00-0-0000000000 12915_WS-3893_DENR_1989_01_27 (2)

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POLLUTION INCIDENT REPORTtG FORM
1. Incld� s Division of Environmental Management
GROUNDWATER SECTION
2. Tabulate only
TYPE OF ACTION
1. Emergency response 3. Complaint investigation 5. Re-evaluation : # /
A 2. Compliance Investigation 4. Routine inventory Other :4U 144L. �`
POTENTIAL HAZARDS Toxic chemicals 2. Radioactivity 3. Air emissons 4. Explosives 5. Fire
INCIDENT
Incident Name
COfOIXtCJ e, Uo
B Address City/town
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County Region DEM Regional Contact
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PERSON REPORTING INCIDENT
Name
eV�a�
Date
Time
1 . Uv
Company/A ency I
Telephone
-)33
Briefly Describe Incident
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REPORTED BY: 1. Responsible party
2. Government agency 3. Private party
RECOMMENDED ACTION
1. Investigation complete J
Initiate/complete cleanup 5. Technical support
7. Enforcement action
2. Continue investigation 4.
Long-term remedial action 6. Drill crew
8. Monitoring plan
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Comments
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LAB SAMPLES:
1. Yes � No
Slg lure
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Date
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GW-61 Revised 11/85 North Carolina Department of Natural Resources and Community Development

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OOLLUTION INCIDENT REPOFONG FORM
Incident
County:
POLLUTANTS INVOLVED
MATERIALS INVOLVED
1rtVlleaddd a6i> oe,
AMOUNT STORED
7- 9rA'L((ivv-,
AMOUNT LOST AMOUNT RECOVERED
�S.
IMPACT ON SURFACE WATERS
WATERS EFFECTED 1. Yes 2.)No No 3. Potentially
Distance to Stream (it)
Amount in Water (gat)
F
�
Name of Stream
Stream Class
FISH KILL: 1. Yes LJ No
RISK ASSESSMENT
Use these Codes: High= 3 Moderate=2 Low=1 None=0
Resource Threat GROUNDWATER Amount Infiltrating Land
Vertical Migration of Contaminant 1
Horizontal Migration of Contaminant
Areal Extent of Contamination SURFACE WATER AIR
Probability of Violations 3
Remedial Action Priority 2-
G Potential Hazard of Substance
Threat to Drinking WaterL_
Seriousness of Threat I
Overall Regional Concern
Please Circle the Appropriate Response(s):
1. This incident poses additional threat to human health by: 1 inhalation (2) absorption (3) ingestion
2. This incident poses additional threat to the environment by potential adverse effects on
(1) sensitive areas (2) wildlife (3) fish `
POTENTIAL SOURCE OF POLLUTION
SOURCE OF POTENTIAL POLLUTION
TYPE OF POLLUTANT
1. Intentional dump
9. Sewer line
1. Pesticide/herbicide
2. Pit, pond, lagoon
10. Stockpile
2. Radioactive waste
3. Leak --underground
11. Landfill
�Gasollne/dlesel
4. Spray irrigation
CJ Spill --surface
4. Other petroleum prod.
Fi
5. Land application
13. Well
5. Sewage/septage
6. Animal feedlot
14. Dredge Spoil
6. Fertilizers
7. Source unknown
15.Nonpoint source
7. Sludge
6. Septic tank
8. Solid waste leachate
9. Metals
MULTIPLE SOURCES AT SITE:
1� Yes 2. No
10. Other Inorganics
11 .Other organics
LOCATION
0Facility
2. Railroad
3. Waterway
4. Pipeline
5. Dumpsite
6. Highway
7. Residence
8. Other
SETTING
1. Residential
0 Industrial
3. Urban
4. Rural
POLLUTION CONFIRMED
1. Yes 2No

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County:
RESPONSIBLE PARTY
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Responsible Party/Names
Telephone
A'\t. S. C. �Q v-e r - 777
i 7,07
Company
Street Address
�O�bN\�. e- 1.We,
. o. .3
City
County
State
Zip Code
ee rd
G akyc�
7 4- (
REASON FOR INCIDENT
SOURCE IN USE
0. N/A
PERMIT TYPE
OWNERSHIP
OPERATION TYPE
1. Transportation Accident
I0Yes
2. No
0. N/A
0. N/A
0. N/A
1
2� Mechanical (allure
1. Nondischarge
1. Municipal
1. Public Service
SOURCE PERMITTED
3. Facility design
Yes
2. No
2. Oil terminal
2. Military
2. Agricultural
4. Inventory only
PERMIT NUMBER
Human
See 4611 e
3. Landfill
3. Unknown
3. Other Source
5. error
4. Mining
Private
4. Educational
SOURCE ON
6. Vandalism
ERRIS LIST
1. Yea
0NPDES
5. Federal
5. Industrial
7. Unknown
P. No
6. RCRA
6. County
6� Commercial
ERRIS NUMBER e
Y
7. Air
7. State
7. Mining
ACTIONS TAKEN
C­oniain'ment. Cleanup. etc.
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Nearest •.. .. .. and Dlzlan�ce

POLLUTION .INCIDENT REPORTING FORM
Incident ,F
County LOCATION OF INCIDENT
Street Address, Road
T-
Data Incident Occurred
I1As/ e�vl
�;4 I (i Wwm L-,)acy
Time Incident Occurrn
VIVV6�r - SaAew%,
Ga«�w.ore �
City/Town
7 1/2 Quad Name
i .,Z_/
Draw Sketch of Area
.OtL'C Vt 0e_ Ik2
County
6"Z
Lat.: Deg: Min: Sec.
Long.: Deg: Min: Sec:
C�rcevtisboro
ATTACH PHOTOCOPY OF MAP SHOWING: 1. Pollutant Source 2. Threatened Water Supplies
3. Direction of Overland Flow

POLLUTION INCIDENT REPOTING FORM
Incident ,r
County:
SOIL TYPES
COASTAL PLAIN REGION PIEDMONT SOIL REGION
LANDFORM
1. River/coastal terrace
1. Middle Coastal Plain 10. Felsic Crystalline
2. Coastal (flat) plain
2. Upper Coastal Plaln/Piedmont 11. Carolina Slate Belt
3. Mountain range
3. Sandhills 12. Triassic Basin
4. Sandhiils
4. Lower Coastal/Wlcomico, Talbot C�Mixed Felsic and Mafic
5. Swamp
5. Lower Coastal Plain/Pamlico
6. Linear (valley) slope
MOUNTAIN SOIL REGION
6. Organic Soil
7. Head slope (concave)
7. Brackish and Freshwater Marsh 14. Low and Intermediate Mountain
8. Nose slope (convex)
6. Outer Banks 15. Basins/Terraces/Flood Plain
9. Foot slope
9. Large River Valleys/Flood Plain 16. High Mountain
10. Barrier island
11. Barrier system
OBSERVED AVERAGE GRADIENTS ESTIMATED DEPTHS
����
To nearest water supply: 1 % To uppermost confining bed: O/A ft.
12. Beach ridge
_(/n
� % To water table: 4- 1t.
13. Tidal marsh
Water table gradient:
14. Floodplain
To nearest stream: % To bedrock: ft.
15 Upland: 0-5% slope
Stream gradient: %
(interstream divide)
ESTIMATE HYDRAULIC CONDUCTIVITIES
AQUIFER USE
1. Little or no use
Soil
Unsaturated zone
Water Table
Upper confined aquifer
t2) Moderate uses
1. high
1. high
1. high
1. high
3. Heavily used
2. medium
2. medium
2. medium
2. medium
3. low
3. low
3. low
3. low
unknown
(4)unknownunknon
unknown
DISTANCE TO NEAREST WATER SUPPLY: -ft.
DISTANCE TO NEAREST BUILDING: It.
Describe general Iitholo y of soil and unsaturated zone
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c !at re ( ®Iler
Provide map showing: 1. Pollutant source 2. Threatened water supplies
3. Direction of overland flow

..dent * rULLU*N INUIULN 1 "r—rUt'i 1 itvl] rUr*
ounty: EMERGENCY INCIDENT RESPONSIBILITIES
RESPONSIBILITY: Local State Federal Responsible party
ON -SCENE COORDINATOR:
name phone number
agency/EOC location EOC phone
EOC contacts
Assumed, date: time: Relinquished, date:
On -site representatives:
TECHI1CAL COORDINATOR:
agency/EOC location
EOC contacts
Assumed, date:
On -site representatives:
name
time: Relinquished, date:
time:
phone number
EOC phone
time:
RESOURCE TRUSTEE: name phone number
agency/EOC location EOC phone
EOC contacts
Assumed, date: time: Relinquished, date: time:
On -site representatives:
PIG:
name agency phone number
Asaumed,date: time: Relinquished, date: time: