FA-29365_48519_CA_SCR__20221227

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
December 27, 2022

Mr. Clark Wipfield
NCDEQ-UST Section
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405

Re: Regular UST Product Line Closure Report
Cedar Creek Food Mart
3209 Cedar Creek Road
Fayetteville, Cumberland County
North Carolina
Facility ID Number: 00-0-0000036220
Incident Number: 48519
GRI Project Number: 6126

Dear Mr. Wipfield,

Please find enclosed the referenced report for the abovementioned site.
If you have any questions, please contact Scott Driscoll at 704-845-4010.

Sincerely,
Geological Resources, Inc.

Leslie Maxtone-Graham
Administrative Assistant

Enclosure

Cc: Mr. Varun Sharma; Jai Shree Sai, Inc.

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
Engineering Certification: C-2727 • Geology Certification: C-127
Regular UST Product Line Closure Report
Cedar Creek Food Mart
3209 Cedar Creek Road
Fayetteville, Cumberland County, North Carolina
Facility ID Number: 00-0-0000036220
Incident Number: 48519
GRI Project Number: 6126

Prepared for:

Mr. Varun Sharma
Jai Shree Sai, Inc.
3209 Cedar Creek Road
Fayetteville, North Carolina 28312

December 27, 2022

Scott Driscoll
Project Manager
Kyle Perry
Staff Scientist

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Regular UST Product Line Closure Report
Prepared on: December 27, 2022 Cedar Creek Food Mart
Project Manager: Scott Driscoll GRI Project No. 6126
ii
EXECUTIVE SUMMARY
The Cedar Creek Food Mart site is located at 3209 Cedar Creek Road in Fayetteville, Cumberland County,
North Carolina. The property operates as a petroleum retail facility and convenience store. There are
one 12,000-gallon gasoline, one 8,000-gallon gasoline, one 10,000-gallon diesel and one 2,000-gallon
kerosene USTs, associated product lines and dispensers located at the site. The kerosene UST is currently
reported to be in temporary closure. The site is covered by asphalt, concrete and grass and the
surrounding properties are mainly used for commercial, residential and agricultural purposes.

On April 28, 2022, NCDEQ conducted a compliance inspection at the site. Results of the inspection noted
a deficiency with the spill containment bucket associated with the 8,000-gallon premium gasoline UST.
The compliance inspection also noted a portion of the regular gasoline product line had delaminated. An
NOV was issued for the deficiencies to Jai Shree Sai, Inc. which instructed them to replace the regular
product line and perform a site check for the deficiency noted at the premium spill containment bucket.

A release (UST Incident #48519) at the site was confirmed on June 16, 2022, upon receipt of mobile UVF
laboratory results for a soil sample collected during spill bucket replacement activities. An unknown
amount of petroleum product was released from the UST System via non-passing UST spill buckets. The
Site Check Report dated July 26, 2022, was submitted to satisfy the site check requirement for the spill
bucket deficiency.

On September 7, 2022, GRI collected four soil samples (PP-1-4’ through PP-4-4’) beneath the delaminated
regular product line to satisfy the closure requirement for the product line. The product line was replaced
from the regular submersible turbine pump to a transition sump in the vicinity of the dispensers. The
samples were collected at a depth of 4 feet bgs and submitted for UVF analyses of TPH-GRO range
petroleum hydrocarbons.

No concentrations of TPH-GRO that exceeded the RALs were reported in the soil samples collected. Based
on this information, soil quality violations related to the delaminated product line do not exist at the site.

In response to the July 26, 2022, Site Check Report submitted for the spill bucket replacement assessment,
NCDEQ issued a Notice of Regulatory Requirements dated July 27, 2022, for the completion of a Limited
Site Assessment for the site. Currently, authorization to proceed with the Limited Site Assessment is
pending.

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Regular UST Product Line Closure Report
Prepared on: December 27, 2022 Cedar Creek Food Mart
Project Manager: Scott Driscoll GRI Project No. 6126
iii
ACRONYMS
ACM: Asbestos Containing Materials
AFVR: Aggressive Fluid-Vapor Recovery
ARR: Acknowledgement of Report Receipt
AS: Air Sparging
AST: Aboveground Storage Tank
ASTM: American Society for Testing and
Materials
BGS: Below Ground Surface
CAP: Corrective Action Plan
CFR: Code of Federal Regulations
CSA: Comprehensive Site Assessment
DPE: Dual Phase Extraction
DRO: Total Petroleum Hydrocarbons Diesel
Range Organics
DWM: Division of Waste Management
DWR: Department of Water Resources
EPA: Environmental Protection Agency
EPH: Extractible Petroleum Hydrocarbons
ESA: Environmental Site Assessment
GCL: Gross Contamination Level
GRI: Geological Resources, Inc.
GRO: Total Petroleum Hydrocarbons
Gasoline Range Organics
LSA: Limited Site Assessment
MAC: Maximum Allowable Concentration as
specified in T15A NCAC 2L.0202
MADEP: Massachusetts Department of
Environmental Protection
MCC: Maximum Contaminant Concentrations
MMPE: Mobile Multi-Phase Extraction
NAPL: Non-Aqueous Phase Liquid, “Free
Product”
NCDEQ: North Carolina Department of
Environmental Quality
NCDOT: North Carolina Department of
Transportation
NFA: Notice of No Further Action
NORR: Notice of Regulatory Requirements
NOV: Notice of Violation
NPDES: National Pollutant Discharge
Elimination System
NRP: Notice of Residual Petroleum
O&M: Operation and Maintenance
PAHs: Polynuclear Aromatic Hydrocarbons
PCA: Pre-Construction Assessment
RAL: Regulatory Action Level
SCLs: Soil Cleanup Level
SPCC: Spill Prevention Control and
Countermeasures
SVE: Soil Vapor Extraction
SVOCs: Semi-Volatile Organic Compounds
SWAP: Source Water Assessment and
Protection
SWPPP: Stormwater Pollution Prevention Plan
TCLP: Toxicity Characteristic Leaching
Procedure (EPA Method SW-846 1311)
TOC: Top of Casing
TPH: Total Petroleum Hydrocarbons
USGS: United States Geological Survey
UST: Underground Storage Tank
UVF: Ultraviolet Fluorescence
VOCs: Volatile Organic Compounds
VPH: Volatile Petroleum Hydrocarbons

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Regular UST Product Line Closure Report
Prepared on: December 27, 2022 Cedar Creek Food Mart
Project Manager: Scott Driscoll GRI Project No. 6126

TABLE OF CONTENTS

SITE INFORMATION ............................................................................................................................ i
EXECUTIVE SUMMARY ....................................................................................................................... ii
ACRONYMS ....................................................................................................................................... iii
A. SITE HISTORY AND CHARACTERIZATION ......................................................................................1
B. UST LINE CLOSURE PROCEDURE ..................................................................................................2
C. SITE INVESTIGATION ...................................................................................................................2
D. SUMMARY AND CONCLUSIONS ...................................................................................................3
E. LIMITATIONS ..............................................................................................................................3

FIGURES

Figure 1: Site Location Map
Figure 2: Site Map
Figure 3: Soil Sample Location Map

TABLES

Table 1: UST Owner/Operator Information
Table 2: UST System Information
Table 3: Summary of Soil Sample Analytical Results

APPENDICES

Appendix A: NCDEQ Registered Tank Report
Appendix B: Boring Logs
Appendix C: Site Specific Health and Safety Plan
Appendix D: Mobile Laboratory Report – Soil Samples

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Regular UST Product Line Closure Report
Prepared on: December 27, 2022 Cedar Creek Food Mart
Project Manager: Scott Driscoll GRI Project No. 6126
1
A. SITE HISTORY AND CHARACTERIZATION
1. UST Owner and Operator Information:
UST owner and operator information has been summarized in Table 1.

2. UST System Information:
UST system information has been summarized in Table 2. There are one 12,000-gallon gasoline, one
8,000-gallon gasoline, one 10,000-gallon diesel and one 2,000-gallon kerosene USTs, associated product
line and dispensers located at the site. According to a recent UST inspection performed by NCDEQ
personnel on April 28, 2022, the kerosene UST system is in temporary closure. A copy of the NCDEQ
Registered Tank Report is shown below and included in Appendix A.

A release at the site was confirmed on June 16, 2022, upon receipt of mobile UVF laboratory results for a
soil sample collected during spill bucket replacement activities. An unknown amount of petroleum
product was released from the UST System via non-passing UST spill buckets. The Site Check report dated
July 26, 2022, was submitted to satisfy the site check requirement for the spill bucket replacement
assessment. On July 27, 2022, NCDEQ issued a NORR for the completion of an LSA. Currently, authorization
to proceed with the LSA activities is pending.

3. Non-UST Information:
No known AST is located at the site.

4. Comprehensive Description of the Release:
On April 28, 2022, NCDEQ conducted a compliance inspection at the site. Results of the inspection noted
a deficiency with the spill containment bucket associated with the 8,000-gallon premium gasoline UST.

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Regular UST Product Line Closure Report
Prepared on: December 27, 2022 Cedar Creek Food Mart
Project Manager: Scott Driscoll GRI Project No. 6126
2
The compliance inspection also noted a portion of the regular gasoline product line had delaminated. An
NOV was issued for the deficiencies to Jai Shree Sai, Inc. which instructed them to replace the regular
product line and a perform a site check for the deficiency noted at the premium spill containment bucket.

5. Description of the Site Characteristics:
The Cedar Creek Food Mart site is located at 3209 Cedar Creek Road in Fayetteville, Cumberland County,
North Carolina (Figure 1). The property operates as a petroleum retail facility and convenience store. The
site is covered by asphalt, concrete and grass. Two gasoline, one diesel and one kerosene USTs, associated
product lines and dispensers are located at the site. The surrounding properties are mainly used for
commercial, residential, and agricultural purposes. A Site Map has been included as Figure 2.

B. UST LINE CLOSURE PROCEDURE
1. Summary of Closure Procedure:
On September 7, 2022, GRI supervised the collection of four soil samples (PP-1-4’ through PP-4-4’)
beneath the delaminated regular product line to satisfy the closure requirement for the product line. The
work was performed while the UST installation contractor, Piedmont Pump & Tank, LLC was removing and
replacing the product line from the regular submersible turbine pump to a transition sump located in the
vicinity of the dispensers. The samples were submitted for UVF analyses of TPH-GRO range petroleum
hydrocarbons. The location of the soil samples collected are shown on Figure 3. Soil boring logs are
included in Appendix B. No soil excavation activities were conducted by GRI. A copy of the Site Health
and Safety Plan is included as Appendix C.

C. SITE INVESTIGATION
1. Field Screening:
The soil samples collected during the September 2022 line closure sampling were not screened with a PID
prior to UVF analyses.

2. Soil Sampling Information:
No concentrations of TPH-GRO that exceeded the RALs were reported in the soil samples collected. A
summary of soil sample analytical results is presented in Table 3. The UVF laboratory report is provided
as Appendix D. A summary of the UVF analyses from the soil sampling conducted during the product line
closure and replacement is summarized below:

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Regular UST Product Line Closure Report
Prepared on: December 27, 2022 Cedar Creek Food Mart
Project Manager: Scott Driscoll GRI Project No. 6126
3 Sample ID Sample Depth (ft-BGS) TPH GRO TPH DRO RAL (mg/kg) 50 100
PP-1-4’ 4 <10 ---
PP-2-4’ 4 13 ---
PP-3-4’ 4 <10 ---
PP-4-4’ 4 <10 ---

3. Quality-Control Measures:
Clean, disposable nitrile gloves were used for the collection of the soil samples. The samples were
collected at a depth of 4 feet bgs from the open product line trench using a decontaminated hand auger
and placed in iced coolers prior to UVF analyses. Strict chain-of-custody procedures were followed.

D. SUMMARY AND CONCLUSIONS
 During the April 2022 NCDEQ UST compliance inspection, deficiencies were noted with the regular
gasoline product line and a UST spill containment bucket associated with the premium UST. An NOV
was issued for the deficiencies to Jai Shree Sai, Inc.
 A release (UST Incident #48519) at the site was confirmed on June 16, 2022, upon receipt of mobile
UVF laboratory results for a soil sample collected during spill bucket replacement activities. The Site
Check Report dated July 26, 2022, was submitted to satisfy the site check requirement.
 On September 7, 2022, GRI collected four soil samples (PP-1-4’ through PP-4-4’) beneath the
delaminated regular product line to satisfy the closure requirements for the product line.
 UVF analytical results of the samples collected beneath the UST product line revealed no TPH
concentrations above the RALs. Based on this information, soil quality violations relating to the
delaminated product line do not exist at the site.
 In response to the July 26, 2022, Site Check Report submitted for the spill bucket replacement
assessment, NCDEQ issued a Notice of Regulatory Requirements dated July 27, 2022, for the
completion of a Limited Site Assessment for the site. Currently, authorization to proceed with the
Limited Site Assessment is pending.

E. LIMITATIONS
This report has been prepared for the exclusive use of Jai Shree Sai, Inc. for the specific application to the
referenced site in Cumberland County, North Carolina. The assessment was conducted based on the
scope of work and level of effort specified by NCDEQ and with resources adequate only for that scope of
work. Our findings have been developed in accordance with generally accepted standards of geology and
hydrogeology practices in the State of North Carolina, available information, and our professional
judgment. No other warranty is expressed or implied.

___________________________________________________________________________________________
Prepared by: Geological Resources, Inc. Regular UST Product Line Closure Report
Prepared on: December 27, 2022 Cedar Creek Food Mart
Project Manager: Scott Driscoll GRI Project No. 6126
4

The data that are presented in this report are indicative of conditions that existed at the precise locations
sampled and at the time the samples were collected. In addition, the data obtained from samples would
be interpreted as being meaningful with respect to parameters indicated in the laboratory report. No
additional information can logically be inferred from these data.

FIGURES
SITE LOCATIONFigure 1 Site Location Cedar Creek Food Mart3209 Cedar Creek RoadFayetteville, North CarolinaCumberland CountyIncident No. N/AGRI Project No. 6126500 M2000 FTDate: 06/18/2022Location: 34.988364° N -78.788226° W Dad

TABLES
UST ID Number 1-4 Facility ID Number
Owner or Operator?
Owner
UST ID Number 1-4 Facility ID Number
Owner or Operator?
Owner
UST ID Number 1-4 Facility ID Number
Owner or Operator?
Owner
UST ID Number 1-4 Facility ID Number
Owner or Operator?
Owner
Address Telephone Number
3209 Cedar Creek Road, Fayetteville, NC 28312-7956 [phone]
00-0-0000036220
Name of Owner or Operator Dates of Ownership / Operation
Jay Ganesh, Inc.05/19/2009 - 05/28/2013
TABLE 1
UST OWNER/OPERATOR INFORMATION
CEDAR CREEK FOOD MART (INCIDENT NO. 48519)
Address Telephone Number
3902 Cedar Creek Road, Fayetteville, NC 28312-7956 [phone]
00-0-0000036220
Name of Owner or Operator Dates of Ownership / Operation
JAI SHREE SAI, INC.05/28/2013 - Current
00-0-0000036220
Name of Owner or Operator Dates of Ownership / Operation
Shivraj (Raj) Kumar Bansal 05/06/2008 - 05/19/2009
Address Telephone Number
Unknown Unknown
00-0-0000036220
Unknown Unknown
Name of Owner or Operator Dates of Ownership / Operation
K & R King, Inc.09/13/2000 - 05/06/2008
Address Telephone Number
Page 1 of 1
Date: 06/16/22
Was Release
Associated
with UST
System?
(Yes / No)
1 Gasoline 12,000 09/13/2000 SW FRP Unknown Pressurized/DW
Flex Current No
2 Gasoline 8,000 09/13/2000 SW FRP Unknown Pressurized/DW
Flex Current Yes
3 Diesel 10,000 09/13/2000 SW FRP Unknown Pressurized/DW
Flex Current No
4 Kerosene 2,000 09/13/2000 SW FRP Unknown Suction - E Temporary
Closure No
TABLE 2
UST SYSTEM INFORMATION
CEDAR CREEK FOOD MART (INCIDENT NO. 48519)
UST
ID
No.
Current
or Most
Recent
Contents
Capacity
(gallons)
Date
Installed
Construction
Details
Tank
Dimensions
Description of
Associated
Product Piping
and
Pumps
Status
of
UST
Facility ID #: 00-0-0000036220
Page 1 of 1
Date: 12/14/2022
Sample IDDate Collected (mm/dd/yy)Sample Depth(ft-BGS)GRO Range TPHDRO Range TPH50 100
PP-1-4'09/07/22 4 <10 ---
PP-2-4'09/07/22 4 13 ---
PP-3-4'09/07/22 4 <10 ---
PP-4-4'09/07/22 4 <10 ---
Notes:
• Results reported in mg/kg (milligrams per kilograms)
• ft-BGS: feet below ground surface.
• RAL: Regulatory Action Level.
• NE: Not Established
• < : Less than the method detection limit specified in the
laboratory report
• Concentrations in bold face type indicate the reported
concentration exceeded the RAL
TABLE 3
SUMMARY OF SOIL SAMPLE ANALYTICAL RESULTS
CEDAR CREEK FOOD MART (INCIDENT NO. 48519)
Facility ID #: 00-0-0000036220
RAL (mg/kg)
Analytical Method UVF
Page 1 of 1

APPENDICES

Appendix A
NCDEQ Registered Tank Report

NCDEQ Registered Tank Report
Facility Id 00-0-0000036220
Facility Name JAI SHREE SAI, INC
Address 3209 CEDAR CREEK ROAD
City FAYETTEVILLE State NC
Zip 28312-7956County Cumberland
Latitude 34.98860Longitude-78.78836
Tank Owner JAI SHREE SAI, INC
Address 3209 CEDAR CREEK ROAD
City FAYETTEVILLE
State NC Zip 28312-7956
Tank Information
Tank Id Product Name Capacity Installation Date Perm Close Date Tank Construction Piping Construction OverFill Protection Spill Protection Tank Status
4 Kerosene, Kero Mix 2000 9/13/2000 Double Wall FRP Other Ball Float Valve Catchment Basin Current
3 Diesel 10000 9/13/2000 Double Wall FRP Other Ball Float Valve Catchment Basin Current
2 Gasoline, Gas Mix 8000 9/13/2000 Double Wall FRP Other Ball Float Valve Catchment Basin Current
1 Gasoline, Gas Mix 12000 9/13/2000 Double Wall FRP Other Ball Float Valve Catchment Basin Current
Tuesday, June 21, 2022 Page 1 of 1

Appendix B
Boring Logs

Geological Resources, Inc.Phone:[phone]
3502 Hayes Road Fax:[phone]
Monroe, NC 28110
SUBSURFACE LOG
Project Cedar Creek Food Mart
Address 3209 Cedar Creek Rd. Fayetteville, NC
Boring Number PP-1-4'Date Drilled
Sample Method Grab Drilling Method Hand Auger
Completion Details boring terminated at 4' bgs
Driller Kyle Perry; 4534-C Log By Kyle Perry
Lab Sample GRO
Depth Sample Interval(ft)mg/Kg LITHOLOGY
0
2
4 4 <10
6
8
10
09/07/22
0.0' - 3.0' pea gravel
boring terminated; sample collected
3.0' - 4.0' dark brown sandy SILT
Geological Resources, Inc.Phone:[phone]
3502 Hayes Road Fax:[phone]
Monroe, NC 28110
SUBSURFACE LOG
Project Cedar Creek Food Mart
Address 3209 Cedar Creek Rd. Fayetteville, NC
Boring Number PP-2-4'Date Drilled
Sample Method Grab Drilling Method Hand Auger
Completion Details boring terminated at 4' bgs
Driller Kyle Perry; 4534-C Log By Kyle Perry
Lab Sample GRO
Depth Sample Interval(ft)mg/Kg LITHOLOGY
0
2
4 4 13.0
6
8
10
3.0' - 4.0' dark brown sandy SILT
09/07/22
0.0' - 3.0' pea gravel
boring terminated; sample collected
Geological Resources, Inc.Phone:[phone]
3502 Hayes Road Fax:[phone]
Monroe, NC 28110
SUBSURFACE LOG
Project Cedar Creek Food Mart
Address 3209 Cedar Creek Rd. Fayetteville, NC
Boring Number PP-3-4'Date Drilled
Sample Method Grab Drilling Method Hand Auger
Completion Details boring terminated at 4' bgs
Driller Kyle Perry; 4534-C Log By Kyle Perry
Lab Sample GRO
Depth Sample Interval(ft)mg/Kg LITHOLOGY
0
2
4 4 <10
6
8
10
3.0' - 4.0' dark brown sandy SILT
09/07/22
0.0' - 3.0' pea gravel
boring terminated; sample collected
Geological Resources, Inc.Phone:[phone]
3502 Hayes Road Fax:[phone]
Monroe, NC 28110
SUBSURFACE LOG
Project Cedar Creek Food Mart
Address 3209 Cedar Creek Rd. Fayetteville, NC
Boring Number PP-4-4'Date Drilled
Sample Method Grab Drilling Method Hand Auger
Completion Details boring terminated at 4' bgs
Driller Kyle Perry; 4534-C Log By Kyle Perry
Lab Sample GRO
Depth Sample Interval(ft)mg/Kg LITHOLOGY
0
2
4 4 <10
6
8
10
3.0' - 4.0' dark brown sandy SILT
09/07/22
0.0' - 3.0' pea gravel
boring terminated; sample collected

Appendix C
Site Specific Health and Safety Plan

1
GEOLOGICAL RESOURCES, INC.
Site Specific Health and Safety Plan

1.0 General Information:
a. Project name: Cedar Creek Food Mart
b. Location: 3209 Cedar Creek Rd. Fayetteville, NC 28312
c. GRI Job #: 6126

2.0 Project Organization:
a. Site Supervisor/H&S Officer: Scott Driscoll
b. Project Manager: Scott Driscoll
c. Subcontractor(s):

3.0 Safety Plan Preparation:
a. Prepared by & date: 09/05/2022
b. Reviewed/approved by & date:

4.0 Site History and Description:
a. Type of site (i.e., spill, leaking UST system, etc.): Deficient UST components
b. Site/project description: UST line closure

5.0 Potential Hazards:
Physical Hazards: (check)
X Slips Overhead Explosion X Sun burn Electricity
X Trips utilities X Noise Cold Weather Pressurized line/vessels
X Falls X Underground Pinch points X Hot Weather
Fire utilities Burns Crush

Chemical Hazards: (check)
X Gasoline Used Oil
X Diesel Solvents
Kerosene Antifreeze
New Oil Acid (sample preservative)

Equipment/Vehicular/Other: (i.e., Geoprobe, drill rig, back hoe, track hoe, traffic, skid steer etc.)

Biological Hazards: (i.e., toxic insects, spiders, poisonous plants, poisonous snakes, aggressive dogs)
NA

2
6.0 Site Organization and Safety Control: (Evaluate the need for site control to protect
persons from exposure to hazardous conditions; i.e. work permits, cones, barricade tape,
exclusion zones, etc.)
a. Work area(s) identified: ____________________________________________________
b. Work area marked _____ Yes_____ No
c. Work area barricaded _____ Yes _____ No
d. Support area established: __________________________________________________
e. Entry and escape routes identified: ___________________________________________
f. Rally point identified: _____ Yes _____ No Location:____________________________
g. Emergency shut-off for water identified _____ Yes _____ No
h. Emergency fuel shut-off identified _____ Yes _____ No
i. Site map attached: _____ Yes _____ No
**Emergency Response Procedures**
Action (i.e. shut off all power equipment) Assemble at rally point
Call 911 for medical or utilities emergency Do NOT enter confined spaces
Discuss what to do if …..cut product line, water line, cable/electric line

7.0 Job Activities in Work Plan:
UST Removal X Soil Sampling Manual FP Recovery
Soil Excavation System O&M Other (specify)
Powered Drilling MMPE/AFVR __________________
X Hand Augering Water sampling __________________

8.0 Required Education and/or Training:
X OSHA 40 hr X Annual 8 hr Refresher OSHA Site Supervisor

9.0 Air Monitoring:
If, in the opinion of the site supervisor, petroleum hydrocarbon vapor concentrations are
excessive, site activities will cease until petroleum hydrocarbon vapor concentrations diminish to
acceptable levels.

10.0 Equipment:
FID/PID Combustible gas indicator Interface Probe
O2 meter X Other Hand Auger/PPE

11.0 Personnel Protection Equipment:
X Hard hat Rubber boots Respirator Hearing
X Safety glasses X Work gloves Sun screen protection
X Steel toe boots X First aid kit Repellent X Nitrile
Tyvek suit X Fire extinguisher Dust mask gloves

12.0 Decontamination Procedures: (evaluate need for decon, describe procedures)

Alconox/DI Water Rinse

3
13.0 Emergency Contacts:
a. Local Assistance:
Site Phone Fire Department 911
Police 911 Ambulance 911
Water Department Sanitary Sewer
Natural Gas Power Company

Nearest Hospital with Emergency Room (directions attached)
Name Cape Fear Valley
Health System

Address 1638 Owen Dr.
Fayetteville, NC

Number 910-609-4000

b. National or Regional Sources of Assistance:
1) Geological Resources, Inc. [phone]
2) Chemtrec (24 Hours) [phone]
3) Bureau of Explosives (24 Hours) [phone]
4) National Response Center, NRC [phone]
(Oil/Hazardous Substances)
5) DOT, Off. Of Haz. Operations [phone]

14.0 Signatures:

This plan has been reviewed by all on-site personnel and all provisions are clear (signatures
required).

Project Manager:
Site Supervisor:
Other personnel:

4
15.0 Amendments:

a. Site Specific Health and Safety Plans are based on information available at the time of
plan preparation. Unexpected conditions may arise. It is important that personal
protective measures be thoroughly assessed prior to and during the planned activities.
Unplanned activities and/or changes in the hazard status should initiate a review of this
plan and may result in major changes to it.
b. Changes in the hazard status or unplanned activities are to be submitted on “Amendment
to the Site Specific Health and Safety Plan” which is included bellow.
c. Amendment must be approved by the Project Manager prior to implementation of the
amendment.

AMENDMENT TO THE SITE SPECIFIC HEALTH AND SAFETY PLAN

A. Changes in field activities or hazards:
NA

B. Proposed amendment:

C. Approval:

Proposed by: ___________________________________date ______________________

Approved by: ___________________________________date _____________________

Amendment number: ____________________________

Amendment effective date: _______________________

Appendix D
Mobile Laboratory Report – Soil Samples

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
Engineering Certification: C-2727 • Geology Certification: C-127
UVF Trilogy Analytical Report

Samples Collected: September 8, 2022
Samples Analyzed: September 8, 2022
Site Name: Cedar Creek Food Mart
Site Address: 3209 Cedar Creek Road, Fayetteville, NC
GRI Project Number: 6126

September 9, 2022

Xavier T. Farmer, GIT
Operator

Technical Procedures
Sample Collection and Handling
Soil samples may be collected using any acceptable procedure. Sampler must use a clean pair of nitrile
gloves for each sample collected. The sample will be placed in a clean, sealable bag (ziplock). Once
collected, the sample must be analyzed immediately or placed on ice. The sample may be kept on ice for
up to 48 hours prior to UVF analyses. If the sample cannot be analyzed within 48 hours, the sample may
be extracted and kept at 4 degrees C for up to 14 days. Proper chain-of-custody procedures must be
followed.
Calibration
The UFV Trilogy has standard calibrations stored for the following analysis:
 GRO
 DRO
 Total PAH
 Target PAH
 Heavy PAH
Prior to use, calibration standards are used to perform a 5-point verification on the factory stored
calibrations for GRO and DRO. The calibration standards used are as follows:
GRO
 0.5 ppm
 1 ppm
 3 ppm
 5 ppm
 10 ppm
DRO
 0.1 ppm
 0.5 ppm
 1 ppm
 3 ppm
 5 ppm
Operation
Sample Extraction
 5mg of soil are weighed into a clean extraction jar
 Methanol is added to the extraction jar to create a 2x or 4x dilution
o 2x Dilution: 10 mL of methanol
o 4x Dilution: 20 mL of methanol
 The extraction jar is shaken for several minutes to thoroughly mix the soil with solvent
(methanol)
 The mixture is allowed to settle for several minutes
 A clean syringe is used to draw liquid from the extraction jar
 A clean filter is attached to the end of the syringe and the liquid dispensed through the filter
into a clean test tube
 This liquid is referred to as the extraction
Dilution Preparation
 An adjustable micropipette is used to precisely measure out the amount of extract needed for
the dilution
Technical Procedures
 The measured out amount of the extract is added to a clean test tube and methanol is added
dilute the extract. Examples of dilutions are shown below:

Extract Amount
500 μL
200 μL
100 μL
50 μL
25 μL

Add Solvent to the
5 mL line
5 mL line
5 mL line
5 mL line
5 mL line
2x Extract
Dilution Factor
20x
50x
100x
200x
400x
4x Extract
Dilution Factor
40x
100x
200x
400x
800x

Sample Analyzation
 The dilution is shaken to thoroughly mix, then poured into a clean glass cuvette
 The desired module is inserted into the UVF Trilogy and the corresponding factory calibration is
selected
 “Measure Fluorescence” is pressed on the touchscreen and the reading is recorded
 The reading should be between the concentrations of the calibration standards (GRO: 0.5-10
ppm; DRO 0.1-5 ppm)
o Reading below the calibration standard range are recorded as below the detection limit
 Detection Limit = (lower range of calibration standards range) x dilution factor
(i.e. a GRO sample with a 100x dilution factor has a detection limit of 50 ppm)
o Readings above the calibration standard range should be further diluted and reanalyzed
o Negative readings are an indication of quenching (see below)
 The reading is multiplied by the dilution factor to calculate the final concentration
 Check suspected contaminated samples for quenching by running additional dilutions
o According to the siteLAB Quick Reference Guide:
“Quenching” can occur when the detector is swamped by too many hydrocarbons or
organic interferences, producing low or negative concentrations. Test the sample at
multiple dilutions to confirm results are linear and accurate.”
QA/QC
Calibration
 The UFV Trilogy will be calibrated daily prior to use
 The calibration results will be saved and entered into the calibration log
Method Blank
 A method blank of methanol will be analyzed following calibration and following the last sample
analyzed for each site
Duplicates
 One duplicate will be analyzed for every 20 samples
 The duplicate will be prepared from the extract of the sample and diluted to the same factor as
the sample analyzed
Project Name:Date Collected:
Project Number:Date Analysed:
Project Manager:Operator:
Sample ID Matrix Dilution
Factor x
GRO
Output
(ppm)
=GRO Value
(mg/Kg)
Dilution
Factor x
DRO
Output
(ppm)
=DRO Value
(mg/Kg)
PP-1-4'Soil 20 <0.5 <10 <0
PP-2-4'Soil 20 0.65 13 <0
PP-3-4'Soil 20 <0.5 <10 <0
PP-4-4'Soil 20 <0.5 <10 <0
DUP-A Soil 20 <0.5 <10 <0
UVF Analytical Report
siteLAB UVF Trilogy
9/8/2022
9/8/2022
Xavier T. Farmer, G.I.T.
Cedar Creek Food Mart
6126
Scott Driscoll
Report Date:
9/9/2022
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