unlikely,but if irritation occurs or persists, seek medical
attention.
INGESTION: Dilute by drinking 1-2 liters of water. Do not induce vomiting. It may induce
diarrhea. If diarrhea persists, seek medical attention.
INHALATION: Liquid product not for inhalation.
DualOx 2024
5. FIRE FIGHTING MEASURES
EXTINGUISHING MEDIA: Deluge with water
FIRE/EXPLOSION HAZARDS: Product in non-combustible but it may release noxious sulfur
compounds during a fire.
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: not available
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.
7. HANDLING AND STORAGE
HANDLING: Avoid contact by using water repellant protective gloves and safety glasses
STORAGE: Use first in, first out storage system. Avoid contamination of opened product.
Avoid contact with reducing agents.
COMMENTS: Use gentle mechanical agitation to avoid producing mist and small droplets
8. EXPOSURE CONTROLS - PERSONAL PROTECTION
All components are non-hazardous
ENGINEERING CONTROLS: None are required. If active ventilation is used, it should be
gentle as to not create dust.
PERSONAL PROTECTIVE EQUIPMENT
EYES and FACE: Safety goggles
RESPIRATOR: Not required
PROTECTIVE CLOTHING: None necessary
GLOVES: rubber, latex or neoprene
DualOx 2024
9. PHYSICAL AND CHEMICAL PROPERTIES
Odor: none to slight sulfur
Appearance: clear liquid
Auto-ignition Temperature Non-combustible
Boiling Point 100 C
Melting Point NA
Density 1.02 gram/cc
Solubility completely water soluble
pH 6-8
10. STABILITY AND REACTIVITY
CONDITIONS TO AVOID: reducing agents.
STABILITY: product is stable
POLYMERIZATION: will not occur
INCOMPATIBLE MATERIALS: reducing compounds may result in noxious hydrogen
sulfide production
HAZARDOUS DECOMPOSITION PRODUCTS: may produce hydrogen sulfide in presence
of reducing agents, and sulfur oxides at elevated temperatures.
11. TOXICOLOGICAL INFORMATION
Acute Toxicity
A: General Product Information
Acute exposure may cause mild skin and eye irritation. Gastrointestinal absorption may cause
acute magnesium poisoning. Symptoms include flushing, sweating, low blood pressure,
depression of reflexes, flaccid paralysis, hypothermia, circulatory collapse, and depression of
CNS and heart function. Excessive long-term ingestion of this product may cause also cause
magnesium poisoning with symptoms described above.
B: Component Analysis - LD50/LC50
No information available.
B: Component Analysis - TDLo/LDLo
TDLo (Oral-Man) 183 mg/kg/4 hours-intermittent: Gastrointestinal: hypermotility, diarrhea;
LDLo (Intraduodenal-Woman) 5344 mg/kg
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
DualOx 2024
12. ECOLOGICAL INFORMATION
Ecotoxicity
No information available.
Environmental Fate
No potential for food chain concentration
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.,I.C.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 Regulated
Packing Group: None
Required Label(s): None
50'Edition International Air Transport Association (IATA):
Not Regulated
INTERNATIONAL MARITIME DANGEROUS GOODS (IMDG)
Material is not regulated under IMDG
15. REGULATORY INFORMATION
UNITED STATES
SARA TITLE III
SECTION 311 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
DualOx 2024
16. OTHER INFORMATION
HMIS:
Health 1
Flammability 0
Physical Hazard 0
Personal Protection E
E: Safety Glasses, gloves and dusk mask
REDOX TECH, LLC ►
"Providing Innovative In Situ Soil and Groundwater Treatment"
Material Safety Data Sheet—Oxygen BioChem
1. Identification
Product identifier Oxygen Biochem (OBC)TM
Other means of identification Not available.
Recommended use Oxygen Biochem (OBC)TM is used to promote chemical oxidation and aerobic bioremediation of
petroleum compounds in groundwater.
Recommended restrictions Use in accordance with supplier's recommendations.
Manufacturer/Importer/Supplier/Distributor information
Manufacturer/Supplier Redox Tech, LLC
Address 200 Quade Drive Cary
NC 2751
Telephone +1 919-6780140
E-mail haselow@redox-tech.com
Contact person Dr. John Haselowi
Emergency Telephone For Hazardous Materials[or Dangerous Goods] Incidents ONLY
(spill, leak,fire, exposure or accident), call CHEMTREC at
CHEMTREC@, USA: 001 (800)424-9300
CHEMTREC@, Mexico(Toll-Free-must be dialed from within country):
01-800-681-9531
CHEMTREC@, Other countries: 001 (703)527-3887
2. Hazard(s) identification
Physical hazards Oxidizing solids Category 3
Health hazards Acute toxicity, oral Category 4
Skin corrosion/irritation Category 2
Serious eye damage/eye irritation Category 2
Sensitization, respiratory Category 1
Sensitization, skin Category 1
Specific target organ toxicity, single exposure Category 3 respiratory tract irritation
OSHA defined hazards Not classified.
Label elements
< >< X >
• r
Signal word Danger
Hazard statement May intensify fire; oxidizer. Harmful if swallowed. Causes skin irritation. Causes serious eye
irritation. May cause allergy or asthma symptoms or breathing difficulties if inhaled. May cause an
allergic skin reaction. May cause respiratory irritation.
Precautionary statement
Prevention Keep away from heat. Keep/Store away from clothing and other combustible materials. Take any
precaution to avoid mixing with combustibles.Wear protective gloves/eye protection/face
protection. Wash thoroughly after handling. Do not eat, drink or smoke when using this product.
Avoid breathing dust/fume. In case of inadequate ventilation wear respiratory protection.
Contaminated work clothing must not be allowed out of the workplace. Use only outdoors or in a
well-ventilated area.
Response In case of fire: Use foam, carbon dioxide, dry powder or water fog for extinction. If swallowed: Call
a poison center/doctor if you feel unwell. Rinse mouth. If on skin:Wash with plenty of water. If
skin irritation or rash occurs: Get medical advice/attention. Take off contaminated clothing and
wash before reuse. If in eyes: Rinse cautiously with water for several minutes. Remove contact
lenses, if present and easy to do. Continue rinsing. If eye irritation persists: Get medical
advice/attention. If inhaled: If breathing is difficult, remove person to fresh air and keep
comfortable for breathing. If experiencing respiratory symptoms: Call a poison center/doctor.
Oxygen Biochem (OBC)TM SIDS US
920293 Version#:01 Revision date:- Issue date:09-May-2014 1 /7
Storage Store in a well-ventilated place. Keep container tightly closed. Store locked up.
Disposal Dispose of contents/container in accordance with local/regional/national/international regulations.
Hazard(s) not otherwise None known.
classified (HNOC)
3. Composition/information on ingredients
Mixtures
Chemical name CAS number %
Sodium persulfate 7775-27-1 70-90
Calcium peroxide 1305-79-9 10-20
Composition comments All concentrations are in percent by weight unless ingredient is a gas. Gas concentrations are in
percent by volume.
4. First-aid measures
Inhalation Move to fresh air. Do not use mouth-to-mouth method if victim inhaled the substance. For
breathing difficulties, oxygen may be necessary. Call a physician or poison control center
immediately.
Skin contact Remove and isolate contaminated clothing and shoes. For minor skin contact, avoid spreading
material on unaffected skin.Wash clothing separately before reuse. If skin irritation or an allergic
skin reaction develops, get medical attention.
Eye contact Immediately flush eyes with plenty of water for at least 15 minutes. Remove contact lenses, if
present and easy to do. Continue rinsing. Get medical attention if irritation develops and persists.
Ingestion Rinse mouth. Do not induce vomiting without advice from poison control center. If vomiting occurs,
keep head low so that stomach content doesn't get into the lungs. Do not use mouth-to-mouth
method if victim ingested the substance. Induce artificial respiration with the aid of a pocket mask
equipped with a one-way valve or other proper respiratory medical device. Get medical attention if
any discomfort continues.
Most important May cause redness and pain. Symptoms may include coughing, difficulty breathing and shortness
symptoms/effects, acute and of breath.
delayed
Indication of immediate Provide general supportive measures and treat symptomatically.
medical attention and special
treatment needed
General information Ensure that medical personnel are aware of the material(s)involved, and take precautions to
protect themselves.
5. Fire-fighting measures
Suitable extinguishing media Water fog. Foam. Dry chemical powder. Carbon dioxide(CO2).
Unsuitable extinguishing None known.
media
Specific hazards arising from Contact with combustible material may cause fire.
the chemical
Special protective equipment Self-contained breathing apparatus and full protective clothing must be worn in case of fire.
and precautions for firefighters
Fire-fighting In the event of fire, cool tanks with water spray.
equipment/instructions
General fire hazards May intensify fire; oxidizer.
6. Accidental release measures
Personal precautions, Keep unnecessary personnel away. Keep people away from and upwind of spill/leak. Wear
protective equipment and appropriate protective equipment and clothing during clean-up. Do not touch damaged containers
emergency procedures or spilled material unless wearing appropriate protective clothing.Avoid skin contact and inhalation
of vapors during disposal of spills.Ventilate closed spaces before entering them. Local authorities
should be advised if significant spillages cannot be contained. For personal protection, see Section
8 of the SDS.
Methods and materials for Stop the flow of material, if this is without risk. Prevent entry into waterways, sewer, basements or
containment and cleaning up confined areas. Following product recovery,flush area with water. For waste disposal, see Section
13 of the SDS.
Environmental precautions Avoid discharge into drains,water courses or onto the ground.
Oxygen Biochem (OBC)TM SIDS US
920293 Version#:01 Revision date:- Issue date:09-May-2014 2/7
7. Handling and storage
Precautions for safe handling Avoid inhalation of vapors/dust and contact with skin and eyes.Wash thoroughly after handling.
Keep away from clothing and other combustible materials. Use only with adequate ventilation. Do
not taste or swallow.Wear appropriate personal protective equipment(See Section 8). Observe
good industrial hygiene practices.
Conditions for safe storage, Store in original tightly closed container. Store away from incompatible materials(See Section 10).
including any incompatibilities Keep locked up.
8. Exposure controls/personal protection
Occupational exposure limits
US.ACGIH Threshold Limit Values
Components Type Value
Sodium persulfate(CAS TWA 0.1 mg/m3
7775-27-1)
Biological limit values No biological exposure limits noted for the ingredient(s).
Appropriate engineering Observe occupational exposure limits and minimize the risk of exposure. Ensure adequate
controls ventilation, especially in confined areas.
Individual protection measures,such as personal protective equipment
Eye/face protection Wear safety glasses with side shields(or goggles).
Skin protection
Hand protection Wear protective gloves.
Other Neoprene or rubber gloves are recommended.Apron and long sleeves are recommended.
Respiratory protection In the case of respirable dust, use self-contained breathing apparatus. Wear positive pressure
self-contained breathing apparatus (SCBA).
Thermal hazards Wear appropriate thermal protective clothing, when necessary.
General hygiene Always observe good personal hygiene measures, such as washing after handling the material
considerations and before eating, drinking, and/or smoking. Routinely wash work clothing and protective
equipment to remove contaminants.
9. Physical and chemical properties
Appearance Off-white, granular solid.
Physical state Solid.
Form Solid.
Color Off-white.
Odor Odorless.
Odor threshold Not available.
pH 11.7±0.4(1-40%solution, slurry)
Melting point/freezing point Not available.
Initial boiling point and boiling Not applicable.
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.
(%)
Flammability limit-upper Not available.
(%)
Explosive limit-lower(%) Not available.
Explosive limit-upper(%) Not available.
Vapor pressure Not applicable.
Vapor density Not applicable.
Relative density 2.76±0.16(25°C)
Oxygen Biochem (OBC)TM SIDS US
920293 Version#:01 Revision date:- Issue date:09-May-2014 3/7
Solubility(ies)
Solubility(water) Soluble in water.
Partition coefficient Not available.
(n-octanol/water)
Auto-ignition temperature Not available.
Decomposition temperature Not available.
Viscosity Not available.
Other information
Oxidizing properties Oxidizing.
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 No dangerous reaction known under conditions of normal use.
reactions
Conditions to avoid Contact with combustibles.
Incompatible materials Combustible material. Oxidizing material. Reducing agents.
Hazardous decomposition No hazardous decomposition products are known.
products
11. Toxicological information
Information on likely routes of exposure
Ingestion Harmful if swallowed.
Inhalation May cause irritation to the respiratory system.
Skin contact Causes skin irritation.
Eye contact Causes serious eye irritation.
Symptoms related to the May cause redness and pain. Exposed individuals may experience eye tearing, redness, and
physical, chemical and discomfort. Symptoms may include coughing, difficulty breathing and shortness of breath.
toxicological characteristics
Information on toxicological effects
Acute toxicity Harmful if swallowed.
Skin corrosion/irritation Causes skin irritation.
Serious eye damage/eye Causes serious eye irritation.
irritation
Respiratory or skin sensitization
Respiratory sensitization May cause allergy or asthma symptoms or breathing difficulties if inhaled.
Skin sensitization May cause an allergic skin reaction.
Germ cell mutagenicity No data available.
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- May cause respiratory irritation.
single exposure
Specific target organ toxicity- No data available.
repeated exposure
Aspiration hazard Not applicable.
Chronic effects Prolonged exposure may cause chronic effects.
Further information No data available.
12. Ecological information
Ecotoxicity This product's components are not classified as environmentally hazardous. However,this does
not exclude the possibility that large or frequent spills can have a harmful or damaging effect on
the environment.
Persistence and degradability No data is available on the degradability of this product.
Bioaccumulative potential No data available for this product.
Oxygen Biochem (OBC)TM SIDS US
920293 Version#:01 Revision date:- Issue date:09-May-2014 4/7
Mobility in soil Not available.
Other adverse effects No data available.
13. Disposal considerations
Disposal instructions Consult authorities before disposal. Dispose in accordance with all applicable regulations.
Hazardous waste code The Waste code should be assigned in discussion between the user, the producer and the waste
disposal company.
Waste from residues/unused Dispose of in accordance with local regulations.
products
Contaminated packaging Empty containers should be taken to an approved waste handling site for recycling or disposal.
14. Transport information
DOT
UN number UN1479
UN proper shipping name Oxidizing solid, n.o.s. (Sodium persulfate)
Transport hazard class(es)
Class 5.1
Subsidiary risk -
Packing group II
Environmental hazards
Marine pollutant No
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
Special provisions 62, I135, IP1
Packaging exceptions None
Packaging non bulk 211
Packaging bulk 242
IATA
UN number UN1479
UN proper shipping name Oxidizing solid, n.o.s. (Sodium persulfate, Calcium peroxide)
Transport hazard class(es)
Class 5.1
Subsidiary risk -
Label(s) 5.1
Packing group II
Environmental hazards No
ERG Code 5L
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
IMDG
UN number UN1479
UN proper shipping name OXIDIZING SOLID, N.O.S. (Sodium persulfate, Calcium peroxide)
Transport hazard class(es)
Class 5.1
Subsidiary risk -
Label(s) 5.1
Packing group II
Environmental hazards
Marine pollutant No
EmS F-A, S-Q
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
Transport in bulk according to This product is not intended to be transported in bulk.
Annex II of MARPOL 73/78 and
the IBC Code
15. Regulatory information
US federal regulations This product is a"Hazardous Chemical'as defined by the OSHA Hazard Communication
Standard, 29 CFR 1910.1200.
All components are on the U.S. EPA TSCA Inventory List.
TSCA Section 12(b) Export Notification (40 CFR 707, Subpt. D)
Not regulated.
Oxygen Biochem (OBC)TM SIDS US
920293 Version#:01 Revision date:- Issue date:09-May-2014 5/7
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-Yes
Delayed Hazard-Yes
Fire Hazard-Yes
Pressure Hazard-No
Reactivity Hazard- No
SARA 302 Extremely hazardous substance
Not listed.
SARA 311/312 Hazardous Yes
chemical
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 This product does not contain a chemical known to the State of California to cause cancer, birth
defects or other reproductive harm.
US. Massachusetts RTK-Substance List
Not regulated.
US. New Jersey Worker and Community Right-to-Know Act
Calcium peroxide(CAS 1305-79-9)
Sodium persulfate(CAS 7775-27-1)
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) Yes
Canada Domestic Substances List(DSL) Yes
Canada Non-Domestic Substances List(NDSL) No
China Inventory of Existing Chemical Substances in China (IECSC) Yes
Europe European Inventory of Existing Commercial Chemical Yes
Substances(EINECS)
Europe European List of Notified Chemical Substances(ELINCS) No
Japan Inventory of Existing and New Chemical Substances(ENCS) Yes
Korea Existing Chemicals List(ECL) Yes
New Zealand New Zealand Inventory Yes
Philippines Philippine Inventory of Chemicals and Chemical Substances Yes
(PICCS)
United States&Puerto Rico Toxic Substances Control Act(TSCA) Inventory Yes
*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).
Oxygen Biochem (OBC)TM SIDS US
920293 Version#:01 Revision date:- Issue date:09-May-2014 6/7
16. Other information, including date of preparation or last revision
Issue date 09-May-2014
Revision date -
Version# 01
Further information HMIS®is a registered trade and service mark of the NPCA.
NFPA Ratings
4 0
ox
List of abbreviations NFPA: National Fire Protection Association.
References Registry of Toxic Effects of Chemical Substances(RTECS)
HSDB®- Hazardous Substances Data Bank
Disclaimer The information contained herein is accurate to the best of our knowledge. However, data, safety
standards and government regulations are subject to change and,therefore, holders and users
should satisfy themselves that they are aware of all current data and regulations relevant to their
particular use of product. CARUS CORPORATION DISCLAIMS ALL LIABILITY FOR RELIANCE
ON THE COMPLETENESS OR ACCURACY OR THE INFORMATION INCLUDED HEREIN.
CARUS CORPORATION MAKES NO WARRANTY, EITHER EXPRESS OR IMPLIED,
INCLUDING, BUT NOT LIMITED TO,ANY WARRANTIES OF MERCHANTIABILITY OR FITNESS
FOR PARTICULAR USE OR PURPOSE OF THE PRODUCT DESCRIBED HEREIN.All conditions
relating to storage, handling, and use of the product are beyond the control of Carus Corporation,
and shall be the sole responsibility of the holder or user of the product.
(Carus and design)is a registered service mark of Carus Corporation.
Oxygen Biochem (OBC)TM SIDS US
920293 Version#:01 Revision date:- Issue date:09-May-2014 7/7
NON E'SIDENTIAL 'WELL CONSTRUCTION RECORD
r North Carolina Department of Environment and Natural Resources-Division of Water Quality
WELL CONTRACTOR CERTIFICATION it 3329
1.WELL CONTRACTOR: ;d. TOP OF CASING IS_0' FT.Above Land Surface*
Nick Perry _ *Top of casing terminated a1/or below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118,
Terra nest Environmental Cons. e. YIELD(gpm): METHOD OF TEST
Well Contractor Company Name
100 E Ruffin St. :f. DISINFECTION:Type Amount
Street Address :g. WATER ZONES(depth):
Mebane NC 27302 :Top Bottom Top Bottom
City or Town Slate Zip Coda :Top Bottom Top Bottom
9( 19 563-9091 'Top Bottom Top Bottom
Area code Phone number Thickness/
2.WELL INFORMATION: ;7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# ;Top 0` Bottom 10' Ft. 2 in. sch 40 PVC
OTHER ASSOCIATED PERMIT#(If applicable) ;Top Bottom Ft.
SITE WELL ID#(if applicable)MW6 :Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring a/Municipal/PubliGLl 8. GROUT: Depth Material Method
Industrial[Commercial❑ Agricultural❑ Recovery❑ Injection❑ ;Top 0' Bottom 6' Ft. Portland Pour
irrigation❑ 01her❑ (list use) :Top 6' Bottom 8' Ft. Bentonite Pour
DATE DRILLED 4/1/1 1 ;Top Bottom Ft.
4.WELL LOCATION: :9. SCREEN: Depth Diameter Slot Size Material
300 Main St.. 27508 :Top 10' Bottom 20' Ft. 2 in. in, .010 in. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) :Top Bottom--Ft. In. in.
CITY: Bunn COUNTY Franklin ;Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope OValley ❑Flat [IRldge ❑Other :10.SANDIGRAVEL PACK:
35 *57 137.0000 "DMS OR 3 DD Depth Size Material
LATITUDE j Top 8 Bottom 20' Ft. coarse Sand
LONGITUDE 78 4 1e 1 Mom "DMS OR 7 DID
Top Bottom Ft.
Latitude/longitude source: BPS ilTopographic map :Top 13otton Ft.
(location of well must be shown on a USGS topo map andattached to
this font if not using GPS) : 11.DRILLING LOG
5.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
Bunn Exxnn _0_015307 : 0' 10.51 GRAVEL
Facility Name Facility ID#(If applicable) : 0'6' -1 10' SANDY LEAN CLAY _
10' / 20' SAND.with clay
Street Address /
I
City or Town State Zip Code /
Contact Name /
P n Box 96 /
Mailing Address /
City or Town State Zip Code
12.REMAR
( 919.8496-3984
Area code Phone number
6.WELL DETAILS: :I DO HERhYbERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCA WELL CO RUCTION STANDARDS,AND THATA COPY OF THIS
a. TOTAL DEPTH: 20' ;REIr
BEEN P VIDED TO THE WELL OWNER.
b. DOES WELL REPLACE EXISTING WELL? YES E7 NO rY :SlGNATUR i CERTIFIED WELL CONTRACTOR DA E
c. WATER LEVEL Below Top of Casing: FT.
(Use"+^if Above Top of Casing) :PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Submit within 30 days of completion to:Division of Water Quality- Information Processing, Rev.2/09
1617 Mail Service Center,Raleigh, NC 27699-161,Phone:(919)807-6300
i,c STA7FQ
k 1 Y ONESIDENTIAL WELL CONSTRUCTION RECORD
? 0 North Carolina Department of Environment and Natural Resources-Division of\Vater Quality
•m^�� WELL CONTRACTOR CERTIFICATION# 3329
1.WELL CONTRACTOR: ;d. TOP OF CASING IS Of FT.Above Land Surface*
Nick Perry 'Top of casing terminated attor below land surface may require
Well Contractor(Individual)Name a variance in accordance with 15A NCAC 2C.0118.
Terra nest Environmental Cons. ;e. YIELD(gpm): METHOD OF TEST
Well Contractor Company Name
100 E Ruffin St. :#. DISINFECTION:Type Amount
Street Address :g. WATER ZONES(depth):
Mebane NC 27302 :fop Bottom Top Bottom
City or Town State Zip Code :Top Bottom Top Bottom
9( 19 ) 563-9091 'Top Bottom Top Bottom
Area code Phone number Thickness)
2.WELL INFORMATION: :7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top 0' Bottom 10' Ft. 2 in. sch 40 PVC
OTHER ASSOCIATED PERMIT#(if applicable) :Top Bottom Ft.
SITE WELL ID#(if applicable)M W 12 :Top Bottom Ft.
3.WELL USE(Check One Box)Monitoring Cs(MunicipaUPublic❑ :8. GROUT: Depth Material Method
Industrial/Commercial LiAgricultural❑ Recovery ci Injection❑ ;Top 0' Bottom 6' Ft. Portland Pour
IrrigaticnC] Other❑ (list use) :Top 6' Bottom 8' Ft. Sentonite Pour
DATE DRILLED 2/7/12 ;fop Bottom Ft.
4.WELL LOCATION: ;9. SCREEN: Depth Diameter Slot Size Material
300 Main St.. 27508 :Top 10' Bottom 25' Ft. 2 in.in. .010 In. PVC
(Street Name,Numbers,Community,Subdivision,Lot No.,Parcel,Zip Code) ;Top Bottom Ft, in. In.
CITY: Bunn COUNTY Franklin ;Top Bottom Ft. in. in.
TOPOGRAPHIC/LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other : 10.SANDlG RAVEL PACK:
35 57 37.0000 ^DMS OR 3 DID Depth size Material
LATITUDE :Top 8 Bottom 25' Ft. coarse Sand
LONGITUDE 78 0 15 15.0000 ^DMS OR 7 DD ;Top Bottom Ft.
Latitude/Iongitude source: ❑GPS VTopographic map :Top Bottom Ft.
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS) : 11.DRILLING LOG
6.FACILITY(Name of the business where the well is located.) Top Bottom Formation Description
Bunn Exxon 0-015307 0' / 0.5' GRAVEL
Facility Name Facility ID#(if applicable) O5=/_10' SANDY LEAN CLAY
300 Mein St 10' / 25' SAND,with clay
Street Address
City or Town State Zip Code /
Ken Pearce /
Contact Name /
Mailing Address /
City or Town State ZIP Code ;12.REMARKS:
( 919 496-3984
Area code Phone number
6.WELL DETAILS: :I DOH FB CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC 2 ,WELL C STRUCTION STANDARDS,AND THAT A COPY OF THIS
a. TOTAL DEPTH: 25' :RE H BE ROV}DEDTO THE WELL OWNER
2/ 2
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO G 'SIGNATUR F CERTIFIED WELL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: FT. �
(Use"+"if Above Top of Casing) :PRINTED NAME dF PERSON CONSTRUCTING THE WELL
Form GW-1b
Submit within 30 days of completion to: Division of Water Quality- Information Processing, Rev.2109
1617 Mail Service Center,Raleigh,INC 27699-161,Phone:(919)807-6300
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
1.Well Contractor Information:
Jonathan R. Grubbs 14.WATER ZONES
Well Contractor Name FROM TO DESCRIPTION
rt. rt.
3001
rL rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Terraquest Environmental Consultants, P.C. FROM TO DIAMETER THICKNESS MATERIAL
0 I. 5 ft. 2 in. schedule 40 1 PVC
Company Name
16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft. ft. in.
17.SCREEN
Water Supply Well:
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 5 ft. 20 ft. 2 in. 0.0101, schedule 40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. 5 ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
❑Imgation ❑Wells>100,000 GPD FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 1 ft. portland cement pour
OMonitoring ❑Recovery ft. 3 ft. bentonite pour
Injection Well:
rt. rt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery El Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
El Aquifer Test ❑Stormwater Drainage 3 rt• 20 rt' no 2 filter sand pour
❑Experimental Technology ❑Subsidence Control
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION(color,hardness,soillrock type, rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0 rt. 5 ft. Orange/brwn coarse to med sand abd clay
4.Date Well(s)Completed: 2/3/21 Well ID# MW 19 5 rt 10 rt light brown clay medium sand
5a.Well Location: 10 ft' 15 rt• light brown med sand moderate clay
Bunn Exxon 0-015307 15 ft. 20 ft- light gray clay with crse/med sand and mica
Facility/Owner Name Facility ID#(if applicable) ft. ft.
300 MAIN STREET, BUNN NC 27508
Physical Address,City,and Zip rt rt
FRANKLIN 2820-05-8360 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
35.96039 N -78.25363 W 2/8/2021
6.Is(are)the well(s): IlPermanent or ❑Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or LhNo 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 20 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths if different(example-3@200'and 2@100')
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells: Copy to DWR,Underground Injection Control(NC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: solid stem auger
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1 6 1 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018