MO-4051_12019_CA_UST-61_19940408_UST Leak Reporting Form

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POLLUTION
INCIDENT/U.S.T.,
LEAK REPORTING
FVKM
Confirm. GW Contamination (Y/N)-4-
Incident # %V
Health, Natural Resources
Department of Environment,
DlvWon of Envlronmental Management
Major Soil Contamination (Y/N)
GROUNDWATER SECTION
Minor Soil Contaminati)-
Date Incident Occurred
or Leak Detected Z 9 y
INCIDENT DESCRIPTION
Incident Location/Name
Ze,qr:2!�,vS N ,,.o,J-
Address
60/ 'I' D Zy Z-7
City/Town o
County t 445.9 &JJ
Region A/Ko
Briefly Describe Incident
-
UJ
POTENTIAL SOURCE OWNER -OPERATOR
Telephone
Potential Source Owner -Operator
Company
Street Address
City
County
State
Code
FIP
OWNERSHIP
0. N/A 1. Municipal
2. Military 3. Unknown Orivate 5.Federal 6. County 7. State
OPERATION TYPE
0. N/A 1. Public Service
2. Agricultrura► 3. Residential 4. Educational/Relig. 5. Industrial t ommercial 7. Mining
POLLUTANTS INVOLVED
MATERIALS INVOLVED
AMOUNT LOST AMOUNT RECOVERED
SOURCE OF POLLUTION
PRIMARY SOURCE OF POLLUTION
PRIMARY POLLUTANT TYPE LOCATION SETTING
(Select one)
(Select one)
1. Intentional dump
13. Well 1. Pesticide/herbicide e!�>acil'rty 1. Residential
2. Pit, pond, lagoon
14. Dredge spoil 2. Radioactive waste 2. Railroad 2. Industrial
eak-underground
15. Nonpoint source (iDtasoline/diesel 3. Waterway 3. Urban
4. Spray irrigation
4. Heating oil 4. Pipeline ural
5. Land application
5. Other petroleum prod. 5. Dumpsite
6. Animal feedlot
6. Sewage/septage 6. Highway
7. Source unknown
7. Fertilizers 7. Residence
8. Septic tank
8. Sludge 8. Other
9. Sewer line
9. Solid waste leachate
10. Stockpile
10. Metals Site Priority
11. Landfill
11.Other inorganics Ranking
12. Spill -surface
12. Other organics
D.E.M. Regional Contact f Signature �� p/- -� Date
- ESL- � 8Ag
GW-61 Revised 3/92

IMPACT ON DRINKING WATER SUPPLIES
WELLS AFFECTED 1. YES
2. NO
NUMBER OF WELLS AFFECTED
Well(s) Contaminated: (Users Name)
1.
2.
3.
4.
5.
Circle Appropriate Responses
Lab Samples Taken By:
1. DEM 2. DHS 3. N Pe a 4. Other 5. None
Samples Taken Include:
,Sal ,
LOCATION OF INCIDENT
7 1/2 Min. Quad Name
LaL: Deg: Min: Sec
Cajc0-�7 St
rd
5 Min. Quad Number
L� : Deg: Min: Sec: a
Q�� u
30
Draw Sketch of Area or Attach Additional Mans

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i' � � • %�.,� - :.;��� it �.� \ . , � ,c ,;;, " 1 1 ``- :� ;G;�
Pl
/i:�tr clt;: I ,� •„ p . u , SITE LOCATION?
1it
l14 l
%r l2J /(� 277 1
o r 1 1 \ I
- t
1 0 1 MILE
t-
1000 0 1000 2000 3000. 4000 5000. 6000 7000 FEET
1 .5 0 1 KILOMETER
CONTOUR INTERVAL 10 FEET
NATIONAL GEODETIC VERTICAL DATUM OF 1929
MN
GN
a3
5'� •
98 MILS 0'15' a�
4 MILS
UTM GRID AND 1987 MAGNETIC NORTH
DECLINATION AT CENTER OF SHEET
N. C.
QUADRANGLE LOCATION
CONCORD SE, N. C.
35030-05-TF-024
1969
PHOTOREVISED 1987
DMA 4854 1 SE —SERIES V842
PRECISION ENVIRONMENTAL INC. BEATTY'S INDIAN RIVER FRUIT COMPANY FIGURE 1: GENERAL LOCATION MAP
120 PENMARC DRIVE, SUITE 101 HIGHWAY 601 AND 24/27 USING U.S. GEOLOGICAL
RALEIGH, NORTH CAROLINA 27603 MIDLAND, NORTH CAROLINA SURVEY TOPOGRAPHIC
MAP

LEGEND
O
Soil Sample Location
S1
Collected During UST
Removal on 2/8/94
MW-1
Monitor Well Location
Well Installed 4/19/94
North
0 Feet 40
Scale is approximate
601
PRECISION ENVIRONMENTAL INC.
120 PENMARC DRIVE, SUITE 101
RALEIGH, NORTH CAROLINA 27603
HIGHWAY 24/27
Grass
Concrete - Dispenser Island u
O D-1
Former Location of USTs MW-1
Concrete----�-- S3 Grass
S1 o S7
- S4
Asphalt Grass S2 p
O S8..:
--- ------ Excavation Limit
The
Sundae
Shop
BEATTY'S INDIAN RIVER FRUIT COMPANY
HIGHWAY 601 AND 24/27
MIDLAND, NORTH CAROLINA
Asphalt
FIGURE 2: GENERAL SITE MAP
SHOWING LOCATION OF
SOIL SAMPLES AND
MONITOR WELL
ft