WS-4653_15063_CA_WR_20160502_ In Situ Remediation Notification

UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES

Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete. DATE: May 2, 2016 , PERMIT NO. (to be filled in by DWR) A. WELL TYPE TO BE CONSTRUCTED OR OPERATED (1) X Air Injection Well……………………………..…Complete sections B-F, K, N
(2) Aquifer Test Well……………………….………..Complete sections B-F, K, N
(3) Passive Injection System…………………..……..Complete sections B-F, H-N
(4) Small-Scale Injection Operation………………….Complete sections B-N
(5) X Pilot Test………………………………………….Complete sections B-N
(6) Tracer Injection Well………………………….….Complete sections B-N
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER – State name of entity and name of person delegated authority to sign on behalf of the business or agency: Name: North Carolina Division of Waste Management
Mailing Address: 1646 Mail Service Center,
City: Raleigh State: _NC___ Zip Code: 27966-1646 County: Wake
Day Tele No.: 919-707-8170 Cell No.: 919-333-3864
EMAIL Address:[e-mail] Fax No.:
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are “permitted by rule” and do not require an individual permit when constructed in accordance with the rules of 15A NCAC 02C .0200. This form shall be submitted at least 2 weeks prior to injection. AQUIFER TEST WELLS (15A NCAC 02C .0220) These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.

2) Small-Scale Injection Operations – Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the surface area of the injection zone wells are located within an area that does not exceed five percent of the land surface above the known extent of groundwater contamination. An individual permit shall be required to conduct more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 2
D. PROPERTY OWNER (if different than well owner)
Name: Derek Shore
Mailing Address: 2424 US Hwy 21
City: Hamptonville State: _NC___ Zip Code:27020 County: Yadkin
Day Tele No.: (704)-546-3200 Cell No.:
EMAIL Address: [e-mail] Fax No.: (704)-546-3205
E. PROJECT CONTACT - Person who can answer technical questions about the proposed injection project. Name: David Loftis
Mailing Address: S&ME 44 Buck Shoals Road, Unit C-3
City: Arden State: _NC__ Zip Code: 28704 County: Buncombe
Day Tele No.: 828-483-012 Cell No.: 828-337-1923
EMAIL Address: [e-mail] Fax No.: 828-687-8003
F. PHYSICAL LOCATION OF WELL SITE (1) Physical Address: 2425 US Hwy 21
County: Yadkin
City: Hamptonville State: NC Zip Code: 27020
(2) Geographic Coordinates: Latitude**: o ′ ″ or o.
Longitude**: o ′ ″ or o.
Reference Datum: Accuracy:
Method of Collection:
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA Land surface area of contaminant plume: 63 square feet
Land surface area of inj. well network: 5000 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: <5% (must be < 5% of plume for pilot test injections) H. INJECTION ZONE MAPS – Attach the following to the notification. (1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and proposed injection wells; and (2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed monitoring wells, and existing and proposed injection wells. (3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing and proposed wells.
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 3
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES – Provide a brief narrative regarding the purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration of injection over time. The UST Section will complete an air sparging test accompanied by mobile multi-phase extraction event. The
event will be conducted over a 96 hour duration. The goal of the activity is to evaluate the affect of air sparging
on the removal of petroleum hydrocarbons released to the environment. Injection rates are expected to be 10 to
20 scfm

J. INJECTANTS – Provide a MSDS and the following for each injectant. Attach additional sheets if necessary. NOTE: Approved injectants (tracers and remediation additives) can be found online at http://portal.ncdenr.org/web/wq/aps/gwpro. All other substances must be reviewed by the Division of Public Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496). Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:

Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA (1) Number of injection wells: Proposed Existing
(2) Provide well construction details for each injection well in a diagram or table format. A single
diagram or line in a table can be used for multiple wells with the same construction details. Well
construction details shall include the following:
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
(c) well contractor name and certification number
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 4

UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 5
L. SCHEDULES – Briefly describe the schedule for well construction and injection activities.

M. MONITORING PLAN – Describe below or in separate attachment a monitoring plan to be used to determine if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.

N. SIGNATURE OF APPLICANT AND PROPERTY OWNER APPLICANT: “I hereby certify, under penalty of law, that I am familiar with the information submitted in this document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible for obtaining said information, I believe that the information is true, accurate and complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment, for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules.” Signature of Applicant Print or Type Full Name
PROPERTY OWNER (if the property is not owned by the permit applicant): “As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to allow the applicant to construct each injection well as outlined in this application and agree that it shall be the responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards (15A NCAC 02C .0200).” “Owner” means any person who holds the fee or other property rights in the well being constructed. A well is real property and its construction on land shall be deemed to vest ownership in the land owner, in the absence of contrary agreement in writing.
Signature* of Property Owner (if different from applicant) Print or Type Full Name * An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form. Submit the completed notification package to:
DWR – UIC Program 1636 Mail Service Center Raleigh, NC 27699-1636 Telephone: [phone]