MO-29269_48436_CA_UST-61_20211105_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? (YIN) Y
Facility ID Number NA
Incident# Risk (H,I,L,U)
Confirmed GW Contamination? (YIN)N
Date Leak Discovered 11/2/2021
Received On Received By
Confirmed Soil Contamination ?(YIN) Y
Comm/Non-Commercial? Non -Comm
Reported by (circle one): Phone, Fax or Report
Samples Taken?(YIN) Y
Reg/Non-regulated? Non -Reg.
Region
Free Product? (YIN) N If Yes, State Greatest
Thickness
INCIDENT DESCRIPTION
Incident Name: 15901 Cramur Road
Address: 15901 Cramur Road
County: Mecklenburg
Regional Office (circle one): AshevilleVooresvilb Fayetteville,
City/Town: Huntersville
Zip Code:28078
Raleigh, Washington, Wilmington, Winsto - aem
Latitude (decimal degrees): 35.428333 N Longitude (decimal degrees) : 80.913889 W
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
Mother
❑unknown
Describe location:
Soil assessment activities were conducted at the site in October, 2021 in the area of two out -of -service
heating oil USTs located at the site. Concentrations of TPH DRO & GRO that exceeded the RALs were
reported in samples collected. The USTs were removed from the site on 111212021. Concentrations of
TPH DRO & GRO that exceeded RALs were reported in the samples collected from excavated soils and
from the walls and base of one of the UST basins. Ground Water was not encountered.
HOW RELEASE WAS DISCOVERED (Release code)
(Check one)
❑ Release Detection Equipment or Methods ❑Visual/Odor ❑Groundwater Contamination
❑ During UST Closure/Removal ❑Water in Tank ❑Surface Water Contamination
X❑ 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 M Petroleum ❑ Gasoline/ Diesel/ ❑ Diesel/Veg. Oil
❑ Piping ❑ Overfill ❑ Non -Petroleum Kerosene Blend
❑X El Dispenser Corrosion Both Heating Oil ❑ Vegetable Oil 100%
❑X ❑
❑ Other Petroleum ❑ E10 — E20
❑ Submersible Turbine Pump ❑ Physical/Mechanical
Location Products
El Delivery Problem Damage (Check one) ❑ E21 — E84
❑ Metals
❑ Install Problem ❑ E85 — E99
❑ Spill Bucket ❑ Other Inorganics
❑ Other X❑Facility ❑Ethanol 100%
❑ Other ❑ Other Organics
El unknown ❑Residence ❑ E01 — E09
❑ Unknown
[:]Other
Definitions presented on reverse
Definitions presented on reverse
Ownership
1. Municipal 2. Military 3. Unknown 4. 40D5. Federal 6. County 7. State
Operation Type
1. Public Service 2. Agricultural 3. Residential 4. Education/Relig. 5. Industrial 6. ommercia 7. Mining
UST Form 61 (02/19) Page 1 of 2

IMPACT ON DRINKING WATER SUPPLIES
Water Supply Wells Affected? 1. Yes
2. No 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 Shirley Keistler
Point of Contact
Address
Shirley Keistler
15905 Cramur Dr.
City Huntersville
State NC
Zip Code
Telephone Number
28078
Unknown
UST SYSTEM OPERATOR
UST Operator/Company
Shirley Keistler
Address
15905 Cramur Dr.
City Huntersville
State NC
Zip Code 28078
Telephone Number
Unknown
LANDOWNER AT LOCATION OF UST INCIDENT
Landowner Shirley Keistler
Address 15905 Cramur Dr.
City
Huntersville
State NC
Zip Code
28078
Telephone Number
Unknown
Draw Sketch of Area (showing two major road intersections) or Attach Map
See attached Maps
Person Reporting Incident Scott Ball
CompanyGeological Resources, Inc.
Telephone Number [phone]
Title Project Manager
Address 3502 Hayes Rd., Monroe, NC 28110
Date 11/5/2021
UST Form 61 (02119)
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 (mown 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

MECKLENBURG COUNTY, North Carolina
POLARIS 3G PARCEL OWNERSHIP AND GIS SUMMARY
Date Printed
Identity
Parcel ID GIS ID
00102370 100102370
Property Characteristics
Legal desc
L1 M69-10
Land Area
1.29 AC
Fire District
HUNTERSVILLE
Special District
FIRE SERVICE D
Account Type
INDIVIDUAL
Municipality
HUNTERSVILLE
Zoning
Contact appropriate Planning Department or see Map.
Water Quality Buffer
Parcel Inside Water Quality Buffer I No
FEMA and Community Floodplain
FEMA Panel#
3710462100J
FEMA Panel Date
03/02/2009
FEMA Flood Zone
OUT:VIEW FEMA FLOODPLAIN TO
VERIFY
Community Flood
Zone
OUT:VIEW COMMUNITY FLOODPLAIN
TO VERIFY
11 /05/2021
Ownership
Owner Name
Mailing Address
SHIRLEY T/A KEISTLER
15905 CRAMUR DR
HUNTERSVILLE NC 28078
Deed Reference(s) and Sale Price
Deed
Fsale Date
I Sale Price
17228-907
05/21 /2004
1$0.00
Site Location
ETJ Area
Huntersville
Charlotte Historic District
No
Charlotte 6/30/2011 Annexation Area
No
Census Tract #
62.04
Post Construction District
Jurisdiction
Huntersville
District
Huntersville
Stream Watershed Districts
Stream Watershed Name LAKE NORMAN
Regulated Drinking Watershed Districts
Watershed Name
LAKE NORMAN
Watershed Class
CA
Built -Upon Area Restriction
Situs Addresses Tied to Parcel
Limit on amount of Built -Upon Area Yes
CRAMUR DR HUNTERSVILLE
This map or report is prepared for the inventory of real property within Mecklenburg County and is compiled from recorded deeds, plats, tax maps,
surveys, planimetric maps, and other public records and data. Users of this map or report are hereby notified that the aforementioned public primary
information sources should be consulted for verification. Mecklenburg County and its mapping contractors assume no legal responsibility for the
information contained herein.
Page 1/1

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LAKE NORMAN
/ THIS DRAWING IS FOR EXHIBIT PURPOSES
ONLY. IT IS TO SHOW RELATIVE LOCATIONS
OF SOIL SAMPLE LOCATIONS WITHIN AN
/ APPROXIMATE SOIL EXCAVATION AREA AS
SHOWN HEREON. IT IS NOT MEANT FOR
CONVEYANCES, SALES OR RECORDING. NO
BOUNDARY WORK, RESEARCH OR UTILITY
LOCATIONS WERE DONE WITHIN THE SCOPE
OF THIS EXHIBIT. ALL LOCATIONS AND
\ PARCEL LINES ARE APPROXIMATE AND
15915 CRAMUR DRIVE
/ \ NOT TO SCALE.
15905 CRAMUR DRIVE
EXHIBIT
PURPOSES ONLY
NOT TO SCALE
/ BUILDING
SB-1 UST
DRO: 5,340 mgA 15901 CRAMUR
GRO: 121 mg/kg DRIVE
/C3 qz
/ I I SB-2X SB-2XX /
I SB-2 /
\ TREE
\ tp DRO:< 12.5 mg/
\ UST GRO: < 6.27 mg/kg
WATER WELL
\ V Ove \ ENCLOSURE
\
15101 NC HIGHWAY 73
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DRAWN BY:
GHL
CHECKED BY:
GH
PROJECT NUMBER:
7736.0921ED
SCALE:
NOT TO SCALE
DATE:
10/14/2021
DRAWING:
15901 Cramur Dr -Figure 1
Copyright 2021 CES Group Engineers, LLP

Beverly, Trudy
From: Beverly, Trudy
Sent: Friday, November 5, 2021 9:53 AM
To: Scott Ball
Cc: Tomie Benton
Subject: RE: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal
Received. Thank you Scott.
Have a great weekend,
Trudy
Trudy Beverly, L.G.
Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
Q,
Dr" 'el UST Section, Mooresville Regional Office
704.235.2182 (Office)
Trudy. B everlykncdenn 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: ht_pt s://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https:Hdeg.nc.gov/about/divisions/waste-management/ust/ast-program
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httos://dea.nc. gov/about/divisions/waste-management/waste-management-rules-data/waste-management-ais-mans
File Review Procedures:
hops://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
bit.ps://deq.nc.gov/about/divisions/waste-management/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.ne.izov/ncdea[Waste%2OMana2ement/DWM/UST/WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df
https:Hfiles.nc.gov/ncdeq/Waste%2OManagement/D WM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Scott Ball[mailto:[e-mail]]
Sent: Friday, November 5, 2021 9:51 AM
To: Beverly, Trudy <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Trudy
Please see attached.
Thanks
Scott Ball
Project Manager

Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Fax [phone]
[e-mail]
www.geologicalresourcesinc.com
NCPCM Vendor of the Year Recipient
From: Beverly, Trudy <[e-mail]>
Sent: Friday, November 5, 2021 8:33 AM
To: Scott Ball <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: RE: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal
Good Morning Scott,
The UST-61 form has not been submitted for this release. Please email me a pdf of the completed form.
UST-61 24-Hour Release and UST Leak Reporting Form
https://deg.nc.gov/about/divisions/waste-management/ust/forms
Thank you,
Trudy
Trudy Beverly, L.G.
D�. E Hydrogeologist, Division of Waste Management
North Carolina Department of Environmental Quality
"'"" UST Section, Mooresville Regional Office
mental 4u'Yly�
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: ht_pt s://deg.nc.gov/about/divisions/waste-management/ust
Branch's Above Ground Storage Tanks Website Address: https://deq.nc.gov/about/divisions/waste-management/ust/ast-pro2Tam
INTERACTIVE MAPS WITH DWM SITES AND PERMITTED FACILITIES:
httns://dea.nc. eov/about/divisions/waste-management/waste-management-rules-data/waste-manaeement-ais-mans
File Review Procedures:
https://deq.ne. gov/about/divisions/waste-management/ust/file-review-procedures#mooresville-regional-office
ONLINE ACCESS TO UST SECTION DOCUMENTS (Laserfiche):
httDs: //dea.nc. eov/about/divisions/waste-mana2ement/laserfiche
Document Submittal & UST File Names for Laserfiche Policies:
htti)s:Hfiles.ne.izov/nedeafWaste%2OMana2ement/DWM/UST[WhatsNew/Final-Electronic-Document-Submittal-Policv.l)df
https:Hfiles.nc.gov/ncdeq/Waste°/`20Management/DWM/UST/Corrective%2OAction/UST%20file%20names%20for%2OLaserfiche.docx
From: Scott Ball [mailto:[e-mail]]
Sent: Friday, November 5, 2021 7:34 AM
To: Beverly, Trudy <[e-mail]>
Cc: Tomie Benton<[e-mail]>
Subject: [External] 15901 Cramur Drive, Huntersville, NC - HHO UST removal
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
We have removed the two heating oil USTs at this site and confirmed soil contamination. The release was discovered in
October 2021 during Phase II ESA activities conducted by CES.
My question is, was a UST-61 form ever submitted to the NCDEQ for the release? If not, should I submit one now for
your/NCDEQ's records? I will be preparing the IAAR in the next few days.
Thanks
Scott Ball
Project Manager
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Main [phone] Fax [phone]
[e-mail]
www.geologicalresourcesinc.com
NCPCM Vendor of the Year Recipient