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Home My WebLink AboutFA-7726_42007_CA_FPR_20220608_MMPEJune 8, 2022 Mr. James Brown North Carolina Department of Environmental Quality NCDEQ Fayetteville Regional Office Division of Waste Management, UST Section Systel Building 225 Green Street, Suite 714 Fayetteville, North Carolina 28301 Subject:Free Product Recovery Report Speedway 8299 291 NC Highway 42 East Clayton,Johnston County,North Carolina Incident No.: 42007 Mid-Atlantic Job No.: R2826.15 Dear Mr.Brown: Speedway LLC is pleased to submit the enclosed Free Product Recovery Report for the Speedway 8299 facility located at 291 NC Highway 42 East in Clayton,North Carolina. The attached report documents the results of the MMPE event from March 21, 2022 through March 25, 2022. If you have any questions, please feel free to contact me at (919) 516-8069 or Trey Marchant with Mid-Atlantic Associates, Inc. at (919) 250-9918. Sincerely, SPEEDWAY LLC Charles A. Chiara Manager, Environmental Services Report Date:June 8, 2022 Project No:R2826.15 FREE PRODUCT RECOVERY REPORT SPEEDWAY 8299 291 NC Highway 42 East, Clayton, Johnston County, North Carolina ENGINEERING & ENVIRONMENTAL SOLUTIONS PREPARED FOR:PREPARED BY: Speedway, LLC 500 Speedway Drive Enon, Ohio, 45323 Mid Atlantic Associates, Inc. 409 Rogers View Court Raleigh, North Carolina, 27610 FREE PRODUCT RECOVERY REPORT SITE INFORMATION 1. Site Identification Date of Report: June 8, 2022 Facility ID:0-036192 UST Incident No. (if known):42007 Site Risk:High Site Rank:H-255-D Land Use Classification:Residential Site Name:Speedway 8299 Site Location:291 NC Highway 42 East,Clayton,North Carolina Nearest City/Town:Clayton County:Johnston Latitude:35.639444°N Longitude:-78.440336°W Description of Geographical Data Point: Approximate UST Area Location Method:Google Earth 2. Information about Contacts Associated with the Leaking UST System UST Owner:Speedway LLC Address:500 Speedway Drive, Enon, Ohio 45323 Phone:(919) 516-8069 UST Operator:Same as UST Owner Address:Phone: Property Owner:Same as UST Owner Address:Phone: Property Occupant:Same as UST Owner Address:Phone: Consultant/Contractor:Mid-Atlantic Associates, Inc. Address:409 Rogers View Ct., Raleigh, NC 27610 Phone:(919) 250-9918 3. Release Information Date Discovered:August 8, 2016 Estimated Quantity of Release:Estimated 600 gallons Cause of Release:A loose valve connection allowed fuel to accumulate in a gasoline STP sump and overflowed to the tank pit. No fuel was released to the land surface. Source of Release (Piping/UST):Gasoline UST system Sizes and contents of UST system(s) from which release occurred:One 6,000-gallon capacity regular-unleaded gasoline UST Criteria Used to Classify Risk:Free product is present on the water table. Two water supply wells are located within 1000 feet of the source area. TABLE OF CONTENTS 1.0 INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 2.0 FIELD ACTIVITIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2.1 Free Product Thickness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2.2 Recovered Free Product . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 2.3 Vacuum Influence and Water Level Drawdown Measurements . . . . . . . . . . 2 3.0 DISCUSSION OF FREE PRODUCT GAUGING RESULTS . . . . . . . . . . . . . . . . . 3 4.0 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS . . . . . . . . . . . . . . . . 3 DRAWINGS Drawing 1.1 - Topographic Site Map Drawing 1.2 - Site and Monitoring Well Location Map Drawing 2.1 - Estimated Lateral Extent of Free Product TABLES Table 2.1 - Summary of MMPE Event Table 2.2 - Summary of Historical Free Product Thickness Data Table 2.3 - Summary of Historical Free Product Recovery Events TABLE OF APPENDICES Appendix A Advanced Environmental's "Mobile Multi-Phase Extraction Report" Appendix B Monitoring Well Construction Records i LIST OF ACRONYMS 2012 Guidelines Underground Storage Tank Section Guidelines for Assessment and Corrective Action For UST Releases, DENR, Division of Waste Management UST Section, July 15, 2008 Version, Change 2, Effective October 1, 2012 AFVR Aggressive Fluid-Vapor Recovery AS Air Sparge AST Aboveground Storage Tank BQL Below (Laboratory Practical) Quantitation Limit BLS Below Land Surface BTEX Benzene, Toluene, Ethylbenzene, Xylenes CAP Corrective Action Plan cm Centimeter COC Constituents of Concern CSA Comprehensive Site Assessment DIPE Diisopropyl Ether (also IPE: Isopropyl Ether) DNAPL Dense Non-Aqueous Phase Liquids DO Dissolved Oxygen DPE Dual-Phase Extraction DPT Direct Push Technology DRO Diesel Range Organics DSCA North Carolina Dry-Cleaning Solvent Act DTW Depth to Water DWM Division of Waste Management DWQ Division of Water Quality EDB Ethylene di-bromide EPA Environmental Protection Agency EPH Extractable Petroleum Hydrocarbons FID Flame Ionization Detector FT Feet GCL Gross Contamination Level GIS Geographic Information System GPM Gallons Per Minute GPS Global Positioning System GRO Gasoline Range Organics ID Identification IDW Investigation Derived Waste IGQS Interim Groundwater Quality Standards LSA Limited Site Assessment LUST Leaking Underground Storage Tank m Meter MADEP Massachusetts Department of Environmental Protection Mid-Atlantic Mid-Atlantic Associates, Inc. MDL Method Detection Limit mg/Kg Milligrams per Kilogram mg/L Milligrams per Liter MMP Minimum Management Practices MMPE Mobile Multi-Phase Extraction MNA Monitored Natural Attenuation MSCC Maximum Soil Contaminant Concentration MSL Mean Sea Level MTBE Methyl tertiary butyl ether g/Kg Micrograms per Kilogram g/L Micrograms per Liter NA Not Analyzed N/A Not Applicable NC North Carolina NCAC North Carolina Administrative Code NCDEQ North Carolina Department of Environmental Quality NCDOT North Carolina Department of Transportation NCGQS North Carolina Groundwater Quality Standards NCSWQS North Carolina Surface Water Quality Standards ND Not Detected NM Not Measured NORR Notice of Regulatory Requirements NOV Notice of Violation NS Not Sampled ORP Oxidation-Reduction Potential OVA Organic Vapor Analyzer PA Prioritization Assessment PAA Prioritization Assessment Agreement PAH Polynuclear Aromatic Hydrocarbons Pb Lead PCBs Polychlorinated Biphenyls PCE Perchloroethylene (also tetrachloroethene) PPB Parts Per Billion PPM Parts Per Million PID Photo Ionization Detector POTW Publicly Owned Treatment Works PQL Practical Quantitation Limit PRF Prioritization Ranking Form PVC Polyvinyl chloride RBCA Risk-Based Corrective Action RCRA Resource Conservation and Recovery Act ROI Radius of Influence s Seconds SAR Soil Assessment Report SOW Scope of Work STG Soil-to-Groundwater SVE Soil Vapor Extraction SVOC Semi-Volatile Organic Compound TDHF Toxicologically Defined Hydrocarbon Fractions TCLP Toxicity Characteristic Leaching Procedure TIC Tentatively Identified Compound TOC Top of Casing TPH Total Petroleum Hydrocarbons US United States USCS Unified Soil Classification System USGS United States Geological Survey UST Underground Storage Tank UT Unnamed Tributary VOC Volatile Organic Compounds VPH Volatile Petroleum Hydrocarbons yr Year 1.0 INTRODUCTION The subject site is the Speedway 8299 facility located at 291 NC Highway 42 East in Clayton, Johnston County, North Carolina (Drawing 1.1). The site is currently in use as a convenience store and retail petroleum dispensing facility and operates one 12,000-gallon gasoline UST, two 6,000-gallon gasoline USTs and one 10,000-gallon diesel UST. The layout of the facility is shown on Drawing 1.2. On August 8, 2016, gasoline was observed inside the containment sumps for both the submersible turbine pump (STP) and the #1 and #2 dispensers associated with the 6,000-gallon regular unleaded gasoline UST (Drawing 1.2). Upon detection, the system was immediately taken out of service until the source of the release (loose connection of valve) could be repaired. A Phase I LSA was conducted at the site in September 2016. Free product was detected in one well (MW-1) and a subsequent AFVR event was performed to recover free product from the water table. Based on the results of the Phase I LSA, the release was classified as high risk with an RRA score of H-255-D due to the presence of two confirmed water-supply wells located within 1,000 feet of the source area of the release. Additional monitoring wells were installed in June 2017 and an MMPE event to recover additional free product from the water table was conducted. Following the completion of the initial MMPE, a CSA was conducted at the site. During the completion of the CSA, six additional type II monitoring wells and one type III deep well were installed on site. It was noted during the second phase of CSA drilling completed in November 2018 that the free product thickness on site had increased significantly in monitoring wells MW-1, MW-3, MW-5 and MW-6. Mid-Atlantic requested a second MMPE event to be conducted while the CSA activities were completed. The second MMPE event was completed using monitoring wells MW-1, MW-3, MW-5, and MW-6 during the week of January 14 through January 18, 2019.Free product gauging indicated that free product was still present in monitoring wells MW-1, MW-3, MW-5, and MW-6. Consequently, consecutive 96-hour events were conducted during the weeks of December 2 through December 6 and December 9 through December 13, 2019.Prior to post MMPE groundwater sampling conducted on January 7, 2020, two additional type II monitoring wells were installed on site. An additional MMPE event was conducted from July 20 through July 24, 2020. Following the July 2020 MMPE event and subsequent August 2020 groundwater sampling event, three additional type II monitoring wells were installed to help define the groundwater plume to the Gross Contaminant Levels (GCLs) as depicted on Drawing 1.2. Additional MMPE events were conducted from February 8, 2021 through February 12, 2021, August 30, 2021 to September 3, 2021, and August 30, 2021 to September 3, 2021.This report documents the March 21, 2022 to March 25, 2022 MMPE activities. The opinions included herein are based on our experience and the information obtained during the study. This report is based on limited observations made on the dates noted Free Product Recovery Report Speedway 8299 Clayton, North Carolina June 8, 2022 Page 1 using the procedures described herein. If additional information becomes available, we request the opportunity to review the information, reassess the potential environmental concerns and modify our conclusions and recommendations, if appropriate. 2.0 FIELD ACTIVITIES A 96-hour MMPE event was conducted using monitoring wells MW-1, MW-3, MW-5, MW-6, MW-11, MW-12, and MW-13 from March 21, 2022 through March 25, 2022. Advanced Environmental Services, Inc. (AES) provided the MMPE services. A copy of AES’ report is provided in Appendix A. 2.1 Free Product Thickness On March 21, 2022,prior to the start of the MMPE event, monitoring wells MW-1, MW-3, MW-5,MW-6, MW-11, MW-12, and MW-13 were gauged for the presence of free product.The results of the pre-MMPE free product gauging activities are summarized in Table 2.1 and depicted on Drawing 2.1. Historical free product thicknesses are also provided in Table 2.2. Well construction records for monitoring wells MW-1, MW-3, MW-5, MW-6, MW-11, MW-12, and MW-13 (from which free product was removed) are provided in Appendix B. 2.2 Recovered Free Product Results of the March 2022 free product recovery activities are documented in AES’ “Mobile Multi-Phase Extraction Report” dated April 13, 2022 (Appendix A). A summary of the MMPE event is provided as Table 2.1. As indicated, approximately 16 gallons of gasoline free product were removed as liquid and 188.79 gallons were removed as vapor. A historical summary of free product recovery events is included in Table 2.3. On-site or off-site effluent discharges: None Certificates of Disposal, Disposition of recovered liquids: Zebra Environmental and Industrial Services, Inc. facility (manifest included in report in Appendix A). 2.3 Vacuum Influence and Water Level Drawdown Measurements During the MMPE event, vacuum readings were measured at monitoring points MW-7, MW-9, MW-10, VE-1, and VE-OW-1 to evaluate the lateral influence of the MMPE in this direction. The measurements are provided on the MMPE Field Log in the contractor’s report in Appendix B. No measurable influence was identified in the wells.Drawdown was measured in MW-7, MW-9, MW-10, VE-1, and VE-OW-1 at 1.64 feet, 0.91 feet, 0.18 feet, 1.58 feet, and 1.1 feet respectively. Refer to Drawing 1.2 for the location of the gauging well relative to the extraction wells. Free Product Recovery Report Speedway 8299 Clayton, North Carolina June 8, 2022 Page 2 3.0 DISCUSSION OF FREE PRODUCT GAUGING RESULTS Free product was detected in wells MW-1, MW-3, MW-5, MW-6, MW-11, MW-12 and MW-13 prior to the start of the MMPE event. Wells MW-1, MW-3, MW-5, MW-6,and MW-11 have historically exhibited free product.Well MW-12 was installed in January of 2020 and well MW-13 was installed in January of 2021. As such, free product was detected in wells MW-12 and MW-13 for the second time since installation during the start of this MMPE event.The estimated lateral extent of free product for the pre- MMPE gauging activities is shown on Drawing 2.1.Post-MMPE gauging was conducted during the groundwater monitoring event conducted on April 13, 2022 and data is provided in Mid-Atlantic's most recent Groundwater Monitoring Report. 4.0 SUMMARY, CONCLUSIONS, AND RECOMMENDATIONS The results of this investigation are summarized as follows: •Free product was detected in wells MW-1, MW-3, MW-5, MW-6, MW-11, MW-12, and MW-13 prior to the start of the MMPE. Thicknesses ranged from 0.59 feet to 6.38 feet; and •The 96-hour MMPE event was conducted at the site from March 21, 2022 through March 25, 2025 using wells MW-1, MW-3, MW-5, MW-6, MW-11, MW-12, and MW-13 as extraction points.During the event, approximately 16 gallons of gasoline free product were recovered as liquid and 188.79 gallons recovered as vapor. Based on these findings, Mid-Atlantic recommends the following: •Continued periodic sampling (at least semi-annual) of the monitoring wells to evaluate contaminant plume movement; •Conducting additional 96-hour MMPE events for free product removal until the majority of free product has been removed and/or a remedial approach can be implemented. The next event should be conducted in September 2022 or earlier; •Continue to move the site towards an active remedial approach.Dual Phase Extraction (DPE) is currently planned to be implemented at this site and is being evaluated for the logistics/feasibility of implementation; and •Submittal of this report to the NCDEQ for their review and comment. Free Product Recovery Report Speedway 8299 Clayton, North Carolina June 8, 2022 Page 3 DRAWINGS DRAWN BY: DATE: ENG. CHECK: JOB NO: APPROVAL: CHH DRAFTCHECK: GIS NO: FIG NO: 1.1 SUBJECT SITE ´ 1:12,000SCALE: §¨¦I40 §¨¦I95 §¨¦I440 §¨¦U70 §¨¦U64 §¨¦U264§¨¦N540 §¨¦U1 JOHNSTON WAKE HARNETT NASH WAYNE WILSON 0 1,000 2,000500Feet REFERENCES:1. USGS TOPOGRAPHIC QUADRANGLE: CLAYTON, NC - 20162. PROPERTY BOUNDARY FROM JOHNSTON COUNTY GIS3. INSET MAP DIGITAL DATA FROM 2002 NATIONAL TRANSPORTATION ATLAS,BUREAU OF TRANSPORATION STATISTICS, WASHINGTON, D.C. TOPOGRAPHIC SITE MAPSPEEDWAY 8299291 NC HIGHWAY 42 E.CLAYTON, NORTH CAROLINA MAY 2022 000R2826.15 5G-R2826.14-01 AREA SHOWN WITHINNORTH CAROLINA CHH CHH CONTOUR INTERVAL = 10 FEET JIE JIE TABLES WELL ID CASING DIAMETER (INCHES) PRODUCT THICKNESS BEFORE MMPE (FEET) - 03/21/22 WATER/ PRODUCT REMOVED (GALLONS) FREE PRODUCT REMOVED (GALLONS AS LIQUID) FREE PRODUCT REMOVED (GALLONS AS VAPOR) MW-1 2 6.38 MW-3 2 4.48 MW-5 2 2.80 MW-6 2 3.15 MW-11 2 0.59 MW-12 2 4.24 MW-13 2 4.25 169,330 188.79 MID-ATLANTIC JOB NO. 000R2826.15 TOTAL GALLONS OF FREE PRODUCT REMOVED = 204.79 TABLE 2.1 SUMMARY OF MMPE EVENT MARCH 21, 2022 THROUGH MARCH 25, 2022 SPEEDWAY 8299 CLAYTON, NORTH CAROLINA WELL NUMBER DATE TOC (ft)DTP (ft)APPARENT FP THICKNESS (ft)DTW (ft), BTOC CORRECTED DTW (ft)SWLE (ft) MW-1 09/30/16 98.82 14.93 0.50 15.43 15.07 83.76 MW-1 06/15/17 98.82 11.86 1.07 12.93 12.15 86.67 MW-1 02/12/18 98.82 13.38 1.44 14.82 13.77 85.05 MW-1 03/09/18 98.82 12.75 2.13 14.88 13.33 85.49 MW-1 10/26/18 98.82 11.79 4.98 16.77 13.13 85.69 MW-1 01/14/19 98.82 7.18 9.43 16.61 9.73 89.09 MW-1 12/02/19 98.82 13.93 5.88 19.81 15.52 83.30 MW-1 01/07/20 98.82 13.83 1.25 15.08 14.17 84.65 MW-1 07/20/20 98.82 12.88 3.71 16.59 13.88 84.94 MW-1 02/08/21 98.82 7.82 2.22 10.04 8.42 90.40 MW-1 08/30/21 98.82 13.81 3.32 17.13 14.71 84.11 MW-1 03/21/22 98.82 12.32 6.38 18.70 14.04 84.78 MW-2 09/30/16 96.68 --0.00 12.96 --83.72 MW-2 06/15/17 96.68 --0.00 10.06 --86.62 MW-2 02/12/18 96.68 --0.00 11.27 --85.41 MW-2 03/09/18 96.68 --0.00 11.07 --85.61 MW-2 10/26/18 96.68 --0.00 11.99 --84.69 MW-2 01/14/19 96.68 --0.00 7.21 --89.47 MW-2 12/02/19 96.68 --0.00 13.19 --83.49 MW-2 01/07/20 96.68 --0.00 11.09 --85.59 MW-2 07/20/20 96.68 --0.00 11.69 --84.99 MW-2 02/08/21 96.68 --0.00 NM --NM MW-2 08/30/21 96.68 --0.00 12.47 --84.21 MW-2 03/21/22 96.68 --0.00 NM --NM MW-3 MW-3 06/15/17 97.63 10.52 1.59 12.11 10.95 86.68 MW-3 02/12/18 97.63 10.55 6.39 16.94 12.28 85.35 MW-3 03/09/18 97.63 11.69 2.15 13.84 12.27 85.36 MW-3 10/26/18 97.63 9.67 7.96 17.63 11.82 85.81 MW-3 01/14/19 97.63 6.01 7.49 13.50 8.03 89.60 MW-3 12/02/19 97.63 13.67 4.08 17.75 14.77 82.86 MW-3 01/07/20 97.63 11.65 3.67 15.32 12.64 84.99 MW-3 07/20/20 97.63 11.33 6.49 17.82 13.08 84.55 MW-3 02/08/21 97.63 4.79 10.05 14.84 7.50 90.13 MW-3 08/30/21 97.63 13.03 2.37 15.40 13.67 83.96 MW-3 03/21/22 97.63 12.53 4.48 17.01 13.74 83.89 Monitoring well installed 6/13/17 TABLE 2.2SUMMARY OF HISTORICAL FREE PRODUCT THICKNESS DATASPEEDWAY 8299CLAYTON, NORTH CAROLINADWM INCIDENT NO.: 42007MID-ATLANTIC JOB NO. R2826.15 Page 1 of 4 WELL NUMBER DATE TOC (ft)DTP (ft)APPARENT FP THICKNESS (ft)DTW (ft), BTOC CORRECTED DTW (ft)SWLE (ft) TABLE 2.2SUMMARY OF HISTORICAL FREE PRODUCT THICKNESS DATASPEEDWAY 8299CLAYTON, NORTH CAROLINADWM INCIDENT NO.: 42007MID-ATLANTIC JOB NO. R2826.15 MW-4 MW-4 06/15/17 98.63 --0.00 11.69 --86.94 MW-4 03/09/18 98.63 --0.00 12.72 --85.91 MW-4 10/26/18 98.63 --0.00 12.87 --85.76 MW-4 01/14/19 98.63 --0.00 NM --NM MW-4 12/02/19 98.63 --0.00 NM --NM MW-4 01/07/20 98.63 --0.00 12.74 --85.89 MW-4 02/08/21 98.63 --0.00 NM --NM MW-4 08/30/21 98.63 --0.00 NM --NM MW-4 03/21/22 98.63 --0.00 NM --NM MW-5 MW-5 03/09/18 98.28 11.52 0.20 11.72 11.57 86.71 MW-5 10/26/18 98.28 9.08 8.68 17.76 11.42 86.86 MW-5 01/14/19 98.28 3.95 12.38 16.33 7.29 90.99 MW-5 12/02/19 98.28 12.25 5.41 17.66 13.71 84.57 MW-5 01/07/20 98.28 11.73 0.21 11.94 11.79 86.49 MW-5 07/20/20 98.28 12.19 0.80 12.99 12.41 85.87 MW-5 02/08/21 98.28 6.70 1.14 7.84 7.01 91.27 MW-5 08/30/21 98.28 11.57 5.36 16.93 13.02 85.26 MW-5 03/21/22 98.28 11.43 2.80 14.23 12.19 86.09 MW-6 MW-6 03/09/18 100.79 13.80 0.19 13.99 13.85 86.94 MW-6 10/26/18 100.79 12.14 5.49 17.63 13.62 87.17 MW-6 01/14/19 100.79 11.05 6.06 17.11 12.69 88.10 MW-6 12/02/19 100.79 15.12 4.30 19.42 16.28 84.51 MW-6 01/07/20 100.79 14.04 0.28 14.32 14.12 86.67 MW-6 07/20/20 100.79 13.03 5.16 18.19 14.42 86.37 MW-6 02/08/21 100.79 8.52 1.60 10.12 8.95 91.84 MW-6 08/30/21 100.79 14.93 1.30 16.23 15.28 85.51 MW-6 03/21/22 100.79 15.02 3.15 18.17 15.87 84.92 MW-6D MW-6D 10/26/18 98.88 --0.00 13.56 --85.32 MW-6D 01/14/19 98.88 --0.00 NM --NM MW-6D 12/02/19 98.88 --0.00 NM --NM MW-6D 01/07/20 98.88 --0.00 NM --NM MW-6D 02/08/21 98.88 --0.00 NM --NM MW-6D 08/30/21 98.88 --0.00 NM --NM MW-6D 03/21/22 98.88 --0.00 NM --NM Monitoring well installed 6/13/17 Monitoring well installed 3/7/2018 Monitoring well installed 3/9/2018 Monitoring well installed 10/25/2018 Page 2 of 4 WELL NUMBER DATE TOC (ft)DTP (ft)APPARENT FP THICKNESS (ft)DTW (ft), BTOC CORRECTED DTW (ft)SWLE (ft) TABLE 2.2SUMMARY OF HISTORICAL FREE PRODUCT THICKNESS DATASPEEDWAY 8299CLAYTON, NORTH CAROLINADWM INCIDENT NO.: 42007MID-ATLANTIC JOB NO. R2826.15 MW-7 MW-7 03/09/18 99.21 --0.00 12.67 --86.54 MW-7 10/26/18 99.21 --0.00 12.51 --86.70 MW-7 01/14/19 99.21 --0.00 NM --NM MW-7 12/02/19 99.21 --0.00 14.86 --84.35 MW-7 01/07/20 99.21 --0.00 7.30 --91.91 MW-7 07/20/20 99.21 --0.00 13.69 --85.52 MW-7 02/08/21 99.21 --0.00 7.93 --91.28 MW-7 08/30/21 99.21 --0.00 14.11 --85.10 MW-7 03/21/22 99.21 --0.00 14.76 --84.45 MW-8 MW-8 03/09/18 96.92 --0.00 10.22 --86.70 MW-8 10/26/18 96.92 --0.00 10.20 --86.72 MW-8 01/14/19 96.92 --0.00 NM --NM MW-8 12/02/19 96.92 --0.00 NM --NM MW-8 01/07/20 96.92 --0.00 7.74 --89.18 MW-8 02/08/21 96.92 --0.00 NM --NM MW-8 08/30/21 96.92 --0.00 NM --NM MW-8 03/21/22 96.92 --0.00 NM --NM MW-9 MW-9 10/26/18 98.19 --0.00 12.47 --85.72 MW-9 01/14/19 98.19 --0.00 NM --NM MW-9 12/02/19 98.19 --0.00 15.01 --83.18 MW-9 01/07/20 98.19 --0.00 7.03 --91.16 MW-9 07/20/20 98.19 --0.00 13.52 --84.67 MW-9 02/08/21 98.19 --0.00 7.60 --90.59 MW-9 08/30/21 98.19 --0.00 14.14 --84.05 MW-9 03/21/22 98.19 --0.00 14.39 --83.80 MW-10 MW-10 10/26/18 98.6 --0.00 13.19 --85.41 MW-10 01/14/19 98.6 --0.00 NM --NM MW-10 12/02/19 98.6 --0.00 15.59 --83.01 MW-10 01/07/20 98.6 --0.00 6.38 --92.22 MW-10 07/20/20 98.6 --0.00 13.82 --84.78 MW-10 02/08/21 98.6 --0.00 8.24 --90.36 MW-10 08/30/21 98.6 --0.00 14.77 --83.83 MW-10 03/21/22 98.6 --0.00 14.18 --84.42 Monitoring well installed 3/8/2018 Monitoring well installed 3/8/2018 Monitoring well installed 10/23/2018 Monitoring well installed 10/23/2018 Page 3 of 4 WELL NUMBER DATE TOC (ft)DTP (ft)APPARENT FP THICKNESS (ft)DTW (ft), BTOC CORRECTED DTW (ft)SWLE (ft) TABLE 2.2SUMMARY OF HISTORICAL FREE PRODUCT THICKNESS DATASPEEDWAY 8299CLAYTON, NORTH CAROLINADWM INCIDENT NO.: 42007MID-ATLANTIC JOB NO. R2826.15 MW-11 MW-11 01/07/20 99.0 --0.00 13.46 --85.54 MW-11 07/20/20 99.0 --0.00 13.89 --85.11 MW-11 02/08/21 99.0 8.61 0.20 8.81 8.66 90.34 MW-11 08/30/21 99.0 14.41 1.16 15.57 14.72 84.28 MW-11 03/21/22 99.0 13.62 0.59 14.21 13.78 85.22 MW-12 MW-12 01/07/20 97.39 --0.00 11.78 --85.61 MW-12 07/20/20 97.39 --0.00 12.02 --85.37 MW-12 02/08/21 97.39 --0.00 7.33 --90.06 MW-12 08/30/21 97.39 11.28 6.70 17.98 13.09 84.30 MW-12 03/21/22 97.39 11.14 4.24 15.38 12.28 85.11 MW-13 MW-13 02/08/21 98.73 --0.00 8.53 --90.20 MW-13 08/30/21 98.73 15.10 2.63 17.73 15.81 82.92 MW-13 03/21/22 98.73 12.50 4.25 16.75 13.65 85.08 Notes: Shaded cells indicate that the water level has been corrected for the presence of free product (DTW - (0.73*FP Thickness)) BTOC - Below Top of Casing (TOC) DTP - Depth to Free Product (in feet)DTW - Depth to Water (in feet)SWLE - Static Water Level Elevation (in feet) Monitoring well installed 1/6/2020 Monitoring well installed 1/28/2021 Monitoring well installed 1/6/2020 Page 4 of 4 RECOVERY METHOD DATE FREE PRODUCT REMOVED AS LIQUID (GALLONS) OFF-GAS EMISSIONS (GALLONS) WATER/PRODUCT REMOVED (GALLONS) AFVR 10/21/2016 0 1.22 110 MMPE 2/12/18 TO 2/16/18 90 118.44 4,680 MMPE 1/14/19 TO 1/18/19 124 123.79 9,644 MMPE 12/2/19 to 12/6/19 and 12/9/19 to 12/13/19 168 375.29 17,327 MMPE 7/20/20 TO 7/24/20 42 137.10 9,270 MMPE 2/8/2021 TO 2/12/2021 18 216.49 9,388 MMPE 8/30/2021 TO 9/3/2021 24 328.20 9,668 MMPE 3/21/2022 TO 3/25/2022 16 188.79 9,330 482 1,489.32 69,417 69,417GRAND TOTALS TABLE 2.3 SUMMARY OF HISTORICAL FREE PRODUCT RECOVERY EVENTS SPEEDWAY 8299 MID-ATLANTIC JOB NO. 000R2826.15 TOTALS 1,971.32 CLAYTON, NORTH CAROLINA APPENDIX A ADVANCED ENVIRONMENTAL'S "MOBILE MULTI- PHASE EXTRACTION REPORT" ADVANCED ENVIRONMENTAL SERVICES, INC. “Your Environmental Solutions Partner” MOBILE MULTI-PHASE EXTRACTION REPORT Site Location: Speedway #8299 291 Hwy 42 East Clayton, NC Prepared for: Mid-Atlantic Associates, Inc. 409 Rogers View Court Raleigh, NC 27610 PM – Mr. Charles Hoffman. PG April 13, 2022 TABLE OF CONTENTS EVENT SUMMARY MMPE FIELD LOG MASS-REMOVAL CALCULATION FIELD NOTES DISPOSAL MANIFESTS MOBILE MULTI-PHASE EXTRACTION EVENT SUMMARY April 13, 2022 Location: Mid Atlantic Associates 291 Hwy 42 East Clayton, NC Client: Mid-Atlantic Associates, Inc. 409 Rogers View Court Raleigh, NC 27610 Event Dates: March 21 – March 25, 2022 Advanced Job # 03 – 2221 Advanced Personnel: Scott Crook and Gary McDaniel MMPE System: MMPE system rated 25”hg at 280 CFM 4’ discharge stack - 6” diameter 6,000 - gallon tanker 200’ of 2.0” hose and 140’ of 1.0” hose to 6 wells Extraction Well: MW-1, MW-3, MW-5, MW-6, MW-11, MW-12, and MW-13 Well Initial FP / WL(ft) Final FP / WL(ft) Stinger depth(ft) Run Time /Changed to MW-1 12.32/18.70 15.22 13 96.0 hours MW-3 12.53/17.01 15.26 13 96.0 hours MW-5 11.43/14.23 14.64 12 96.0 hours MW-6 15.02/18.17 16.05 15 96.0 hours MW-11 13.62/14.21 16.60 14 96.0 hours MW-12 11.14/15.38 12.40/12.51 12 24.0 hours MW-13 12.50/16.75 14.50 13 96.0 hours Description of Event: The MMPE event ran from 12:10 March 21, through 12:10 March 25, 2022. The MMPE system was active for 96.0 hours. During the event vacuum at the recovery pump ranged from 19 to 21 inches of mercury and stabilized at approximately 19 inches of mercury. Airflow rates ranged from 1,400 to 1,500 feet per minute and stabilized at approximately 1,500 feet per minute. System temperature ranged from 108 – 130 degrees F and humidity ranged from 28 – 56 percent. Field gauged volatile organic compounds (VOC’s) decreased from 40,000 to 14,000 parts per-million (PPM) throughout the event. Groundwater / Product Mix Recovered: During the event a total of 9,330 gallons of product/water mix were removed from the site and properly disposed at a certified North Carolina disposal facility. An estimated 16.0 gallons of free product was recovered as liquid. Total fluids recovered, was measured based on stick readings conducted during and following the event. Based on 96.0 hours of operation and a total of 9,330 gallons recovered, the average groundwater recovery rate was calculated to be approximately 97.18 gallons per hour. Events Results: Based on mass-removal calculations, 1,161.42 pounds or 188.79 gallons of VOC’s were removed as vapor. Approximately 16 gallons of product was visible in the tanker following the event. Using Dwyer Magnahelic gauges, vacuum influence was measured at monitoring points MW-7, MW-9 and VE- OW-1. Vacuum influence was measured at 0.10, 0.25, and 1.60 inches of water respectively. Mounding was identified in MW-7, MW-9, MW-10, VE-1 and VE-OW-1 at 1.64, 0.91, 0.18, 1.58 and 0.90 feet respectively. Following the event, 0.11 feet of free product was measured in MW-12. No other well had product visible. MMPE FIELD LOG: CLIENT: Mid Atlantic Associates JOB NAME: Speedway #8299 LOCATION: Clayton, NC MMPE EVENT DATES: March 21- 25, 2022 EXTRACTION POINTS: MW-1, MW-3, MW-5, MW-6, MW-11, MW-12 and MW-13 AES JOB NUMBER: 03 - 2221 DATE TIME FLOW (f/m) HUM.(%) TEMP. (F)VOC's(ppm)VAC. (hg")GALLONS STINGER/WL's EXTRACTION POINTS (hg") MW-1 MW-3 MW-5 Stinger(ft)13.0 13 12 Start 12:10 Initial WL's 12.32/18.70 12.53/17.01 11.43/14.23 03/21/22 12:40 1,500 28.0 108 40,000 19.0 14.0 14.0 13.0 13:40 1,500 42.0 116 36,000 19.0 14.0 14.0 13.0 17:30 1,500 54.0 126 30,000 19.0 14.0 14.0 13.0 21:20 1,500 56.0 124 26,000 19.0 14.0 14.0 13.0 03/22/22 5:00 1,500 54.0 126 22,000 19.0 14.0 14.0 13.0 7:30 1,500 54.0 126 22,000 19.0 14.0 14.0 13.0 15:00 1,500 50.0 130 20,000 19.0 2,640 gal.14.0 14.0 13.0 21:30 1,500 54.0 126 19,000 19.0 14.0 14.0 13.0 03/23/22 5:10 1,500 52.0 128 18,000 19.0 14.0 14.0 13.0 11:10 1,500 50.0 130 16,000 19.0 P/O 4,770 14.0 14.0 13.0 18:50 1,500 50.0 130 15,000 19.0 14.0 14.0 13.0 21:10 1,500 52.0 128 15,000 19.0 14.0 14.0 13.0 03/24/22 5:10 1,500 52.0 128 15,000 19.0 1,650 gal.14.0 14.0 13.0 12:30 1,500 50.0 130 15,000 19.0 14.0 14.0 13.0 17:50 1,500 52.0 128 14,000 19.0 14.0 14.0 13.0 21:40 1,500 54.0 126 14,000 19.0 14.0 14.0 13.0 03/25/22 7:50 1,500 52.0 128 14,000 19.0 4,080 gal.14.0 14.0 13.0 11:30 1,400 46.0 122 15,000 21.0 15.0 15.0 14.0 P/O 4,560 Total gallons 9,330 gal. End 12:10 Total free product:16 gal.Final WL's 15.22 15.26 14.64 DATE TIME STINGER/WL's EXTRACTION POINTS (hg") cont. Well Gauging (ft) / Vacuum Influence (H2O") MW-6 MW-11 MW-12 MW-13 MW-7 MW-9 MW-10 VE-1 VE-OW-1 Start 12:20 Stinger(ft)15 14 12 13 Initial WL's 15.02/18.17 13.62/14.21 11.14/15.38 12.50/16.75 03/21/22 12:40 14.0 13.0 off-line 13.0 14.76 14.39 14.18 4.46 3.50 13:40 14.0 13.0 off-line 13.0 0.00 0.00 0.00 0.00 0.00 17:30 14.0 13.0 off-line 13.0 21:20 14.0 13.0 off-line 13.0 03/22/22 5:00 14.0 13.0 13.0 13.0 14.01 14.26 14.13 3.23 2.71 7:30 14.0 13.0 off-line 13.0 0.00 0.10 0.00 0.00 1.10 15:00 14.0 13.0 off-line 13.0 21:30 14.0 13.0 off-line 13.0 03/23/22 5:10 14.0 13.0 13.0 13.0 13.53 14.22 14.11 3.05 2.44 11:10 14.0 13.0 off-line 13.0 0.00 0.20 0.00 0.00 1.20 18:50 14.0 13.0 off-line 13.0 21:10 14.0 13.0 off-line 13.0 03/24/22 5:10 14.0 13.0 13.0 13.0 13.25 14.08 14.07 2.95 2.35 12:30 14.0 13.0 off-line 13.0 0.10 0.25 0.00 0.00 1.20 17:50 14.0 13.0 off-line 13.0 21:40 14.0 13.0 off-line 13.0 03/25/22 7:50 14.0 13.0 off-line 13.0 13.12 13.48 14.00 2.88 2.40 11:30 15.0 14.0 off-line 14.0 0.10 0.25 0.00 0.00 1.60 End 12:10 Final WL's 16.05 16.60 12.40/12.51 14.50 Page 1 of 1 MOBILE MULTI-PHASE EXTRACTION EVENT SITE NAME: Speedway #8299 CLIENT: Mid Atlantic Associates INCIDENT NUMBER: AVERAGE DEPTH TO GROUNDWATER: 11 - 16 feet DESCRIBE SOIL IN THE SATURATED ZONE: AVERAGE HYDRAULIC CONDUCTIVITY (if known): EXTRACTION WELLS USED FOR MMPE: MW-1, MW-3, MW-5, MW-6, MW-11, MW-12, and MW-13 SPECIFICATIONS OF THE MMPE SYSTEM (cfm @ in Hg): 280 cfm @ 25.0"Hg DRY STANDARD CUBIC FEET PER MINUTE (DSCFM) AIR FLOW CALCULATIONS (Qstd) Date Hours Vacuum Velocity Pipe ID Temp Rel Humid Water Water Qstd(inches of Hg)(ft/min)(in)(°F)(%)Vapor (Wt%)Vapor (Vol%)(flow) 3/21/22 24.00 19.00 1500.00 6 119 45.0 0.032 0.049 256 3/22/22 48.00 19.00 1500.00 6 127 53.0 0.049 0.073 246 3/23/22 72.00 19.00 1500.00 6 129 51.0 0.050 0.074 244 3/24/22 96.00 19.50 1475.00 6 127 50.3 0.046 0.069 243 3/25/22 NOTES Qstd = Flow at DSCFM Vacuum = The level of vacuum being applied should be recorded from the MMPE system (inches of Hg) Velocity = The rate at which air flows is measured at the blower discharge piping (anemometer or pitot tube) Pipe ID = The inside diameter of the blower discharge piping (from the MMPE system) Temperature = The temperature of the air stream exiting the blower discharge piping (dry bulb temp., in deg.°F)Relative humidity = The % relative humidity of the air stream exiting the blower discharge piping Bwsw = water vapor % by weight, i.e., pounds of water per pound of dry air, derived from the Psychrometric chart (temp Vs relative humidity) Bws = water vapor % by volume EQUATIONS Bws = (Bwsw/18 lb-mole H20)/[(1/28.84 lb-mole dry air) + (Bwsw/18 lb-mole H2O)]Qstd = (1-Water Vapor) * velocity * (PI * (diameter/24)2) * (528°R/(Temp + 460)) EMISSION CALCULATIONS Elapsed Time Flow PPMmeasured PPMwet PPMdry K PPMconc Cc:m Cc PMRc PMRg PMR (hour)(DSCFM)(ppm)(#C - gas)(mg/dsm3)(lb/dscf)(lb/hour)(lb/hour)(lb) 24 256 33000 33000 34692 1 34692 17310 0.00108066 16.58 19.19 460.50 48 246 20750 20750 22379 1 22379 11166 0.000697111 10.27 11.89 285.37 72 244 16000 16000 17282 1 17282 8623 0.00053833 7.90 9.14 219.29 96 243 14500 14500 15569 1 15569 7768 0.000484967 7.07 8.18 196.26 Total emissions in pounds 1161.42 Total emissions as gallons (pounds / 6.152)188.79 NOTES PPMmeasured = Actual measurements (ppm) taken with a OVA or TVA at the blower discharge piping PPMwet = "wet" concentration PPMdry = "dry" concentration K = Number of carbons in calibration gas: (Methane K = 1, or Propane K = 3, or Hexane K = 6) PPMc= PPMv, Volumetric concentration of VOC emissions as carbon, dry basis at STP Cc:m = mg/dsm3, mass concentration of VOC emissions as carbon Mc = 12.01 mg/mg-mole, molecular weight of carbon K3 = 24.07 dsm3/106 mg-mole, mass to volume conversion factor at STP Cc = lb/dcsf, mass concentration of VOC emissions as carbon, dry basis at STP PMRc = lb/hr, pollutant mass removal rate of VOC's as carbon PMRg = lb/hr, pollutant mass removal rate of of VOC's as gasolinePMR = lb, pollutant mass removal of VOC's as gasoline EQUATIONS PPMwet = PPMmeasuredPPMdry = (PPMwet)/(1-Bws) PPMc = (PPMd)(K) Cc:m = (PPMc)(Mc / K3)Cc = (Cc:m)(62.43x10-9 lb-m3/mg-ft3) PMRc = (Cc)(Qstd)(60 minute/hour) PMRg = (PMRc)(Mg/Mcg) PMR = (PMRg)(#hours) MMPi. Field Log Oient: f() tb n, LA..S., Job Number. Site Name: S?e <rA '-f .:::#=-8' 2 9 9 , Event Dates: Extraction WeUs: 1'("14-1 _/ l Mt--) -3 'l""',,.;-S 1 m w-,.-,, n w-/ I f '' 1.--> -"22. .:_ , -_ I ·., '<_,·•;,,!:; -l -1 ._ -, ._ z.; D Page#_J_ MMPI Field Log Went: !'r1t b AnA #J, ( c... Job Number: J · -,... ··-_ · SiteName: S;>Ee.bwA-Y -::#==-J'Z-q°t EventDates: ,~ ·?.., · :··.:•.,-,.: .:. Extraction wen.: Mt.Jo-,f\4 v-:?, n11.,,,J-.s; 11.1,;..l-GJ I M.1....J-n ·. ,IV.:.,._, __ 1-·· I"".,.,. .... -ZZ. 3-zy -z.-z. s~,o - MATERIAL M.ANIFEST Manifest Document No. O ".s23 2 ~ 2. Page of EMERGENCY PHONE NO. (336) 841-5276 POST OFFICE BOX 357 TEL (336) 841-5276 Job ~ 3 (:.., HIGH POINT, NC 27261 FAX (336) 841-5509 GENERATOR INFORMATION HM a. b. c. ADDITIONAL I a. b. c. Malllng Address USDOT Proper Shipping Name (Complete All Items for Hazardous Materials) GENERATOR'S CERTIFICATION US EPA ID No. Phone No. Con:S~at+ Hazard UN I NA Packing Containers Total Class or Div ID No. Group Qty. Type Quantity Unit Wt.Nol. ll\ 710C- ERG No. Zebra Profile Code Facility Use This is to certify that the above-described materials are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. I further certify that none of the materials described above are a hazardous waste as defined by EPA 40 CFR Part 261 or any applicable state law, and unless specifically identified above, the materials contain Jess than 1,000 ppm total halogens and do not contain quantifiable levels (2 ppm) of PCBs as defined by EPA 40 CFR Parts 279 and 761. -:Z:D~lL TRANSPORTER Transporter Zebra Environmental & Industrial Services Inc I hereby acknowledge receipt f t')1 above-described materials for transport _A_d_d-re-s-,----------------------ifrom th.• generator site list a ~.. f,,£...,~"-"'~--{J J/'2 9'') L 901 East Springfield Road .'J J 7 ' 1 High Point, NC 27263 Signature /q 0. "f.1/\ ,.-. Shipment Date I hereby ackno escribed materials were received -:;~:::-~:-:;:-:~D-::-po:-:Nrt::--: 0 ~:-:r-::-o'.:"'r ___ N_C_0-9-9-1-3-0-25-5-9-----i-1~::-=:---:::::---:=--1from the ge t &!~~-~,--d to the facility list~ j"Jjl: 2 (~)W~ 7 2 Signature v, Delivery ate FACILITY INFORMATION Facility Zebra Environmental & Industrial Services, Inc. Address Facility or EPAID No. Phone 901 East Springfield Road High Point, NC 27263 NCO991302669 (336) 841-5276 Contact Bill Hunter I hereby acknowledge receipt of the materials covered by this manifest except for any discrepancy noted below. Signature Receipt Date Discre ancles / Routln Codes I Handin Methods a. b. c. ORIGINAL• Faclllty Retain COPY 2 • Return to Generator COPY 3 -Transporter Retain COPY 4 -Generator Retain MATERIAL MANIFEST Manifest Document No. EMERGENCY PHONE NO. (336) 841-5276 Name \ I? ?t" -i ,._,,,. -< St~t Addni s, . , 1 _,-r-' 1 v\ YI J-tW'j ..,,.. ,:; r.<;+ DESCRIPTION OF MATERIALS bra -44 :::ti Page fil.+onmenlaf I J.,,.JlcN POST OFFICE BOX 357 TEL (336) 841-5276 Zebra Job No. HIGH POINT, NC 27261 FAX (336) 841-5509 I GENERATOR INFORMATION US EPAID No. Maillng Address Contact S°,-{ -I t USDOT Proper Shipping Name Hazard UN/NA Packing Containers of Total Unit HM (Complete All Items for Hazardous Materials) Class or Div ID No. Group Qty. Type Quantity Wt.Nol. a. / / 11 1S-fu /J 1"Vr1 "' Ur, r I , ~r ,,.J < /~//).-:., l v 1 (-- b. ( , c. ADDITIONAL INFORMATION ERG No. Zebra Profile Code Facility Use a. r -t-,, .,, e,, ' ,fl ./ ,,., ,,. 4 4" ,, b. c. GENERATOR'S CERTIFICATION This is to certify that the above-described materials are properly classified, described, packaged, marked and labeled, and are in proper condition for transportation according to the applicable regulations of the Department of Transportation. I further certify that none of the materials described above are a hazardous waste as defined by EPA 40 CFR Part 261 or any applicable state law, and unless specifically identified above, the materials contain less than 1,000 ppm total halogens and do not contain quantifiable levels (2 ppm) of PCBs as defined by EPA 40 CFR Parts 279 and 761. Mo. ay r. _z.5 -2-Z. TRANSPORTER INFORMATION Transporter Zebra Environmental & Industrial Services Inc / hereby acknowledge receipt of the above-described materials for transport ------------------------1from the generator site listed above. Address 901 East Springfield Road High Point, NC 27263 Slgnatureltr. v,-. i I, (5o ,1 Shipment Date ----------------~....,.,...,,..,.....-----1' hereby acknowledge receipt of the above-described materials were received Transporter or NCO991302669 I U,nJ.!. N/.o,. -, ... , from the generator site and were transported to the facility listed below. EPA ID No. KT Phone (336) 841-5276 Signature Delivery Date FACILITY INFORMATION Facility Zebra Environmental & Industrial Services, Inc. / hereby acknowledge receipt of the materials covered by this manifest _______________________ except for any discrepancy noted below. Address Facility or EPAID No. Phone Contact 901 East Springfield Road High Point, NC 27263 NCO991302669 (336) 841-5276 Bill Hunter Signature Receipt Date Dlscreoancles / Routlna Codes/ Handlna Methods a. b. c. ORIGINAL -Facility Retain COPY 2 -Return to Generator COPY 3 -Transporter Retain COPY 4 • Generator Retain APPENDIX B MONITORING WELL CONSTRUCTION RECORDS WELL CONSTRUCTION RECORD This form can be used for single or multiple wells Form GW-1 North Carolina Department of Environment and Natural Resources – Division of Water Quality Revised Jan. 2013 1. Well Contractor Information: Well Contractor Name NC Well Contractor Certification Number Company Name 2. Well Construction Permit #: List all applicable well construction permits (i.e. County, State, Variance, etc.) 3. Well Use (check well use): Water Supply Well: □Agricultural □Municipal/Public □Geothermal (Heating/Cooling Supply) □Residential Water Supply (single) □Industrial/Commercial □Residential Water Supply (shared) □Irrigation Non-Water Supply Well: □Monitoring □Recovery Injection Well: □Aquifer Recharge □Groundwater Remediation □Aquifer Storage and Recovery □Salinity Barrier □Aquifer Test □Stormwater Drainage □Experimental Technology □Subsidence Control □Geothermal (Closed Loop) □Tracer □Geothermal (Heating/Cooling Return) □Other (explain under #21 Remarks) 4. Date Well(s) Completed: ____________ Well ID#______________________ 5a. Well Location: Facility/Owner Name Facility ID# (if applicable) Physical Address, City, and Zip County Parcel Identification No. (PIN) 5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (if well field, one lat/long is sufficient) N W 6. Is (are) the well(s): □Permanent or □Temporary 7. Is this a repair to an existing well: □Yes or □No If this is a repair, fill out known well construction information and explain the nature of the repair under #21 remarks section or on the back of this form. 8. Number of wells constructed: For multiple injection or non-water supply wells ONLY with the same construction, you can submit one form. 9. Total well depth below land surface: (ft.) For multiple wells list all depths if different (example- 3@200’ and 2@100′) 10. Static water level below top of casing: (ft.) If water level is above casing, use “+” 11. Borehole diameter: (in.) 12. Well construction method: (i.e. auger, rotary, cable, direct push, etc.) FOR WATER SUPPLY WELLS ONLY: 13a. Yield (gpm) Method of test: 13b. Disinfection type: Amount: 14. WATER ZONES FROM TO DESCRIPTION ft. ft. ft. ft. 15. OUTER CASING (for multi-cased wells) OR LINER (if applicable) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. 16. INNER CASING OR TUBING (geothermal closed-loop) FROM TO DIAMETER THICKNESS MATERIAL ft. ft. in. ft. ft. in. 17. SCREEN FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ft. ft. in. ft. ft. in. 18. GROUT FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT ft. ft. ft. ft. ft. ft. 19. SAND/GRAVEL PACK (if applicable) FROM TO MATERIAL EMPLACEMENT METHOD ft. ft. ft. ft. 20. DRILLING LOG (attach additional sheets if necessary) FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.) ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. ft. 21. REMARKS 22. Certification: Signature of Certified Well Contractor Date By signing this form, I hereby certify that the well(s) was (were) constructed in accordance with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a copy of this record has been provided to the well owner. 23. Site diagram or additional well details: You may use the back of this page to provide additional well site details or well construction details. You may also attach additional pages if necessary. SUBMITTAL INSTUCTIONS 24a. For All Wells: Submit this form within 30 days of completion of well construction to the following: Division of Water Quality, Information Processing Unit, 1617 Mail Service Center, Raleigh, NC 27699-1617 24b. For Injection Wells: In addition to sending the form to the address in 24a above, also submit a copy of this form within 30 days of completion of well construction to the following: Division of Water Quality, Underground Injection Control Program, 1636 Mail Service Center, Raleigh, NC 27699-1636 24c. For Water Supply & Injection Wells: In addition to sending the form to the address(es) above, also submit one copy of this form within 30 days of completion of well construction to the county health department of the county where constructed. For Internal Use ONLY: