WI0300436_Permit (Issuance)_20200623

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. 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 .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.
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: June 10, 2020 PERMIT NO. W 10300436 (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) Passive Injection System...............................Complete sections B through F, H-N
(4) Small -Scale Injection Operation ......................Complete sections B through N
(5) X 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:
Company Name
Delegated Signatory Authority: Mr. Charles Chiara, Environmental Representative
Mailing Address: 500 Speedway Drive
City: Enon State: OH Zip Code: 45323 County: Clark
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 1

Day Tele No.: 919-516-8069
Cell No.:
937-591-1283
EMAIL Address: cachiarakspeedway.com
Fax No.:
419-420-1495
D. PROPERTY OWNER(S) (if different than well owner)
Company Name PFJ Southeast LLC
Mailing Address: PO Box 54710
City: Lexington State: KY
Zip Code:40555-4710
County:
Day Tele No.: [phone]
Cell No.:
EMAIL Address:
Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: James L. Young, PG, STS / Senior Geologist
Company Name Mid -Atlantic Associates, Inc.
Mailing Address: 409 Rogers View Court
City: Raleigh State: NC
Zip Code: 27610
County: Wake
Day Tele No.: [phone]
Cell No.:
[phone]
EMAIL Address: jyoung(kmaaonline.com
Fax No.:
[phone]
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Speedway 7971
1343 Rock Barn Road
City: Conover County: Catawba Zip Code: 28613
(2) Geographic Coordinates: Latitude": 350 43' 16.15"
Longitude": 81 ° 11' 21.09"
Method of Collection: Google Earth Pro Software
"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
The site is currently regulated by the North Carolina Department of Environmental Quality (NCDEQ),
Division of Waste Management (DWM), Underground Storage Tank (UST) Section. The site is ranked
high risk. The current groundwater cleanup goals are the removal of free product and the North Carolina
Gross Contamination Levels (GCLs). Diesel fuel free product remains present on the water table at wells
MW-3, MW-18, and MW-22. Dissolved -phase benzene concentrations exceed the NCGQS (NC
Groundwater Quality Standards) at several wells. The "area of contaminant plume" indicated below refers
to the approximate area of the diesel fuel free product plume, which is the treatment area for this pilot test.
Land surface area of contaminant plume: 4,050 square feet
Land surface area of inj. well network: 25 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant 3plume area to be treated: 0.6% (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 2

H. INJECTION ZONE MAPS — Attach the following to the notification. Provided in Attachment A
(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.
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.
Approximately 10 ft of free product remains present on the water table at well MW-3. This is despite
running a dual -phase extraction system on site intermittently for a period of 2 years. In an effort to
improve/expedite remediation efforts at Speedway 7971 in Conover NC (Incident #36396), a small pilot
study at the site is being suggested, as follows:
• Shut the treatment system off on June 30, 2020, which coincides with the end of the approved
performance period.
• On or approx. the following day, measure well MW-3 for depth to product (DTP) and depth to
water (DTW), followed by gravity -fed injection of 100 gal of a 4% diluted mixture of
EnviroCleanTM (EC-165) into this well, which exhibited over 10 ft of free product in January 2020.
• On this same day (approx. July 1), the contents inside the external equalization (EQ) tank that
cannot flow by gravity will be manually pumped into the oil/water separator (OWS) and processed
through the system, after which it will be disconnected from the OWS. This will leave us with an
empty tank capable of storing approx. 1,500 gal of liquid. The high level alarm float will remain
in the EQ tank so that it can trigger automatic shutdown of the treatment system.
• On approximately July 15, return to the site to re -measure DTP and DTW, and restart the system,
but only have it pull from Bank 4, which has 2 extraction wells (DRW-7 and DRW-8) near well
MW-3. Run the system until the EQ tank is full, which should take about 2 days or less.
• The following week (approx. July 22), return to the site to re -measure DTP and DTW in well MW-
3 and inspect the contents within the EQ tank to determine if the contents could be processed
through the treatment system or would need to be removed via vacuum truck. If deemed necessary,
collect a sample of the contents in the EQ tank and submit for lab testing.
The pilot study described above is intended to determine if surfactant injection events could be used to
"loosen" product thought to be adhering tightly to soils. EnviroCleanTM EC-165 is a widely -used surfactant
which has been used at other sites for this type of use case, and falls under the permit -by -rule injection
permit category.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant. Attach additional sheets if necessary.
Provided in Attachment B
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 h!W:Hdeq.nc.gov/about/divisions/water-
resources/water-resources-Dermits/wastewater-branch/eround-water-Drotection/around-water-aDDroved-ini ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919
807-6496).
Injectant: EnviroClean EC-165
Volume of injectant:
Concentration at point of injection: 4%
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 3

Percent if in a mixture with other injectants:
K, WELL CONSTRUCTION DATA Provided in Attachment C
(1) Number of injection wells: 0 Proposed 1 Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-1 s, 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
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Only existing well MW-3 will be used for injection (none are proposed). The injection event is currently
scheduled for the week of July 1, 2020, followed by operation of the existing DPE treatment system within 2
weeks after the injection event. The surfactant injection will take approximately 4 hours for completion and the
treatment system is expected to run for approximately 40 hours. Free product gauging and well sampling will be
conducted approximately two to four weeks following completion of the treatment system operation.
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.
The site is currently regulated by the NCDEQ DWM UST Section. Sampling of 22 site monitoring wells is
performed on a 6-month schedule with results reported to the UST Section. Please note that EnviroClean is a
proprietary blend of water -based, biodegradable surfactants that was specifically engineered as a cleanup/
mitigation agent and vapor suppressant for use on a wide range of hydrocarbon products. EnviroClean, in and
of itself, does not cause or catalyze specific chemical reactions, nor does it contain any bacteria cultures. The
basic principle of EnviroClean is to emulsify and encapsulate hydrocarbon particles. As such, the
injection activity is not anticipated to result in violations of the NCGQS for additional compounds other than
those already noted from the previous gasoline and diesel fuel releases releases.
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 1 SA NCAC 02C 0200 Rules. "
Charles Chiara, Env. Representative
Signature of Applicant Print or Type Full Name and Title
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 wells) conform to the Well Construction Standards
(1 SA NCAC 02C . 0200). "
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 4

"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 and Title
*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]
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 5

ATTACHMENT A
DRAWINGS
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 6

N
REFERENCES:
1. NEWTON, NC DIGITAL RASTER GRAPHIC FILE, US GEOLOGICAL SURVEY.
SCANNED FROM 1:24,000-SCALE USGS TOPOGRAPHIC MAP: NEWTON, NC,
1993.
2. INSET MAP DIGITAL DATA FROM 2002 NATIONAL TRANSPORTATION ATLAS,
BUREAU OF TRANSPORTATION STATISTICS, WASHINGTON, D.C.
3. SUBJECT SITE PROPERTY BOUNDARY DATA FROM CATAWBA COUNTY GIS.
Mid Atlantic
Engineering & Environmental Solutions
1
TOPOGRAPHIC SITE MAP
SPEEDWAY 7971
1343 ROCKBARN ROAD
CONOVER, NORTH CAROLINA
SCALE: 1:12,000
500 1,000
DRAWN
BY: RDC
DRAFT
CHECK:
ENG.
CHECK:
APPROVAL:
� Feet
2,000
DATE:
JANUARY 2018
JOB NO:
OOOR1915.52
GIS NO:
06G-R1915.52-1
DWG NO: 1.1

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�9. N� 3 0 / MW-5 Ln (n
° v < (80.70) _ CD
MW-8 / r
I 20,000-GALLON (78'97) / VENT PIPES /s r
DIESEL USTs
° MW-13 /� o
♦ (NM) t 12,000-GALLON > O
♦ I REGULAR GASOLINE w U
/ASPHALT i UST 05 Q -v
v Q
LEGEND E
MW-1 MONITORING WELL LOCATION ENTRANCE / w U
MW-25 MONITORING WELL LOCATION FOR THE ASSESSMENT
AND RECOVERY OF FREE PRODUCT W
O MW-10D DEEP MONITORING WELL LOCATION (TYPE III) z
® VE-OW-1 VAPOR EXTRACTION PILOT TEST WELL LOCATION •SP WATER SPIGOT (FP) FREE PRODUCT PRESENT IN WELL; MEASUREMENT NOT USED IN CONTOURS Ld
LIGHT POLE O FIRE HYDRANT (78.08') GROUNDWATER ELEVATION (AT LOCATION) 0 30' Ld
UST PRODUCT LINES —sss— SEWER LINE GROUNDWATER FLOW DIRECTION
—TTT— TELEPHONE LINE Ld
—eEe— ELECTRICAL LINES 78' ESTIMATED WATER TABLE CONTOUR SCALE: 1"= 30' �
PROPERTY BOUNDARY —wWw— WATER LINE

CONNECT TO EXISTING /
STORM SEWN,
25' x /
SYSTEM FENCINGNG
WITH 12' GATE
TRUCK
PARKING
MW-20
s
� MW-21
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MONITORING WELL LOCATION
EMW-10D
DEEP MONITORING WELL LOCATION (TYPE III)
••
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® VE-OW-1
VAPOR EXTRACTION PILOT TEST WELL LOCATION
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—s—s—E—
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O
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REMEDIAL SYSTEM UNDERGROUND UTILITY TRENCH—T—T—T—
TELEPHONE LINE
/
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LEGEND 00
0 MW-1 MONITORING WELL LOCATION 00 O O
0 MW-10D DEEP MONITORING WELL LOCATION (TYPE III) N
• SB-1 SOIL BORING LOCATION (MARCH 200B) CD
OGP-1 GEOPROBE BORING LOCATION (AUGUST 2008) J - O
LL_
m FP-1 FREE PRODUCT PROBES - N m � U�
E LIGHT POLE WILCOHE55 LLJ
O Q7
-• - UST PRODUCT LINES
—E—E—c— ELECTRICAL LINES (OVERHEAD) N381 STORE ASPHALT 0- O
PROPERTY BOUNDARY LJ CD
�► ESTIMATED GROUNDWATER FLOW DIRECTION to z � O
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= U
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DGP-33 <•• <•• O,• a.•
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i! om am wm ¢m
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MW-4 �• G %!i
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PUMP ISLAND / �. Z
h•/• DGP=38 AND DISPENSERS ENTRANCE /% Q
DGP-30 O O Z
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DGP-40 T1Ch 36 UST i!% c I Q�Z U
pJ/ �y.�, / UNDERGROUND _
DGP-28 OQyI 0MW-(i SG/ .�'�•�: ELECTRICAL LINES In Z U) m I-
GqS\ /.�i - CONCRETE " MW-10D -'! �- / O ElfO of
OGP-39 � ` .ter DGP-35 APRON : MW-9 " :/ N 4 ... • GP-169 MW-7 c% U ¢ U Z
DGP-27 i.� GP-16 6 / U U U O LLI O
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/ \ APRON \\ A GP-17B cO 3r n > F
PUMP \..� / J It O Za
CONTAINMENT 'n / O Z J
i \•\•�• SUMP F
GP-17 / O Q
DGP-41 MW- \ (RELEASE POINT) GP-26 ��;\ ® _1 t/ j - U
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a 8 DGP-42 �•�\ /n \`\ \ \ \ DGP-18
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a GP-23 W-8 v GP-ZZZZZZ00000O A'
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♦ / H y Z
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�I 12,000-GALLON �I py
REGULAR GASOLINE �` w �1 O
♦ c c/ UST L V § Q
♦
rA a
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SCALE: 1"= 30' W Elf

C9-C22 STGW
MSCC ISOPLETH
(34 mg/kg)
110'
50'
LEGEND
SCREENED INTERVAL
— �— — — — WATER LEVEL B/13/OB UNLESS NOTED
M/C MEDIUM TO COARSE SAND
A SILTY CLAY [CL] OR [CH]
B SUGHTLY TO MODERATELY CLAYEY SILT, MICACEOUS [ML]
DIESEL FUEL
c
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o CONCRETE
CONCRETE m I I O1 I� TOG-
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99.87' 99.61, 100.0'
A A A
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B
B
JN< A 1ND
TD=20' TD=20'
_s
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TO =40 IC5-CB
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S (8/14/08) MI—i WATER "'—" TD=38,
B 3.
540 NOT SAMPLED
AUGUST 200E
E I Z.bUU (ND IN MAY 2008)
B WITH QUARTZ AND GNEISS FRAGMENTS
68'=BLOW COUNTS>50 OVER 5 INCHES
WHITE AND BLACK SILT tt WEATHERED BROWN,
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I MW-10D WATER I
NOTE DATA LEGEND
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ATTACHMENT B
INJECTANT INFO
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 7

ENVIRO�CU
SAFETY DATA SHEET
SECTION 1 MATERIAL IDENTIFICATION
PRODUCT NAME / DESCRIPTION: EnviroClean
DISTRIBUTED / MANUFACTURED BY:
ENVIRO CLEAN PRODUCTS & SERVICES DATE: 05/18/2015
PO BOX 721090 PHONE: [phone]
OKLAHOMA CITY, OK 73172 EMERGENCY PHONE: [phone]
FUNCTION: Industrial Cleaner and Remediation Agent
SECTION 2 HAZARD IDENTIFICATION
CLASSIFICATION:
Acute Toxicity- Oral
Category 4
Skin Corrosion/Irritation
Category 3
Eye Damage/Irritation
Category 2B
Target Organ Specific Toxicity: Single
I Category 3
Target Organ Specific Toxicity: Chronic
I Category 2
SIGNAL WORD:
WARNING!
HAZARD STATEMENTS:
Harmful if swallowed
Causes mild skin irritation
Causes eye irritation
May cause respiratory irritation
May cause damage to organs through prolonged or repeated exposure
> <s !Rr"04
PRECAUTIONARY STATEMENTS:
Obtain special instructions before use
Do not handle until all safety precautions have been read and understood
Use personal protective equipment as required
Avoid breathing dust/fume/gas/mist/vapors/spray
Use only outdoors or in a well ventilated area
Wash all exposed skin thoroughly after handling
Avoid release to the environment

ENVIRO�CU
Store in a well ventilated place
TOXICITY INFO:
See Section 11.
SECTION 3 HEALTH HAZARDS
CHEMICAL NAME
(Proprietary Formula)
%WIW CAS NUMBER
Proprietary Blend of Ethoxylated Octylphenolic Surfactants
Non-ionic water based liquid blend, concentrate
This product does not contain any hazardous ingredients as defined by CERCLA and California's Prop. 65.
SECTION 4
Potential acute health effects:
FIRST AID
Eyes: May cause irritation with redness and pain.
Skin: May cause irritation with redness and pain.
Inhalation: Inhalation may cause irritation.
Ingestion: Ingestion may cause severe irritation, corrosion/ulceration, nausea, and vomiting.
Medical Conditions Aggravated by Exposure:
None known.
Eye Contact: In case of contact, immediately flush eyes with cool running water. Lift and
separate eyelids while flushing with plenty of water for at least 15 minutes. Get
medical attention.
Skin Contact: Wash with soap and water. Get medical attention if irritation occurs. Wash
clothing before reuse. Destroy contaminated shoes.
Inhalation: Remove victim to fresh air and keep at rest in a position confortable for breathing.
If not breathing, give artificial respiration. If breathing is difficult, give oxygen.
Seek medical attention if symptoms develop.
Ingestion: Do NOT induce vomiting unless directed to do so by medical personnel. Never
give anything by mouth to an unconscious person. If large quantities of this
material are swallowed, call a physician immediately. Give plenty of water.
SECTION 5 FIRE FIGHTING MEASURES
Fire Hazard Classification (OSHA/NFPA): 0
Extinguishing Media: As required for fire being fought.
Special Fire Fighting Procedures: Use self-contained breathing apparatus.
Hazardous combustion products: No known.

ENVIRO�CU
SECTION 6 ACCIDENTAL RELEASE MEASURES
Personal Precautions, PPE, and Emergency Procedures:
Wear protective clothing as described in Section 8 of this safety data sheet.
Containment Procedures: Stop the flow of material, if this is without risk. Wear appropriate protective
equipment and clothing during clean-up. Do not allow the spilled product to enter
public drainage system or open water courses.
Clean -Up Procedures: Sweep up or gather material and place in appropriate container for disposal.
Wash spill area thoroughly. Wear appropriate protective equipment during
cleanup. Dispose of collected material according to regulations.
SECTION 7 HANDLING AND STORAGE
Handling: Avoid contact with eyes, skin and clothing. Do not take internally. For industrial
use only. Wash after handling. Don't breathe dust, vapor, or gas. Keep this and
all chemicals out of reach of children.
Storage: Keep away from heat, sparks, and open flames. Prevent spills. Keep container
tightly closed and in a cool, well -ventilated place away from incompatible
materials. Empty product containers may contain product residue, do not reuse.
SECTION 8
PERSONAL PROTECTION / EXPOSURE CONTROLS
Ventilation System:
Always keep exposure below permissible exposure limits. In general, dilution
ventilation is a satisfactory health hazard control for this substance. However, if
conditions of use create discomfort to the worker, a local exhaust system should
be considered.
Airborne Exposure Limits: None Established.
Personal Protection:
As prescribed in the OSHA Standard for Personal Protective Equipment (29 CFR
1920.132), employers must perform a Hazard Assessment of all workplaces to
determine the need for, and selection of, proper protective equipment for each
task performed.
Eyes:
Wear face shield, safety glasses, or chemical goggles.
Hands & Skin:
For prolonged or repeated handling, use impervious gloves. Gloves should be
tested to determine suitability for prolonged contact. Use of impervious apron
and boots are recommended.
Respiratory:
If ventilation is not sufficient appropriate NIOSH/MSHA respiratory protection
must be provided.
Work Practices:
Eye wash fountain and emergency showers are recommended.
SECTION 9 TYPICAL PHYSICAL AND CHEMICAL PROPERTIES
Physical Form: Liquid
Color: Red

ENVIRO�CU
Odor:
Wintergreen
Odor Threshold:
NE
pH:
8.5+/-0.5
Boiling Point:
NE
Melting Point:
N/A
Flash Point:
>200 deg F
Evaporation Rate (Butylacetate = 1)
NE
Flammability:
Non -Flammable
UEL:
NE
LEL:
NE
Vapor Pressure:
NE
Vapor Density:
NE
Specific Gravity (Water =1):
1.03 +/- .05
Solubility Water:
Complete
Partition Coefficient:
NE
Auto -ignition Temperature:
NE
Decomposition Temperature:
NE
Viscosity (CPS):
NE
SECTION 10 STABILITY AND REACTIVITY
Stability: This product is stable under normal temperatures and pressures.
Incompatibility: Strong Oxidizers and strong acids.
Decomposition Products: No Known hazardous products.
Conditions to Avoid: Sparks/flames/high heat.
SECTION 11 TOXICOLOGICAL PROPERTIES
Raw Material Test Result Route Species
N/A
See Section 4 for symptoms.
CARCINOGENICITY:
No known carcinogens, mutagens, or reproductively toxic ingredients
SECTION 12 ECOLOGICAL INFORMATION
Raw Material Test Result Time Species
N/A
PERSISTENCE & DEGRADABILITY:
NE

ENVIRO�CU
BIOACCUMULATION:
NE
MOBILITY
NE
SECTION 13 DISPOSAL CONSIDERATIONS
Whatever cannot be saved for recovery or recycling should be managed in an appropriate and approved
waste disposal facility. Processing, use, or contamination of this product may change the waste
management options. State and local disposal regulations may differ from federal disposal regulations.
Dispose container and unused contents in accordance with federal, state, and local requirements.
SECTION 14 TRANSPORT INFORMATION
Not Regulated by DOT or IATA.
SECTION 15 REGULATORY INFORMATION
US FEDERAL REGULATIONS
SARA (SUPERFUND AMENDMENTS AND REAUTHORIZATION ACT):
SARA 302 EXTREMELY HAZARDOUS SUBSTANCES LIST: NA
SARA 312 HAZARD CATEGORY:
SARA 313 TOXIC CHEMICALS LIST:
M
NA
CERCLA (COMPREHENSIVE ENVIRONMENTAL RESPONSE. COMPENSATION AND
LIABILITY ACT): NA
RCRA (RESOURCE CONSERVATION AND RECOVERY ACT) LISTED HAZARDOUS WASTES:
NA
CWA (CLEAN WATER ACT) LISTED SUBSTANCES: NA
FDA (FOOD AND DRUG ADMINISTRATION): NA
TOXIC SUBSTANCES CONTROL ACT (TSCA): NA
IATA: NA

ENVIRO�CLEAN
NFPA HAZARD INFORMATION SIGN
101
4 - DEADLY
3 - EXTREME DANGER
2 - HAZARDOUS
1 - SLIGHTLY HAZARDOUS
0 - NORMAL MATERIAL
[0]
FLASH POINTS:
4
- BELOW 73 F
3
-BELOW 100 F
2
- BELOW 200 F
1
- ABOVE 200 F
0
- WILL NOT BURN
[01 REACTIVITY HAZARD (YELLOW DIAMOND)
4 - MAY DETONATE
3 - SHOCK AND HEAT MAY DETONATE
2 - VIOLENT CHEMICAL CHANGE
1 - UNSTABLE IF HEATED
0 - STABLE
[] SPECIFIC HAZARD (WHITE DIAMOND)
OXY
OXIDIZER
ACID
ACID
ALK
ALKALI
COR
CORROSIVE
W
USE NO WATER
SECTION 16 OTHER INFORMATION
THIS INFORMATION IS OFFERED IN GOOD FAITH AS TYPICAL VALUES AND NOT AS A
PRODUCT SPECIFICATION. NO WARRANTY, EXPRESSED OR IMPLIED, IS HEREBY MADE. THE
RECOMMENDED INDUSTRIAL HYGIENE AND SAFE HANDLING PROCEDURES ARE BELIEVED
TO BE GENERALLY APPLICABLE. HOWEVER, EACH USER SHOULD REVIEW THESE
RECOMMENDATIONS IN THE SPECIFIC CONTEXT OF THE INTENDED USE AND DETERMINE
WHETHER THEY ARE APPROPRIATE.

ATTACHMENT C
WELL CONSTRUCTION DATA
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 8

a
1, WELL CONTRACTOR:
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Depanment of Environment mid Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION it
Tommy Bolyard
Well Contractor (Individual) Name
Environmental Drilling & Probing Services, LLC (EDPS)
Well Contractor Company Name
STREET ADDRESS 17538 Greenhill Road
Charlotte NC 2827E
City ar Town State Zip Code
704 )_ 607-7529
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID ktit applicable) NA
STATE WELL PERMIT#(il applicable) NA
DWQ or OTHER PERMIT #(if applicable) NA
WELL USE (Check Applicable Box) Monitoring 91 MunicipallPublic ❑
Industrial/Commercial ❑ Agricullural ❑ Recovery D Injection ❑
Irrigation❑ Other ❑ (list use)
DATE DRILLED 3/27/08
TIME COMPLETED NA AM❑ PM El
3. WELL LOCATION:
CITY: Conover COUNTY
1343 Rock Dam Road, Conover, North Carolina
IStreet Name, Numbers, Community, Subdidsian, Lai No., Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING:
❑Slope ❑Valley ®Flat. ❑Ridge ❑ Other
(check appropriate box)
LATITUDE 3 NA May be in degrees,
minutes, seconds or
LONGITUDE NA in a decimal format
Latitude/longitude source: ❑GPS ❑Topographic map
Oocation of well must be shown on a USGS loon map and
attached to this loan if not using GPS)
4. FACILITY -is me name al me business where me well Is loaned.
FACILITY ID #(if applicable)
NAME OF FACILITY WilcoHess Travel Plaza 4351
STREET ADDRESS
1343 Rock Bam Road
Conover
NC
City or Town
Slate Zip Code
CONTACT PERSON
S. Williams
MAILING ADDRESS
University Plaza
Winston-Salem
NC
City or Town
State Zip Code
NA 1 NA
Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 37.
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C
c. WATER LEVEL Below Top of Casing: NA FT.
(Use'+• if Above Top of Casing)
3307
d. TOP OF CASING IS 0
FT. Above Land Surface'
'Top or casing terminated atlor below land surface may require
a variance in accordance with
15A NCAC 2C .0118,
e. YIELD (gpm): NA
METHOD OF TEST NA
L DISINFECTION: Type
NA Amount NA
g. WATER ZONES (depth):
From NA To NA
From NA To NA
From NA To NA
From NA To NA
From NA TO NA
From NA To NA
G. CASING:
Thickness/
Depth
Diameter Wehlg�r�
2'
MalP�nal
From 27
To D
Ft.
sc
PP�Vr
From
To
Ft.
From
To
FI.
7. GROUT:
Depth
Material
Method
From 25
To 22
Ft.
Bentonite
Tremie
From 22
To_ _
Ft
Grout
Tremie
From To Ft.
B. SCREEN: Depth Diameter Slot Size Material
From 37 To 27 Ft. 2 in, 0.01 in. PVC
From_ To Ft.—M. in.
FromTo— FL_in. in.
9. SANDIGRAVEL PACK:
Depth Size Material
From 37 TO 25 Ft. #2,med Sand
From Tc Ft.
From To Ft.
10. DRILLING LOG
From To Formation Description
0-37 (clay/silt)
11. REMARKS:
Well ID#: MW- 3
[DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT COPY OF THIS
RECORO HAS BE OVIDEO TOTHE , OWNER.
4116/08
SIGNATUR OF CERZIFIED WELLp69NTRACTOR DATE
Tik tit U Bd�., rzrr-r`
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt., Form
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. GW-1b
Rev.7105

Dfeet
DEPTH 1
TVA Reading
PPm) -'
DESCRIPTION
0.0 — 4.0
—
Asphalt at land surface. Hand auger, no samples
collected
4.0 — 8.0
7.01
Reddish -brown silty CLAY [CH]
8.0 —12.0
141
Reddish -brown clayey SILT [ML]
12.0 —16.0
49.11
Light brown micaceous clayey SILT [ML]
16.0 — 20.0
7.80
Same as 12.0 —16.0
20.0-24.0
4.47
Light brown and reddish -brown and black
micaceous slightly clayey SILT [ML]
24.0 — 28.0
4.40
Same as 20.0 — 24.0
28.0- 32.0
4.22
Same as 20.0 — 24.0
Boring terminated at 32.0 feet
TEST BORING LOG
REMARKS: Soil samples collected
using direct -push technology (Geoprobe).
BORING NUMBER: MW-3
Well boring advanced using hollow stem
DATE DRILLED: 3/28108
augers. Type II Monitoring Well
PROJECT NUMBER: R7915.OB
installed upon boring completion. See
PROJECT: WILCOHESS #351
Well Construction Record for details.
PAGE 1 OF 1
MID -ATLANTIC ASSOCIATES, INC.
Engineering and Environmental Solutions

TABLE 7;1
MONITORING WELL CONSTRUCTION INFORMATION
WILCOHESS #351
CONOVER; NORTH'CAROLINA
DWM INCIDENT NO. 36396 ,
MID -ATLANTIC JOB°NO: 00OR1915.01
WELL NUMBER.
-' DIAMETER
(INCHES)
CONSTRUCTION
DATE
CASING DEPTH
(FEET BLS)
SCREENED INTERVAL
(FEET BLS)
MW-1
2
3/27/2008
33
23 - 33
M W-2
2
3/27/2008
34
24 - 34
MW-3
2
3/28/2008
37
27 - 37
MW-4
2
3/28/2008
40
25 - 40
MW-5
2
5/2/2008
38
23 - 38
MW-6
2
8/11/2008
37
27 - 37
MW-7
2
B/11/2008
36
26 - 36
MW-8
2
8/8/2008
37
27 - 37
MW-9
2
8/8/2008
36
26 - 36
MW-10d
6/2
8/12-14/2008
65/80
75 - 80
FP-1
1
8/11/2008
18
B - 18
FP-2
1
8/11/2008
18
8-18
NOTES:
BLS - Below land surface