MO-29127_48311_CA_UST-61_20220308_24-Hour Release and UST Leak Reporting Form

UST-61
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)
Date Leak Discovered 3/2/20_
Received On Received By
Confirmed Soil Contamination ?(Y/N) _Y
Comm/Non-Commercial? _Non_
Reported by (circle one): Phone, Fax or Report
Samples Taken?(Y/N) Y
Reg/Non-regulated? Non_
Region
Free Product? (Y/N) _N If Yes, State
Greatest Thickness
INCIDENT DESCRIPTION
Incident Name: Puckett/Nash Assemblage
Address: 10219 and 10200 Puckett Road
County: Mecklenburg
Regional Office (circle one): Asheville, Mooresville, Fayetteville,
City/Town: Charlotte, NC
Zip Code: 28216
Raleigh, Washington, Wilmington, Winston-Salem
Latitude (decimal degrees): 35.214028 Longitude (decimal degrees) :-80.504156
Obtained by:
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
lmp;;rtpd soll were identified with a photo-ioni7ation dptprtc)r (Pin) during thp rpmoval of two
550-gallon out of service heating oil underground storage tanks (USTs). Suspected impacted soils were excavated as
part of IAA activities. I he soils were later hauled o -si e Tor proper disposal Tollowing the installation ot a road/bridge
that would allow access to the release areas.
xOther Google Earth
Describe location: UST
Location
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
Release Detection Equipment or Methods x Visual/Odor ❑Groundwater Contamination
x 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 primary source) (Check primary cause) (Check one) (Check primary product type released)
X Tank Spill X Petroleum Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
Piping Overfill Non -Petroleum Kerosene Blend
X Heating Oil ❑ Vegetable Oil 100%
Dispenser Corrosion Both Other
❑ E10 — E20
Submersible Turbine Pump Physical/Mechanical Location Petroleum
Damage Products ❑ E21 — E84
Delivery Problem (Check one)
Install Problem Metals ❑ E85 — E99
Spill Bucket
Other Facility Other Inorganics [:]Ethanol 100%
Other
X Unknown X Residence Other Organics ❑ E01 — E09
Unknown
Other
Definitions presented on reverse
Definitions resented on reverse
Ownership
1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining
UST Form 61 (02/19) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes
2. No 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
Joe Lee, Mack Vance Puckett, and James Geoffrey Nash
Point of Contact
Address
Same
19306 Wildcat Trail
City
State
Zip Code
Telephone Number
Davidson
NC
28036
336-722-0885
UST SYSTEM OPERATOR
UST Operator/Company
Address
Unknown
City
State
Zip Code
Telephone Number
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner
Address
Same
City
State
Zip Code
Telephone Number
Draw Sketch of Area (showing two major road intersections) or Attach Map
Person Reporting Incident Steve Libbey
Company Hart & Hickman
Telephone Number 704-302-4404
Title Project Manager
Address 2923 South Tryon Street, Charlotte, NC
Date 01/19/22
UST Form 61 (02/19)
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 off at 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

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Beverly, Trudy
From: Beverly, Trudy
Sent: Wednesday, March 9, 2022 10:21 AM
To: Steve Libbey
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Thank you.
Trudy
D- � E 5 Q�xk-�
rH •atx ..�.
N.or�
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. Bever] y a)ncdenr.gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Steve Libbey[mailto:[e-mail]]
Sent: Wednesday, March 9, 2022 10:14 AM
To: Beverly, Trudy <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Terry is our contact:
Withrow Capital, Inc.
1341 East Morehead Street, Suite 201
Charlotte, North Carolina, 28226
Attn: Terry Williams
[e-mail]
Steve
From: Beverly, Trudy <[e-mail]>
Sent: Wednesday, March 9, 2022 10:06 AM
To: Steve Libbey <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
I'm going to list the UST-1 & UST-2 closures as separate sites since they are on different parcels. Looks like both parcels
have been owned by Metrolina Properties, LTD Partnership/Withrow Capital, Inc. since June 10, 2020. Do you have a
name and email address for the Metrolina Properties, LTD Partnership/Withrow Capital, Inc. contact?
Thank you,
Trudy

Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
44 North Carolina Department of Environmental Quality
tee,
r"" '� UST Section, Mooresville Regional Office
4�'
704.235.2182 (Office)
Trudy.B everlykncdenr. gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Steve Libbey[mailto:[e-mail]]
Sent: Wednesday, March 9, 2022 9:43 AM
To: Beverly, Trudy <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Charlotte. Revised 61 attached.
Thanks
From: Beverly, Trudy <[e-mail]>
Sent: Wednesday, March 9, 2022 9:37 AM
To: Steve Libbey <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Is the city considered Charlotte or Huntersville?
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
.EQ North Carolina Department of Environmental Quality
r" �../ C, I$, UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy.Beverlykncdenr. , og_v
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Beverly, Trudy
Sent: Wednesday, March 9, 2022 9:33 AM
To: Steve Libbey <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Hey Steve,
The UST-61 has Union County. It's this one in Mecklenburg? If so, please correct the UST-61 and resend.
Thank you,
Trudy
Trudy Beverly, L.G.
D- � E Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
r" QVLACX11NA UST Section, Mooresville Regional Office
awn
704.235.2182 (Office)
Trudy. B everlyL& ncdenr. gov

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: hops://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hitps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-eis-mans
File Review Procedures:
https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
ho2s://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.nc.eov/nedea/Waste%2OManauement/DWM/UST/W hatsNew/Final-Electronic-Document-Submittal-Policv.l)df
https:Hfiles.nc. gov/ncdeq[Waste%2OManagement/D WMiUST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx
From: Steve Libbey[mailto:[e-mail]]
Sent: Tuesday, March 8, 2022 1:13 PM
To: Beverly, Trudy <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Thanks so much!
From: Beverly, Trudy <[e-mail]>
Sent: Tuesday, March 8, 2022 1:13 PM
To: Steve Libbey <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Hey Steve,
I'll do my best to have the report reviewed within the next week.
Trudy
�D Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
cd� -�EQ North Carolina Department of Environmental Quality
FazFrrm UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B ev erly(a),ncdenr. gov
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: htws://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hops://deg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
htt )s://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-eis-mans
File Review Procedures:
hops://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
hitps://deq.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.nc.¢ov/ncdeg/Waste%2OManaizement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df
htips:Hfiles.nc. gov/ncdeq/\Vaste%20Management/D WMiUST/Corrective%2OAction/UST%2Ofile%20names%20for%2OLaserfiche.docx

From: Steve Libbey[mailto:[e-mail]]
Sent: Tuesday, March 8, 2022 10:56 AM
To: Beverly, Trudy <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hi Trudy, I apologize for being a pest. The client just emailed me about this project. Will you have time to review this
report in the next week or so?
Thanks,
Steve
From: Beverly, Trudy <[e-mail]>
Sent: Tuesday, March 8, 2022 6:31 AM
To: Steve Libbey <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Received. Thank you Steve.
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
w, D- � E North Carolina Department of Environmental Quality
PM `" CAACX11NA UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlykncdenr. gov
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://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hops://deq.nc.gov/about/divisions/waste-mana2ement/ust/ast-proeram
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httDs://dea.nc. eov/about/divisions/waste-manaeement/waste-management-rules-data/waste-manaeement-ais-mans
File Review Procedures:
https://deg.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
https://deq.nc.gov/about/divisions/waste-manaizement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
https:Hfiles.nc.eov/ncdea/W aste%2OMana2ement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policy.odf
hgps:Hfiles.nc. gov/ncdeq/Waste%2OManagement/D WM[U ST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Steve Libbey [mailto:[e-mail]]
Sent: Monday, March 7, 2022 3:48 PM
To: Beverly, Trudy <[e-mail]>
Subject: FW: [External] Puckett/Nash Assemblage, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.

Trudy, I apologize, please see the attached UST-61 with the correct signature date (today).
Steve
From: Steve Libbey
Sent: Monday, March 7, 2022 3:46 PM
To: Beverly, Trudy <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Attached, thanks!
Please call me if you have any questions.
Thanks,
Steve
Stephen Libbey, PG, Project Manager
Hart &Hickman, PC
2923 S Tryon Street, Suite 100 • Charlotte, NC 28203
Direct:704-887-4606 Mobile:[phone]
www.harthickman.com I Im
From: Beverly, Trudy <[e-mail]>
Sent: Friday, March 4, 2022 10:59 AM
To: Steve Libbey <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Please submit a UST-61 form for the site. The information contained in the form is used for database entry.
https://deg.nc.gov/about/divisions/waste-management/underground-storage-tanks-section/ust-forms
Thank you and happy friday,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
�i a�.m�UST Section, Mooresville Regional Office
urns vawe `
704.235.2182 (Office)
Trudy.BeverlyL&ncdenr.gov
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Steve Libbey[mailto:[e-mail]]
Sent: Friday, March 4, 2022 10:41 AM
To: Beverly, Trudy <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
I don't see that Ayla ever sent one. Do you need one to complete the incident/report review?

Thanks,
Steve
From: Beverly, Trudy <[e-mail]>
Sent: Thursday, March 3, 2022 7:36 PM
To: Steve Libbey <[e-mail]>
Subject: RE: [External] Puckett/Nash Assemblage, Charlotte, NC
Do you have a UST-61 form for this one?
Thanks,
Trudy
cc���DE <A
QW;
fH i:ak ,
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.13everlykncdenn gov
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://deq.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: hitps:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://deo.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-management-eis-mans
File Review Procedures:
https://deq.nc. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
htt2s://deg.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
httys:Hfiles.nc.eov/nedea/Waste%2OMana2ement/DWM/UST/W hatsNew/Final-Electronic-Document-Submittal-Policv.udf
htt 2s:Hfiles.nc.gov/ncdeq/Waste%2OManagement/DWMiUST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Steve Libbey [mailto:[e-mail]]
Sent: Thursday, March 3, 2022 4:23 PM
To: Beverly, Trudy <[e-mail]>
Subject: [External] Puckett/Nash Assemblage, Charlotte, NC
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hi Trudy, please find attached an IAA report for this site. You discussed this site with Ayla in our office early last
year. Recall, we weren't able to remove the impacted soil stockpiles due to site access issues (-485 cut off the original
site access roads). Access was gained and the stockpiles were removed in October 2021.
Please call me if you have any questions.
Thanks,
Steve
Stephen Libbey, PG, Project Manager
Hart & Hickman, PC
2923 S Tryon Street, Suite 100 • Charlotte, NC 28203

Direct: 704-887-4606 • Mobile: [phone]
www.harthickman.com 10