MO-9528_40963_CA_UST-61_20191120_24-Hour Release and UST Leak Reporting Form & Receptor Discussion

UST-61
I 24-Hour Release and UST Leak Reporting Form.
For Releases This form should be completed and submitted to the UST Section's regional office following a known or suspected release from
an underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or
in NC suspected release
(DWM USE ONLY)
Suspected Contamination? (Y/N) Y
Facility ID Number N/A
Incident # Risk (H,I,L,U)
Confirmed GW Contamination? (Y/N) N
Date Leak Discovered 11/20/19
Received On Received By
Confirmed Soil Contamination ?(Y/N) Y
Comm/Non-Commercial? Non-Qgmm.
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) Y
Reg/Non-regulated? Non -Reg.
Region
Free Product? (Y/N) N If Yes, State Greatest
Thickness N/A
INCIDENT DESCRIPTION
Incident Name: Wagner Residence
Address: 1132 Providence Road
County: Mecklenburg
City/Town: Charlotte
Zip Code: 28207
Regional Office (circle one): Asheville, Mooresville Fayetteville,
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): N 35.19222629' Longitude (decimal degrees) : W 80.82473991 °
Obtained by:
M GPS
Briefly describe suspected or confirmed release: (including but not limited to: nature of release, date of release, amount
of release, amount of free product present and recovery efforts, initial responses conducted, impacts to receptors)
❑ Topographic map
❑ GIS Address matching
❑ Other
❑ Unknown
Describe location:
-Soil contamination discovered by observing surface staining from heating oil
floating out of tank following heavy precipitation during storm
-TPH results attached
-Tank was removed on November 11, 2019
-Soil contamination confirmed beneath UST to be addressed with NRP
-Soil contamination at surface removed during Initial Abatement Activities
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑ Release Detection Equipment or Methods ❑ Visual/Odor ❑ Groundwater Contamination
81 During UST Closure/Removal ❑ Water in Tank ❑ Surface Water Contamination
❑ Property Transfer ❑ Water Supply Well Contamination ❑ Other (specify)
SOURCE OF CONTAMINATION
Source of Release Cause of Release Type of Release Product Type Released
(Check one to indicate primary (Check one to indicate primary (Check one) (Check one to indicate primary product type
source) cause) released)
M Tank M Spill M Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Kerosene Blend
❑ Piping ❑ Overfill ❑ Non -Petroleum
M Heating Oil ❑ Vegetable Oil 100%
❑ Dispenser ❑ Corrosion ❑ Both ❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump ❑ Physical or Mechanical Products
❑ E21 E84
—
❑ Delivery Problem Damage Location ❑ Metals
❑ ❑ E85 E99
❑ Install Problem (Check one) Other Inorganics —
❑ Other
❑ Other Facility ❑ Other Organics ❑Ethanol 100%
❑ Unknown O Eo1 — Eoe
t� Unknown ®Resiaence
Definitions presented on reverse Definitions presented on reverse ❑ Other
Ownership
1. Municipal 2. Military 3. UnknownOPrivate 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. AgriculturalOResidential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
U01 runn o 1 kuuuo) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes ONo 3. Unknown
Number of Water Supply Wells Affected
Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary)
1.
2.
3.
UST SYSTEM OWNER
UST Owner/Company Sean Wagner
Point of Contact
Address
1132 Providence Road
City
State
Zip Code
Telephone Number
Charlotte
NC
28207
[phone]
UST SYSTEM OPERATOR
UST Operator/Company
Address
Unknown
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Same as UST System Owner
Address
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
See Attached Map
Person Reporting Incident Ben Robinson
Company Paragon Environmental Consultants, InC.
Telephone Number(336) 669-6037
Title Geologist
Address P.O. Box 157, Thomasville, NC 27361
Date 11-20-2019
UST Form 61 (02/08)
Page 2 of 2
Definitions of Sources
Tank: means the tank that stores the product and is part of the underground storage tank system
Piping: means the piping and connectors running from the tank or submersible turbine pump to the dispenser or other end -use equipment ( Vent, vapor recovery, or fill
lines are excluded.)
Dispenser: includes the dispenser and the equipment used to connect the dispenser to the piping (e.g., a release from a suction pump or from components located above
the shear valve)
Submersible Turbine Pump (STP) Area includes the submersible turbine pump head (typically located in the tank sump), the line leak detector, and the piping that
connects the submersible turbine pump to the tank
Delivery Problem: identifies releases that occurred during product delivery to the tank. (Typical causes associated with this source are spills and overfills.)
Other: serves as the option to use when the release source is known but does not fit into one of the preceding categories (e.g., for releases from vent lines, vapor
recovery lines, and fill lines)
Unknown: identifies releases for which the source has not been determined
Definitions of Causes
Spill: use this cause when a spill occurs (e.g., when the delivery hose is disconnected from the tank fill pipe or when the nozzle is removed from the dispenser)
Overfill: use when an overfill occurs (e.g., overfills may occur from the fill pipe at the tank or when the nozzle fails to shut offat the dispenser)
Physical or Mechanical Damage: use for all types of physical or mechanical damage, except corrosion (e.g., puncture of tank or piping, loose fittings, broken
components, and components that have changed dimension)
Corrosion: use when a metal tank, piping, or other component has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation Problem: use when the problem is determined to have occurred specifically because the UST system was not installed properly
Other: use this option when the cause is known but does not fit into one of the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined

L.RISM Full -Service Analytical
Environmental Solutions
LABORATORIES, INC.
Paragon Environmental Consultants, Inc.
Brandon Moore
PO Box 157
Thomasville, NC 27361
NC Certification No. 402
NC Drinking Water Cert No. 37735
SC Certification No. 99012
Project: Wagner Residence
Lab Submittal Date: 11/13/2019
Prism Work Order: 9110220
Case Narrative
11 /20/19 15:28
This data package contains the analytical results for the project identified above and includes a Case Narrative, Sample
Results and Chain of Custody. Unless otherwise noted, all samples were received in acceptable condition and processed
according to the referenced methods.
Data qualifiers are flagged individually on each sample. A key reference for the data qualifiers appears at the end of this case
narrative.
Please call if you have any questions relating to this analytical report.
Respectfully,
PRISM LABORATORIES, INC.
a,j
Angela D. Overcash
VP Laboratory Services
Data Qualifiers Key Reference:
Reviewed By Angela D. Overcash
VP Laboratory Services
DO Surrogates diluted out.
RLM Sample container suspected to have low methanol content. Results possibly biased high.
SR Surrogate recovery outside the QC limits.
BRL Below Reporting Limit
MDL Method Detection Limit
RPD Relative Percent Difference
* Results reported to the reporting limit. All other results are reported to the MDL with values between MDL and
reporting limit indicated with a J.
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 - Charlotte, NC 28224-0643
Phone: [phone] - Toll Free Number: 1-800/629-6364 - Fax: [phone] Page 1 of 17

Summary of Detections
PRISM
Full-Servico Analytical &
Environmental Solutions
11/20/2019
.&A'
kL�dUNATORIE3, ING
Prism Work Order: 9110220
Prism ID
Client ID
Parameter
Method
Result Units
9110220-01
TI-6.5
Diesel Range Organics
'8015C
8700 mg/kg dry
9110220-01
TI-6.5
Gasoline Range Organics
'8015C
63 mg/kg dry
9110220-02
X-1
Diesel Range Organics
'8015C
11000 mg/kg dry
9110220-02
X-1
Gasoline Range Organics
"8015C
51 mg/kg dry
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 - Charlotte, NC 28224-0643
Phone: [phone] - Toll Free Number: 1-800/629-6364 - Fax: [phone] Page 3 of 17

PRISM Full -Service Analytical &
Environmental Solutions
tJ�U�PATORI[S ma
Laboratory Report
11 /20/2019
Paragon Environmental Consultants, Inc.
Attn: Brandon Moore
PO Box 157
Thomasville, NC 27361
Project: Wagner Residence
Sample Matrix: Solid
Client Sample ID: TI-6.5
Prism Sample ID: 9110220-01
Prism Work Order: 9110220
Time Collected: 11/11/19 10:30
Time Submitted: 11/13/19 08:00
Parameter Result Units Report MDL Dilution Method Analysis Analyst Batch
Limit Factor DatefTime ID
Diesel Range Organics by GC/FID
Diesel Range Organics 8700 mg/kg dry 630 180 50 A8016C 11120/19 10:18 ZRC P91<0322
Surrogate Recovery Control Limits
o-Terphenyl 0 % 31-123 DO
Gasoline Range Organics by GC/FID
Gasoline Range Organics 63 mg/kg dry 7.8 2.1 50 A801SC 11/19/19 10:11 TBL P9K0286
Surrogate
a,a,a-Trill uorotoluene
Recovery Control Limits
85 % 50-137
General Chemistry Parameters
% Solids 65.6 % by 0.100 0.100 1 'SM2640 G 11/18/19 7:66 EDV P9K0291
Weight
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 - Charlotte, NC 28224-0543
Phone: [phone] - Toll Free Number: 1-800/629-6364 - Fax: [phone] Page 4 of 17

F
S M I Full -Service Analytical &
Environmental Solutions
LAeeRRTINiI[S ING
Laboratory Report
11 /20/2019
Paragon Environmental Consultants, Inc. Project: Wagner Residence Client Sample ID: X-1
Attn: Brandon Moore Prism Sample ID: 9110220-02
PO Box 157 Prism Work Order: 9110220
Thomasville, NC 27361 Sample Matrix: Solid Time Collected: 11 /11 /19 10:45
Time Submitted: 11/13/19 08:00
Parameter Result Units Report MDL Dilution Method Analysis Analyst Batch
Limit Factor Date[Time ID
Diesel Range Organics by GC/FID
Diesel Range Organics 11000 mg/kg dry 690 200 60 '8016C 11/20/19 10:66 ZRC 1291(0322
Surrogate Recovery Control Limits
o-Terphenyl 0 % 31-123 DO
Gasoline Range Organics by GC/FID
Gasoline Range Organics 61 mg/kg dry 9.4 2.6 60 '8015C 11/19/19 9:43 TBL PSK0286
Surrogate Recovery Control Limits
a,a,a-Tdfluorotoluene 124 % 50-137
General Chemistry Parameters
% Solids 59.8 % by 0.100 0.100 1 'SM2640 G 11/18/19 7:66 EDV P91(0291
Weight
This report should not be reproduced, except in its entirety, without the written consent of Prism Laboratories, Inc.
449 Springbrook Road - P.O. Box 240643 - Charlotte, NC 28224-0643
Phone: [phone] - Toll Free Number: 1-800/629-6364 - Fax: [phone]
Page,5 of 17

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Beverly, Trudy
From: Ben Robinson <[e-mail]>
Sent: Tuesday, December 3, 2019 8:34 AM
To: Beverly, Trudy
Subject: Re: [External] Wagner Residence UST-61
External email. Do not click links or open attachments unless you verify. Send all suspicious email as an
attachment to [e-mail]
Good morning Trudy,
There are no supply wells located within 150' of the release. I apologize for omitting that
information. Hope you had a good holiday! Thanks!
Ben Robinson, L.G.
Paragon Environmental Consultants, Inc.
On Mon, Dec 2, 2019 at 1:37 PM Beverly, Trudy <trudy.beverlykncdenr.gov> wrote:
Ben,
Neither the UST-61 nor the Initial Abatement Report contains receptor information. Are there any water
supply wells located within 150' of the release.
Thanks,
Trudy
From: Beverly, Trudy
Sent: Monday, December 2, 2019 8:29 AM
To: Ben Robinson <[e-mail]>
Subject: RE: [External] Wagner Residence UST-61
Received
Trudy
1

cc�DEQ
14/1
rlmeneoi €mavnmentJ1 &Wft
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. [e-mail]
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Office Mailing Address:
610 East Center Avenue, Suite 301
Mooresville, NC 28115
Branch's Underground Storage Tanks Website Address: https://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
https://deg.nc.gov/about/divisions/waste-management/waste-management-rules-data/waste-management-gis-maps
File Review Procedures:
https://deg.nc.gov/about/divisions/waste-management/ust/file-review-procedures#mooresviIIe-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
https://files.nc.pov/ncdeq/Waste%20Management/DW M/UST/Corrective%2OAction/Electronic%2ODocument%2OSubmittal%20Memo%20Update.pdf
hiips:Hfiles.nc. gov/ncdegiW aste%2OManagement/D W M/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche. docx
From: Ben Robinson[mailto:[e-mail]]
Sent: Wednesday, November 20, 2019 4:37 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Wagner Residence UST-61

CAUTION: -1 chments unless ou v
Hello,
!rify. Send all suspicious email as an
please find attached to this e-mail the UST-61 for the Wagner Residence, located at 1132 Providence
Road, Charlotte, NC 28207. Thank you very much!
Ben Robinson, L.G.
Paragon Environmental Consultants, Inc.