WS-28609_47852_CA_UST-61_20221213

usr-61 24-Hour Release and UST Leak
Thisformsnouhbecompteteoanostromitteotoltler.lsrSection,sregionaloffi."folloffi
an underground storage tank (UST) system. This form is required to-be submitted withini4 hours of discovery of , rno*n or.suspected release
For Releases
in NG
(DWM USE ONLY)
lncident # Risk (H,I,L,U)_
Received On _ Received By _Reported by (circle one): Phone, Fax or Report
Region
Suspected Contamination? (Y/N)Y
Confirmed GW Contamination? (Y/N) Y
Confirmed Soil Contamination ?fr/N) N
Samples Taken?(YiN) Y
Free Product? (YiN) y lf Yes, State Greatest
ThiCKNESS O,2I' LNAPL MW.7 ANd O, I4' LNAPL MW.I2
Facility lD Number 0-0-023468
Date Leak Discovered 12/13/2022
Comm/Non-Commercial? Comm
Reg/Non-regulated? Reg-
INCIDENT DESCRIPTION
lncident Name: gu*6.ld,s General Store
Address: 2048 South NC Highway I l9 County: Alamance
City/Town: Mebane , ,rO "*r-r*,
Regional Office (circle one): Asheville, Mooresvltte, fayettevilte
Raleigh. Washington, Wilmington,@
Obtained by:
!ces
!Topographic map
ffiGtS Rooress matching
flotnu,
Iunknor
Describe location:
Latitude(oecrmat oesrees): 36.05938'N Longitude(deomar oesrees): j9.30437t1N
of release, amount of ftge product present aN rccovery effofts. initiat resoonses conducted imnects fo rceentorsl
During the semi-annual groundyater sampling event" LNAPL was measured in well MW-7 at a thickness of 0.21and in monitori
Basoline Prndrrct line failed ils tightness test Cary Oil and the contractor are crrrently tryi;g fo figure orrt whereIine failure is located. Site check activities have been scheduled.
f'ect
INT
HOW RELEASE WAS DISCOVERED lRereasecooel
(Check one)
lRelease Detection Equipment or Methods I Evsrauooo, | llGroundwater contamination
flouring UST closure/Removal I nw.t", in r.nt ! Errn"." water contaminarion
leropertv rransrer
I n*.,", suppty Wel conramination I Eo,n". t.p""'v}|^$!iltilffiH
CONTAMINATION
Tvpe of Release
(Check one)
I tr"u,u,, II l-l Non-Petroteum II nrn* I
I lo".rion I
L::1"' I
I
=l:::"-
|
SOURCE OF
Cause of Release
(Check pimary cause)
n spitt
! Overtltt
! Corrosion
! ehysicatiMechanicat
Damage
! tnstatt Problem
I otne,
I unmown
Definitions presented on rcverse
Product Tvoe Released
(Check pimary product type released)
I ranr
Elpipins
I Dispense'.
! Submersible Turbine Pump
! oetivery Problem
! spitt aucret
Iotne,
! unkno*n
lefinitions presented on reverse
I Gasoline/ DieseU
Kerosene
! Heating Oil
! otn"r Petroleum
Products
! uetrrs
fl otn"r tnorganics
! Otn", Organics
! DieselA/eg. Oil
Blend
f]Vegetabte oit 1oo%
! ero - ezo
I ezr - ea+
! ees - ess
!Ethanol 1007o
! ror - eos
Source of Release
(Check pimary source)
1. Municipal 2. Military 3. Unknown 5. Federal 6. County 7. State
Ooeration Tvoe
1. Publicservice 2. Agricultural 3. Residential 4. Education/Relig. 5. lndustrial 7. Mining
UST Form 61 (02119)Page I of 2
Water SupPlY Wells Affected? 1. Yes
ffiTERSUPPLIES
6G) 3. Unknown\--l
Number of Water Supply Wells Affected
I sheet if necessary\
UST SYSTEM OWNER
Cary Oil Company, Inc.
Point of Contacl
Aimee Gibbs
l9) 462-l 100
UST SYSTEM OPERATOR
2048 South NC HighwaY I 19
Operator/ComPanY
Hawfield's General Store
Telephone Number
(9 r 9) s63-2800
LANDOWNER AT LOCATION OF UST INCIDENT
Address
2048 South NC HighwaY I l9Chris Cagle
[phone]
intersections) or Attach MaP
Telephone Number (9 I 9)56 1 -3893ATC Associates of NC on behalf of Cary OilPerson Reporting lncident M. Jackson, PG Date Dggsrnfsr 13.2022Address 2725 E. Millbrook Road. suite l2l Raleigh- NC 27604
UST Form (02119)'age 2 ol 2
Delinitions of Sources
Tank: means the tank that stores the product and is part ofthe underground storage tank system
piping: means the piping and connectors running from dre tank or sublmersible tur6ine 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
Delrvery problem: identifies releases that occuned during product delivery to the tank. (Typical causes associated wtth this source are spills and overfills )
Other: serves as the option to use when the release sourie-is known but d-oes not fit into one ofthe preceding categories (e g., for releases fiom vent lines' vapor
recovery lines, and fill lines)
tJnknown: 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 occu. fiom the fill pipe at the tank or when the nozzle fails to shut offat the dispenser)
physical or Mechanical Damage: use for all types ofphysical.or mechanical damage, except conosion (e g.' puncture oftank or piping, loose fittings' broken
components, and components that have changed dimension)
Corrosion. use when a metal t;k:;ip*g, oi odr"..ornpinent has a release due to corrosion (e.g., for steel, corrosion takes the form of rust)
Installation problem: ur" *t
"n
iiJ jrof,tm is determined to have occuned specifically because the UST system was not installed properly
Other: use this option when the cause is known but does noi tit into one of'the preceding categories (e.g., putting regulated substances into monitoring wells)
Unknown: use when the cause has not been determined
MW-2MW-2MW-6MW-3MW-11MW-12VMW-1MW-1MW-7MW-8HAWFIELDSGENERALSTOREFORMERKEROSENUST BASINEXISTINGGASOLINEUST BASINN.C.HIGHWAY 119OLD HILLSBOROUGH ROAD= MONITORING WELL LOCATION