WI0800531_Permit (Issuance)_20191213

CES@NCa
November 25, 2019
Shristi R. Shrestha
DWR — UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
RE: Notification of Intent to Operate Injection Wells
GPM 3066 (Scotchman #66)
267 Western Boulevard
Jacksonville, Onslow County, North Carolina
NCDEQ UST Incident No.: 20072
Dear Ms. Shrestha:
On behalf of the responsible party/applicant GPM Southeast, LLC, CES of NC, PLLC is submitting the
enclosed Notification of Intent to Operate Injection Wells. The document details "deemed permitted"
passive injection activities utilizing existing monitoring wells for the purpose of groundwater remediation
associated with the referenced incident number. Following review should you have any questions or require
additional information, please do not hesitate to contact me by phone at [phone] or email at
awilliamsonkcrawfordenvironmental.com.
Sincerely,
CES of NC, PLLC
-If
Aaron Williamson
Project Manager
Enclosure

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT (NOI) 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 (NOTE: This form must be received at least 14 DAYS 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 .02251 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 (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: 11/22 , 2019 PERMIT NO. W10800531 (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well......................................Complete sections B through F, K, N
(2) Aquifer Test Well.......................................Complete sections B through F, K, N
(3) X Passive Injection System...............................Complete sections B through F, H-N
(4) Small -Scale Injection Operation ......................Complete sections B through N
(5) Pilot Test.................................................Complete sections B through N
(6) Tracer Injection Well...................................Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): GPM Southeast, LLC — Rolfe Lann, VP of Environmental
Mailing Address: 8565 Magellan Parkway, Suite 400
City: Richmond State: VA Zip Code: 23227 County: Richmond
Day Tele No
910-796-2418
Cell No.:
EMAIL Address: rlann(c-bg=pminvestments.com
Fax No.: 910-798-2025
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 1

D.
E.
F.
G.
H.
PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Same as Above
Company Name:
Mailing Address:
City:
Day Tele No.:
EMAIL Address:
State: Zip Code: County:
Cell No.:
Fax No.:
PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Aaron Williamson, Project Manager
Company Name Crawford Environmental Services of NC, PLLC
Mailing Address: 5104 Reagan Drive, Suite 7
City: Charlotte State: NC Zip Code: 28206 County: Mecklenburg_
Day Tele No.: 980-819-9333
EMAIL Address: awilliamson(a,crawfordenvironmental.com
PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: GPM 3066
267 Western Boulevard
Cell No.:
Fax No.: 540-343-6259
City: Jacksonville County: Onslow Zip Code: 28546
(2) Geographic Coordinates: Latitude**: 0 " or 340.75918IN
Longitude* 0 " or 770.382395W
Reference Datum: WGS84 Accuracy: 2 meters
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
TREATMENT AREA
Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
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.
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 2

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.
Application of sodium persulfate and potassium permanganate well socks within four impacted monitoring wells
(MW-4, MW-9, MW-11, MW-12). Socks will contain sodium persulfate and potassium permanganate
combination cylinders, each 1.5-feet long. Each well is constructed with 10-feet of well screen. Six feet of
cylinders will be placed into each monitoring well within the saturated well screen.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-inj ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: Sodium Persulfate WAS #7775-27-1)
Volume of injectant: 34.5 pounds per injection point
Concentration at point of injection: 100%
Percent if in a mixture with other injectants: 38%
Injectant: Potassium Permanganate (CAS #7722-64-7)
Volume of injectant: 34.5 pounds per injection point
Concentration at point of injection: 100%
Percent if in a mixture with other injectants: 38%
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 4 Existing (provide GW-1s)
(2) For Proposed wells or Existing wells not having GW-1s, 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 (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
ISCO cylinders to be installed in existing monitoring wells January/February 2020. Semi-annual maintenance
will be performed to evaluate condition of the -cylinders.
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.
A Fzroundwater mon itori ng event will be conducted prior to c linder installation. Subse went monitoring events
are proposed on a semi-annual basis concurrent with al rem oval/rel2lacement. Groundwater sam p les will
be submitted for laboratoi analysis of volatile or 3anic compounds by Standard Methods 6200B includin
BTEX MTBE IPE EDB and naphthalene. See NQDEQ UST Incident Number 20072.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well 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 I,��y]1TCAC 02C 0200 Rules. "
of Applicant
Print or Type Full Name and Title
Property Owner if tEse prp er is not owned by Lhe Well Owner/Al icant :
"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
(1 SA IVCAC 02C . oL. "
"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
abspaee-a� contrary agreement in writing.
y/-9 �)
e �1-�-
"- gnaturek of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR - UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation N0I Rev. 3-21-2018 Page 4

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[e-mail]
CLIENT: GPM Southeast, LLC.
267 Western Boulevard Figure 5
LOCATION. Jacksonville, North Carolina
GPM 3066
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Toluene Above 2L Standards
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Sampling Date: August 13, 2019
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0 15' 30' 60'
1 inch equals 30 feet
[e-mail]
CLIENT: GPM Southeast, LLC.
267 Western Boulevard Figure 8
LOCATION: Jacksonville, North Carolina
GPM 3066
Estimated Horizontal Extent of
MTBE Above 2L Standards
Groundwater Monitoring Report

Legend
Mw—i 0 Monitoring Well (Type II)
T_t 0 Monitoring Well (Type III)
ev Utility/Power Pole
)�f Light Pole
OH Overhead Electric Line
W Water Line
Natural Gas Line
Sanitary Sewer Line
Communication Line
EOP End of Pavement
® Stormwater Inlet
Q Sanitary Sewer Manhole
►� Water Valve
4) Fire Hydrant
© Liquefied Petroleum Tank
Communication Pedestal
O Bollards
(<5.0) IPE Concentration
IPE Concentration Contour
(NS) Not Sampled
Units: micrograms per Liter (ug/L)
Sampling Date: August 13, 2019
IPE 2L Standard: 70 ug/L
IPE GCL: 70,000 ug/L
0 15' 30' 60'
1 inch equals 30 feet
[e-mail]
CLIENT: GPM Southeast, LLC.
267 Western Boulevard Figure 9
LOCATION: Jacksonville, North Carolina
GPM 3066
Estimated Horizontal Extent of
IPE Above 2L Standards
Groundwater Monitoring Report

ASPHALT
GRASS
GE SWALE ss
DRAINA
m z-0
1,40 �
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(INS)c�
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TRAVELS
ery Utility/Power Pole
SIGN
N
3�f Light Pole
EOP (INS)FTI
ASPHALT (INS)(9.9)
I
,
— off — Overhead Electric Line
MW-5
-1 ®
RA S�
Z
W Water Line
MW 3
0
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WET AREA MW-1
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--- (480) ------ i
(EPHEMERAL)
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PRODUCT LINE I, MYy_g
MW-4 I
i ,
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I
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_
(480) Naphthalene Concentration
v > MW-2
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6
(INS) Not Sampled
I r�
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Units: micrograms per Liter (ug/L)
Date: August 13, 2019
D (640)1 I I
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% 11
I I
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roe
Naphthalene 2L Standard: 6 ug/L
O I
FORMER
®
Naphthalene GCL: 6,000 ug/L
DISPENSER
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CLIENT: GPM Southeast, LLC.
Figure 10
267 Western Boulevard
LOCATION:
Jacksonville, North Carolina
S (
�G<
T�A�FJ
GPM 3066
Estimated Horizontal Extent of
GRASS
Naphthalene Above 2L Standards
TRANSMISSION
TOWER
Groundwater Monitoring Report

SWnmery 0 HiVnm-,1 AnaA— I-- —
WHITE STREET
MI
FORMER
KEROSENE
MW-5
UST BASIN
- - - - - - - — —
— _ T
HA- IEIL
HA-21 I
MW_1 ©
- -
- ao
�\
I ACTIVE I ---------
\
m
FORMER
•
H e �3
I GASOLINq II
I UST BASiW III
I MW-3
FORMER II
PRODUCT
GASOLINE II
LINE
UST BASIN I
II
I
•51
mZ
Mw72
So IL-------
I
1
a
I
o
--
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fn
MW-4
S5 • SCOTCHMAN
#66
s4 •
I `+
I
I
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•
S3 •
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DISPENSER
GRASS
ISLAND
(TYP.)
MW-7
m MW-6
P.
-..i
n
z
co
0
f
M
D
�J m MW-8
0
Detected
mocund
Sotl-to-
Groundwater
MSCC
Resldenual
MSCC
am Ie ID:
M -1
MW-2
MW-3
MW-4
T-1
S-1
S-2
S-3
pepth:
Unk.
Unk.
Unk.
Unk
Unk
Unk.
Unk
Unk
Unk
Unk
Unk
Data:
31=98
8/fif98
aims
sees
8f61911
12/4/98
1274/98
12/4/98
1214198
12/4/98
12/4/98
EPA METHOD
Benzene
Toluene
uTBE
54
7,000
920
22,000
3.200 p00
156,000
15
19
14
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
250
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
?-EP-VPH
C5-CS
C9-C72
C9-C70
72 000
7255,000
34,000
939,000
9.38fi 000
4fi9.000
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
2500
1400
1,5W
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
EPA METHOD
5010
Gasobne
10=0
NA
BOL
9.600
197.0001
NA
1200.000
BOL
BOL
BOL
BOL
67,000
EPA METHOD
asse
�=NA
Diesel Y2
40.000
NA
51,000
111000
387.p00
BOL
BOL
BOL
BOL
820p0
Note: Highlighted parameters are irate exceerbng Sail -to -Groundwater standards
All concentrations are expressed as pans per billion (ppb)•
Unk: Unknown
1: Gasolne and Diesel $2 are not covered understandards so the action levels have been fisted
2. Not AYialyzed
3: Below Ouanutzhon Lund
Summary of Analytical Results for Sod -Comprehensive Site Assessment
am le 10:
HA -I
HA-2
HA-3
PMW-5
PMW-6
PMW-7
PMW-6
Detectetl Com ound
Sod -to-
Groundwater
MSCC
Resldenlal
MSCC
ample Depth:
2 feet
2 feel
2 feet
Unknown
Unknown
Unknown
Unknown
PID ( m):
0.5
2
1.6
11
NA
NA
NA
ample Date:
10/15199
10/15199
10/15/99
929199
9129/99
9129199
929199
EPA ?A OD 9260
p-isopropynoluene
BOL
BOL
SOL
1 412
1 SOL
BOL
I SOL
MADEP-EPH
C9-C78
424.799.000
9,388.OD0
SOL
BOI.
109.000
BOL
SOL
SOL
SOL
C19C36
a
93.BW.000
SOL
30200
90.400
SOL
BOL
BOL
BOL
C71-C22
34A00
469.000
SOL
BOL
279,000
BOL
BOL
SOL
SOL
Note. Highlighted parameters we those exceading Sod -to -Groundwater Standards
Ad concentrenons are expressed as parts per bdllon (ppb)
1: Not analyzed
2- Below quanuabon Itm1t
rl: Considered immobile
-N
�I
i`.
of
0 a0
SCALE IN FEET
LGND
MW-1 ©
MONITORING WELL
O
TELESCOPING WELL
®
SANITARY SEWER MANHOLE
®
STORM DRAIN
~�
FIRE HYDRANT
©
TELEPHONE BOOTH
S1 •
SOIL BORINGS INSTALLED ON 12 / 4 / 98
HA-1 E
HAND AUGERS INSTALLED ON 10 / 15 / 99
/ 1
ESTIMATED EXTENT OF TPH IN SOIL
s
a
o
ESTIMATED EXTENT OF EPH IN SOIL
•• o

W
FORMER
KEROSENE
UST BASIN
� I
FORMER,
PRODUCT
LINE
GRASS
B'
MW-6
�I
LEGEND
m
MONITORING WELL
O
TELESCOPING WELL
®
SANITARY SEWER MANHOLE
®
STORM DRAIN
MW-8
FIRE HYDRANT `
A' ©
TELEPHONE BOOTH
0 40
SCALE IN FEET

A
MW-5
100'
85
80
V&
70
65
ME
MW-4
MW-8 A
100,
Man -Made Materials
SP = Poorly -Graded Sand (little or no fines)
® CL = Silty Clay
SM = Silty Sand
BENZENE CONCENTRATIONS
WELL ID
BENZENE (ppb)
MW-2
141
MW-5
BQL
MW-7
BQL
MW-1
1,820
T-1
BQL
MW-4
19,100
MW-3
813
MW-8
BQL
MW-6
BOL
BQL = BELOW QUANTITATION LIMIT (0.5 ppb)

B
MW-2
100' �,
n
ti
85
80
75
70
65
w
MW-3
77
&I
' x
1,000 ppb
� r
—1 ppb
B'
MW-6
100'
i� Man -Made Materials
k•-: '.•:I SP = Poorly -Graded Sand (little or no fines)
® CL = Silty Clay
SM = Silty Sand
ML = Clayey Silt
BENZENE CONCENTRATIONS
WELL ID
BENZENE (ppb)
MW-2
141
MW-5
BQL
MW-7
BQL
MW-1
1,820
T-1
BQL
MW-4
19,100
MW-3
813
MW-8
BQL
MW-6
BQL
BQL = BELOW QUANTITATION LIMIT (0.5 ppb)

LSAFETY DATA SHEET
1. Identification
Product identifier RemOx@ SR+ ISCO Reagent
Other means of identification None.
Recommended use In situ and ex situ chemical oxidation of contaminants and compounds of concern for
environmental remediation applications.
Recommended restrictions Use in accordance with supplier's recommendations.
Manufacturer/Importer/Supplier/Distributor information
Company name CARUS CORPORATION
Address 315 Fifth Street,
Peru, IL 61354, USA
Telephone [phone] - All other non -emergency inquiries about the product should be
directed to the company
E-mail [e-mail]
Website www.caruscorporation.com
Contact person Dr. Chithambarathanu Pillai
Emergency Telephone For Hazardous Materials [or Dangerous Goods] Incidents ONLY
(spill, leak, fire, exposure or accident), call CHEMTREC at
CHEMTREC@, USA: 001 [phone]
CHEMTREC@, Mexico (Toll -Free - must be dialed from within country):
01-800-681-9531
CHEMTREC@, Other countries: 001 [phone]
2. Hazard(s) identification
Physical hazards Oxidizing solids Category 3
Health hazards Acute toxicity, oral Category 4
Skin corrosion/irritation Category 1 B
Sensitization, respiratory Category 1
Sensitization, skin Category 1
Specific target organ toxicity, single exposure Category 1 (Respiratory system)
Specific target organ toxicity, repeated Category 1 (Central Nervous System,
exposure Respiratory system)
Environmental hazards Hazardous to the aquatic environment, acute Category 1
hazard
Hazardous to the aquatic environment, Category 1
long-term hazard
OSHA defined hazards Not classified.
Label elements
+ F-
<eX >
Signal word Danger
Hazard statement May intensify fire; oxidizer. Harmful if swallowed. Causes severe skin burns and eye damage. May
cause allergy or asthma symptoms or breathing difficulties if inhaled. May cause an allergic skin
reaction. Causes damage to organs (Respiratory system). Causes damage to organs (Central
Nervous System, Respiratory system) through prolonged or repeated exposure. Very toxic to
aquatic life with long lasting effects.
RemOx@ SR+ ISCO Reagent SIDS US
923162cp Version#:01 Revision date:- Issue date: 04-April-2015 1/9

Precautionary statement
Prevention
Keep away from heat. Keep/Store away from cloth i ng//com busti ble materials. Do not breathe
dust. Wear protective gloves/protective clothing/eye protection/face protection. Do not eat, drink
or smoke when using this product. Wash thoroughly after handling. Take any precaution to avoid
mixing with combustibles. [In case of inadequate ventilation] wear respiratory protection.
Contaminated work clothing must not be allowed out of the workplace. Avoid release to the
environment.
Response
In case of fire: Use water for extinction. If swallowed: Rinse mouth. Do NOT induce vomiting. If on
skin (or hair): Take off immediately all contaminated clothing. Rinse skin with water/shower. If
inhaled: Remove person to fresh air and keep comfortable for breathing. If in eyes: Rinse
cautiously with water for several minutes. Remove contact lenses, if present and easy to do.
Continue rinsing. If experiencing respiratory symptoms: Call a poison center/doctor. Take off
immediately all contaminated clothing and wash it before reuse. If exposed or concerned: Call a
poison center/doctor. Immediately call a poison center/doctor. Collect spillage.
Storage
Store locked up.
Disposal
Dispose of contents/container in accordance with local/regional/national/international regulations.
Hazard(s) not otherwise
None known.
classified (HNOC)
3. Composition/information on ingredients
Substances
Chemical name Common name and CAS number %
synonyms
Potassium permanganate 7722-64-7 20 - 40
Sodium persulfate 7775-27-1 20 - 40
Composition comments All concentrations are in percent by weight unless ingredient is a gas. Gas concentrations are in
percent by volume.
4. First -aid measures
Inhalation Remove victim to fresh air and keep at rest in a position comfortable for breathing. For breathing
difficulties, oxygen may be necessary. Get medical attention immediately.
Skin contact Remove contaminated clothing and shoes. Wash contaminated clothing before reuse. Get medical
attention immediately.
Contact with skin may leave a brown stain of insoluble manganese dioxide. This can be easily
removed by washing with a mixture of equal volume of household vinegar and 3% hydrogen
peroxide, followed by washing with soap and water.
Eye contact
Immediately flush with plenty of water for up to 15 minutes. Remove any contact lenses and open
eyelids wide apart. Continue rinsing. Get medical attention immediately.
Ingestion
Immediately rinse mouth and drink plenty of water. Never give anything by mouth to a victim who is
unconscious or is having convulsions. Do not induce vomiting. If vomiting occurs, keep head low
so that stomach content doesn't get into the lungs. Get medical attention immediately.
Most important
Contact with this material will cause burns to the skin, eyes and mucous membranes. Permanent
symptoms/effects, acute and
eye damage including blindness could result.
delayed
Indication of immediate
Provide general supportive measures and treat symptomatically. Symptoms may be delayed.
medical attention and special
treatment needed
General information
In the case of accident or if you feel unwell, seek medical advice immediately (show the label
where possible). Ensure that medical personnel are aware of the material(s) involved, and take
precautions to protect themselves.
5. Fire -fighting measures
Suitable extinguishing media Flood with water from a distance, water spray or fog.
Unsuitable extinguishing Dry chemical. Foam. Carbon dioxide (CO2). Halogenated materials.
media
Specific hazards arising from Oxidizing agent, may cause spontaneous ignition of combustible materials. By heating and fire,
the chemical corrosive vapors/gases may be formed.
RemOx® SR+ ISCO Reagent SIDS US
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015 2/9

Special protective equipment Self-contained breathing apparatus and full protective clothing must be worn in case of fire.
and precautions for firefighters Selection of respiratory protection for firefighting: follow the general fire precautions indicated in
the workplace.
Fire fighting Move container from fire area if it can be done without risk. Cool containers exposed to flames with
equipment/instructions water until well after the fire is out. Prevent runoff from fire control or dilution from entering
streams, sewers, or drinking water supply. Dike fire control water for later disposal. Water runoff
can cause environmental damage.
General fire hazards The product is not flammable. May intensify fire; oxidizer.
6. Accidental release measures
Personal precautions,
Keep unnecessary personnel away. Avoid inhalation of dust and contact with skin and eyes. Do
protective equipment and
not touch damaged containers or spilled material unless wearing appropriate protective clothing.
emergency procedures
Wear protective clothing as described in Section 8 of this safety data sheet. Local authorities
should be advised if significant spillages cannot be contained.
Methods and materials for
Keep combustibles (wood, paper, oil, etc.) away from spilled material. Should not be released into
containment and cleaning up
the environment. This product is miscible in water. Stop leak if possible without any risk. Dike the
spilled material, where this is possible.
Never return spills in original containers for re -use. For waste disposal, see Section 13 of the SIDS
Environmental precautions Do not allow to enter drains, sewers or watercourses. Contact local authorities in case of spillage
to drain/aquatic environment.
7. Handling and storage
Precautions for safe handling Take any precaution to avoid mixing with combustibles. Keep away from clothing and other
combustible materials. Do not get this material in your eyes, on your skin, or on your clothing. Do
not breathe dust or mist or vapor of the solution. If clothing becomes contaminated, remove and
wash off immediately. When using, do not eat, drink or smoke. Good personal hygiene is
necessary. Wash hands and contaminated areas with water and soap before leaving the work site.
Avoid release to the environment.
Do not expose to sparks, heat, open flames, or hot surfaces. It is important that smoking is not
allowed in proximity to RemOx® SR. Do not cut RemOx® SR ISCO Reagent with any cutting tool
which could produce friction (i.e. hand saws, circular saws, reciprocal saws, etc.) as it may cause
ignition of the material.
Conditions for safe storage, Store locked up. Keep container tightly closed and in a well -ventilated place. Store in a cool, dry
including any incompatibilities place. Store away from incompatible materials (See Section 10). Follow applicable
local/national/international recommendations on storage of oxidizers.
8. Exposure controls/personal protection
Occupational exposure limits
US. OSHA Table Z-1 Limits for Air Contaminants (29 CFR 1910.1000)
Components
Type
Value
Potassium permanganate
Ceiling
5 mg/m3
(CAS 7722-64-7)
US. ACGIH Threshold Limit Values
Components
Type
Value
Form
Potassium permanganate
TWA
0.1 mg/m3
Inhalable fraction.
(CAS 7722-64-7)
0.02 mg/m3
Respirable fraction.
Sodium persulfate (CAS
TWA
0.1 mg/m3
7775-27-1)
US. NIOSH: Pocket Guide to Chemical
Hazards
Components
Type
Value
Form
Potassium permanganate
STEL
3 mg/m3
Fume.
(CAS 7722-64-7)
TWA
1 mg/m3
Fume.
Biological limit values No biological exposure limits noted for the ingredient(s).
Exposure guidelines Follow standard monitoring procedures.
RemOx® SR+ ISCO Reagent
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015
SIDS US
3/9

Appropriate engineering
Provide adequate general and local exhaust ventilation. An eye wash and safety shower must be
controls
available in the immediate work area.
Individual protection measures, such as personal protective equipment
Eye/face protection
Wear safety glasses with side shields (or goggles). Wear face shield if there is risk of splashes.
Skin protection
Hand protection
Use protective gloves made of: Rubber or plastic. Suitable gloves can be recommended by the
glove supplier.
Other
Wear chemical -resistant, impervious gloves.
Respiratory protection
In case of inadequate ventilation or risk of inhalation of dust, use suitable respiratory equipment
with particle filter. In the United States of America, if respirators are used, a program should be
instituted to assure compliance with OSHA 29 CFR 1910.134.
Thermal hazards
Wear appropriate thermal protective clothing, when necessary.
General hygiene
When using, do not eat, drink or smoke. Keep from contact with clothing and other combustible
considerations
materials. Remove and wash contaminated clothing promptly. Wash hands before breaks and
immediately after handling the product. Handle in accordance with good industrial hygiene and
safety practice.
9. Physical and chemical properties
Appearance
White solid.
Physical state
Solid.
Form
Solid.
Color
White.
Odor
Paraffinic.
Odor threshold
Not applicable.
pH
Not applicable.
Melting point/freezing point
130 °F (54.44 °C)
Initial boiling point and boiling
Not applicable.
range
Flash point
Not applicable.
Evaporation rate
Not applicable.
Flammability (solid, gas)
Non flammable.
Upper/lower flammability or explosive limits
Flammability limit - lower Not applicable.
N
Flammability limit - upper Not applicable.
N
Explosive limit - lower (%) Not applicable.
Explosive limit - upper (%) Not applicable.
Vapor pressure
Vapor density
Relative density
Solubility(ies)
Solubility (water)
Partition coefficient
(n-octanol/water)
Auto -ignition temperature
Decomposition temperature
Viscosity
Other information
Explosive properties
Oxidizing properties
10. Stability and reactivity
Reactivity
Not applicable.
Not applicable.
1.18 (25 °C)
Not available.
Not applicable.
Not available.
Not available.
Not applicable.
Not explosive. Can explode in contact with sulfuric acid, peroxides and metal powders.
Oxidizer.
The product is stable and non -reactive under normal conditions of use, storage and transport.
RemOx® SR+ ISCO Reagent SIDS US
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015 4/9

Chemical stability Stable at normal conditions.
Possibility of hazardous Contact with combustible material may cause fire.
reactions
Conditions to avoid Contact with combustibles.
Incompatible materials Acids. Peroxides. Reducing agents. Combustible material. Metal powders. Contact with
hydrochloric acid liberates chlorine gas.
Hazardous decomposition By heating and fire, corrosive vapors/gases may be formed.
products
11. Toxicological information
Information on likely routes of exposure
Inhalation May cause irritation to the respiratory system.
Skin contact Causes severe skin burns.
Eye contact Causes serious eye damage.
Ingestion Harmful if swallowed.
Symptoms related to the Contact with this material will cause burns to the skin, eyes and mucous membranes. Permanent
physical, chemical and eye damage including blindness could result.
toxicological characteristics
Information on toxicological effects
Acute toxicity Harmful if swallowed.
Components Species Test Results
Potassium permanganate (CAS 7722-64-7)
Acute
Dermal
LD50
Rat 2000 mg/kg
Oral
LD50
Rat 2000 mg/kg
Skin corrosion/irritation
Causes severe skin burns.
Serious eye damage/eye
Causes serious eye damage.
irritation
Respiratory or skin sensitization
Respiratory sensitization May cause allergy or asthma symptoms or breathing difficulties if inhaled.
Skin sensitization May cause allergic skin reaction.
Germ cell mutagenicity Test data conclusive but not sufficient for classification.
Carcinogenicity Test data conclusive but not sufficient for classification.
OSHA Specifically Regulated Substances (29 CFR 1910.1001-1050)
Not listed.
Reproductive toxicity Test data conclusive but not sufficient for classification.
Specific target organ toxicity - Causes damage to organs (respiratory system).
single exposure
Specific target organ toxicity - Causes damage to organs (respiratory system, central nervous system) through prolonged or
repeated exposure repeated exposure.
Aspiration hazard Based on available data, the classification criteria are not met.
Chronic effects May cause damage to respiratory system. Prolonged exposure, usually over many years, to
manganese oxide fume/dust can lead to chronic manganese poisoning, chiefly affecting the
central nervous system.
Further information No other specific acute or chronic health impact noted.
12. Ecological information
Ecotoxicity Very toxic to aquatic life with long lasting effects.
RemOx® SR+ ISCO Reagent SIDS US
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015 5/9

Components Species Test Results
Potassium permanganate (CAS 7722-64-7)
Aquatic
Fish LC50 Bluegill (Lepomis macrochirus)
Persistence and degradability
Bioaccumulative potential
Mobility in soil
Mobility in general
Other adverse effects
13. Disposal consideration:
Disposal instructions
Local disposal regulations
Hazardous waste code
Waste from residues / unused
products
Contaminated packaging
14. Transport information
DOT
Carp (Cyprinus carpio)
Goldfish (Carassius auratus)
2.7 mg/I, 96 hours static
2.3 mg/I, 96 hours flow through
2.3 mg/I, 96 hours
1.8 - 5.6 mg/I
3.16 - 3.77 mg/I, 96 hours
2.97 - 3.11 mg/I, 96 hours
3.3 - 3.93 mg/I, 96 hours static
Milkfish, salmon -herring (Chanos > 1.4 mg/I, 96 hours
chanos)
Rainbow trout (Oncorhynchus mykiss) 1.8 mg/I, 96 hours
1.08 - 1.38 mg/I, 96 hours
0.77 - 1.27 mg/I, 96 hours
Expected to be readily converted by oxidizable materials to insoluble manganese oxide.
Potential to bioaccumulate is low.
Not available.
The product is water soluble and may spread in water systems.
None known.
Dispose of contents/container in accordance with local/regional/national/international regulations.
Dispose in accordance with all applicable regulations.
D001: Ignitable waste
The Waste code should be assigned in discussion between the user, the producer and the waste
disposal company.
Do not allow this material to drain into sewers/water supplies. Dispose in accordance with all
applicable regulations.
Since emptied containers may retain product residue, follow label warnings even after container is
emptied. Empty containers should be taken to an approved waste handling site for recycling or
disposal.
UN number
UN1479
UN proper shipping name
Oxidizing solid, n.o.s. (Sodium persulfate, Potassium permanganate)
Transport hazard class(es)
Class
5.1
Subsidiary risk
-
Label(s) Packing
5.1
group Environmental
II
hazards
Marine pollutant
Yes
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
Special provisions
62, 1B5, IP1
Packaging exceptions
None
Packaging non bulk
211
Packaging bulk
242
IATA
UN number
UN1479
UN proper shipping name
Oxidizing solid, n.o.s. (Sodium persulfate, Potassium permanganate)
Transport hazard class(es)
Class
5.1
Subsidiary risk
-
Rem0x@ SR+ ISCO Reagent SIDS US
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015 6/9

Label(s) Packing
5.1
group Environmental
II
hazards ERG Code
Yes
5L
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
IMDG
UN number
UN1479
UN proper shipping name
OXIDIZING SOLID, N.O.S. (Sodium persulfate, Potassium permanganate)
Transport hazard class(es)
Class
5.1
Subsidiary risk
-
Label(s) Packing
5.1
group Environmental
II
hazards
Marine pollutant
Yes
EmS
F-A, S-Q
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
Transport in bulk according to
Not applicable.
Annex II of MARPOL 73/78 and
the IBC Code
15. Regulatory information
US federal regulations This product is a "Hazardous Chemical' as defined by the OSHA Hazard Communication
Standard, 29 CFR 1910.1200.
All components are on the U.S. EPA TSCA Inventory List.
TSCA Section 12(b) Export Notification (40 CFR 707, Subpt. D)
Not regulated.
OSHA Specifically Regulated Substances (29 CFR 1910.1001-1050)
Not listed.
CERCLA Hazardous Substance List (40 CFR 302.4)
Potassium permanganate (CAS 7722-64-7) LISTED
Superfund Amendments and Reauthorization Act of 1986 (SARA)
Hazard categories Immediate Hazard - Yes
Delayed Hazard - Yes
Fire Hazard - Yes
Pressure Hazard - No
Reactivity Hazard - No
SARA 302 Extremely hazardous substance
Not listed.
SARA 311/312 Hazardous Yes
chemical
SARA 313 (TRI reporting)
Chemical name
Potassium permanganate
CAS number % by wt.
7722-64-7 20 - 40
Other federal regulations
Clean Air Act (CAA) Section 112 Hazardous Air Pollutants (HAPs) List
Potassium permanganate (CAS 7722-64-7)
Clean Air Act (CAA) Section 112(r) Accidental Release Prevention (40 CFR 68.130)
Not regulated.
Safe Drinking Water Act Not regulated.
(SDWA)
Drug Enforcement Administration (DEA). List 2, Essential Chemicals (21 CFR 1310.02(b) and 1310.04(f)(2) and
Chemical Code Number
Potassium permanganate (CAS 7722-64-7) 6579
Drug Enforcement Administration (DEA). List 1 & 2 Exempt Chemical Mixtures (21 CFR 1310.12(c))
Potassium permanganate (CAS 7722-64-7) 15 %WT
RemOx® SR+ ISCO Reagent SDS US
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015 7/9

DEA Exempt Chemical Mixtures Code Number
Potassium permanganate (CAS 7722-64-7) 6579
US state regulations This product does not contain a chemical known to the State of California to cause cancer, birth
defects or other reproductive harm.
US. Massachusetts RTK - Substance List
Potassium permanganate (CAS 7722-64-7)
US. New Jersey Worker and Community Right -to -Know Act
Potassium permanganate (CAS 7722-64-7)
Sodium persulfate (CAS 7775-27-1)
US. Pennsylvania Worker and Community Right -to -Know Law
Potassium permanganate (CAS 7722-64-7)
US. Rhode Island RTK
Potassium permanganate (CAS 7722-64-7)
US. California Proposition 65
Not Listed.
International Inventories
Country(s) or region
Inventory name
On inventory (yes/no)"
Australia
Australian Inventory of Chemical Substances (AICS)
Yes
Canada
Domestic Substances List (DSL)
Yes
Canada
Non -Domestic Substances List (NDSL)
No
China
Inventory of Existing Chemical Substances in China (IECSC)
Yes
Europe
European Inventory of Existing Commercial Chemical
Yes
Substances (EINECS)
Europe
European List of Notified Chemical Substances (ELINCS)
No
Japan
Inventory of Existing and New Chemical Substances (ENCS)
No
Korea
Existing Chemicals List (ECL)
Yes
New Zealand
New Zealand Inventory
Yes
Philippines
Philippine Inventory of Chemicals and Chemical Substances
Yes
(PICCS)
United States & Puerto Rico
Toxic Substances Control Act (TSCA) Inventory
Yes
*A "Yes" indicates this product complies
with the inventory requirements administered by the governing country(s).
A "No" indicates that one or more
components of the product are not listed or exempt from listing on the inventory administered by the governing
country(s).
16. Other information, including date of preparation or last revision
Issue date 01-December-2014
Revision date -
Version # 01
NFPA ratings
0
ox
List of abbreviations
LD50: Lethal Dose, 50%.
LC50: Lethal Concentration, 50%.
References Chemical safety report.
ECHA registered substances database
RemOx® SR+ ISCO Reagent SIDS US
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015 8/9

Disclaimer The information contained herein is accurate to the best of our knowledge. However, data, safety
standards and government regulations are subject to change and, therefore, holders and users
should satisfy themselves that they are aware of all current data and regulations relevant to their
particular use of product. CARUS CORPORATION DISCLAIMS ALL LIABILITY FOR RELIANCE ON
THE COMPLETENESS OR ACCURACY OR THE INFORMATION INCLUDED HEREIN. CARUS
CORPORATION MAKES NO WARRANTY, EITHER EXPRESS OR IMPLIED, INCLUDING, BUT
NOT LIMITED TO, ANY WARRANTIES OF MERCHANTIABILITY OR FITNESS FOR PARTICULAR
USE OR PURPOSE OF THE PRODUCT DESCRIBED HEREIN. All conditions relating to storage,
handling, and use of the product are beyond the control of Carus Corporation, and shall be the sole
responsibility of the holder or user of the product.
RemOx® is a registered trademark of Carus Corporation
RemOx® SR+ ISCO Reagent SDS US
923162cp Version#: 01 Revision date:- Issue date: 04 -April-2015 9/9

Table 4
Summary of Well Construction Data
Scotchman #3066
267 Western Boulevard, Jacksonville, NC
CES of NC Project Number 9.0464
Incident #: 20072
Facility ID: 0-020149
Well No.
Boring
Depth
b s
(ft g)
Well
Screen
Interval
(ft, bgs)
Well
Diameter
inches
( )
Top of
Casing
Elevation
(ft)
Installation
Date
Well Status
MW-1
12
2-12
2
98.73
1998
Present
MW-2
12
2-12
2
99.12
1998
Present
MW-3
12
2-12
2
98.68
1998
Present
MW-4
12
2-12
2
99.38
1998
Present
MW-5
12
2-12
2
98.67
1999
Present
MW-6
12
2-12
2
99.38
1999
Present
MW-7
12
2-12
2
99.32
1999
Present
MW-8
12
2-12
2
99.72
1999
Present
MW-9
12
2-12
2
99.37
06/2013
Present
MW-10
12
2-12
2
98.85
06/2013
Present
MW-11
12
2-12
2
99.45
06/2013
Present
MW-12
12
2-12
2
98.82
06/2013
Present
T-1
35
30 - 35
2
98.72
1998
Present
Notes:
- ft, bgs denotes feet below ground surface
-NA denotes data not available
-MW-1, MW-S, MW-10, and T-1 manways reconstructed and TOC resurveyed on June 9, 2017
Revision Date: 8/29/19

N0r1T1-1 CAROUNA DEPARTL(ENT OF ENVIRONMENT. #(CAL Tit AND NATUn AL Fir SOURCES
DIVISION Or ENV1nOf(L(C11rTAL L(ANAGCL(rNT - GnOWIDWATER SECTION
P.O. 13OX 27G87-RALEIGN. Tic 27G11-2Ga7
PI LONE [phone]
CES #97202
WELL CONSTRUCTION RECORD
MW- 4
Quad No _
La t.
Minor t3asin
Basin Codo
tJ
FOR OFFICE USE ONLY
-_ Soria[ No. _
Long.
Scotchman ffi6 f oador L-nl. GW-1 Ent.
L
DRILLING CONTRACTOR &erican [;emediation Technology
-. DRILLER REGISTRATION NUMBER 1509 STATE WELL CONSTRUCTION
PERMIT NUMBER: n/a
I WELL LOCATION: (Show sketch of the location below)
—1 Nearest Town: Jacksonville, NC r County: OnSIOW
(Road. Community. or Subdivision and Lot No.)
` OWNER WC)rSI Py CaMpanieS Inc.
ADDRESS
Street or Houle No.
I,li l M1 nnttn n NC 28406
City or Town State Zip Code
DATE DRILLED 8-6-98 USE OF WELL monitoring
TOTAL DEPTH 12 • • 01 CUTTINGS COLLECTED ® Yes ❑ No
DOES WELL REPLACE EXISTING WELL? ❑ Yes U No
STATIC WATER LEVEL- 3 FT O above TOP OF CASING.
TOP OF CASING IS (1 IR below
F T ABOVE LAND SURFACE.
_ YIELD (gom)- n/a METHOD OF TEST n/a
WATER ZONES (depth) surflclal aqui fier
CHLORINATION: Type n d n a
Amount
CASING:
Depth Wall Thickness
Diameter or Wei ht/Ft.
From 0 To 2 Ft 211 S& 40
From To Ft.
From To
Ft.
1 GROUT:
Depth
From To
DRILLING LOG
Formation Description
see attached
If additional space is needed use back of form.
Material
PVC LOCATION SKETCH
(Show direction and distance from at 'least two Stale Roads.
or other map reference points)
0 Depth Material Method
-- - From To 1 Ft. cement i n-pl ace
From To Ft.
;SCREEN:
Depth Diameter Slot Size
Material
—'' From _2 To 12 Ft. 2 .010 P ti'C
in in.
From To Ft.
itt in.
From To FL
irL n
a®� GRAVEL PACK:
® Depth Size
Material
From— 1.5 To 12 Ft coarse sand
From -- To
Ft,
1 REMARKS:
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRU TE
STANDARDS AND THAT A COPY OF THIS RECORD HAS f EE
see attached
NCAC 2C. WELL CONSTRUCTION
J
Ii REVISED?J90 SIGNATURE OF C ACTOR OR AGENT ATE
Submit original to Division of Environmental Management and rnnv to well owner.

SrA a
COP
S'3 �
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Ina
Well Contractor Company Name
9088 North Field Dr
Street Address
Fort Mill SC 29707
City or Town State Zip Code
(____) [phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) 9
3. WELL USE (Check One Box) Monitoring gg Municipal/Public ❑
Industrial/Commercial D Agricultural ❑ Recovery D Injection ❑
Irrigation❑ Other D (list use)
DATE DRILLED_ 6/13/13
4. WELL LOCATION:
267 Western Boulevard Jacksonville, NC
(Street Name, Numbers, Community, Subdivision,, Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
ESlope ❑Valley DFlat DRidge ❑Other
LATITUDE 34.757805 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE-77.381668 " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: ❑GPS Oropographic map
pocation of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Tip Code
Environmental Services and solutions
Contact Name
PO Box 12055
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
9( 10 ) 470-7066
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES D NO
c. WATER LEVEL Below Top of Casing: FT,
(Use -+- if Above Top of Casing)
3476
d. TOP OF CASING IS 0
FT. Above Land Surface -
'Top of casing terminated
attor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):
METHOD OF TEST
: f. DISINFECTION: Type
Amount
g. WATER ZONES (depth):
:Top 2 Bottom
12 Top Bottom
Top Bottom
Top Bottom
;Top Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
Top__?__ Bottom 12
Ft. 2" 40 pvc
Top Bottom
Ft.
Top Bottom
Ft,
8. GROUT: Depth
Material Method
Top 0 Bottom 1
Ft. Portland pour
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top 2 Bottom 12
Ft. 2 in. 010 in. pvc
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
10. SANDIGRAVEL PACK:
Depth
Size Material
Top 1.5 Bottom 12
Ft. #2 sand
Top Bottom
Ft.
: Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0 / 12 sand
/
12. REMARKS:
shallow water table 2'
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER
�� ��QQ% 6/17/2013
1T11Qi 4i i DF�F��CERTiAED WELL CONTRACTOR DATE
Randv Hoffman
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing, Form GW-1b
1617 Mail Service Center, Raleigh, NC 27699.161, Phone [phone] Rev. 2/09

NoNRESIDENTIAL WELL
_ . North Carolina Department of Environment and Natural
•au�"�"„Km• WELL CONTRACTOR CERTIFICATION #
_ 1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Ina
Well Contractor Company Name
9088 North Field Dr
Street Address
Fort Mill SC 29707
City or Town State Zip Code
(�) [phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) 11
3. WELL USE (Check One Box) Monitoring pg Munlcipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED_ 6/13/13
4. WELL LOCATION:
267 Western Boulevard Jacksonville. NC
(Street Name, Numbers, Community, Subdivision, Lot No.. Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
CiSlope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 34.757805 " DMS OR 3X.XXXXXXXXX DD
LONGITUDE -77.38166E " DMS OR 7X.XXXXXXXXX DD
Latitude/longitude source: Q3PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. FACILITY (Name of the business where the well is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Environmental Services and solutions
contact Name
PO Box 12055
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
9( 10 ) 470-7066
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
Division of Water Quality
3476
: d. TOP F CASING IS 0 FT. Above Land Surface -
'op of casing terminated attor below land surface may require
variance in accordance with 16A NCAC 2C .0118.
e. YIEL
(gpm):
METHOD OF TEST
:.f. DISIN
FECTION: Type
Amount
g. WATER
ZONES (depth):
To
Bottom
12 Top Bottom
Top
Bottom
Top Bottom
Top
Bottom
Top Bottom
Thickness/
:7. CASING:
Depth
Diameter Weight Material
Top 2
Bottom 12
Ft. 2" 40 pva
To
Bottom
Ft.
Top Bottom
Ft.
8. GROUT: Depth
Material Method
Top 0 Bottom 1
Ft. Portland pour
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top__I_ Bottom 12
Ft. 2 in. 010 in. pva
Top Bottom
Ft. In. in.
Top Bottom
Ft. in. in.
: 10. SAND/GRAVEL PACK:
Depth Size Material
Top 1.5 Bottom 12 FL #2 sand
Top Bottom FL
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 / 12
/
/
/
/
Formation Description
sand
12. REMARKS:
shallow water table 2'
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
_ 6/17/2013
51 1• CERTiF�`tD WELL CONTRAC` O�R - DATE
c. WATER LEVEL Below Top of Casing: FT. Randy Hoffman
(Use "+" if Above Top of Casing) : PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Probessing, Form GWAb
1617-Mail Service Center, Raleigh, NG 27699-161, Phone : [phone] ' Rev. 2/09

„.srarEo
NONRESIDENTIAL WELL CONSTRUCTION RECORD
` North Carolina Department of Environment and Natural Resources- Division of Water Quality
• 't",m,• WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Randy Hoffman
Well Contractor (Individual) Name
SAEDACCO Inc
Well Contractor Company Name
9088 North Field Dr
Street Address
Fort Mill SC 29707
City or Town State Zip Code
[phone]
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(If applicable) 12
3. WELL USE (Check One Box) Monitoring 0 Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Other ❑'(Iist use)
DATE DRILLED 6/13/13
4. WELL LOCATION:
267 Western Boulevard Jacksonville, NC
(Street Name, Numbers. Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: COUNTY
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 34.757805 ” DMS OR 3X.XXXXXXXXX DD
LONGITUDE-77.381668 " DMS OR 7X.XXXXXXXXX DD
Latitude/longltude source: ❑3PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form If not using GPS)
5. FACILITY (Name of the business where the well Is located.)
Facility Name Facility ID# (if applicable)
Street Address
City or Town State Zip Code
Environmental Services and solutions
Contact Name
PO Box 12055
Mailing Address
Wilmington NC 28405
City or Town State Zip Code
9( 10 ) 470-7066_
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IM
c. WATER LEVEL Below Top of Casing: FT,
(Use "+" if Above Top of Casing)
3476
: d. TOP OF CASING IS 0 FT. Above Land Surface -
'Top of casing terminated at/or below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm):
METHOD OF TEST
f. DISINFECTION: Type
Amount
g. WATER ZONES (depth):
Top 2 Bottom
12 Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
Top 2 Bottom 12
Ft. 2" 40 pvc
Top Bottom
Ft. —
Top, — Bottom-
Ft.
8. GROUT: Depth
Material Method
Top 0 Bottom 1
Ft. Portland pour
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top 2 Bottom 12
Ft. 2 in. 010 in, __Eye
Top Bottom
Ft. In. in.
Top Bottom
Ft. in. in.
: 10. SANDIGRAVEL PACK:
Depth Size Material
: Top 1.5 Bottom 12 Ft. #2 sand
Top Bottom Ft.
Top Bottom Ft.
: 11. DRILLING LOG
Top Bottom Formation Description
0 / 12 sand
/
12. REMARKS:
shallow water table 2'
: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
16A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
_% _ 6/17/2013
SI - FFfI CERTiPTO WELL CONTRACTOR DATE
Randy Hoffman
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within.30 daYys of dom" letion to: Division of Water Quali Form GW 1b
p ty - Information Processing, Rev. 2/09
1617 Mail Service Center, Raleigh, NC 27699-161, Phone : [phone]