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Home My WebLink AboutWS-29519_48706_CA_UST-61_20061006UST-61 For Releases in NC Incident # __________Risk (H,I,L,U) __________ Received On _________Received By ___________ Region _______________ Incident Name: Address: City/Town:Zip Code:27006 Latitude (decimal degrees): Location (Check one) Confirmed Soil Contamination ?(Y/N) ___Y__ 24-Hour Release and UST Leak Reporting Form. This form should be completed and submitted to the UST Section’s regional office following a known or suspected release froman underground storage tank (UST) system. This form is required to be submitted within 24 hours of discovery of a known or suspected release. (DWM USE ONLY)Suspected Contamination? (Y/N) _____Facility ID Number ___________________ Confirmed GW Contamination? (Y/N) N W 79.476981 Obtained by: Reported by (circle one): Phone, Fax or Report Free Product? (Y/N) ______ Date Leak Discovered ___10/5/22______ INCIDENT DESCRIPTION Roy's Country Store Groundwater Contamination Surface Water Contamination Other (specify) Comm/Non-Commercial? ____Comm__ Describe location: N 36.014373 Longitude (decimal degrees) : If Yes, State Greatest Reg/Non-regulated?__Reg______ Thickness ______ Type of Release Product Type Released (Check One) 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)GPS Topographic map GIS Address matching X Other Unknown Soil contamination discovered during UST closure beneath fuel lines near junction with USTs HOW RELEASE WAS DISCOVERED (ReleaseCode) (Ptype) (Check one)(Check one to indicate primary source) 1027 NC Highway 801 County: Davie Advance Regional Office (circle one): Asheville, Mooresville, Fayetteville, Raleigh, Washington, Wilmington, Winston-Salem SOURCE OF CONTAMINATION Source of Release Cause of Release (Check one to indicate primary cause) (Check one to indicate primary product type released) Spill Overfill Corrosion Physical or Mechanical Damage Install Problem Other X Unknown X Petroleum Non-Petroleum Both Release Detection Equipment or Methods X During UST Closure/Removal Property Transfer X Visual/Odor Water in Tank Water Supply Well Contamination X Gasoline/Diesel/Kerosene Heating Oil Other Petroleum Products Metals Other Inorganics Other Organics (Source of Release)(Cause)(Type) 1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. Commercial 7. Mining X Facility Residence Other Definitions presented on reverse Definitions presented on reverse Ownership Tank X Piping Dispenser Submersible Turbine Pump Delivery Problem Other Unknown 1. Municipal 2. Military 3. Unknown 4. Private 5. Federal 6. County 7. State Operation Type State Telephone Number NC 336-722-3441 State Telephone Number NC 336-722-3441 State Telephone Number NC 336-722-3441 Person Reporting Incident: J. Ballsieper Title: Director of Env. Serv.Date:10/6/2022 IMPACT ON DRINKING WATER SUPPLIES Water Supply Wells Affected? 1. Yes______ 2. No 3. Unknown___X____ Number of Water Supply Wells Affected _________________ Water Supply Wells Contaminated: (Include Users Names, Addresses and Phone Numbers. Attach additional sheet if necessary) Mr. Don McIver 1540 Silas Creek Parkway 1. 2. 3. UST SYSTEM OWNER UST Owner/Company Quality Oil Company, LLC Point of Contact Address Quality Oil Company, LLC 1540 Silas Creek Parkway City Zip Code Winston-Salem 27127 UST SYSTEM OPERATOR Landowner Address Winston-Salem 27127 1540 Silas Creek Parkway LANDOWNER AT LOCATION OF UST INCIDENT UST Operator/Company Address Quality Oil Company, LLC City Zip Code City Zip Code Address: P.O. Box 5884, Winston-Salem, NC 27113 Draw Sketch of Area (showing two major road intersections) or Attach Map SEE ATTACHED FIGURE Company Progress Environmental Group, Inc. Telephone Number: 336-722-9999 Winston-Salem 27127 REV 0 DRAWING TITLE DRAWING NUMBER FIGURE 2 LEGEND Soil Sample Location fromPerimeter of Over-Excavation Site MapRoy's Convenience Store1027 NC Highway 801Advance, North Carolina DR.: JAB OCT 2022 CK.: JSL APP'D.: SCALE: SHOWNSoil Sample Location from Beneath UST Components www.progressenvironmental.com P.O. Box 5884 Winston-Salem, North Carolina 27113(336) 722-9999 Progress Environmental Group, Inc. N-1 T-1-1 Kerosene AST T-1-1 T-2-1 T-1-3 T-2-2 T-2-1 T-2-3 T-3-2 T-3-1 T-3-3 T-4-1 T-4-2 D-1 D-2 L-1 L-2 L-3 L-4 UST REmoval Excavation W-1 N-1E-1 S-1 B-1 Over-Excavation of Contaminated Soil Hydrocarbon Analysis Results Client:PROGRESS ENVIRONMENTAL Samples taken Thursday, October 6, 2022 Address:Samples extracted Thursday, October 6, 2022 Samples analysed Thursday, October 6, 2022 Contact:JEFF BALLSIEPER Operator MAX MOYER Project:1027 NC HIGHWAY 801 ; TRUST FUND 23 H09382 Matrix Sample ID Dilution used BTEX (C6 - C9) GRO (C5 - C10) DRO (C10 - C35) TPH (C5 - C35) Total Aromatics (C10-C35) 16 EPA PAHs BaP HC Fingerprint Match % light % mid % heavy s SOUTH 2 1014 10.9 <0.27 <0.27 <0.27 <0.27 <0.05 <0.09 <0.011 0 0 0 ,(FCM) s N-1 1046 23.2 <0.58 <0.58 <0.58 <0.58 <0.12 <0.19 <0.023 0 0 100 Residual HC,(BO),(P) s E-1 1050 19.4 7 37.4 113.2 150.6 9.2 0.33 <0.019 98.4 1.5 0.2 Deg.Diesel 88.2%,(FCM) s W-1 1051 20.2 3.3 28.3 27.7 56 5.3 <0.16 <0.02 98.4 1.4 0.3 Deg.Diesel 87.8%,(FCM) s S-1 - TRUCK 5 1052 268.0 <6.7 346.3 <6.7 346.3 35.9 <2.1 <0.27 99.8 0.2 0 Deg.Gas 93%,(FCM) s B-1 1053 17.3 <0.43 52 134.4 186.4 8.8 0.34 <0.017 99.7 0.3 0 Deg.Kerosene 86.5%,(FCM) s B-2 1124 13.0 <0.32 12.6 65.8 78.4 3.6 0.14 <0.013 98.5 1.3 0.2 Deg.Kerosene 75%,(FCM) s E-2 1126 20.0 <0.5 <0.5 <0.5 <0.5 <0.1 <0.16 <0.02 0 0 0 PHC not detected s S-2 1138 19.5 <0.49 12.2 10.3 22.5 0.65 <0.16 <0.02 99.8 0.2 0 Deg.Diesel 58%,(FCM) Initial Calibrator QC check OK Final FCM QC Check OK 95.4 % Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone content Fingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library (SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate present Ratios Hydrocarbon Analysis Results Client:PROGRESS ENVIRONMENTAL Samples taken Wednesday, October 5, 2022 Address:Samples extracted Wednesday, October 5, 2022 Samples analysed Wednesday, October 5, 2022 Contact:JEFF BALLSIEPER Operator MAX MOYER Project:1027 NC HIGHWAY 801 ; TRUST FUND 9 H09382 Matrix Sample ID Dilution used BTEX (C6 - C9) GRO (C5 - C10) DRO (C10 - C35) TPH (C5 - C35) Total Aromatics (C10-C35) 16 EPA PAHs BaP HC Fingerprint Match % light % mid % heavy s T-2-1 0839 25.7 <0.64 <0.64 <0.64 <0.64 <0.13 <0.21 <0.026 0 0 0 Residual HC s T-2-2 0841 24.8 <0.62 <0.62 <0.62 <0.62 <0.12 <0.2 <0.025 0 0 0 PHC not detected,(P) s T-2-3 0843 22.4 <0.56 <0.56 <0.56 <0.56 <0.11 <0.18 <0.022 0 100 0 PHC not detected,(BO),(P) s T-1-1 0940 16.9 <0.42 9 1.1 10.1 0.35 <0.14 <0.017 98.2 0.8 1 Deg.Fuel 53%,(FCM),(BO),(P) s T-1-2 0944 20.5 <0.51 <0.51 <0.51 <0.51 <0.1 <0.16 <0.02 0 100 0 Residual HC,(BO) s T-1-3 0945 21.0 <0.52 <0.52 <0.52 <0.52 <0.1 <0.17 <0.021 0 0 0 PHC not detected,(P) s T-3-1 1016 18.7 <0.47 3.6 <0.47 3.6 <0.09 <0.15 <0.019 99.5 0 0.5 Deg.Gas,(FCM),(BO) s T-3-2 1018 17.7 <0.44 <0.44 <0.44 <0.44 <0.09 <0.14 <0.018 0 0 0 PHC not detected,(BO) s T-3-3 1020 22.6 5.4 <0.57 <0.57 <0.57 <0.11 <0.18 <0.023 100 0 0 PHC not detected,(P) Initial Calibrator QC check OK Final FCM QC Check OK 100.4 % Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone content Fingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library (SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate present Ratios Hydrocarbon Analysis Results Client:PROGRESS ENVIRONMENTAL Samples taken Thursday, October 6, 2022 Address:Samples extracted Thursday, October 6, 2022 Samples analysed Thursday, October 6, 2022 Contact:JEFF BALLSIEPER Operator MAX MOYER Project:1027 NC HIGHWAY 801 ; TRUST FUND 11 H09382 Matrix Sample ID Dilution used BTEX (C6 - C9) GRO (C5 - C10) DRO (C10 - C35) TPH (C5 - C35) Total Aromatics (C10-C35) 16 EPA PAHs BaP HC Fingerprint Match % light % mid % heavy s BASE - TRUCK 3 0824 26.0 12.5 55.2 67.4 122.6 3.1 <0.21 <0.026 99.7 0.1 0.1 Deg.Gas 84.7%,(FCM) s BOTTOM 0903 23.4 7.2 23.9 25.1 49 1.7 <0.19 <0.023 99.1 0.6 0.2 No Match found s NORTH 0925 21.8 <0.55 <0.55 <0.55 <0.55 <0.11 <0.17 <0.022 100 0 0 Residual HC s EAST 0927 20.0 <0.5 11.9 5.8 17.7 2.3 <0.16 <0.02 99.2 0.8 0 Deg Gas 85.8%,(FCM) s WEST 0928 114.0 <2.9 13.2 151.6 164.8 6.6 <0.91 <0.11 96.6 3.4 0 Deg.Kerosene 70.9%,(FCM) s SOUTH - TRUCK 4 0933 22.0 <0.55 120.5 289.6 410.1 19.6 0.73 <0.022 98.4 1.5 0.1 Undeg.Diesel 93.7%,(FCM) s WEST 2 1009 20.6 <0.52 5.2 3.7 8.9 1.4 <0.17 <0.021 98.5 1.3 0.3 Deg.Fuel 69.8%,(FCM),(P) Initial Calibrator QC check OK Final FCM QC Check OK 101.2 % Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone content Fingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library (SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate present Ratios Hydrocarbon Analysis Results Client:PROGRESS ENVIRONMENTAL Samples taken Wednesday, October 5, 2022 Address:Samples extracted Wednesday, October 5, 2022 Samples analysed Wednesday, October 5, 2022 Contact:JEFF BALLSIEPER Operator MAX MOYER Project:1027 NC HIGHWAY 801 ; TRUST FUND 8 H09382 Matrix Sample ID Dilution used BTEX (C6 - C9) GRO (C5 - C10) DRO (C10 - C35) TPH (C5 - C35) Total Aromatics (C10-C35) 16 EPA PAHs BaP HC Fingerprint Match % light % mid % heavy s MID EAST 1 1507 21.7 <0.54 2.7 <0.54 2.7 0.47 <0.17 <0.022 98.5 1.5 0 Deg.Gas 87.7%,(FCM) s BOTTOM ; TRUCK 2 1531 289.0 <7.2 325.8 38.6 364.4 10.8 <2.3 <0.29 99.9 0.1 0 Deg Gas 64.8%,(FCM) s WEST 1528 20.5 5.3 27.5 161.6 189.1 17.6 0.65 <0.02 93.7 6 0.4 Deg.Diesel 85.5%,(FCM) s EAST 1529 21.5 21.3 44.6 158.3 202.9 13.5 0.49 <0.021 97.8 2.1 0.2 Deg.Diesel 81.1%,(FCM) s NORTH 1530 18.2 <0.45 185.7 0.45 186.15 23.8 0.95 <0.018 99.2 0.6 0.1 Deg.Gas 91.5%,(FCM),(P) Initial Calibrator QC check OK Final FCM QC Check OK 99 % Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone content Fingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library (SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate present Ratios Hydrocarbon Analysis Results Client:PROGRESS ENVIRONMENTAL Samples taken Wednesday, October 5, 2022 Address:Samples extracted Wednesday, October 5, 2022 Samples analysed Wednesday, October 5, 2022 Contact:JEFF BALLSIEPER Operator MAX MOYER Project:1027 NC HIGHWAY 801 ; TRUST FUND 4 H09382 Matrix Sample ID Dilution used BTEX (C6 - C9) GRO (C5 - C10) DRO (C10 - C35) TPH (C5 - C35) Total Aromatics (C10-C35) 16 EPA PAHs BaP HC Fingerprint Match % light % mid % heavy s L-3 1238 23.4 <0.59 1.7 <0.59 1.7 <0.12 <0.19 <0.023 100 0 0 Deg.Gas,(FCM) s L-4 1239 21.0 <0.52 <0.52 <0.52 <0.52 <0.1 <0.17 <0.021 0 0 0 PHC not detected s L-1 1248 2898.0 1702 10657 3302 13959 1087 39 <2.9 99.4 0.6 0 Deg Gas 89.3%,(FCM),(PFM) s TRUCK 1 1436 273.0 <6.8 30 394.9 424.9 105.4 3.8 <0.27 78.2 20.6 1.3 Deg.Diesel 83.9%,(FCM) Initial Calibrator QC check OK Final FCM QC Check OK 100.4 % Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone content Fingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library (SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate present Ratios Hydrocarbon Analysis Results Client:PROGRESS ENVIRONMENTAL Samples taken Wednesday, October 5, 2022 Address:Samples extracted Wednesday, October 5, 2022 Samples analysed Wednesday, October 5, 2022 Contact:JEFF BALLSIEPER Operator MAX MOYER Project:1027 NC HIGHWAY 801 ; TRUST FUND 14 H09382 Matrix Sample ID Dilution used BTEX (C6 - C9) GRO (C5 - C10) DRO (C10 - C35) TPH (C5 - C35) Total Aromatics (C10-C35) 16 EPA PAHs BaP HC Fingerprint Match % light % mid % heavy s T-4-1 1028 17.1 <0.43 <0.43 <0.43 <0.43 <0.09 <0.14 <0.017 0 0 0 PHC not detected,(P) s T-4-2 1030 24.5 <0.61 <0.61 <0.61 <0.61 <0.12 <0.2 <0.025 0 0 0 PHC not detected,(P) s D-1 1215 22.0 <0.55 <0.55 <0.55 <0.55 <0.11 <0.18 <0.022 0 0 0 PHC not detected s D-2 1217 20.0 <0.5 <0.5 <0.5 <0.5 <0.1 <0.16 <0.02 0 0 0 PHC not detected s L-2 1218 23.2 <0.58 <0.58 <0.58 <0.58 <0.12 <0.19 <0.023 0 0 0 PHC not detected,(P) Initial Calibrator QC check OK Final FCM QC Check OK 106.9 % Results generated by a QED HC-1 analyser. Concentration values in mg/kg for soil samples and mg/L for water samples. Soil values are not corrected for moisture or stone content Fingerprints provide a tentative hydrocarbon identification. The abbreviations are:- FCM = Results calculated using Fundamental Calibration Mode : % = confidence for sample fingerprint match to library (SBS) or (LBS) = Site Specific or Library Background Subtraction applied to result : (PFM) = Poor Fingerprint Match : (T) = Turbid : (P) = Particulate present Ratios