WI0300210_Complete File - Historical_20180321

NC_
Water Resources
Environmental Quality
I/VJ-0 300 210
March 21, 2018
CERTIFIED MAIL # 7012 1640 0000 9792 3230
RETURN RECEIPT REQUESTED
Sharon Ghiold
Former NCDOT Asphalt Testing Site #2-66
1557 Mail Service Center
Raleigh, NC 27699-1557
Subject. Notice of Expiration (NOE)
UIC In -situ Groundwater Remediation Injection Permit
Permit No. WI0300210
Iredell County
Dear Ms. Ghiold:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
groundwater remediation injection well system located at 164 Bostian Bridge Dr., Statesville, NC
28677 was issued on 11/09/2012, and expired on 10/31/2017.
Please note the following:
• If you intend to conduct additional injections or pursue any injection -related activities that
are beyond the scope of the permit referenced above, you should submit an application to
renew the permit (attached) and any well construction records (GW-1) or abandonment
records (GW-30) if not previously submitted.
• If you do not intend to conduct further injection activities, per 15A NCAC 2C
.0225(k)(2)(C) and the MONITORING AND REPORTING REQUIREMENTS section of
your permit, a Final Project Evaluation (FPE) is due within 9 months after completion
of the injection operation. If it has been 9 months or longer since injection activities were
completed, please submit the required FPE. When all.permit conditions are satisfied, a
Permit Completion Letter will be sent and the permit will be closed.
Nothing Compares-7,,
State of North Carolina I Environmental Quality I Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919-707-9129

If any injection well(s) are no longer being used for any purpose, they should be permanently
abandoned per to the regulatory requirements specified in rule 15A NCAC 02C .0240. If any
injection well(s) are permanently abandoned, copies of the GW-30s must be submitted to our
office. NOTE: injection wells using Direct Push/Geoprobe® technology are considered wells and
GW-1 and GW-30s are required to be submitted. However, if the well construction is essentially
the same, only one well construction/abandonment record is needed. Just indicate the number of
wells in the Remarks/Comments line of the form. If injection wells are converted to monitoring
or other use, indicate on Injection Well Status Form (GW-68). These can be downloaded from
DWR's website.
Within 30 days of receipt of this letter, please provide any of the above information and/or your
intentions regarding the permit. Send referenced forms to the address below:
Division of Water Resources
UIC Program
Attn: Shristi Shrestha
1636 Mail Service Center
Raleigh, NC 27699-1636
Please contact Shristi Shrestha, 919-807-6406, [e-mail] if you have any
questions. Please include the permit number on any correspondence, or in the subject line of any
emails regarding this permit.
Best Regards,
041WIVI
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Mooresville- Regional Office — WQROS w/out enclosures
Central Files - Permit No. WI0300210 w/out enclosures
Matt Bramblett, DSCA Program, 2923 S Tryon St., Charlotte, NC 28203-5449

Water Resources w
Environmental Quality
March 21, 2018
CERTIFIED MAIL # 7012 1640 0000 9792 3230
RETURN RECEIPT REQUESTED
Sharon Ghiold
Former NCDOT Asphalt Testing Site #2-66
1557 Mail Service Center
Raleigh, NC 27699-1557
Subject: Notice of Expiration (NOE)
UIC In -situ Groundwater Remediation Injection Permit
Permit No. WI0300210
Iredell County
Dear Ms. Ghiold:
ROY COOPER
Governor
MICHAEL S. REGAN
Secretary
LINDA CULPEPPER
Interim Director
The Underground Injection Control (UIC) Program of the North Carolina Division of Water
Resources (DWR) is entrusted to protect the groundwater quality and resources of the State of
North Carolina, and is responsible for the regulation of injection well construction and operation
activities within the state. Our records indicate that the above -referenced operating permit for the
groundwater remediation injection well system located at 164 Bostian Bridge Dr., Statesville, NC
28677 was issued on 11/09/2012, and expired on 10/31/2017.
Please note the following:
• If you intend to conduct additional injections or pursue any injection -related activities that
are beyond the scope of the permit referenced above, you should submit an application to
renew the permit (attached) and any well construction records (GW-1) or abandonment
records (GW-30) if not previously submitted.
• If you do not intend to conduct further injection activities, per 15A NCAC 2C
.0225(k)(2)(C) and the MONITORING AND REPORTING REQUIREMENTS section of
your permit, a Final Project Evaluation (FPE) is due within 9 months after completion
of the injection operation. If it has been 9 months or longer since injection activities were
completed, please submit the required FPE. When all permit conditions are satisfied, a
Permit Completion Letter will be sent and the permit will be closed.
Nothing Compares? i- ._
State of North Carolina I Environmental Quality I Division of Water Resources
Water Quality Regional Operations Section
1636 Mail Service Center I Raleigh, North Carolina 27699-1636
919-707-9129

If any injection well(s) are no longer being used for any purpose, they should be permanently
abandoned per to the regulatory requirements specified in rule 15A NCAC 02C .0240. If any
injection well(s) are permanently abandoned, copies of the GW-30s must be submitted to our
office. NOTE: injection wells using Direct Push/Geoprobe® technology are considered wells and
GW-1 and GW-34s are required to be submitted. However, if the well construction is essentially
the same, only one well construction/abandonment record is needed. Just indicate the number of
wells in the Remarks/Comments line of the form. If injection wells are converted to monitoring
or other use, indicate on Injection Well Status Form (GW-68). These can be downloaded from
DWR's website.
Within 30 days of receipt of this letter, please provide any of the above information and/or your
intentions regarding the permit. Send referenced forms to the address below:
Division of Water Resources
UIC Program
Attn: Shristi Shrestha
1636 Mail Service Center
Raleigh, NC 27699-1636
Please contact Shristi Shrestha, 919-807-6406, [e-mail] if you have any
questions. Please include the permit number on any correspondence, or in the subject line of any
emails regarding this permit.
Best Regards,
Al"�
Shristi Shrestha
Hydrogeologist
Division of Water Resources
Water Quality Regional Operations Section
Enclosures
cc: Mooresville- Regional Office — WQROS w/out enclosures
Central Files - Permit No. WI0300210 w/out enclosures
Matt Bramblett, DSCA Program, 2923 S Tryon St., Charlotte, NC 28203-5449

From: Steve Libbey [mailto:[e-mail]
Sent: Tuesday, May 15, 2018 3:53 PM
To: Shrestha, Shristi R <[e-mail]>
Cc: Pitner, Andrew <[e-mail]>; Matt Bramblett <[e-mail]>
Subject: [External] W10300210 NCDOT Site #2-66
Shristi, as requested, an electronic copy of the August 10, 2016 Semi -Annual Groundwater Monitoring Report for the
above -referenced site is attached.
Please let me know if you need anything else.
Thanks,
Steve
.Steve Libbey, PG, Project Manager
Hart & Hickman, PC
2923 S Tryon Street, Suite 100 • Charlotte, NC 28203
Direct: 704-887-4606 • Mobile: [phone]
. www.harthickman.com loom

30 0 21 b
Shrestha, Shristi R
From:
Pitner, Andrew
Sent:
Wednesday, May 16, 2018 12:35 PM
To:
Shrestha, Shristi R
Cc:
Watson, Edward M
Subject:
FW: [External] WI0300210 NCDOT Site #2-66
Hi Shristi,
We did have the 2016 report, just not the new 2018 cover letter. After a quick look at the data again and their notes
on turbidity potentially being associated with the uptick in the metals (and confounding info that upgradient deep
wells also had metals increases), MRO is ok with rescission of this permit. Let me know if you need additional input
from the MRO.
Andrew
From: Pitner, Andrew
Sent: Wednesday, May 16, 2018 12:02 PM
To:'Steve Libbey' <[e-mail]>
Cc: Matt Bramblett <[e-mail]>
Subject: RE: [External] W10300210 NCDOT Site #2-66
Thanks for the clarification.
Andrew
From: Steve Libbey [mailto:[e-mail]]
Sent: Wednesday, May 16, 2018 11:58 AM
To: Pitner, Andrew <[e-mail]>
Cc: Matt Bramblett <[e-mail]>
Subject: RE: [External] W10300210 NCDOT Site #2-66
Andrew, there is no April 3, 2018 report. We resent the August 2016 with a cover letter explaining that the report
fulfills the requirements of the Final Project Evaluation (FOE). I have attached the cover letter and report sent in
April 2018.
Please let me know if you need anything else.
Thanks,
Steve
From: Pitner, Andrew <[e-mail]>
Sent: Wednesday, May 16, 2018 9:51 AM
To: Steve Libbey <[e-mail]>; Shrestha, Shristi R <[e-mail]>
Cc: Matt Bramblett <[e-mail]>
Subject: RE: [External] W10300210 NCDOT Site #2-66
Hi Steve,
Is there any chance you can send along the April 3, 2018 Final Project Evaluation Report? MRO does not seem to
have a copy of that to review. Thanks,

DO
VtaejI Underground Injection Control
�t(-2A-dour Permit Application
NC DOT ATS No. 2-66
v00
I T
#)
164 Bostian Bridge Road
Statesville, North Carolina
H&H Job No. DOT-404
August 24, 2012
RECEIVEDIDENHWO
SEP 0 6 2012
Aquifer Protection Section l
fr
.14
hart '%• hickman
W_
SMARTER ENVIRONMENTAL SOLUTIONS
2923 South Tryon Street, Suite 100 I 3334 Hillsborough Street
Charlotte, NC 28203 Raleigh, NC 27607 www.harthickman.com
704.586.0007 main 919.847.4241 main

List of Tables
Table A-1
Summary of Post -Excavation Soil Analytical Results
Table A-2
Summary of Saprolite Groundwater Analytical Results
Table A-3
Summary of Bedrock Groundwater Analytical Results
Table A-4
Summary of Surface Water Analytical Results
Table B-1
Monitoring Well Construction Details and Groundwater Elevation Data
Table G-1
Water Supply Well Inventory
Table G-2
Summary of Water Supply Well Analytical Results
List of Figures
Figure H-1
Site Location Map
Figure H-2
Site Map and Cross -Section Location Map
Figure H-3
Confirmatory Soil Sample Locations and Soil Excavation Extent
Figure H-4
Estimated Horizontal Extent of TCE in Shallow Ground Water
Figure H-5
Cross -Section A -A' and Estimated Vertical Extent of TCE
Figure H-6
Cross -Section B-B' and Estimated Vertical Extent of TCE
Figure H-7
Estimated Shallow Groundwater Potentiometric Map — February 2012
Figure H-8
Proposed EOS® Injection Points
Figure H-9
Temporary Well Diagram and Typical Injection Equipment Schematic
Figure H-10
Water Supply Well Location Map
List of Appendices
Appendix A
Site History
Appendix B
Geology and Hydrogeology
Appendix C
Injection Fluid Composition
Appendix D
Injection Rationale
Appendix E
Injection Procedure and Equipment
Appendix F
Monitoring Plan
Appendix G
Well Data and Receptor Survey Information
Appendix H
Maps
s:tnaa•masterprojects\ncdot -dot\dot-004statesville2-661cosinjectionkicpennit applicationtinjeetionapplication documentation final.doc hart : hickman
SMARTER ENNRONMEPM SOWTIONS

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells — In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
• Do not use this form for remediation systems that extract contaminated groundwater, treat it, and reinject the treated groundwater.
• Submit TWO copies of the completed application and all attachments to the address on the last page of this form.
• Any changes made to this form will result in the application package being returned.
Application Number (to be completed by DWQ): CAJ
I. GENERAL INFORMATION:
1. Applicant's Name (generally the responsible party): NCDOT— Roadside Environment Unit
2. Signing Official's Name*: Thomas C. Niver for NCDOT Title: REE III
* Signing Official must be in accordance with instructions in part VI on page 7.
Mailing address of applicant: 1557 Mail Service Center
City: Raleigh State: NC Zip: 27607
Telephone number: [phone] 7 0 -2 -1 172Fax number: [phone]
3. Property Owner's Name (if different from Applicant): Superior Properties of Iredell LTDP ET AL
4. Property Owner's mailing address: PO Box 5339
City: Statesville State: NC Zip: 28687
5. Name and address of contact person who can answer questions about the proposed injection project:
Name: Matt Bramblett Title: Principal
Company: _Hart & Hickman. PC
Address: 2923 South Tryon Street, Suite 100
�4
City: Charlotte State: NC Zip: 28203
Telephone number: [phone] Fax number: [phone]
Email Address: [e-mail]
II. PERMIT INFORMATION:
I . Project is: © New Modification of existing permit Q Renewal of existing permit without modification
Renewal of existing permit with modification
2. If this application is being submitted for renewal or modification to an existing permit, provide:
existing permit number and the issuance date
For renewal without modifications, fill out sections I & II only, sign the certification on the last page of this
form, and obtain the property owner's signature to indicate consent (if the applicant is not the owner).
For all renewals, submit a status report including monitoring results of all injection activities to date.
Revised 6/09 UIC-50T Pagel of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells — In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
III. INCIDENT & FACILITY DATA
A. FACILITY INFORMATION
1. Facility name: Former NCDOT Asphalt Testing Site No 2-66 (currently occupied by Maymead Inc)
2. Complete physical address of the facility: 164 Bostian Bridge Drive
City: Statesville County: Iredell State: NC Zip: 28677
B. INCIDENT DESCRIPTION
1. Describe the source of the contamination: From approximately 1964 through 1989 NC DOT operated an asphalt
testing laboratory in the north central portion of the asphalt production plant that may have used chlorinated
volatile organic compounds (VOCs) including carbon tetrachloride WTC) trichloroethene (TCE) and/or 1 1 1
trichloroethane (1.1.1-TCA) in batch testing of asphalt Previous site environmental assessment activities
have indicated the presence of chlorinated organic compounds (TCE 1 11-TCA and their degradation or
daughter products) in soil and/or shallow ground water in the vicinity of the former testing laboratory
L.
Approximately 162 tons of source area soil were excavated in September 2001 Following excavation the site
groundwater was monitored on a semi-annual basis until 2009 when sampling was reduced to annually
2. List all contaminants present in soils or groundwater at the site (contaminants may be listed in groups, e.g.,
gasoline, diesel, jet fuel, fuel oil, chlorinated ethenes, chlorinated ethanes, metals, pesticides/herbicides, etc):
Chlorinated ethenes and ethanes
3. Has LNAPL or DNAPL ever been observed at the site (even if outside the injection zone)?
❑ Yes If yes, list maximum measured separate phase thickness feet
R1No If no, list maximum concentration of total VOCs observed at site: —1,058 ppb
4. Agency managing the contamination incident:
UST Section Superfund Section (including REC Program and DSCA sites)
DWQ Aquifer Protection Section Solid Waste Section
Hazardous Waste Section X Other:Eligible for REC Program
5. Incident managers name: NA and phone number NA
6. Incident number or other site number assigned by the agency managing the contamination incident:
DENR APS Incident Number 17413
C. PERMITS
List all permits or construction approvals that have been issued for the facility or incident, including those not
directly related to the proposed injection operation:
1. Hazardous Waste Management program permits under RCRA: None
2. DWQ Non -Discharge or NPDES permits: None
3. County or DEH subsurface wastewater disposal permits: None
4. Other environmental permits required by state or federal law: None
Revised 6109
UIC-5I/5T
Page 2 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells— In Siat Groundwater Remediation / Type 5T Wells — Tracer Injection
- IV. INJECTION DATA
A. INJECTION FLUID DATA
1. List all proposed injectants.
NOTE: Any substance to be injected as a tracer or to promote in situ remediation must be reviewed by the
Occupational and Environmental Epidemiology Section (OEES) of the Division of Public Health, Department of
Health and Human Services. Review the list of approved injectants or contact the UIC Program to determine if
the injectants you are proposing have been reviewed by OEES.
Injectant: EOS 598B42 (emulsified oil substrate) with EOS Vitamin Bi-,Supplement
Concentration at point of injection: to be diluted at approximately 1:10 (EOS° to water)
Percent if in a mixture with other injectants: EOS - 9.1% Potable Water — 91%
Injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
2. Source of fluids used to dilute or chase the injectants listed above:
None
Municipal Water Supply
Groundwater from private well or any well within''/4 mile of injection site
Air
Other:
3. If any well within'/4 mile of injection site, a private well, or surface water is to be used as the fluid source, supply
the following information: NA
a. Location/ID number of source: WSW-4; located —500 ft east of source area (see Figure H-2
b. Depth of source: 160 ft.
c. Formation: Bedrock
d. Rock/Sediment type: Quartz Diorite
e. In Attachment C, provide a current, complete chemical analysis of the water from the source well, including
analyses for all contaminants suspected or historically recognized in soil or groundwater on the site.
NOTE: If contaminated groundwater is to be used as the dilution or chase fluid, this is not the proper permit
application form. You must apply for a closed -loop groundwater remediation permit using application form
GWRS.
Revised 6/09 UIC-51/5T Page 3 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/
_ OR USE A WELLS FOR INJECTION
Type 5I Wells —In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
B. PROPOSED OPERATING PARAMETERS
1. Duration of Injection: 12 — 35 field days
a. Maximum number of separate injection events: One event
b. Expected duration of each injection event: 12 — 35 field days
c. Expected duration between events (if more than one event): NA
2. Injection rate per well: 1- 3 gallons per minute (gpm)
3. Total Injection volume: max —1,350 gallons per day (gpd); gallons per event (if separate events)
4. Injection pressure: <60 pounds/square inch (psi)
5. Temperature at point of injection: Ambient - — 50 OF
6. Briefly describe how the above parameters will be measured and controlled: Flow rate will be measured
with flow meters and slurry tank volume change Pressure will be measured with gauges Temperature will
be measured with a thermometer. Valves and pump will be used to control flow and pressure
7. Estimated hydraulic capacity of the well: 1-3 gpm
C. INJECTION WELL CONSTRUCTION DATA
1. Injection will be via:
❑ Existing well(s) proposed for use as an injection well. Provide the data in (2) through (6) below to the best of
your knowledge.
Proposed well(s) to be constructed for use as an injection well. Provide the data in (2) through (6) below as
proposed construction specifications.
2. Well Drilling Contractor's Name: Geologic Exploration
NC Well Contractor Certification number: A-2579
3. Date to be constructed: November 2012 (Upon execution of the UIC Permit) Number of borings: 35
Approximate depth of each boring (feet): 38-40
4. Screened interval/Injection interval of injection wells:
Depth: 20 to 40 feet below ground surface (if multiple intervals, indicate shallowest and deepest depth).
5. Well casing (N/A if injection is through direct push rods): N/A — Injection through direct push rods.
Type: ( PVC ( Stainless steel ( Other:
Casing depth: to ft.
6. Grout (N/A if injection is through direct push rods): N/A — Injection through direct push rods.
Type: ( Cement ( Bentonite ( Other:
Grout depth: to ft.
Revised 6/09
UIC-5I/5T
Page 4 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells - In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
V. ATTACHMENTS
Provide the following items as separate attachments with the given headings:
A. SITE HISTORY
Provide a brief description of the site history including:
(1) site usage historically and present,
(2) origin of the contamination,
(3) previous remedial action(s).
NOTE. G.S. 89E-18 requires that any geologic plans, reports, or documents in which the performance is related to the
public welfare or safeguarding of the environment be prepared by a licensed geologist or subordinate under their
direction. G.S. 89E-13 requires that all drawings, reports, or documents involving geologic work prepared or approved
by a licensed geologist, or a subordinate under their direction, be signed and sealed by the licensed geologist.
B. HYDROGEOLOGIC DESCRIPTION
Provide a hydrogeologic description, soils description, and cross section of the subsurface to a depth that includes the
known or projected depth of contamination. The hydrogeologic description shall include:
(1) the regional geologic setting;
(2) significant changes in lithology;
(3) the hydraulic conductivity, transmissivity, and specific yield of the aquifer to be used for injection, including a
description of the test(s) used to determine these parameters; and
(4) the depth to the mean seasonal high water table.
C. INJECTION FLUID COMPOSITION
Describe the chemical, physical, biological and radiological characteristics of each injectant. Attach the Material Safety
Data Sheet (MSDS) for each injectant. If a private well or a well within'/a mile of the injection site is used as the source
well, include chemical analysis of source fluid here.
D. INJECTION RATIONALE
Attach a brief description of the rationale for selecting the injectants and concentrations proposed for injection, including:
(1) goals of the injection project;
(2) explanation and/or calculations of how the proposed injectant volume and concentration were determined;
(3) a description of the reactions between the injectants and the contaminants present including specific breakdown
products or intermediate compounds that may be formed by the injection; and
(4) summary results of modeling or testing performed to investigate the injectant's potential or susceptibility to change
(biological, chemical or physical) in the subsurface.
E. INJECTION PROCEDURE AND EQUIPMENT
Provide a detailed description of all planned activities related to the proposed injection including but not limited to:
(1) construction plans and materials;
(2) operation procedures;
(3) a detailed diagram of the surface and subsurface portions of the system; and
(4) a planned injection schedule.
Revised 6/09
UIC-5I/5T
Page 5 of 7

iJ \
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells —In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
F. MONITORING PLAN
Provide a plan for monitoring the results of the injection, including:
(1) a list of existing and proposed monitoring wells to be used;
(2) a list of monitoring parameters and analytical methods to be used; and
(3) a.schedule for sampling to monitor the proposed injection.
NOTE.- The selected monitoring wells must be located so as to detect any movement of injection fluids, process by-
products, or formation fluids outside the injection area or zone. The monitoring parameters should include the target
contaminants as well as secondary or intermediate contaminants which may result from the injection and other
parameters which may serve to indicate the progress of the intended reactions, such as pH, ORP, dissolved oxygen, and
other electron acceptors and donors. The monitoring schedule should be consistent with the pace of the anticipated
reactions and rate of transport of the injectants and contaminants.
G. WELL DATA
Provide a tabulation of data on all existing or abandoned wells within '/4 mile of the injection well(s) which penetrate the
proposed injection zone, including, but not limited to, monitoring wells and wells proposed for use as injection wells.
Such data shall include a description of each well's use (water supply, monitoring, etc), total depth, screened or open
- borehole depth interval, and well construction or abandonment record, if available. TABLES G-1 & G-2
H. MAPS
Attach the following scaled, site -specific maps:
(1) Area map based on the most recent USGS 7.5' topographic map of the area, at a scale of 1:24,000 and
showing the location of the proposed injection site. FIGURE H-1
(2) Site map including:
a. all property boundaries; FIGURE H-2
b. all buildings within the property boundary; FIGURE H-2
c. existing and proposed injection wells or well field(s) FIGURE H-8
d. any existing sources of potential or known groundwater contamination, including waste storage,
treatment or disposal systems within''/4 mile of the injection well or well system;
e. all surface water bodies within'/4 mile of the injection well or well system; and FIGURE H-1 and H-2
f. all existing or abandoned wells within %4 mile of the injection well(s) which penetrate the proposed
injection zone, including, but not limited to, monitoring wells and wells proposed for use as injection
wells. FIGURES H-8 and H-10
(3) Potentiometric surface map(s) including: FIGURE H-7
a. direction of groundwater movement
b. existing and proposed monitoring wells
c. existing and proposed injection wells
(4) Contaminant plume map(s) including: FIGURES H-4 and Figure H-8
a. the horizontal extent of the contaminant plume, including isoconcentration lines
b. existing and proposed monitoring wells
c. existing and proposed injection wells
(5) Cross-section(s) to the known or projected depth of contamination, including: FIGURES H-5 and H-6
a. horizontal and vertical extent of the contaminant plume, including isoconcentration lines
b. major changes in lithology
c. existing and proposed monitoring wells
d. existing and proposed injection wells
Revised 6/09
UIC-5I/5T
Page 6 of 7

1W
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 51 Wells — lit Situ Groundwater Remediation / Type ST Wells — Tracer Injection
CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .021 l (b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or
ranking publicly elected official
4. for all others: by the well owner.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the applicant that
names and authorizes their agent.
I hereby certify under penalty of law that I have personally examined and am familiar with the information
submitted in this document and all attachments therein, 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 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(s)
and all related appurtenances in accordance with the approved specifications and conditions of the Permit.
Printed Name and Title: C'� .,Vftel" '^`+
Signature:
6-
Date: 711 Z--
vll. CONSENT OF PROPERTY OWNM (if the property is not owned by the applicant)
("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.)
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
(Title 15A NCAC 2C .0200).
Printed Name and
Signature: Date:
Submit TWO copies of the completed application package, including all attachments, to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
Revised 6/09 UIC-5115T Page 7 of 7

APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
Type 5I Wells — In Situ Groundwater Remediation / Type 5T Wells — Tracer Injection
VI. CERTIFICATION (to be signed as required below or by that person's authorized agent)
NCAC 15A 2C .0211(b) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or
ranking publicly elected official
4. for all others: by the well owner.
If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the applicant that
names and authorizes their agent.
1 hereby certify under penalty of law that I have personally examined and am familiar with the information
submitted in this document and all attachments therein, 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 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(s)
and all related appurtenances in accordance with the approved specifications and conditions of the Permit.
Printed Name and Title:
Signature: Date:
V1I. CONSENT OF PROPERTY OWNER (if the property is not owned by the applicant)
("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.)
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
(Title 15A NCAC 2C .0200).
Printed Name and Title 401
Signature: ' "-Y Date:
Submit TWO copies of the completed application package, including all attachments, to:
UIC Program
Aquifer Protection Section
North Carolina DENR-DWQ
1636 Mail Service Center
Raleigh, NC 27699-1636 RECOVEDIDENRIM
Telephone [phone]
sEP 06 2012
Aquifer Protection Section
Revised 6/09 UIC-5I/5T Page 7 of 7

Table A-1
Summary of Post -Excavation Soil Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
Sample ID / Sample Location
IHSB Residential Health
Based Soil Remediation
Goal
CAP Site-SpecificTarget
Remediation Criteria
Compound
Trichloroethene
SS-1
Western Sidewall
SS-2
Excavation Bottom
SS-3
Eastern Sidewall
SS-4
Excavation Bottom
<0.001
<0.001
0.0031
<0.001
0.88
1 50
1,1,1-Trichloroethane
<0.001
<0.001
0.0034
<0.001
640
1,247
Notes:
All samples collected were collected by H&H in September 2001and analyzed by EPA Method 8021.
Only those compounds detected are shown above.
IHSB = Inactive Hazardous Sites Branch
SAAAA-Master ProjectslNC DOTOot-177eb-05 Reportl2-05 Datffables.xlffable A-1
6/11/2012 Hart & Hickman, PC

Table A-2
Summary of Saprolite Groundwater Analytical Results
NC DOT Site No. 2.66
Statesville, North Carolina
H&H Job No. DOT-404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichloroethene
1,1-
Dichloroethane
1,2-
Dichloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroethene
1,4-Dioxane
Methylene
Chloride
Chiorobenzene
Well ID
Analysis
Sam le DateTrichloroethane
NC 2L Groundwater Standard
200
3
6
0.4
7
70
3
5
50
601
Dec-96
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Oct-98
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Aug-01
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Feb-02
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
1 Au -02
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Feb-03
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Au"3
<1
<1
<1
<1
<1
I <1
NA
<5
<1
601
Feb-04
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Aug-04
I <1
<1
<1
<1
<1
<1
<5.0
<5
<1
NS
Feb-08
NS
NS
NS
NS
NS
NS
NS
NS
NS
SMW-1
601
Au -06
0.0
<1.0
<1.0
0.0
0.0
0.0
NA
<2.0
0.0
601
Feb-07
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<2.0
<1.0
601
Au -07
<1.0
0.0
<1.0
0.0
<1.0
<1.0
NA
<2.0
0.0
601
Feb-08
0.0
0.0
<1.0
0.0
0.0
<1.0
NA
<1.0
<1.0
601
Aug-08
0.0
0.0
0.0
0.0
0.0
0.0
NA
0.0
<1.0
601
Feb-09
<1.0
0.0
<1.0
<1.0
<1.0
<1.0
NA
<1.0
<1.0
601
Au -09
0.0
<1.0
<1.0
0.0
<1.0
<1.0
NA
<1.0
<1.0
601
Au -10
0.0
0.0
<1.0
<1.0
<1.0
<1.0 I
NA
<5.0
<1.0
8200E
Au -11
0.0
<1.0
<1.0
0.0 1
0.0
<1.0
NA
<2.0
0.0
NS
Feb-12
NS
NS
NS
NS
NS
NS
N5
NS I
NS
SA-W Master Projects= DOTIDot-I AFeb-05 Reponl2-05 Data\Tables.dslTable A-2 Page 1 of 9
611302012 Hart & Hickman, PC

Table A-2
Summary of Saprolite Groundwater Analytical Results
NC DOT Site No. 2.66
Statesville, North Carolina
H&H Job No. DOT-004
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichloroethene
1 1,1-
Dichioroethane
1,2-
Dichloroethane
1,1-
Dlchloroethene
cis-1,2-
Dichloroethene
1,4-Dioxane
Methylene
Chloride
Chiorobenzene
Well ID
Analysis
Sample DateTrichloroethane
601
Dec-96
<1
<1
<7
<1
<1
<1
NA
<5
<1
601
Oct-98
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Aug-01
<1
<1
4.3
<1
1.9
<1
NA
<5
<1
601
Feb-02
<1
<1
3.7
<1
<1
<1
NA
<5
<1
601
Aug-02
<1
<1
1 4.8
<1
1.8
<1
NA
<5
<1
601
Feb-03
<1
<1
8.1
<1
2.7
<1
NA
<5
<1
601
Aug-03
<1
<1
11
<1
<1
<1
NA
<5
<1
601
Feb-04
<1
<1
8.9
<1
1.4
<1
NA
<5
<1
601
Aug-04
<1
<1
6.2
<1
0.961
<1
<5.0
<5
<1
601
Feb-05
<1.0
<1.0
5.9
0.0
0.0
<1
NA
<1.0
<1.0
601
Aug-05
<1
<1
8.6
<1
<1
<1
NA
<2
<1
SMW-2
601
Feb-06
<1
<1
6.7
<1
<1
<1
NA
<2
<1
601
Au -06
<1.0
<1.0
5.6
0.0
0.0
<1.0
NA
<2.0
<1.0
601
Feb-07
0,0
0.0
4.7
<1.0
<1,0
<1.0
NA
<2.0
0.0
601
Au -07
<1.0
<1.0
3.5
<1.0
0.0
0.0
NA
<2,0
<1.0
601
Feb-08
0.0
<1.0
3.8
<1.0
<1.0
<1.0
NA I
<1.0
<1.0
601
Au -08
0.0
<1.0
3.1
<1.0
0.0
<1.0
NA
<1,0
<1.0
601
Feb-09
<1.0
<1.0
3.5
<1.0
<1.0
<1.0
NA
<1.0
<1.0
601
Au -09
41.0
<1.0
1.9
<1.0
<1.0
<1.0
NA
<1.0
<1.0
601
Au -10
<1.0
<1.0
5.8
<1.0
0.0
<1.0
NA
<5.0
<1.0
601
Au -10
<1.0
<1.0
5.8
<1.0
<1.0
<1.0
NA
<5.0 I
<1.0
6200E
Aug-1 I
<1.0
<1.0
2.1
<1.0
<1.0
<1.0
NA
<2.0
0.0
NS
Feb-12
NS
NS
NS
NS
NS
NS
NS
NS
NS
SAAAPWaster Pwjeft= DOTOoI-171FetM5 Rep.M.05 09617rebtea.*ITable A-2
611312012
Page 2 of 9
Hart & Hickman, PC

Table A-2
Summary of Saprolite Groundwater Analytical Results
NC DOT Site No. 2.66
Statesville, North Carolina
H&H Job No. DOT404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichioroethene
1,1-
Dichloroethane
1,2-
Dichloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroethene
1,4-Dioxane
Methylene
Chloride
Chlorobenzene
Well ID
Analysis
Sample DateTrichioroethane
801
Dec-96
4
1
1
<1
2
6
NA
<5
<1
601
Oct-98
3
<1
10
<1
<1
7
NA
<5
<1
601
Aug-01
4.4
<1
6.2
<1
<1
<1
NA
<5
<1
601
Feb-02
2.3
1.5
8.3
<1
<1
<1
NA
<5
<1
601
Aug-02
1.6
2.1
11
<1
1.5
2.8
NA
<5
<1
801
Feb-03
4.0
1.6
11
41
<1
1.3
NA
<5
<1
601
Aug-03
1.1
<1
12
<1
<1
<1
NA
<5
<1
601
Feb-04
<1
<1
7.1
<1
e1
2.9
NA
<5
c1
601
Aug-04
<1
<1
4.7
<1
<i
1.7
<5.0
<5
<1
601
Feb -OS
<1.0
<1.0
3.1
41.0
<1.0
1.9
NA
<1.0
<1.0
601
Aug-05
I
<1
5.7
<1
<1
2.8
NA
<2
<7
SMW-3
601
Feb-06
<1
<1
7.7
<1
<1
3.0
NA
42
<1
601
Aug-06
0.0
<1.0
6.9
0.0
<1.0
2.8
NA
<2.0
<1.0
601
Feb-07
<1.0
<1.0
7.7
<1.0
<1.0
2.7
NA
<2.0
0.0
601
Aug-07
<1.0
<1.0
6.7
<1.0
<1.0
3.4
NA
<2.0
<1.0
601
Feb-08
<1.0
<1.0
8.7
<1.0
<1.0
2.3
NA
<1.0
<1.0
601
Aug-08
<1.0
1.5
7.9
<1.0
<1.0
1.9
NA
<1.0
<1.0
601
Feb-09
<1.0
<1.0
8.8
<1.0
<1.0
3.7
NA
<1.0
0.0
601
Au -09
<1.0
<1.0
4.5
<1.0
0.0
2.8
NA
<1.0
<1.0
601
Aug-1 0 1
0.0
<1.0
4.7
<1.0
<1.0
2.1
NA
<5.0
<1.0
6200E
Au -11
<1.0
<1.0
3.7
<1.0
<1.0
1.4
NA
<2.0
<1 0
NS
Feb-12
NS
NS
NS
NS
NS
NS
NS
NS
NS
SMWr1
601
Dec-96
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Oct-98
<1
<1
<1
<i
<1
<1
NA
<5
<1
SMW-6A
601
Dec-96
1
<1
0
<1
6
<1
NA
<5
<1
&wan-raersera(olectsM00rnoa11nFea05RepoM-05DatalTabiea.awableA-2 Page 3 of 9
611312012 Han` & Hickman, PC

Table A-2
Summary of Saprolite Groundwater Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichloroethane
Trichloroethene
1,1-
Dichloroethane
1,2-
Dichloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroethene
1,4-Dioxane
Methylene
Chloride
Chlorobenzene
Well ID
Analysis
Sample Da
601
Dec-96
53
47
26
<1
37
53
NA
<5
1
8260E
Jan-97
59
54
28
<5
51
59
NA
<5
<5
601
Oct-98
30
41
28
<1
40
59
NA
<5
<1
601
1 Aug-01
110
110
61
<1
51
56
NA
<5
<1
601
Feb-02
66
84
31
<1
64
58
NA
<5
<1
601
Aug-02
42
51
23
<1
36
1 30
NA
<5
<1
601
Feb-03
17
26
16
<1
17
21
NA
<5
<1
601
Aug-03
27
49
30
<1
27
39
NA
<5
<1
601
Feb-04
4.2
8.9
9.1
<1
6.8
10
NA
<5
<1
601
Aug-04
2.6
5.6
5.3
<1
4.5
7.4
<5.0
<5
<1
601
Feb-05
2.7
7.4
6.1
<1.0
603
9.7
NA
<2.0
<1.0
DMW-1
NS
Au -05
NS
NS
NS
NS
NS
NS
NS
NS
NS
NS
Feb-06
NS
NS
NS
NS
NS
NS
NS
NS
NS
601
Aug-06
1.5
5.8
4.9
<1.0
2.4
4.9
NA
<2,0
<1.0
601
Feb-07
1.8
5.3
4.9
<1.0
3.0
7.2
NA
<2.0
<1.0
601
Au -07
<1.0
1.4
2.0
<1.0
1.2
2.7
NA
<2.0
<1.0
601
Feb-08
<1.0
2.1
1.7
<1.0
1.2
2.7
NA
<1.0
<1.0
601
Au -08
<1.0
2.4
1.2
<1.0
2.0
1.8
NA
<1.0
<1.0
601
Feb-09
1.2
3.8
4.7
<1.0
3.2
4.4
NA
<1.0
<1.0
601
Au -09 I
<1.0
2.9
1.9
<1.0
1.8
2.5
NA
<1.0
<1.0
601
Aug-10
4.0
3.5
4.7
<1.0
3.8
4.8
NA
<5.0
<1.0
6200E
Au -11
<1.0
2.4
3.7
<1.0
1.7
3.5
NA
<2.0
<1.0
6200E
Feb-12
<1.0
1.3
1.8
<1.0
<1.0
1.6
NA
<2.0
0.0
S.W"asterarolea8wcoonoot.IAFe o5Reaomz.osomOtTames.*rcoulex2 Page 4 of 9
6/1312012 Hart & Hickman, PC

Table A-2
Summary of Saprolite Groundwater Analytical Results
NC DOT Site No. 2.66
Statesville, North Carolina
H&H Job No. DOT-404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichioroethene
1,1-
Dichloroethane
1,2-
Dichloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroethene
1,4-Dioxane
Methylene
Chloride
Chlorobenzene
Well ID
Analysis
Sample DateTrichloroethane
601
Mar-97
210
120
72
<2.5
130
<2.5
NA
<12.5
<2.5
601
Oct-98
29
18
48
<1
39
<1
NA
<5
<1
601
Aug-01
9.9
11
43
<1
17
1.7
NA
<5
<1
601
Feb-02
23
18
49
<1
32
<7
NA
<5
<1
601
Aug-02
21
22
55
<1
32
6.1
NA
<5
<1
601
Feb-03
12
17
23
<1
13
2.8
NA
<5
<1
601
Aug-03
21
37
94
<1
23
<1
NA
<5
<1
601
Feb-04
13
28
73
<1
18
6.6
NA
<5
<1
601
Aug-04
27
48
86
<1
38
15
<5.0
<5
<1
601
Feb-05
18
38
40
<1.0
32
12
NA
<2.0
<1.0
601
Aug-05
20
36
67
<1
19
12
NA
<2
<1
DMW-2
601
Feb-06
15
42
59
<1
19
9.1
NA
<2
<1
601
Aug-06
13
29
58
<1.0
14
12
NA
<2.0
<1.0
601
Feb-07
8.2
19
40
<1.0
11
8.3
NA
<2.0
<1.0
601
Aug-07
4.3
10
37.8
0.0
6.2
4.2
NA
<2,0
<1.0
601
Feb-08
2.1
6.6
22
0.0
3.0
2.8
NA
<1.0
0.0
601
Aug-08
1.4
6.0
17
0.0
3.2
2.1
NA
0.0
<1.0
601
Feb-09
2.1
5.8
16
<1.0
4.5
3.0
NA
0.0
0.0
601
Aug-09
1.6
6.6
9.2
<1.0
3.2
1.9
NA
<1.0
<1.0
601
Aug-10
4.8
4.3
8.9
<1.0
3.5
1.9
NA
<5.0
0.0
6200B
Aug-1 I
<1.0
<1.0
<1.0
0.0
<1.0
<1.0
NA
<2.0
<1.0
6200B
Feb-12
<1.0
<1.0
2.0
<1.0
<1.0
0.0
NA
<2.0
0.0
s vwn-Maur Proleaswc oonoot-Ir,FQo-os arnomzos oaretTnbi a -*%Table A.2 Page 5 of 9
611m2012 Hart & Hickman, PC

Table A-2
Summary of Seprolite Groundwater Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
M&H Job No. DOT-404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichloroethene
1,1-
Dichloroethane
1,2-
Dichloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroethene
1,4-Dioxane
Methylene
Chloride
Chlorobenzene
Well ID
Analysis
Sample DateTrcchooroethane
6230D
Jan-99
<0.5
<0.5
<0.5
<0.5
<0.5
<0.5
NA
<5
<0.5
601
Au -01
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Feb-02
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Au -02
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Feb-03
<1
<1
<1
<1
<1
<1
NA
<5
<1
801
Aug-03
<1
<1
<1
<1
<1
<1
NA
<5
<1
DMW-5
601
Feb-04
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Au -04
<1
<1
<1
<1
<1
<1
<5.0
<5
<1
601
Feb-05
<1.0
<1.0
<1,0
<1.0
<1,0
<1
NA
<2,0
<1.0
601 1
Aug-05
<1
<1
<1
<1
<1
<1
NA
<2
<1
601
Feb-06
<1
<1
<1
<1
<1
<1
NA
<2
<1
601
Au -06
<1.0
<1.0
<1.0
0.0
<1.0
<1.0
NA
<2.0
<1.0
NS
Feb-12
NS
NS
NS
NS
NS
NS
NS
NS
NS
S:MA-Master Pmjects=DOTDot-IMeb-05 Repod%2-050ata1Teble9.ilelTable A-2 Page 6 of 9
51132012 1 Hart & Hickman, PC

Table A-2
Summary of Saprolite Groundwater Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
HBH Job No. DOT-404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichloroethene
1,1-
Dichloroethane
1,2-
Dlchloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroethene
1,4-Dloxane
Methylene
Chloride
Chlorobenzene
Well ID
Analysis
Sample DateTrichloroethane
6230D
Jan-99
74
67
42
<0.5
160
1.5
NA
<5
<0.5
601
Aug-01
95
57
60
<1
93
4.5
NA
<5
<1
601
Feb-02
140
170
89
<1
500
<10
NA
<5
<10
601
Aug-02
140
190
120
<1
590
18
NA
<5
<10
601
Feb-03
100
180
77
<1
430
<10
NA
<5
<10
601
Aug-03
97
170
80
4.3
420
14
NA
8.5
<1
601
Feb-04
63
140
74
<1
350
10
NA
<5
<1
601
Aug-D4
61
150
74
<10
380
SAJ
180
<50
<10
601
Feb-05
49
150
69
7.8
250
10
NA
5.6
<1.0
601
Aug-05
65
170
83
<5
290
12
NA
<10
<5
DMW-6
601
Feb-06
44
220
98
1.8
390
9.2
180
5.8
<1
601
Aug-06
19
190
83
<5
270
9.0
NA
<10
<5.0
601
Feb-07
39
170
81
<5
330
12.0
180
<10
<5.0
601
Aug-07
40.3
157
100
<10.0
290
<10.0
NA
<20.0
<10.0
601
Feb-08
33
130
77
<1.0
200
6.9
170
<1.0
<1.0
601
Aug-08
24
100
77
3.6
180
6.1
NA
<1.0
0.0
601
Feb-09
18
96
67
<1.0
220
8.7
NA
0.0
<1.0
601
Aug-09
23
120
83
4.9
220
6.6
NA
<1.0
<1.0
601
Aug-10
16
100
79
<1.0
200
8.6
NA
<5.0
<1.0
6200B
Aug-11
10.6
100
75.9
1.3
147
3.9
NA
<2.0
<1.0
6200E
Feb-12
5.9
68.5
53.1
<1.0
90.5
3.0
NA
<2.0
<1.0
S:WW- Mast" PmjecWWCDOTDot-177eb-05Repoli-05Delffeble&*lTebleA-2 Page 7 of 9
e11=012 Hart & Hickman, PC

Table A-2
Summary of Seprolite Groundwater Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichloroethane
Trichloroethene
1'1-
Dichloroethane
1,2-
Dichloroethane
1,1-
Dtchloroethene
cis-1,2-
Dichloroethene
IkDioxane
Methylene
Chloride
Chlorobenzene
Well ID
Analysis
Sample Date
001
Aug-01
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Feb-02
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Aug-02
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Feb-03
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Au -03
<1
<1
<1
<1
<1
<1
NA
<5
<1
601
Feb-04
<1
<1
<1
c1
<1
<1
NA
<5
<1
601
Au -04
<1
<1
<1
<1
<1
<1
<5.0
<5
<1
601
Feb-05
<1
<1
<1
<1
<1
<1
NA
<1.0
<1
601
Au -05
<1
<1
<1
<1
<1
<1
NA
<2
<1
601
Feb-06
<1
<1
<1
<1
<1
<1
NA
<2
c1
DMW-8
601
Au -06
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<2.0
<2.0
601
Feb-07
<1.0
<1.0
<1.0
<1.0
<1.0
0.0
NA
<2.0
<2.0
601
Au -07
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<2.0
<1.0
601
Feb-08
<1.0
<1.0
<1.0
<1.0
<1.0
0.0
NA
0.0
<11.0
601
Au -08
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<1.0
<1.0
601
Feb-09
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<1.0
<1.0
601
Au -09
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<1.0
<1.0
601
Au -10
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<5.0
<1.0
8200B
Aug-1 1
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<2.0
<1.0
62008
Feb-12
< 0 1
0.0
<1.0
<1.0
<1.0
<1.0
NA
<2.0
<1.0
S:WAA-Mortar Pro)ac%WC DO'nDot-1776-05 Repor02.05 DatelTable ASITeble A-2 Page 8 of 9
611U2012 Hart 8r Hickman, PC

Table A-2
Summary of Saprolite Groundwater Analytical Results
NC DOT Site No. 2.66
Statesville, North Carolina
H&H Job No. DOT-404
DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trcchloroethene
1,1-
Dichloroethane
1,2-
Dichloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroethene
1,4-Dioxane
Methylene
Chloride
Chlorobenzene
Well ID
Analysis
Sample DateTrichioroethane
DMW-9
6200B
Feb-12
<1.0
3.3
4.5
<1.0
2.1
<1.0
<1.0
<2.0
<1.0
DMW-10
6200B
Feb-12
<1.0
<1.0
0.0
0.0
<1.0
<1.0
NA
<2.0
<1.0
DMW-11
6200B
Feb-12
0.0
10.8
10.9
0.0
16.0
<1.0
<1.0
<2,0
0.0
Notes:
Bold indicates concentration exceeds standard
Analytical method numbers are shown beside sample IDs. 1,4-Dioxane was analyzed by Select Ion Monitoring
Resutls are in micrograms per liter (µg/1)
SS - Shallow Saprolite; DS - Deep Saprolite; GW - Ground Water
NA = Not Analyzed for this parameter, NS = Well not sampled
J= The analyte was positively identified but the value is estimated below the reporting limit
SMW-5A was abandoned March 21, 2002
SMW-4 Is damaged and could not be sampled, August 2004; SMW-4 repaired July 2006
DMW-2 reported Chloroform at an estimated value = 0.78J µg/I, August 2004
Vinyl chloride (1.7 ug/1) and 1,1,2-tdchloroethane (1.8 ug11) were detected in DMW-6 in February 2005
Chloroform (3 ug/1), and ,1,1,2-trichloroethane (3.5 ug/1) were detected in DMW-6 in February 2006
1,1,2,2-Tdchloroethane (2.2 ug/1) was detected in DMW-6 in February 2008
Chloroform (3.5 ug/1), and ,1,1,2-tdchloroethane (2.5 ug/1) were detected in DMW-6 In August 2009
1,1,2-trichloroethane (1.2 ug/1) was detected in DMW-6 in August 2011
SAAAA-Master ProleclsiNC D0rpot-1?Te"5 Reporm-050ate1TaWes.idffable A•2 Page 9 of 9
e11=012 Hart & Hickman, PC

Table A-3
Summary of Bedrock Groundwater Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
.DOT Target Compounds
Non -Target
COMPOUND
1,1,1-
Trichloroethane
Trichlaroethene
1,1-
Dichloroethene
1,1-
Dichloroethene
cis 1,2-
Dichloroethene
1,4-Dioxane
-Compound
Chlorobenzene
Well ID Analysis Sample Data
NC 2L Groundwater Standard
200
3
6
7
70
3
50
601
Mar-97
<1
<1
<1
<1
<1
NA
<1
601
Oct-98
<1
<1
<1
<1
<1
NA
<1
601
Feb-03
<1
c1
<1
<1
<1
NA
<1
601
Aug-03
<1
<1
<1
<1
<1
NA
<1
601
Feb-04
<1
<1
<1
<1
<1
NA
<1
601/8260
Aug-04
<1
<1
<1
<1
<1
<5,0
<1
601
Feb-05.
<1
<1
<1
<1
<1
NA
<1
601
Aug-05
<1
<1
<1
<1
<1
NA
<1
601
Feb-06
<1
<1
<1
<1
<1
NA
<1
DMW-3
601
Aug-06
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<1.0
601
Feb-07
<1.0
<1.0
<1.0
<1.0
0.0
NA
<1.0
601
Aug-07
<1.0
<1.0
<1.0
<1.0
0.0
NA
0.0
601
Feb-08
<1.0
<1.0
<1.0
c1.0
<1.0
NA
<1.0
601
Aug-08
<1.0
41.0
<1.0
<1.0
<11.0
NA
0.0
601
Feb-09
<1.0
<7.0
<1.0
<1.0
<1.0
NA
<1.0
601
Aug-10
<1.0
<1.0
0.0
<1.0
<1.0
NA
c1.0
6200E
Aug-1 1
<1.0
<1.0
41.0
<1.0
<1.0
NA
41.0
NS
Feb-12
NS
NS
NS
NS
NS
NS
NS
601
Mar-97
<1
<1
<1
ci
<1
NA
<1
601
Oct-98
<1
<1
<1
<1
<1
NA
<1
601
Aug-01
<1
<1
<1
<1
<1
NA
<t
601
Feb-02
<1
<1
<1
<t
<1
NA
<1
601
Aug-02
<1
<1
<1
<1
<1
NA
<1
601
Feb-03
<1
<1
<1
<1
<1
'NA
<1
601
Aug-03
<1
<1
<1
<1
<1
NA
<1
601
Feb-04
41
<1
<1
<1
<1
NA
<1
60118260
Aug-04
<1
<1
<1
<1
<1
<5.0
<1
601
Feb-05
<1
<1
<1
<1
<1
NA
<1
DMW-4
601
Aug-05
<1
<1
<1
<1
<1
NA
<1
601
Feb-06
<1
<1
<1
<1
<1
NA
<1
601
Aug-06
<1.0
41.0
<1.0
0.0
<1.0
NA
<1.0
601
Feb-07
<1.0
<7.0
41.0
<1.0
<1.0
NA
<1.0
601
Aug-07
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<1.0
601
Feb-06
<1.0
<1.0
<1.0
<9.0
<1.0
NA
<1.0
601
Aug-08
<1.0
<7.0
<1.0
<1.0
0.0
NA
<1.0
601
Aug-09
<1,0
0.0
41.0
<1.0
<7.0
NA
<1,0
601
Aug-10
0.0
0.0
<1.0
<1,0
<1.0
NA
<7.0
62008
Aug41
<1.0
<1.0
<1.0
<1.0
<1.0
NA
<1.0
NS
Feb12
NS
NS
NS
NS
NS
NS
NS
S:~-Master Pmjects%NC DOTIDot-171Feb-05 Repor02-05 Date\Tables.xlslTable A-3
6/1112012 Hart & Hickman, PC

Table A-3
Summary of Bedrock Groundwater Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
DOT Target Compounds
Non -Target
Compound
COMPOUND
1,1,1-
Trichloroethane
Trichloroethene
1,1-
Dlchloroethane
1,1-
Dichloroethene
cis-1,2-
Dichloroelhene
1.4 Dioxane
Chlorobenzene
Well ID Analysla Sample Date
NC 2L Groundwater Standard
200
3
6
7
70
3
50
601
Aug-01
<1
<1
<1
<1
<t
NA
<1
601
Feb-02
<1
<1
41
1.9
<1
NA
<1
601
Aug-02
2.4
6.3
1.6
14
<1
NA
41
601
Feb-03
2.1
2.4
<1
2.6
<7
NA
<t
601
Aug-03
3.8
7.0
1.6
12
<7
NA
<1
601
Feb-04
<1
1.5
c1
2.6
<1
NA
<1
601/8260
Aug-04
0.811
2.2
0.70J
3.6
<1
<5.0
<1
601
Feb-05
<1
2.1
<1.0
3.9
<1
NA
<1
601
Aug-05
<1
1.6
<1
1.9
<1
NA
<1
601
Feb-06
<1
3.7
1.5
3
<1
NA
<1
DMW-7
601
Aug-06
<1.0
4.6
1.3
3.3
<1.0
NA
41.0
601
Feb-07
<1.0
2.2
1.8
2.5
41.0
NA
47.0
601
Aug-07
<1.0
2.7
12
3.5
<1.0
NA
<1.0
601 1
Feb-08
<1.0
2.2
<1.0
1.6
<1.0
NA
<1.0
601
Aug-08
<1.0
3.1
<1.0
2.6
<1.0
NA
41.0
601
Feb-09
<1.0
2.3
1.4
2.8
<1.0
NA
0.0
601
Aug-09
<1.0
2.1
<1.0
1.3
<1.0
NA
<1.0
601
Aug-10
<1.0
3.2
1.1
2.8
<1.0
NA
<1.0
6200E
Aug-11
<1.0
<7.0
<1.0
<1.0
<1.0
NA
<1.0
6200E
Feb•12
<1.0
<1.0
-1.0
<1.0
<1.0
NA
<1.0
Notes.
Analytical method numbers are shown beside sample IDs.
Bold Indicates concentration exceeds standard
GW - Ground Water
Results are in micro grams per liter (pgn)
J= The analyte was positively identified but the value is estimated below the reporting limit
NA = Not Analyzed for this parameter
NS = Not Sampled
1,4-Dioxone was analyzed by Method SW848-8260B/SIM
SAW -Master ProjectslNC DOTIDot-171Feb-05 Reportl2-05 DatalTables,xiffable A-3
611112012 Hart & Hickman, PC

Table A-4
Summary of Surface Water Analytical Results
NC DOT Site No. 2-66
Statesville, North Carorina
H&H Job No, DOT404
Compound
SS-1
Upgradlent
Tributary
SS-2
Downgradient
Tdbuta
SS-3
Upgradlent
Third Creek
SS-4
Mid -Point
ThirdCreek
SS-5
Downgradient
Third Creek
Feb-99
Feb-99
Au -01
Au -02
Au -03
Au -04
Au -05
Au -06
Au -07
Au -08
Feb-09
Au -09
Au -10
Au -11
Feb-99
Feb-99
Feb-99
14-Dioxane
NA
NA
NA
NA
NA
<5.0
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
111-Trichloroethane
<0.5
<0.5
<1
<t
<1
<1
<1
<1.0
<7.0
<1.0
<11.0
<1.0
<1.0
<1.0
<0.5
<0.5
1 40.5
Tdchioroethene
<0.5
<0.5
<1
<1
<1
<1
<1
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<0.5
<0.5
<0.5
11-Dlchloroethane
<0.5
<0,6
I <1
<1
<1
<1
<1
<1.0
41.0
<1.0
<1.0
<1.0
<1.0
<1.0
<0.5
<0.5
<0.5
cis-12-Dichloroethene
<0.5
<0.5
<1
<1
<1
<1
<1
I <1.0
o.0
<1.0
o.0
<1.0
<1.0
c1.0
<0.5
<0.5
<0.5
11=Dichloroethene
<0.5
<0.5
<1
<t
<1
<1
<t
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<0.5
<0.5
<0.5
Chloroform
<0.5
<0.5
<1
<7
<1
e1
<1
<1.0
<1.0
<1.0
<1.0
<1.0 I
<1.0
<1.0
<0.5
<0.5
<0.5
Notes:
Results are in micrograms per tiler (ttg/l)
"c" indicates compound was not detected above the analytical detection limit
NA - Not Analyzed for this parameter.
S;~-Master ProiectsM DDTOol-1T1Feb-05 Repor112-05 DatffablesalsRable A-4
611 U2012 Hart & Hickman, PC

Table B-1
Monitoring Well Construction Details and Groundwater Elevation Data
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
August 18, 2009
August 26, 2010
August 17, 2011
Februar 2, 2012
Well I.D.
Depth (ft)
Screen (ft)
Screened
Aquifer
Zone
Elevation
TOC (ft)
100 ft Datum
Static
Water Table
ft below TOC
Water Table
Elevation (ft)
100 ft Datum
Static
Water Table
ft below TOC
Water Table
Elevation (ft)
100 ft Datum
Static
Water Table
ft below TOC
Water Table
Elevation (ft)
100 ft Datum
Static
Water Table
(ft below TOC)
Water Table
Elevation (ft)
(100 ft Datum
SMW-1
30
20-30
Shallow Saprolite
90.73
26.60
NA
26.07
NA
27.25
NA
26.62
64.11
SMW-2
35
25-35
Shallow Saprolite
93.92
28.97
NA
28.58
NA
29.66
NA
29.15
64.77
SMW-3
40
30-40
Shallow Saprolite
98.79
32.20
66.59
31.67
67.12
32.14
66.65
32.63
66.16
SMW4
35
25 - 35
Shallow Saprolite
100.52
NM
NA
23.14
77.38
26.11
74.41
26.39
74.13
SMW-5A
30
20 - 30
Shallow Saprolite
95.14
NM
NA
NM
NA
NM
NA
NM
NA
DMW-1
50
45 - 50
Deep Saprolite
98.11
32.46
65.65
31.94
66.17
33.33
64.78
32.72
65.39
DMW-2
40
35-40
Deep Saprolite
92.72
28.29
NA
27.91
NA
28.94
NA
28.40
64.32
DMW-3
60
55 - 60
Shallow Bedrock
101.15
NM
NA
26.24
74.91
28.96
72.19
28.75
72.40
DMW-4
70
65 - 70
Shallow Bedrock
98.08
32.39
65.69
32.39
65.69
33.20
64.88
31.71
66.37
DMW-5
38.5
28.5 - 38.5
Deep Saprolite
78.57
NM
NA
NM
NA
NM
NA
NM
NA
DMW-6
36.25
26.25 - 36.25
Deep Saprolite
79.60
18.88
60.72
18.74
60,86
19.26
60.34
18.80
60.80
DMW-7
65
60 - 65
Shallow Bedrock
79.00
18.15
60.85
17.95
61.05
18.46
60.54
17.94
61.06
DMW-8
24
14 - 24
Deep Saprolite
68.34
8.18
60.16
8.04
60.30
8.59
59.75
7.94
60.40
DMW-9
40
3040
Deep Saprolite
88.72
NM
NA
NM
NA
NM
NA
25.94
62.78
DMW-10
38
28-38
Deep Saprolite
86.24
NM
NA
NM
NA
NM
NA
25.76
60.48
DMW-11
40
3040
Deep Saprolite
85.13
NM
NA
NM
NA
NM
NA
23.62
61.51
Notes:
TOC = Top of PVC well casing.
Ail wells referenced to an assumed datum of 100 feet.
NA - Not Available/Not Applicable
NM - Not Measured
SMW-5A was abandoned March 21, 2002
DMW-3, DMW-4 and DMW-7 are Type III double -cased wells.
Due to ongoing construction activities at the site, the well casings for monitoring wells SMW-1, SMW-2 and DMW-2 may
have changed. The TOCs for these wells will be resurveyed once the construction activities are completed.
DMW-5 discovered damaged in August 2008 and could not be sampled.
SMW-4 could not be located in August 2009.
DMW-3 could not be located in August 2009.
S:1AAA-Master ProjectslNC DO'RDot-171Feb-05 Report%2-05 DatalTablesAffable B-1
6/11/2012 Hart & Hickman, PC

Table G-1
Water Supply Well Inventory
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
Map ID
Well Owner &Address
well status
Distance and Direction from Former Asphalt
Testing Laboratory
WSWA
Maymead, Inc., 164 Bostian Bridge Drive, Statesville
Abandoned
On -site, near former asphalt laboratory
WSW-2
Maymead, Inc., 164 Bostian Bridge Drive, Statesville
Abandoned
On -site, near former asphalt laboratory
WSW-3
Dorothy Davis, 124 Bostian Bridge Drive, Statesville
Active
—1,200 ft, cross -gradient
WSW-4
Maymead, Inc., 164 Bostian Bridge Drive, Statesville
Active
On -site, —500 ft, upgradient
WSW-4A
Maymead, Inc., 164 Bostian Bridge Drive, Statesville
Inactive
On -site, —500 ft, upgradient
WSW-5
Lance & Melissa Lingle, 913 Buffalo Shoals Road, Statesville
Active
—650 ft, cross -gradient
WSW-6
Fred Davis, Buffalo Shoals Road, Statesville
Active
—800 ft, upgradient
WSW-7
Fred Davis Estate, Buffalo Shoals Road, Statesville
Active
—1,000 ft, upgradient
WSW-8
Dorothy Davis, 868 Buffalo Shoals Road, Statesville
Active
—1,100 ft, upgradient
WSW-9
Dorothy Davis, 868 Buffalo Shoals Road, Statesville
Active
—1,100 ft, upgradient
WSW-10
Jerry Hinson, 917 Buffalo Shoals Road, Statesville
Active
—900 ft, upgradient
WSWA 1
Jack & Betty Wooten, 897 Buffalo Shoals Road, Statesville
Active
—1,000 ft, upgradient
WSW-12
Margaret Cloer, 881 Buffalo Shoals Road, Statesville
Active
—1,200 ft, upgradient
WSW-13
Jack & Betty Wooten, 871 Buffalo Shoals Road, Statesville
Active
—1,200 ft, upgradient
WSW-14
Jack & Betty Wooten, 865 Buffalo Shoals Road, Statesville
Active
—1,400 ft upgradient
WSW-15
Jerry Hinson, 911 Buffalo Shoals Road, Statesville
Active
—900 ft, upgradient
WSWA 6
Wooten Family of NC, 847 Buffalo Shoals Road, Statesville
Active
—1,200 ft, upgradient
WSW-17
Garland Cloer, 889 Buffalo Shoals Road, Statesville
Active
—1,200 ft, upgradient
Notes:
Owner and address information based on Iredell County GIS Database and August 2011 H&H windshield survey.
WSW-15 and WSW-16 were located during the updated receptor survey in August 2006.
WSWA7 was located during the updated receptor survey in August 2010.
Water supply well locations are provided on Figure 2.
S:~-Master ProjectsM DOTTot-171Feb-05 ReporU-05 DataWablesAslTable G-1
6/11/2012 Hart & Hickman, PC

Table G-2
Summary of Water Supply Well Analytical Results
NC DOT Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT404
WSW-1 (-213')
WSW-2
-100'
WSW-3 (100')
WSW-4 (-165')
WSW-4A
Abandoned Site Well
Abandoned
Site Well
Davis Residential Well
Site Well (� table)
Inactive Site Well
6230D
6230D
601
601(Dup)
601
6230D
601
6230D
601
601
601
601
601
601
601
601
601
601
601
601
601
601
601
601
601
62008
601
COMPOUNDS
Standard
Oct-96
Sep-97
Oct-98
Oct-98
Oct-98
Sep-97
Oct-98
Jan-99
Aug-01
Feb-02
Aug-02
Feb-03
Aug-03
Feb-04
Aug-04
Feb-05
Aug-05
Feb-06
Aug-06
Feb-07
Aug-07
Feb-08
Au -08
Au -09
Au -10
Aug-1 1
Fea09
1,1,1-Trichloroethane
200
2
<0.5
<1
<1
<1
<0.5
<1
<0.5
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1.0
<1.0
<1.0
c1.0
<1.0
<1.0
<1.0
<1.0
<11.0
Tdchloroethene
3
0.7
<0.5
<1
<1
<1
<0.5
<1
<0.5
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
1,1-Dichloroethane
6
0.9
<0.5
<1
<1
<1
<0.5
<1
<0.5
<1
<1
<1
<1
<1
<1
-Cl
<1
<1
<1
<1.0
<1.0
<1:0
<11.0
<1.0
<1.0
<1.0
<1.0
<1.0
1,1-Dichioroethene
7
0.8
<0.5
<1
<1
<1
<0.5
<1
<0.5
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
Methyl-tert butyl ether
20
1
0.7
NA
NA
NA
<0.5
NA
<0.5
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
m/p-xylenes
500
0.5
<0.5
NA
NA
NA
<0.5
NA
<0.5
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
1,2,4-Tdmethylbenzene
400
1
<0.5
NA
NA
NA
<0.5
NA
<0.5
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
n-Propylbenzene
70
0.9
<0.5
NA
NA
NA
<0.5
NA
<0.5
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Naphthalene
6
0.7
<0.5
NA
NA
NA
<0,5
NA
<0.5
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
1,4-Dioxane
3
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
<5.0
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
1,2-DicNoroethane
0.4
6.9
<0.5
<1
<1
<1
<0.5
<1
<0.5
<1
<1
<1
<t
<1
<1
<1
<1
<1
<1
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
<1.0
Diisopropyl ether
70
0.8
<0.5
NA
NA
NA .
<0.5
NA
<0.5
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Ethylbenzene
600
0.5
<0.5
NA
NA
NA
<0.5
NA
<0.5
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
Notes:
Analytical method numbers are shown below sample IDs.
Results are in micrograms per liter (Vg/l)
NA - Not Analyzed for this parameter.
Bold indicates concentration exceeds standard.
Dup - Duplicate sample
GW - Ground Water
Well depth is shown in parenthesis
1,4-Dioxane was analyzed by Method SW846-8260B/SIM
S.9AAA Mesta Roje=WC DOTWOt-VWebaS Repo=-05 DatelTetieL)&%TaNe C62
6n3r1012 Hart & Hickman, PC

APPENDIX A
SITE HISTORY
A.1 Historical and Present Site Usage
The former North Carolina Department of Transportation (NC DOT) Asphalt Testing Site No. 2-
66 is located at 164 Bostian Bridge Road in Statesville, NC. From 1964 to approximately 1989
the NC DOT operated an asphalt testing laboratory at the property. Currently, Maymead Inc.
(Maymead) leases the facility and conducts mineral processing and asphalt production activities.
The property is presently owned by Superior Properties of Iredell Limited Partnership. A site
vicinity map is provided on Figure H-l. A detailed site map is presented on Figure H-2.
A.2 Origin of the Contamination
The former asphalt testing laboratory was located in the central portion of the property (Figure H-
2). During the period of asphalt plant operations, on -site testing of asphalt following the
American Society of Testing Materials (ASTM) Method D 2172-88 was conducted at this
laboratory. The testing procedures required the use of one or more of the following chlorinated
solvents: trichloroethene (TCE), 1,1,1-trichloroethane (1,1,1-TCA), or carbon tetrachloride
(CTC).
Pursuant to a Memoranda of Agreement between NC DOT and the North Carolina Department
of Environment and Natural Resources (DENR), the scope of the environmental incident is
specifically limited to assessment and remediation of TCA, TCE, CTC, and their degradation
daughter products. Of these three compounds, only TCE and 1,1,1-TCA (and their daughter
products) have been detected at the site.
A.3 Previous Remedial Action
H&H completed a Corrective Action Plan (CAP) in June 1999 that proposed excavation of
A-1
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hart hickman
SMMTER ENVMWMNTAL SOLUTIONS

source area soils followed by natural attenuation of impacted groundwater as the remedial
approach for the site. In September 2001, an area of impacted soil (approximately 30 ft x 13 ft)
was excavated to a depth of 10 ft along the northern side of the former asphalt testing laboratory
building. Based upon weight tickets, a total of 161.53 tons of non -hazardous impacted soil was
removed.
Following excavation activities, groundwater monitoring was conducted on a semi-annual basis
through 2009. Currently, H&H collects groundwater samples from monitoring wells SMW-1,
SMW-2, and SMW-3; deeper saprolite monitoring wells DMW-1, DMW-2, DMW-6, and
DMW-8; bedrock monitoring wells DMW-3, DMW-4, and DMW-7; and the on -site water
supply well WSW-4 on an annual basis to monitor natural attenuation.
Post -Remedial Soil and Groundwater Quality
Soil Quality
Following excavation activities, H&H collected two sidewall samples and two base samples
from the excavation pit. The soil samples were analyzed for volatile organic compounds (VOCs)
by EPA Method 8021. The VOCs TCE and 1,1,1-TCA were detected in one sidewall sample at
concentrations of 0.0031 mg/kg and 0.0034 mg/kg, respectively. At the time, site -specific soil
target levels were calculated for TCE for groundwater protection. A site -specific soil target level
was not calculated for 1,1,1-TCA as concentrations did not exceed screening groundwater
protection values. To calculate the TCE soil target level, H&H utilized VLEACH Version 2.2a
(a US EPA one-dimensional finite difference vadose zone leaching model). Based on the outputs
of the model, a soil target level of 0.050 mg/kg for TCE was proposed in the CAP and approved
by DENR. Additionally, the detected concentrations of TCE and 1,1,1-TCA are below their
current Inactive Hazardous Sites Branch (IHSB) Health Based Soil Remediation Goals
(HBSRGs) of 0.88 mg/kg and 640 mg/kg, respectively.
Based on the post -excavation sampling data, impacted soil at the site was adequately excavated
which removed the potential secondary source of groundwater impacts at the site. A summary of
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post -excavation soil analytical results is available on Table A-1. Limits of the remedial soil
excavation and post -excavation sampling locations are presented on Figure H-3.
Groundwater Quality
Based on the most recent groundwater analytical results for shallow saprolite wells, groundwater
is not impacted above NCAC 2L Groundwater Standards (21, standards). However, TCE, 1,1-
DCA, l,l-DCE, and 1,2-DCA are present in deeper saprolite monitoring wells DMW-6 and
DMW-11 at concentrations above their respective 2L standards. Additionally, TCE is present
above its 2L standard in monitoring well DMW-9. Target compounds were not detected above
2L standards in the bedrock monitoring wells. Target compounds were not detected in the active,
upgradient on -site water supply well or in the downgradient stream. VOC concentrations have
generally decreased in site monitoring wells since 1997.
No groundwater impacts have been detected in monitoring well DMW-8 which is located on the
opposite side of the unnamed tributary of Third Creek from the former asphalt -testing laboratory.
The absence of groundwater impacts in DMW-8 indicates that the tributary is acting as an effective
hydraulic barrier.
Groundwater analytical data indicate VOC reductive dechlorination daughter products 1,1-DCA,
cis-1,2-DCE, and l,l-DCE (also a potential abiotic substitution daughter product of 1,1,1-TCA)
continue to be present in shallow groundwater, and 1,1-DCA and 1,1-DCE continue to be present
in deeper groundwater. In addition, natural attenuation parameters generally indicate acceptable
to favorable conditions for continued reductive dechlorination. A summary of saprolite
groundwater analytical data is available on Table A-2. A summary of bedrock groundwater
analytical data is available on Table A-3. The estimated horizontal extent of TCE in shallow
ground water is presented on Figure H-4.
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SMARTER ENVMWrMENTAL soLunous

APPENDIX B
GEOLOGY AND HYDROGEOLOGY
A description of the regional and site geology and hydrogeology is provided below. The
summary provided below incorporates information obtained from published materials and field
activities conducted during site assessment.
11.1 Regional Geology/Hydrogeology
The subject property is located in the Piedmont Physiographic Province of North Carolina.
According to the Geologic Map of North Carolina dated 1985, the subject property lies within
the Charlotte Belt of the Piedmont. In the site area, underlying bedrock is composed of
metamorphosed quartz diorite. The land surface of the area is generally characterized as gently
sloping, which may become moderately steep where intersected by streams.
In the Piedmont, the bedrock is overlain by a mantle of weathered rock termed saprolite or
residuum. The saprolite consists of unconsolidated clay, silt, and sand with lesser amounts of
rock fragments. Due to the range of parent rock types and their variable susceptibility to
weathering, the saprolite ranges widely in color, texture, and thickness. Generally, the saprolite
is thickest near interstream divides and thins toward streambeds. In profile, the saprolite
normally grades from clayey soils near the -land surface to highly weathered rock above the
competent bedrock.
The occurrence and movement of groundwater in the Piedmont is typically within two separate
but interconnected water -bearing zones. A shallow water -bearing zone occurs within the
saprolite, and a deeper water -bearing zone occurs within the underlying bedrock.
Groundwater in the shallow saprolite zone occurs in the interstitial pore spaces between the
grains comprising the saprolite soils. Groundwater in this region is typically under water table or
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SINARTEN QMNONMEllfAL SOWTIOHS

unconfined conditions. Groundwater movement is generally lateral from recharge areas to small
streams that seine as localized discharge points.
The occurrence and movement of groundwater in the underlying crystalline bedrock is controlled
by secondary joints, fractures, faults, and dikes within the bedrock. On a regional scale, the
direction of groundwater flow is typically from uplands to major streams and groundwater sinks
which is similar to the saprolite groundwater flow direction. The saprolite has a higher porosity
than the bedrock and serves as a reservoir that supplies water to a network of fractures in the
bedrock.
B.2 Site Geology and Hydrogeology
The geology of the site consist of a layer of fill material overlying unconsolidated saprolite
grading downward into competent bedrock. Examination of soil collected during site drilling
activities indicate that the fill material ranges in thickness from approximately three to 15 ft and
consist of variable soil textures containing gravel and asphalt. - The saprolite is composed of
primarily of a reddish brown and orange silty clay becoming more stiff with depth. Competent
bedrock or auger refusal has been encountered during site assessment activities at depths ranging
from approximately 36 ft in monitoring well DMW-5 to approximately 42 ft in monitoring well
DMW-3. Based upon drilling observations, the bedrock appears to be comprised of granitic
rock.
Groundwater levels were most recently gauged in site related monitoring wells on February 2,
2012. Depth to groundwater below top -of -casing at shallow saprolite groundwater monitoring
wells ranged from approximately 26.39 ft at monitoring well SMW-4 (upgradient of the
proposed injection area) to approximately 32.63 ft at monitoring well SMW-3 (upgradient of
proposed injection area). Groundwater levels in deeper saprolite monitoring wells ranged from
approximately 7.94 ft at monitoring well DMW-8 (downgradient of the proposed injection area)
to approximately 32.72 ft at monitoring well DMW-1 (upgradient of proposed injection area).
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SMARTER MMONMENTAL SOLUMNS

An estimated saprolite groundwater potentiometric map is provided as Figure H-7. The shallow
groundwater potentiometric map indicates that shallow groundwater at the site generally flows to
the northwest toward Third Creek, which is consistent with site topography (Figure H-1). Based
on the February 2012 groundwater elevation data, the calculated horizontal hydraulic gradient for
shallow groundwater in the plume area is approximately 0.02 ft/ft. Monitoring well construction
data and recent groundwater levels are summarized on Table B-1.
Based on slug test data previously collected from monitoring wells SMW-1, SMW-4, and DMW-
1, H&H used AQTESOLV software utilizing the Bouwer and Rice solution method to calculate
hydraulic conductivities. Based on H&H's analyses, the geometric mean hydraulic conductivity
for monitoring wells SMW-1, SMW-4, and DMW-1 is approximately 1.1 ft/day or 4x104 CM/S.
Based on both site specific data and published values, groundwater velocity was estimated for the
site using the following equation:
K dH
J?Y
lie dL
Where:
17X = Average linear groundwater velocity parallel to groundwater now direction
K = Hydraulic conductivity (site specific)
n. = Effective Porosity (published value)
dH = Hydraulic gradient (site specific)
A
Utilizing the geometric mean hydraulic conductivity of 1.1 ft/day, the hydraulic gradient of 0.02
ft/ft, and an effective porosity for silt of 15% (EPA, 1998), the shallow groundwater velocity is
estimated to be approximately 0.15 ft/day or approximately 55 ft/year.
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APPENDIX C
INJECTION FLUID COMPOSITION
This project will involve injecting emulsified oil substrate (EOS®) into the aquifer to stimulate in
situ biodegradation. EOS®, commercially available from EOS Remediation, LLC, is an
emulsified oil product which contains a blend of soybean oil, lactate, non-ionic surfactants,
macro and micronutrients, and vitamins specially formulated to stimulate anaerobic
biodegradation. The specific EOS® product proposed for injection is EOS® 598B42. A Material
Safety Data Sheet (MSDS) for this product is attached in this appendix, and the composition is
summarized below.
Ingredient
Percent by Weight
Soybean Oil
59.8 f 2%
Sodium Lactate/Lactic Acid
4 f 0.2%
Food Additives/Emulsifiers/Preservatives
10.1 t 0.2%
Extracts
2 f 0.2%
Water
Balance
Percent Organic, by Weight
74 f 2%
EOSO 598B42 also includes a vitamin B12 supplement. Several studies have shown that growth
of dechlorinating microorganisms may be enhanced by providing these bacteria with amino acids
and/or vitamins, specifically vitamin B12. Materials contained in EOS® are Generally
Recognized As Safe (GRAS) food -grade materials (21 CFR 184.1400).
EOS® is engineered to have droplet sizes significantly smaller than most aquifer pore spaces,
with an effective diameter of approximately 1.0 micron. Thus, the oil droplets can easily pass
through the pores with negligible clogging of the aquifer. The density of EOS® varies as a
function of oil content which is dependent on the amount of water used to dilute the emulsion
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concentrate. The specific gravity of the concentrate is 0.92, and the specific gravity of the
diluted, injected emulsion typically varies between 0.96 and 1.00. The injected emulsion also
has a low viscosity which allows it to be easily injected and distributed throughout the aquifer.
The injected emulsion is typically 1.3 to 2.1 times as viscous as water depending on the amount
of dilution water used.
EOS® 5981342 is shipped to the site in concentrate form in 55-gallon drums and is diluted with
water prior to injection. Implementation of the process at this site will involve on -site dilution of
the EOSOconcentrate with potable water. Water used for dilution purposes will be obtained from
onsite water supply well (WSW) WSW-4. This WSW has been routinely sampled since 1999
and site constituents of concern (COCs) have never been detected above laboratory method
detection limits in the groundwater samples collected from this well.
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APPENDIX D
INJECTION RATIONALE
The goal of the proposed injection project is to stimulate in situ biodegradation of chlorinated
solvents in source area groundwater to improve the speed of natural attenuation. The
constituents of concern at the site are amenable to anaerobic biodegradation. The project will
involve injecting and distributing EOS® throughout the targeted treatment zone using direct push
technology (DPT) installed temporary injection wells. Once injected, the oil becomes trapped
within the soil pores leaving a residual oil phase to support long-term anaerobic biodegradation
of the target contaminants. As the oil slowly biodegrades, it provides a continuous source of
dissolved organic carbon (i.e., fermentation products) to the native microbial community to
stimulate microbiological consumption of oxygen and production of hydrogen. The hydrogen
itself then drives the desired anaerobic biological metabolism of the target contaminants by a
more specialized group of microorganisms. These microbial metabolic transformations -are
illustrated in the following equations:
Cs6HIoo06 (edible oil) + 106 H2O --� 56 CO2 + 156 H2
C2HC13 (TCE) + 3 H, , CA (ethene) + 3 Cl + 3 H+
C214303 (1,1,1-TCA) + 3 H2 ---- > CZH6 (ethane) + 3 Cl + 3 H+
TCE and 1,1,1-TCA are sequentially reduced via reductive dechlorination. TCE is transformed
to cis and trans-1,2-dichloroethene, then vinyl chloride, and finally ethene. Similarly, 1,1,1-TCA
is reduced to 1,1-dichloroethane to chloroethane to ethane. EOS° has been successfully
demonstrated to stimulate these reactions and degrade chlorinated organic solvents (Lieberman et
al, 2004; Borden et al, 2003).
Implementation of enhanced anaerobic bioremediation can also cause changes in the
geochemistry of the aquifer. Secondary water quality can be degraded as a result of mobilization
of formerly insoluble forms of metals (e.g., iron and manganese) that occur naturally in the
aquifer. However, the metals are precipitated and immobilized downgradient of the treatment
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SMARTER ENVUMNMENTAL SOLUTIONS

zone when conditions return to the background oxidizing state. Biodegradation of the injected
- oil also results in increases in chemical oxygen demand (COD), biological oxygen demand
(BOD), total dissolved solids (TDS), and sulfides that can affect taste and odor. The elevated
levels of these parameters are typically observed in the anaerobic reactive zone, and levels
typically return to near -background as substrate typ y b s bst ate is consumed and groundwater migrates out of the
treatment zone (AFCEE, 2004). Because the proposed injection activities are limited to the near
source area, the geochemistry changes should pose no significant human or environmental health
risks.
References
AFCEE. 2004. Principals and Practices of Enhanced Anaerobic Bioremediation of Chlorinated
Solvents.
Borden, R.C., Coulibaly, K.M., Jung, Y., Long, C.M., Harvin, A.S., and Lindow, N.L. 2003.
Use of Emulsified Edible Oil for In Situ Anaerobic Bioremediation. In Situ and On -Site
Bioremediation. The Seventh International Symposium. Orlando, FL, June 2-5.
Lieberman, M.T., C. Zawtocki, R.C. Borden, and G.M. Birk. 2004. Remediation ofPerchlorate
and Trichloroethane in Groundwater Using Edible Oil Substrate (EOS"). NGWA
Conference, MTBE and Perchlorate: Remediation and Public Policy. Costa Mesa, CA.
June 3-4.
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APPENDIX E
INJECTION PROCEDURE AND EQUIPMENT
H&H proposes to inject EOS® in the area of highest chlorinated solvent concentrations at the
site. The proposed temporary injection well network extends from the north of the former testing
laboratory near DMW-9 for a distance of approximately 170 ft to the north-northwest beyond
DMW-6. The proposed injection well network is approximately 110 ft to 160 ft wide. The
objective of the injection is to reduce chlorinated solvents in this area such that the ground water
concentrations will meet standards in a shorter time frame. The infection will target a 20-ft thick
vertical interval starting at the water table which is approximately 18 ft to 20 ft below ground
surface (bgs) and extending to approximately 38 ft to 40 ft bgs. Proposed injection points are
presented on Figure H-8
Thirty five temporary injection wells will be installed within the targeted treatment area. The
injection sequence will consist of blending the EOS® concentrate with potable water and
injecting the diluted EOS® into the injection wells. Additional details are provided in the
following sections.
E.1 Injection Well Construction
Thirty five temporary injection wells will be installed downgradient of the source area, which is
north of the former asphalt testing laboratory. Based on discussions with the EOSO
representative and H&H's experience, the injection wells will be installed approximately 20 ft
apart perpendicular to ground water flow and approximately 30 ft apart parallel to ground water
flow at the approximate locations shown on Figure H-8.
Each injection location will be advanced using DPT drilling equipment to a depth of
approximately 20 ft below the water table. The water table depth is typically 18 ft to 20 ft below
ground surface (bgs) in the area targeted for injection. A four-ft long, 1 3/4-inch diameter
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SMAKIER MKONMEMAL SOUMONS

stainless steel sheath with a detachable drive point will be driven to the target total depth of 38 ft
to 40 ft bgs. The rods and sheath will be retracted up the borehole at four ft intervals to allow
injection of a predetermined volume of EOS® through each four ft interval. This process will
continue over the 20 ft treatment interval. Following each injection, the borehole will be
abandoned with a bentonite-grout slurry. No drill cuttings are expected. A typical temporary
injection well diagram is shown on Figure H-9.
E.2 Injection Process
Based on the TCE plume extent, a total of thirty one 52.2 gallon drums of EOS® concentrate will
be delivered to the site. The EOS° concentrate will be diluted in the field prior to injection using
potable water which will be obtained from WSW-4. Because the water used for the injections is
analyzed for site COCs on a regular basis, the water will not be treated prior to use in the
injection process. The EOS® concentrate will be mixed with water prior to injection at a ratio of
1:10 (EOS®: water). A total of approximately 1,618 gallons of EOS® concentrate mixed with
approximately 16,180 gallons of potable water will be injected into the subsurface.
The EOS° will be batch -mixed in a small, portable tank, and then pumped into the injection
points utilizing an injection pump. Each injection well will have a pressure gauge, a flow meter,
and a valve to regulate the pressure and flow rate. During the injection process, flow rates and
volumes will be measured with a totalizing flow meter. The pressure gauges will be utilized to
monitor and maintain the injection pressure between 10 pounds per square inch (psi) and 60 psi
to prevent significant hydraulic fracturing of the formation which could create preferential
pathways and limit the effectiveness of the EOS® bioenhancement. An injection equipment
schematic is shown in Figure H-9.
To better understand the capacity of the aquifer to accept the injection mixture, the injection
volume was compared to the injection zone pore volume. Based on the anticipated ROI of 20 ft,
an aquifer thickness of 20 ft (saturated injection interval) and an effective porosity of 15%, a
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SMARTER ENVIRONMENTAL SOLUTIONS

- calculated injection zone pore volume of approximately 28,200 gallons is estimated at each
- injection location. Assuming an approximate total injection volume of 17,800 gallons (EOS®
and water mixture) and a total injection zone pore volume of approximately 987,000 gallons
(28,200 gallons at each of the 35 injection locations) the injection mixture to aquifer pore space
volume ratio is approximately 1 : 55 (injection volume : aquifer pore space volume). This ratio
suggests the aquifer is capable of accepting the proposed injection volume while minimizing
stress on the aquifer.
During the injection process, mounding of the water table around the injection wells will be
monitored by measuring the depth to water in nearby monitoring wells and comparing the
readings with pre -injection measurements. Assuming the wells can be injected at a rate of 1.0 to
3.0 gallons per minute (gpm), it will take approximately 2.8 to 8.5 hours to complete the
injection process at each well. The injection activities should be completed in approximately 12
to 35 field days.
E-3
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SMARTER ENVaM&S MAL SOUMM

APPENDIX F
MONITORING PLAN
F.1 Monitoring Well Installations
H&H recently installed three permanent shallow monitoring wells (DMW-9, DMW-10, and
DMW-11) to further delineate groundwater impacts downgradient of the source area (Figure H-
2). These three wells surround DMW-6, where the highest concentrations are present. Baseline
groundwater sampling data from the wells was utilized to finalize the proposed injection area.
Additionally, the wells will be utilized as observation wells following the bioenhancement event
to monitor the effectiveness of the injection.
The wells were constructed of two-inch diameter PVC casing with 10 feet of 0.010-inch slotted
well screen installed to screen the deep saprolite zone of the shallow aquifer. Monitoring wells
DMW-9 and DMW-11 were completed to total depths of 40 ft, and DMW-10 was completed to a
total depth of 38 ft. The wells were completed at the surface with steel stick-up boxes and
secured with 2 ft by 2ft concrete well pads. Soil cuttings and development water generated
during the installation was spread in the vicinity of the new monitoring wells. The top of casing
elevations were surveyed relative to the existing monitoring well network.
The three newly installed monitoring wells were sampled during the baseline sampling event
discussed below. The monitoring well installation activities and analytical results will be further
discussed in the first semi-annual monitoring report, also detailed below.
F.2 Baseline Monitoring
A baseline sampling event was conducted immediately following installation of the new
monitoring wells and prior to submittal of this UIC permit application. The baseline sampling
consisted of measuring water levels from all site monitoring wells. Groundwater samples were
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SMARTEN ENVIRONMENTAL SOWTIONS

collected from deeper saprolite monitoring wells DMW-1, DMW-2, DMW-6, DMW-8, DMW-9,
DMW-10, and DMW-11, and bedrock monitoring well DMW-7. Field measurements, including
dissolved oxygen (DO), oxidation-reduction potential (ORP), pH, specific conductivity, ferrous
iron, and temperature, were recorded during purging activities at each of the monitoring well
locations. Groundwater samples were submitted to a North Carolina certified laboratory for
analysis of purgaeble halocarbons according EPA Method 601. In addition, groundwater
samples were collected from each of the above listed monitoring wells for laboratory analysis of
natural attenuation parameters including metabolic acids, nitrate, sulfate,. methane, ethane,
ethene, and total organic carbon (TOC).
F.3 Performance Monitoring
Performance monitoring will include two years of post -injection quarterly sampling to evaluate
the effectiveness of the EOS® injection at reducing VOC concentrations in groundwater. Two of
the quarterly sampling events each year will only include select monitoring wells to monitor the
effectiveness of the EOS® injection. The other two quarterly sampling events each year will be
comprehensive sampling events in which all site related monitoring wells will be sampled. The
first quarterly monitoring event will be performed within approximately one month of
completing the injection activities.
During each quarterly sampling event, groundwater samples will be collected from deeper
saprolite monitoring wells DMW-1, DMW-2, DMW-6, DMW-8, DMW-9, DMW-10, and
DMW-11, and bedrock monitoring well DMW-7. Field measurements, including DO, ORP, pH,
specific conductivity, ferrous iron, and temperature, will be recorded during purging activities at
each of the monitoring well locations. Groundwater samples will be submitted to a North
Carolina certified laboratory for analysis of purgeable halocarbons according EPA Method 601.
In addition, groundwater samples will be collected from each of the previously listed monitoring
wells for laboratory analysis of natural attenuation parameters including metabolic acids, nitrate,
sulfate, methane, ethane, ethene, and TOC. Groundwater samples will be analyzed for metabolic
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acids during the first year of post -injection sampling (four groundwater sampling events).
Metabolic acids will not be analyzed during the second year of post -injection sampling.
Additional parameters may be analyzed if stipulated by the UIC permit.
During the comprehensive semi-annual sampling events (two events per year; every other
quarterly event), samples will be collected from the previously referenced monitoring wells and
from the other monitoring wells (shallow saprolite monitoring wells SMW-1, SMW-2, and
SMW-3, and bedrock monitoring wells DMW-3 and DMW-4). Groundwater samples collected
from these monitoring wells will be submitted to a North Carolina certified laboratory for
analysis of purgeable halocarbons according to EPA Method 601. Laboratory analysis of natural
attenuation parameters will not be conducted on groundwater samples collected from monitoring
wells SMW-1, SMW-2, SMW-3, DMW-3, and DMW-4. Field measurements collected from
these monitoring wells will be the same as specified above.
H&H will also collect a groundwater sample from the active on -site water supply well WSW-4
and from the creek located on the northern portion of the site during the comprehensive semi-
annual sampling events. The water supply well will be purged for approximately 15 minutes
prior to sample collection. The samples will be analyzed in the laboratory for VOCs by EPA
Method 601.
During the semi-annual sampling event in the second half of each year, H&H will update the
water supply well survey. Potential receptors will be discussed in the semi-annual monitoring
reports.
FA Reporting
In accordance with the UIC permit, an Injection Event Record will be submitted to the UIC
Program within 30 days of completing the injection activities. In addition, monitoring reports
will be prepared and submitted on a semi-annual basis. The first semi-annual report will include
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SMARTER ENMONMEMAL SOWIIONS

a description of the injection activities and the results of the baseline and first two post -injection
quarterly sampling events. The remaining three semi-annual reports will include the results of
the two previous quarterly sampling events, an evaluation of the effectiveness of the enhanced
bioremediation, and recommendations for future monitoring, and/or site activities. The
monitoring reports will include water level gauging data, potentiometric maps, sample analytical
results, water supply well survey information, and an evaluation of biodegradation processes.
The monitoring reports will be prepared under the supervision of a Professional Engineer or
Licensed Geologist. The first semi-annual monitoring report following the EOS® injection will
serve as the evaluation report as expected to be required by the UIC permit.
F-4 14
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SMARTER EHVOMMEMAL SOLUTIM

APPENDIX G
WELL DATA AND RECEPTOR SURVEY INFORMATION
The August 2011 receptor survey update was performed by reconnaissance within 1,500 ft of the
- former asphalt -testing laboratory and by contacting the local utility department to confirm that no
municipal wells are in the area. During the August 2011 receptor update, no additional water
supply wells were identified within 1,500 ft of the site. On -site abandoned and active water
wells and off -site water supply well locations are depicted on Figures H-2 and H-10,
A total of 18 water supply wells (active, inactive, or abandoned) are located within a 1,500-ft
radius of the former asphalt -testing laboratory. The locations of the water supply wells are
indicated on Figure H-10, and a summary of water supply well information is provided in Table
G-1. Of the 18 water supply wells, four wells are located on -site and are designated as WSW-1,
WSW-2, WSW-4, and WSW-4A. H&H abandoned water supply wells WSW-1 and WSW-2 in
September 2001. Water supply wells WSW-4 and WSW-4A are located approximately 500 ft
southeast and upgradient of the source area. WSW-4 serves the entire subject property and
WSW-4A is inactive. Target volatile organic compounds (VOCs) have not been detected in
WSW-4 during semi-annual monitoring with the last sample collected in August 2011.
Available water supply well analytical data is provided on Table G-2
No off -site water supply wells are located downgradient of the former asphalt -testing laboratory.
Each of the 14 off -site water supply wells are located upgradient or cross -gradient of the former
asphalt laboratory. The closest off -site water supply well (WSW-5) is situated cross -gradient of
the site approximately 650 ft southwest of the former asphalt laboratory.
One of the 14 off -site water supply wells (WSW-3) is located cross -gradient of the former
asphalt -testing laboratory on the Dorothy Davis property (across an unnamed tributary of Third
Creek; and approximately 1,200 ft northeast of the former laboratory). WSW-3 was sampled in
September 1997 and again in October 1998. No target compounds were identified in either
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- sample. Further, a deep saprolite monitoring well (DMW-8), located on the same side of the
tributary as WSW-3, is not impacted. The lack of impacts in DMW-8 indicates that the tributary
acts as an effective hydraulic barrier.
Based on the distance from the former laboratory, the known extent of the contaminant plume,
and topographic and hydraulic gradient considerations, the potential for site groundwater impacts
to affect the off -site water supply wells is considered to be low.
Two surface water bodies are located within a 0.25-mile radius of the subject site (Figures H-1
and 2). An unnamed tributary to Third Creek is located approximately 300 ft north-northwest of
the former laboratory and borders the northern property boundary. In addition, Third Creek is
located approximately 400 ft west of the former laboratory and borders the western property
boundary. Both of these surface water bodies are discharge locations for site groundwater.
In February 1999, surface water samples were collected from both the unnamed tributary and
Third Creek at locations along the northern and western property boundaries of the site. In
August 2011, H&H collected a surface water sample (labeled SS-2) from the unnamed tributary
of Third Creek (Table A-4 and Figure H-2). Target compounds were not detected in the surface
water samples. In addition, groundwater modeling conducted as part of the CAP indicates that
target compounds will not be present in these surface waters above surface water quality
standards in the future. Surface water analytical data is provided on Table A-4
G-2 hart hickman
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SMARTER ENVIRONMENMAL SOUIMNS

MATERIAL SAFETY DATA SHEET
EMULSIFIED EDIBLE OIL SUBSTRATE ---- HM.IS----
HEALTH 1
D.O.T. HAZARD CLASSIFICATION: NONE FLAMMABILITY 0
REACTIVITY 0
PERSONAL PROTECTION B
MANUFACTURER'S NAME
EOS Remediation, Inc
3722 Benson Drive, Suite 101
Ralelgh,NC 27609
DATE OF PREPARATION
01-24-03, Rev. 02-16-04
INFORMATION TELEPHONE NO.
919-873-2204
SECTION I - PRODUCT IDENTIFICATION
PRODUCT NAME EOS®CONCENTRATE 1.1 (698B 42)
PRODUCT CLASS VEGETABLE OIL BASED EMULSION
CAS NUMBER MIXTURE
SECTION II - HAZARDOUS INGREDIENTS
COMPONENT(S) EXPOSURE LIMIT
THIS PRODUCT IS A MIXTURE OF EDIBLE FOOD GRADE ADDITIVES AND CONTAINS NO
HAZARDOUS INGREDIENTS.
SECTION III - PHYSICAL DATA
BOILING POINT: 212°F
SPECIFIC GRAVITY: .92
VAPOR PRESSURE: NOT ESTABLISHED
PERCENT VOLATILE BY VOLUME (%): 24 (AS WATER)
VAPOR DENSITY: HEAVIER THAN AIR
EVAPORATION RATE: NOT ESTABLISHED
SOLUBILITY IN WATER: SOLUBLE
APPEARANCE AND ODOR: OFF WHITE LIQUID WITH VEGETABLE OIL ODOR
r

EMULSIFIED EDIBLE OIL SUBSTRATE
FLASH POINT:
FLAMMABLE LIMITS:
EXTINGUISHING MEDIA:
UNUSUAL FIRE AND
EXPLOSION HAZARDS:
SPECIAL FIRE FIGHTING
PROCEDURES:
SECTION IV - FIRE AND EXPLOSION HAZARD DATA
>300°F
NOT ESTABLISHED
CO2, FOAM, DRY CHEMICAL
NOTE: WATER, FOG, AND FOAM MAY CAUSE
FROTHING AND SPATTERING.
BURNING WILL CAUSE OXIDES OF CARBON.
WEAR SELF CONTAINED BREATHING APPARATUS
AND CHEMICAL RESISTANT CLOTHING. USE WATER
SPRAY TO COOL FIRE EXPOSED CONTAINERS.
STABILITY:
CONDITIONS TO AVOID:
INCOMPATIBILITY:
HAZARDOUS DECOMPOSITION
PRODUCTS:
HAZARDOUS POLYMERIZATION:
SECTION V - PHYSICAL HAZARDS
STABLE
NONE
STRONG ACIDS AND OXIDIZERS.
THERMAL DECOMPOSITION MAY PRODUCT OXIDES
OF CARBON.
WILL NOT OCCUR
SECTION VI - HEALTH HAZARDS
SIGNS AND SYMPTOMS OF EXPOSURE:
1. Acute Overexposure - NONE
2. Chronic Overexposure - NONE
MEDICAL CONDITIONS GENERALLY NONE KNOWN
AGGRAVATED BY EXPOSURE:
CHEMICAL LISTED AS CARCINOGEN OR POTENTIAL CARCINOGEN:
N.T.P. - NO I.A.R.C. - NO OSHA- NO
EMERGENCY AND FIRST AID PROCEDURES:
1.) Inhalation- REMOVE TO FRESH AIR.
2.) Eyes- FLUSH WITH WATER FOR 15 MINUTES, IF IRRITATION PERSISTS
SEE PHYSICIAN.
3.) Skin- WASH WITH MILD SOAP AND WATER.
4.) Ingestion- PRODUCT IS NON -TOXIC. IF NAUSEA OCCURS, INDUCE VOMITING
AND SEEK MEDICAL ATTENTION.
2

EMULSIFIED EDIBLE OIL SUBSTRATE
SECTION VII - SPECIAL PROTECTION INFORMATION
RESPIRATORY PROTECTION: NOT NORMALLY REQUIRED
VENTILATION: LOCAL EXHAUST
PROTECTIVE GLOVES: NOT NORMALLY REQUIRED
EYE PROTECTION: NOT NORMALLY REQUIRED
OTHER PROTECTIVE CLOTHING
OR EQUIPMENT: NONE
SECTION VIII - SPECIAL PRECAUTIONS AND SPILL/LEAK PROCEDURES
PRECAUTIONS TO BE TAKEN DO NOT STORE NEAR EXCESSIVE HEAT OR
IN HANDLING AND STORAGE: OXIDIZERS.
OTHER PRECAUTIONS: NONE
STEPS TO BE TAKEN IN CASE SOAK UP WITH DRY ABSORBENT AND FLUSH AREA
MATERIAL IS SPILLED: WITH LARGE AMOUNTS OF WATER.
WASTE DISPOSAL METHODS: DISPOSE OF ACCORDING TO FEDERAL, STATE, AND
LOCAL REGULATIONS.
SECTION IX - ADDITIONAL REGULATORY INFORMATION
SARA TITLE III
UNDER THE PROVISIONS OF TITLE 111, SECTION 311/312 OF THE SUPERFUND
AMENDMENTS AND REAUTHORIZATIONS ACT, THIS PRODUCT IS CLASSIFIED
INTO THE FOLLOWING HAZARD CATEGORIES: NONE
THIS PRODUCT DOES NOT CONTAIN SECTION 313 REPORTABLE INGREDIENTS.
THE INFORMATION CONTAINED HEREIN IS BASED ON AVAILABLE DATA AND IS BELIEVED TO BE
CORRECT. HOWEVER, EOS REMEDIATION, INC. MAKES NO WARRANTY, EXPRESSED OR IMPLIED,
REGARDING THE ACCURACY OF THIS DATA OR THE RESULTS TO. BE OBTAINED THEREOF. THIS
INFORMATION AND PRODUCT ARE FURNISHED ON THE CONDITION THAT THE PERSON RECEIVING
THEM SHALL MAKE HIS/HER OWN DETERMINATION AS TO THE SUITABILITY OF THE PRODUCT FOR
HIS/HER PARTICULAR PURPOSE.
3

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7
SMARTER ENVIRONMENTAL SOLUTIONS04.586.0007(p) 704.586.0373(f)
DATE: 8-24-12 REVISION NO: 0
JOB NO: DOT-404 FIGURE NO: 1

APPENDIX H
MAPS
The attached maps depict the requested information.
H-1 19 hart hickman
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SMARTER MMONMENTAL SOUMONS

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ESTIMATED GROUNDWATER
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SCALE IN FEET
('°"ESTIMATED HORIZONTAL EXTENT OF TCE IN
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NCDOT ATS #2-66
STATESVILLE, NORTH CAROLINA
hart 044 hickman
704-586-MM(p) 704-58&0373(0
im Lic=sc # C-1269 / #C-245 GwIoff
DATE. 8-24-12 1 REVISION NO. 0 1
JOB NO. DOT-404
FIGURE NO. H-4

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JOB NO. DOT-404
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STATESVILLE, NORTH CAROLINA
2923 S(YATcycm Smea.Suice 100
hart hickman ���,�� 2no3
SfNAR1FR 9111�t0 lIW 50111NONi Ucc= # C-1269 / #G245 Geology
I DATE: 8-24-12 1 1

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SOUTHERN RAILROAD
LEGEND
SITE PROPERTY BOUNDARY
— STREAM
* SHALLOW MONITORING WELL
0 DEEP MONITORING WELL
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WATER SUPPLY WELL
ABANDONED WATER SUPPLY
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(s1.51) SAPROLITE GROUND WATER
ELEVATION (FT) (FEBRUARY 2012)
64 GROUNDWATER
POTENTIOMETRIC CONTOUR (FT)
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NM NM NOT MEASURED
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0 100 200
SCALE IN FEET
ESTIMATED SHALLOW GROUNDWATER
POTENTIOMETRIC MAP - FEBRUARY 2012
NCDOT ATS #2-66
STATESVILLE, NORTH CAROLINA
hart 04Z hickman 2Cm..sa��
® 704-586MM(p) 704-586M73(0
SMARiBt B XQJfAL SOIl1Ibm license # C•1769 / #G245 Geology
DATE: B-24-12 1 REVISION NO. 0

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SITE PROPERTY BOUNDARY
- • • — • • - STREAM
SHALLOW MONITORING WELL
Q DEEP MONITORING WELL
♦• MONITORING WELL BEDROCK
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WELL
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ESTIMATED GROUND WATER
FLOW DIRECTION
• EOS INJECTION LOCATION
3 TCE ISOCONCENTRATION
CONTOUR (NgA)
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0 100 200
SCALE IN FEET iiiia
1 1 ' ' ' ' I I I I PROPOSED EOS INJECTION POINTS
SOUTHERN RAILROAD
1 NCDOT ATS #2-66
STATESVILLE, NORTH CAROLINA
d 2923 South Tryon Stc«t-Suite 100
j hart hickman �o nh7 �58 -0 2D3
(P) (Q
SMARIHt BiVOtQFiIIABRAL SOIUiIONS Iicease # C-1269 / #C-245 Geolo
I DATE: 8-24-12 REVISION NO. 0
JOB NO. DOT-404 FIGURE NO. H-8

TYPICAL INJECTION EQUIPMENT
RETURN LINE
TO TANK
GAUGE
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GATE VALVE
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it T
15' I I INJECTION INTERVAL
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EXPENDABLE DRIVE POINT
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ACCESS ROAD
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G DEEP MONITORING WELL SAPROUTE
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PiO= NC DOT ATS #2-66
STATESVILLE, NORTH CAROLINA
hart hickman Zaazloeu,NonhaCaml1na2820300
704-586-M(p) 704-586-0373(f)
WAMM EAM NIVIEWAL SOI UnONS Ucrose # G1269 / #G245 Geolo,
DATE: 8-24-12 REVISION NO. 0
JOB NO: DOT-404. FIGURE NO. H-3

OV
�.�. �asfMFM•
��-W w Z
FORMER ASPHALT
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0 ABANDONED WATER SUPPLY WELL
---- SITE PROPERTY BOUNDARY
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—► ESTIMATED GROUND WATER FLOW DIRECTION
NOTES:
1. MAP BASED ON RICHARD CATLIN & ASSOCIATES JUNE
1997 CSA & IREDELL COUNTY GIS DATABASE
2. WATER SUPPLY WELLS ARE KEYED TO TABLE 1
APPROXIMATE
No soo 1000
SCALE IN FEET
WATER SUPPLY WELL LOCATION MAP
NC DOT ATS NO. 2-66
STATESVILLE, NORTH CAROLINA
2923 South Tryon Street -Suite 100
hart hickman chd , l2 2o
SNAKIER @tV1120 11FMAI SOl1HIM License # C-1269 / #G245 Geolc
DATE:' 8-24-12 REVISION NO. 0
JOB NO: DOT-404 FIGURE NO.H-10

MCDENR
North Carolina Department of Environment and Natural Resources
Beverly Eaves Perdue
Governor
Thomas C. Niver, REE III
NCDOT — Roadside Environmental Unit
1557 Mail Service Center
Raleigh, NC 27607
Division of Water Quality
Charles Wakild, P.E.
Director
November 9, 2012
Ref: Issuance of Injection Permit WI0300210
Former NCDOT Asphalt Testing Site No. 2-66
Statesville, Iredell County, North Carolina.
Dear Mr. Niver:
Dee Freeman
Secretary
In accordance with the application received on September 6, 2012, and the supporting data received September 17, 2012
and November 1, 2012, we are forwarding permit number WI0300210. This permit is to inject EOS 5981342 with EOS
Vitamin B12 Supplement for the degradation and enhanced biodegradation of chlorinated Ethenes and Ethanes at the
facility referenced above. This permit shall be effective from the date of issuance until October 31, 2017, and shall be
subject to the conditions and limitations stated therein, including the requirement to submit a final project evaluation as
stated in PART VII'— MONITORING AND REPORTING REQUIREMENTS. 'Please read the entire permit to ensure
that you are aware of all compliance requirements of the permit, and note that additional parameters have been added to
the list of groundwater sampling parameters and that baseline pre -injection surface water sampling and post -injection
surface water sampling have been added to the permit.
You will need to notify this office by telephone 48 hours prior to initiation of operation of the facility. In. order to
continue uninterrupted legal use of the injection facility for the stated purpose, you must submit an application to renew
the permit 120 days prior to its expiration date. Please contact me at 919-807-6352 or at [e-mail] if
you have any questions about your permit.
Regards,Best
1 � �
David Goodrich, L.G.
Hydro geologist
cc: Andrew Pitner, Mooresville Regional Office
Division of Waste Management-REC Program
Matt Bramblett, P.E., Hart & Hickman, PC, 2923 South Tyron Street, Suite 100, Charlotte, NC 28203
WI0300210 Permit File
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N, Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone]
Internet: www.nmaterauality.org
An Equal Opportunity 1 Affirmative Action Employer
One
NorthCarolina
A&`._.

"
ha
r irk
SMAktEk tNVIkONMtNTAL 5,OLUTI.O*N5:
Via Email
November 1, 2012
Aquifer Protection Section
North Carolina Department of
Environment and Natural Resources - DWQ
1636 Mail Service Center
Raleigh, North Carolina 27699
Attention: Mr. David Goodrich
Re: VIC Permit Application Addendum
NC DOT Asphalt Testing Site No. 2-66
Statesville, North Carolina
H&H Job No. DOT-404
Dear Mr. Goodrich:
Y'pn1=M
In response to your email dated October 22, 2012 and on behalf of NC DOT, please find attached
information to supplement to Underground Injection Control permit application dated August 24,
2012 for the above site. The Geologic Cross -Section A -A' (Figure H-5) was revised to depict
the approximate locations of the proposed EOSO injection wells. Please note that Geologic
Cross -Section B-B' does not cross the proposed injection area 'and was not revised.
In addition, a copy of the access agreement for the Davis property, where monitoring well
DMW-8 is located, is attached. We understand that you intend to require surface water sampling
to monitor whether the EOSO substrate is discharging to the adjacent stream in locations
upstream and downstream of the injection area. These surface water sampling locations can also
be accessed through the Davis property.
If you have any questions or need additional information, please contact me at [phone].
Sincerely,
Hart & Hickman, PC
Matt Bramblett, PE
Principal
Enclosures
cc: Mr. Chris Niver, NC DOT (via mail)
2923 South Tryo i.Street,: Suite 3.00. 3334 Aillsi orough (
Chad,ate;. NC 2.8203 Meigh, NC 27607
704,586,0007 m 1h: 919.847A241 Main
a.
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FILL
CLAY'
GRA.NMC BEDROCK
4 A - AND ESTIMATED
EA' XTENT OF TCE
NCDOTATS #2-66
STATESVILLE; NORTH CAROLIN..A
L•— #G120/NC-245C-IM
REVISION NO. 0
FIGURE NO. H-5

Site # 2-66
STATE OF NORTH CAROLINA
COUNTY OF —MDELL
AGREEMENT FOR ENTRY
This agreement made and entered into by ;and between the North Carolina Department of
Transportation (the "Department"). and Mr. Gene Davis (the "Owner") provides the following:
Whereas, the Department' operated an asphalt testing laboratory located adjoining the
Owner's property in Iredell County that is the subject of this agreement (the "subject property"),
said property being more particularly described as follows:
Tax Parcel No. 4723-99-5848 (Davis Property), situated adjacent to the north of APAC
Carolina, Inc. in Statesville, North Carolina.
Whereas, the Department conducted a soil and ground water investigation on the APAC
Carolina. Inc. property to determine if the contaminants of 1,1,1 trichloroethane, trichioroethene
or carbon tetrachloride were present in soil or ground water. This investigation included taking
soil samples from soil borings and ground water samples monitoring wells and water supply
wells; and,
.Whereas, the Department discovered the existence of one or more of these contaminants
on the APAC Carolina. Inc. property; and
Whereas, the Department has notified the North Carolina Department of Environment
and Natural Resources ("DENR") of the contamination of the APAC Carolina Inc. property;
and, ,
Whereas, DENR is requiring investigation of the adjoining Davis Property to determine if
contamination is present on that property; and,
Whereas, the Department has agreed to conduct this investigation by taking and
collecting ground water samples to determine the horizontal and vertical extent of the
contamination on the adjoining Davis Property. .
NOW, THEREFORE, for good and valuable consideration, because contamination from
the APAC Carolina. Inc. property may have migrated to the Owner's property, the Owner and
the Department agree as follows:
1. The Department may enter the subject property to conduct an investigation of the
contamination of the property.
2. The Owner agrees to grant the Department such reasonable access as the Department
determines to be necessary to conduct the investigation, including the right to
temporarily remove fences, barricades, or other obstructions which may impede the
c%dmIewienty agm=cnt - &%iLd=

•+_ter ..
Site # 2-66
Department's ability to conduct the investigation. The Department agrees that any
fences, barricades, or other obstructions removed will be replaced by the Department,
at the Department's sole cost, upon completion of the investigation. The Department
will return the subject property to its condition prior to entry by the Department
within 30 days of the completion of the investigation.
3. The investigation will be conducted by taking and collecting ground water samples by -
means of borings'- and monitoring wells and any other reasonable means the
Department may determine to be necessary.
4. The Department will share the results and conclusions, and provide copies of all
written documents records, etc., of the investigation with the Owner;; however, all
written reports, conclusions; and other such documents generated in connection with
the investigation shall remain the sole property ofthe Department.
5. The investigation will focus on the contaminants 1,1,1-Trichlorethane,
Trichloroethene, and/or Carbon Tetrachloride that may be present in ground water on
the.Owner's property. The expense of all sampling, testing, etc. will be home -by the
Department.
6. The Department and the Owner, by signing this agreement, do not admit liability for
any contamination of the property or violation of any federal or state environmental
law.
7. Neither this agreement of entry or any activity of the Department undertaken in
connection with the investigation shall be deemed_ a trespass on or a taking of the
Owner's property by the.D,epartment. .
This agreement, executed in duplicate Ahis the _- day of .1999.
W�,a
North Carolina Department of Transportation
By:
Title:
G1doa%= arty aveamt - &%Udw

10129A
Goodrich, David
To: [e-mail]
Subject: Additional Information Request for Permit Application NC DOT ATS No. 2-66 (W0300210)
Dear Matt,
We are in receipt of the subject permit to inject EOS at the subject site.
I am writing to request that you provide us with revised geologic cross -sections which include the proposed injection
borings.
We are also requesting a copy of the access agreement for accessing the neighboring property (for monitoring well
DMW-8),
and for obtaining surface water samples from locations upstream and downstream of the injection area. We intend to
include
surface water sampling upstream and downstream of the injection area for field parameters in the injection permit, with
further sampling at those locations contingent upon the results of the field parameter readings.
Please contact me by email, or at [phone] if you have any questions.
Regards,
David Goodrich
Office Telphone Number: [phone]
Aquifer Protection Section Main Number: [phone]
Fax Number: [phone]

WNW
North Carolina Department of Environment and Natural Resources
Division of Water Quality
Beverly Eaves Perdue Charles Wakild, P.E. Dee Freeman
Governor Director Secretary
September 18, 2012
Thomas C. Niver — REE III
NC DOT - Roadside Environment Unit
1557 Mail Service Center
Raleigh, NC 27607
Dear Mr. Niver:
Subject: Acknowledgement of
Application No. WI0300210
Former NCDOT Asphalt
Testing Site No. 2-66
Injection Deemed In -situ
Groundwater Remediation Well
System
Iredell County
The Aquifer Protection Section acknowledges receipt of your permit application and supporting
documentation received on 9/6/2012. Your application package has been assigned the number listed .
above, and the primary reviewer is David Goodrich.
Central and Mooresville Regional Office staff will perfonn a detailed review of the provided
application, and may contact you with a request for additional information. To ensure maximum
efficiency in processing permit applications, the Aquifer Protection Section requests your assistance in
providing a timely and complete response to any additional information requests.
Please note that processing standard review permit applications may take as long as 60 to 90 days
after receipt of a complete- application. If you have any questions, please contact
David Goodrich at [phone] or [e-mail].
Sincerely,
for Debra J. Watts
Groundwater Protection Unit Supervisor
cc: Mooresville Regional Office, Aquifer Protection Section
Matt Bramblett — Hart & Hickman, PC
Permit File= W10300210
AQUIFER PROTECTION SECTION
1636 Mail Service Center, Raleigh, North Carolina 27699-1636
Location: 512 N. Salisbury St., Raleigh, North Carolina 27604
Phone: [phone] FAX: [phone] One
Internet; www.nmateraualitv.om NOrthCaroha
An Equal Opportunity 1 Affirmative Action Employer
iZtul'Q��

Goodrich, David
From:
Schutte, Maria
Sent:
Monday, October 22, 2012 1:55 PM
To:
Goodrich, David
Subject:
W10300210
David,
I was trying to enter an inspection for this site, but BIMS still views it as an application and will not allow me. Please let
me know when it is converted to permit status and I will add my info.
Thank You!
Maria
Maria Schutte, Environmental Specialist - [e-mail]
Division of Water Quality - Aquifer Protection Section
Mooresville Regional Office (MRO)
North Carolina Department of Environment & Natural Resources
610 East Center Avenue, Suite 301, Mooresville, NC 28115
MRO Main Phone: [phone]
Direct Office Phone: [phone]
MRO Fax: [phone]
APS website: http://h2o.enr.state.nc.us/agw.html
NOTICE: Emails sent to and from this account are subject to the North Carolina Public Records Law and may be disclosed
to third parties unless the content is exempt by statute or other regulation.

AQUIFER PROTECTION REGIONAL STAFF REPORT
Date: October 19, 2012 County: Cabarrus
To: Aquifer. Protection Central Office Permittee: NCDOT Roadside Environment Unit
Central Office Reviewer: David Goodrich Project Name: Former NCDOT Asphalt
Testing Site No. 2-66
Regional Login No: Application No.: WI0300210
I. GENERAL INFORMATION
1. This application is (check all that apply): ® New ❑ Renewal
❑ Minor Modification ❑ Major Modification
❑ Surface Irrigation ❑ Reuse ❑ Recycle ❑ High Rate Infiltration ❑ Evaporation/Infiltration Lagoon
❑ Land Application of Residuals ❑ Attachment B included ❑ 503 regulated ❑ 503 exempt
❑ Distribution of Residuals ❑ Surface Disposal
❑ Closed -loop Groundwater Remediation ® Other Injection Wells (including in situ remediation)
Was a site visit conducted in order to prepare this report? ® Yes or ❑ No.
a. Date of site visit: 10/12/12
b. Person contacted and contact information: Matt Bramblett 704-586-0007; [e-mail]
Site visit included: Matt Bramblett and Steve Libbey (both from H&H)
c. Site visit conducted by: Maria Schutte
d. Inspection Report Attached: ❑ Yes or ® No.
2. Is the following information entered into the BIMS record for this application correct?
® Yes or ❑ No. If no, please complete the following or indicate that it is correct on the current application.
For Treatment Facilities:
a. Location:
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
e. Regulated Activities / Type of Wastes (e.g., subdivision, food processing, municipal wastewater):
For Disposal and Injection Sites:
(If multiple sites either indicate which sites the information applies to copy and paste a new section into the
document for each site or attach additional pages for each site)
a. Location(s): ok
b. Driving Directions:
c. USGS Quadrangle Map name and number:
d. Latitude: Longitude:
II. & III. - deleted
FORM: WI0300210 staff report Former NCDOT Asphalt Site - 164 Bostian Bridge Road Statesville Oct 20122 1

AQUIFER PROTECTION REGIONAL STAFF REPORT
IV. INJECTION WELL PERMIT APPLICATIONS (Complete these two sections for all systems that use injection
wells, including closed -loop groundwater remediation effluent injection wells, in situ remediation injection wells, and heat
pump injection wells.)
Description Of Well(S) And Facilities — New, Renewal, And Modification
1. Type of injection system:
❑ Heating/cooling water return flow (5A7)
❑ Closed -loop heat pump system (5QM/5QW)
® In situ remediation (5I)
❑ Closed -loop groundwater remediation effluent injection (5L/"Non-Discharge")
❑ Other (Specify:
2. Does system use same well for water source and injection? ❑ Yes ® No
3. Are there any potential pollution sources that may affect injection? ® Yes ❑ No
What is/are the pollution source(s)? The proposed injection site is within the plume of "TCE" contamination.
What is the distance of the injection well(s) from the pollution'source(s)? 0 ft.
4. What is the minimum distance of proposed injection wells.from .the property-boundary?.Aoprox. 50 feet_
5. Quality of drainage at site: ❑ Good ®. Adequate ❑ Poor
6. Flooding potential of site: ❑ Low ® Moderate ❑ High
7. For groundwater remediation systems, is the proposed and/or existing groundwater monitoring program
(number of wells, frequency. of monitoring, monitoring parameters: etc.). adequate?: ❑ Yes: Z Nor.-- Attach_
map of existing monitoring well network if applicable. If No, explain and recommend. any changes.to the_=
groundwater monitoring program: Add metals, sulfide to analytical parameters — as mentioned in EOS
literature — parameters that could become elevated by injectant. Add up -stream & down -stream sampling for
field parameters (pH, ORP, etc.) and potentially all parameters based on results.
8. Does the map presented represent the actual site (property lines, wells, surface drainage)? ® Yes or ❑ No. If
no or no map, please attach a sketch of the site. Show property boundaries, buildings, wells, potential pollution
sources, roads, approximate scale, and north arrow.
Infection Well Permit Renewal And Modification Only:
1. For heat pump systems, are there any abnormalities in heat pump or injection well operation (e.g. turbid water,
failure to assimilate injected fluid, poor heating/cooling)?
❑ Yes ❑ No. If yes, explain:
2. For closed -loop heat pump systems, has system lost pressure or required make-up fluid since permit issuance
or last inspection? ❑ Yes ❑ No. If yes, explain:
FORM: WI0300210 staff report Former NCDOT Asphalt Site - 164 Bostian Bridge Road Statesville Oct 20122 2

AQUIFER PROTECTION REGIONAL STAFF REPORT
3. For renewal or modification of groundwater remediation permits (of any type) will
continued/additional/modified injections have an adverse impact on migration of the plume or management of
the contamination incident? ❑ Yes ® No. If yes, explain:
4. Drilling contractor: Name: Geologic Exploration
Address:
Certification number: A-2579
5. Complete and attach Well Construction Data Sheet.
V. EVAL UATIONAND RECOMMENDATIONS
1. Provide any additional narrative regarding your review of the application:
This proposal. calls for a maximum injection of 17,798 gallons of EOS and water (a 10% slurry). The network of 35
direct push injection points -will be used to place the slurry within a plume of chlorinated solvents. The suspected
origin of the solvent release is improper handling practices from a former NCDOT asphalt testing laboratory. The
Asphalt facility and laboratory closed in 1989. This location is currently an active asphalt grinding and apparent
debris storage facility, as there are significant piles of road rubble present.
The proposed injection site begins near DMW-9 and covers a fairly large area about 120 feet long with widths
ranging from about 60 —170 feet. The injection area is roughly sandwiched between monitoring wells DMW-
6/DMW-7, DMW-9 and DMW11. The entire injection area is currently covered with concrete construction debris,
which DOT says it can remove and grind within a week. There are many WSWs within a'/ mile radius. The on -
site WSW-4 will be used for potable water. Shallow groundwater flow is approx. 55ft/yr - West toward the
unnamed creek, which is a tributary to Third Creek and about 55 ft from the proposed injection area. Historical
sampling at SS-2 does not show surface water impact, but the MRO recommends up -gradient / down -gradient
sampling (bracketing the area of injection) as this will be the likely source of any injection impact. The MRO is
unsure whether up -gradient sampling results could reflect activities from adjacent property, which would be
unrelated to this site. (There is an old gasoline tanker truck parked on this property — appeared to be intact, but
vegetation was growing up around it.) The MRO also notes below the additional info request to include copies of
pertinent access agreement and updated cross -sections with injection area included.
It is important to note that, per communication with staff from DWM-IHSB, that there is not currently clear
regulatory oversight in place for this pollution incident. DWM-IHSB is currently taking legal action against
NCDOT to allow DWM-IHSB access to site information. We note that the application indicates that NCDOT is
"eligible for the REC Program. " NCDOT has been operating for several years on previous approval of a natural
FORM: W10300210 staff report Former NCDOT Asphalt Site - 164 Bostian Bridge Road Statesville Oct 20122 3

AQUIFER PROTECTION REGIONAL STAFF REPORT
attenuation CAP from DWQ when DWQ had oversight of these kinds of pollution incidents and this is a substantial
change of corrective action from natural attenuation only. DWM-IHSB has not had an opportunity to review this
site in detail to determine if the previous assessment and corrective actions meet their requirements. MRO
recommends that APS-CO consult with DWM-CO to be clear that we are looking at a permit for a project that they
have not reviewed nor approved. Any ongoing discussions between DWM and NCDOT about a MOAIMOU are
outside the scope of this staff report, but DWQ-CO needs to be aware of this situation and potential internal DENR
issues that may arise.
2. Attach Well Construction Data Sheet - if needed information is available — n/a
3. Do you foresee any problems with issuance/renewal of this permit? ® Yes ❑ No. If yes, please explain
briefly. See notes above about DWM and NCDOT.
4. List any items that you would like APS Central Office to obtain through an additional information request.
Make sure that you provide a reason for each item:
Item
Reason
Updated cross sections to include injection
Basic requirement
wells
Copy of access agreement for the neighbor's
Basic requirements — DOT does not own
property — location of DMW-8 and easiest
property of main site or neighboring property.
access to stream
5. List specific Permit conditions that you recommend to be removed from the permit when issued. Make sure
that you provide a reason for each condition:
Condition Reason
6. List specific special conditions or compliance schedules that you recommend to be included in the permit when
issued. Make sure that you provide a reason for each special condition:
Condition
Reason
Add surface water sampling (for field
parameters — with additional parameters as field
results dictate) — upstream and downstream —
bracketing injection area.
Stream is the most likely potential receptor that
could be impacted by injection
Add metals and sulfide to sampling parameters
Potential change from injectant
FORM: W10300210 staff report Former NCDOT Asphalt Site - 164 Bostian Bridge Road Statesville Oct 20122 4

AQUIFER PROTECTION REGIONAL STAFF REPORT
7. Recommendation: ❑ Hold, pending receipt and review of additional information by regional office; ❑ Hold,
pending review of draft permit by regional office; ❑ Issue upon receipt of needed additional information;
Issue; ❑ Deny. If deny, please state reasons:
8. Signature of report preparer(s): Maria Schulte
DNwT Yprcd Oy.udm.xmrcr .
Andrew H. Pitner
Signature of APS regional supervisor:
Date: October 19, 2012
ADDITIONAL REGIONAL STAFF REVIEW ITEMS
FORM: WI0300210 staff report Former NCDOT Asphalt Site - 164 Bostian Bridge Road Statesville Oct 20122 .5

r
AQUIFER PROTECTION SECTION
APPLICATION REVIEW REQUEST FORM
Date: September 19, 2012
To: ❑
Landon Davidson, ARO-APS
❑
Art Barnhardt, FRO-APS
X
Andrew Pitner, MRO-APS
❑
Jay Zimmerman, RRO-APS
From: David Goodrich , Land Application Unit
❑ David May, WaRO-APS
❑ Charlie Stehman, WiRO-APS
❑ Sherri Knight, WSRO-APS
Telephone: [phone] Fax. [phone]
E Mail. [e-mail]
A. Permit Number: WI0300210
B. Owner: NCDOT —Roadside Environment Division
C. Facility/Operation: Former DOT Asphalt TestingF,acility Number 2-66
❑ Proposed X Existing X Facility X Operation
D. Application:
I. Permit Type: ❑ Animal ❑ Surface Irrigation ❑ Reuse ❑ H-R Infiltration
❑ Recycle ❑ I/E Lagoon X GW Remediation (ND)5I Injection
❑ UIC - (5A7) open loop geothermal
For Residuals: ❑ Land App. ❑ D&M ❑ Surface -Disposal
❑ 503 ❑ 503 Exempt ❑ Animal
2. Project Type: X New ❑ Major Mod. ❑ Minor Mod. ❑ Renewal ❑ Renewal wt Mod.
E. Comments/Other Information: ❑ I would like to accompany you on a site visit.
Attached, you will find all information submitted in support of the above -referenced application for your
review, comment, and/or action. Within 30 calendar days, please take the following actions:
X Return a Completed APSARR Form. - Please comment
❑ Attach Well Construction Data Sheet.
❑ Attach Attachment B for Certification by the LAPCU.
❑ Issue an Attachment B Certification from the RO.*
* Remember that you will be responsible for coordinating site visits and reviews, as well as additional
information requests with other RO-APS representatives in order to prepare a complete Attachment B for
certification. Refer to the RPP SOP for additional detail.
When you receive this request form, please write your name and dates in the spaces below, make a copy
of this sheet, and return it to the appropriate Central Office -Aquifer Protection Section contact person
listed above.
RO-APS Reviewer:
Date:
FORM: APSARR 07/06 Page 1 of 1

Central Files: APS SWP
09/18/12
Permit Number W10300210 Permit Tracking Slip
Program Category Status Project Type
Deemed Ground Water In review New Project
-Permit Type Version Permit Classification
Injection Deemed In -situ Groundwater Remediation Well Individual
Primary Reviewer Permit Contact Affiliation
david.goodrich Matt Bramblett
Coastal SW Rule
Permitted Flow
Facili
2923 S Tryon St
Charlotte NC 282035449
Facility Name Major/Minor Region
Former NCDOT Asphalt Testing Site No. 2-66 Minor Mooresville
Location Address County
164 Bostian Bridge Dr Iredell
Statesville NC 28677 Facility Contact Affiliation
Owner
Owner Name Owner Type
NCDOT - Roadside Environmental Unit Government - State
Owner Affiliation
Thomas C. Niver
PG
4809 Beryl Rd
Raleigh NC 27606
Dates/Events
Scheduled
Orig Issue App Received Draft Initiated Issuance Public Notice Issue Effective -Expiration
09/06/12
Regulated Activities
Outfall NULL
Waterbody Name Stream Index Number Current Class Subbasin

January 25, 2007
Gary Birk
Director of Marketing & Sales
EOS Remediation, Inc.
1101 Nowell Road
Raleigh, NC 27607
Michael F. Easley, Governor
William G. Ross Jr., Secretary
North Carolina Department of Environment and Natural Resources
Alan W. Klimek, P.E. Director
Division of Water Quality
Subject: EOSO Remediation Product Line Risk Assessment
Dear Mr. Birk,
In response to our conversations over the past week regarding risk evaluation for the
EOSO product line, you stated that the product,�EO:SS..-tha -:w..as=oriilnall apprav n-2Q _has
been renamed to EOS® 5981342. From my conversation today with Dr. Luanne Williams of the
Division of Public Health, Epidemiology Section the products EOSO 400, EOSO 450, EOS®
598, EOS® 600 and EOS® 600EX can all be considered approved under the original approval
for EOSO now called EOS98B�;27--)This approval stems from the similarities in the
formulation noted from her inspection of the product literature at the EOSO Remediation Inc.
web site: http://www.eosremediation.com/literature/EOS Family f %20Products.html.
If you have any questions regarding this letter, please contact me at [phone] or
[e-mail].
Sincerely,
Peter Pozzo
Hydrogeologist
Aquifer Protection Section
cc: UIC Files
Dr. Luanne Williams, Epidemiology Section
Nc ehCarolina
Aquifer Protection Section 1636 Mail Service Center Raleigh, NC 27699-1636 Phone [phone] Customer Service
Internet: http://h2o.enr.state.nc.us 2728 Capital Boulevard Raleigh, NC 27604 Fax [phone]
Fax [phone]
An Equal Opportunity/Affirmative Action Employer— 50% Recycled/10% Post Consumer Paper

dQVF
J
� S
North Carolina Department of Health and Human Services
Division of Public Health • Epidemiology Section
1912 Mail Service Center • Raleigh, North Carolina 27699-1912
Tel [phone] • Fax [phone]
Michael R Easley, Governor
MEMORANDUM
TO: Evan Kane
Groundwater Section
FROM: Luanne K. Williams, Pharm.D., Toxic ologist&(/t—
Medical Evaluation and Risk Assessment Unit
Occupational and Environmental Epidemiology Branch
North Carolina Department of Health and Human Services
1Z'
Carmen Hooker Qom, Secretary
GO O Q
r
Gn
� ter;
O q0
�o
N G'
SUBJECT: Use AM GI -to Enhance Biodegradation of Contaminated Groundwater
I am writing in response to a request for a health risk evaluation regarding the use
of EOS ® to -Enhance Biodegradation of Contaminated Groundwater. Based upon my
review of the information submitted, I offer the following health risk evaluation:
WORKER PRECAUTIONS DURING APPLICATION
The specific chemicals present in the products are not provided for proprietary
reasons. However, some effects reported to be associated with the chemicals
present in the product following short-term exposure are as follows:
• Exposure can cause irritation of skin, eyes, nose and throat (New Jersey
Department of Health and Senior Services Hazardous Substance Fact Sheet,
Micromedex TOMES Plus System CD-ROM Database, Volume 58, 2003).
• Significant inhalation exposure can cause coughing, wheezing, and shortness
of breath (New Jersey Department of Health and Senior Services Hazardous
Substance Fact Sheet, Micromedex TOMEs Plus System CD-ROM Database,
Volume 58, 2003).
• May cause a skin allergy where very low future exposures can cause itching
and a skin rash (New Jersey Department of Health and Senior Services
Hazardous Substance Fact Sheet, Micromedex TOMES Plus System CD-
ROM Database, Volume 58, 2003).
2. If the products are released into the environment in a way that could result in a
suspension of fine solid or liquid particles (e.g., grinding, blending, vigorous
shaking or mixing), then it is imperative that proper personal protective
equipment be used. The application process should be reviewed by an industrial
1 of 2
® Location: 2728 Capital Boulevard • Parker Lincoln Budding • Raleigh, N.C. 27604 An Equal OpporMwW Employer

hygienist to ensure that the most appropriate personal protective equipment is
used.
Persons working with this product should at least wear goggles or a face shield,
gloves, and protective clothing. Face and body protection should be used for
anticipated splashes or sprays. Again, consult with an industrial hygienist to
ensure proper protection.
4. Eating, drinking, smoking, handling contact lenses, and applying cosmetics
should never be permitted in the application area during or immediately following
application.
5. Safety controls should be in place to ensure that the check valve and the pressure
delivery systems are working properly.
6. The Material Safety Data Sheets should be followed to prevent adverse reactions
and injuries.
OTHER PRECAUTIONS
Access to the area of application should be limited to the workers applying the
product. In order to minimize exposure to unprotected individuals, measures
should be taken to prevent access to the area of application.
2. Measures should be taken to prevent contamination of this product to nearby
wells and surface water bodies.
Please do not hesitate to call me if you have any questions at [phone].
LW:pw
cc: Mr. Tony Lieberman, RSM
Bioremediation Program Manager
Solutions-IES
3722 Benson Drive
Raleigh, NC 27609
Mr. Gary Birk, P.E.
EOS Remediation, Inc.
3722 Benson Dr., Suite 101
Raleigh, NC 27609
2 of 2

W-140500 2, 1&
hart hickman
SMARTER ENVIRONMENTAL SOLUTIONS
Via US Mail
January 18, 2012
North Carolina Department of Environment and Natural Resources
Aquifer Protection Section — UIC Program
DENR - Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Attention: Mr. David Goodrich
Re: Injection Event Record (Form UIC-IER)
NC DOT Asphalt Testing Site No. 2-66
164 Bostian Bridge Road
Statesville, North Carolina
H&H Job No. DOT-404
Dear Mr. Goodrich:
On behalf of the NCDOT Roadside Environmental Unit, Hart & Hickman, PC (H&H) is
submitting the enclosed Injection Event Record for the EOSO injection event performed on
December 10 through 19, 2012 at the referenced facility. All injection wells were abandoned
with Portland cement after the injection event. Should you have any questions or need any
additional information, please feel free to contact me at [phone].
Very truly yours,
Hart & Hickman, PC
/n
Matt Bramblett, PE
Principal
Attachments
cc: Ethan Caldwell, NCDOT
2923 South Tryon Street, Suite 100 3334 Hillsborough Street
Charlotte, NC 28203 Raleigh, NC 27607
704.586.0007 main 919.847.4241 main
RECEVED1%p�,,,'
JqN 2 21N'"v�Q
013
Aquiferp,t�on
11
www.harthickman.com
SAAAA-Master Proiects\NC DOT-DOT\DOT404 Statesville2-66\EOS IniectionUniection Event Record\UIC-IER Cover Letter.doc

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Quality
Permit Number WI0300210
1. Permit Information
NCDOT-Roadside Environmental Unit
Permittee
ormer NCDOT Asphalt Testing Site No. 2-66I
Facility Name
164 ostian Bridge Road,
Statesville, NC
Facility Address
2. Injection Contractor Information
Hart & Hickman, PC
Injection Contractor / Company Name
Street Address 2923 S Tryon St, Ste 100
Charlotte NC 28203
City State Zip Code
[phone]
Area code — Phone number
3. Well Information
Number of wells used for injection 36
Wellnames B-1 through B-35 + B-2B
Were any new wells installed during this injection
event?
❑X Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells see below
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ® Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include two copies of the GW-lb for each
well insta�, led.
36-Injecte Stainless Steel Extractable Well
Screens in Geoprobe Bore Hole
Were any wells abandoned during this injection
event?
❑x Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells 36
Please include two copies of the GW-30 for each
well abandoned.
4. Injectant Information
EOS 598B42 with B12 Supplement
Injectant Type B-2-B-10= -20% EOS/-.80% water
B-1, B-11-B-35, + B-2B=
Concentration -14% EOS/-86% Water
If the injectant is diluted please indicate the source
dilution fluid. Public Water
-1,618 gallons EOS
Total Volume Injected -,10, 666 gallons Water
-46 gallons EOS
Volume Injected per well-276-460 gallons water
5. Injection History
Injection number (e.g. 3 of 5) 1
Is this the last injection at this site?
❑x Yes ❑ No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDA OUT IN THE PERMIT.
/ _?
SIGNATUR160F INJECTION CONTRACTOR ATE
Steve Libbey for Hart & Hickman, PC
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-733-3221
Form UIC-IER
Rev. 11/06

N,.,ro,y
NON-RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
I. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-1
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection N Top Bottom Ft.
Irrigation[] Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 12/18/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley Fw(Flal ❑Ridge ❑Other
LATITUDE 35 ^ 45 - 56.6500 " DMS OR DD
LONGITUDE 80 ^ 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: WPS ❑Topographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO V
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: 9. SCREEN:
Depth
Diameter
Top
Bottom
Ft. in.
Top
Bottom
Ft. In.
Top
Bottom
Ft. in.
10. SAND/GRAVEL PACK:
Depth
Size
: Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
: Top Bottom
0.0 / 42.0
/
/
12. REMARKS:
Method
Slot Size Material
in.
In.
in.
Material
Formation Description
DIRECT PUSH
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 H BEEN PROVIDED TO THE WELL OWNER.
01/17/13
SIGNA ' RTIF ED WEL M1TMA=R DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-1
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable user Monitoring 0 Residential
❑ Municipal/Public ❑ Industrial/Commercial 0 Agricultural
❑ Recovery M Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION: .
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Streel/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley r/ Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _° 45 56.6500 ^ DMS OR DID
LONGITUDE 80 55 2.5700 ^ DMS OR DD
Latitude/longitude source: &t;PS pfopographic map
(location of well must be shown on a USGS topo map andattached to
this fonn if not using GPS)
5. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point Is 0.0 ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known):
N/A ft. in.
b. Casing Removed:
N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
: 8. SEALING MATERIAL:
Neat Cement
Sand Cement
Cement lb.
Cement lb.
Water gal.
Water oal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
n.,,,,,,.,r 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of Iheell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialaised
11. DATE WELL ABANDONED 12/18/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY . The name of the business where the well is located. Complete 4a:
: WITH 16A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS R OR-D HAS BEEN PBVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
-
\��/�C �nJf
V��_ 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONMELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

'
NONRESIDENTIAL
A rr �•:� Z' P
WELL CONSTRUCTION R>;CORD
North Carolina Department of Environmcnt Natural Resources- Water
and Division of Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(ir applicable) : Top Bottom Ft.
SITE WELL ID *(if applicable) 13-2 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 5( Top Bottom Ft.
Irrigation[] Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 12/10/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley SdFlal ❑Ridge ❑Other
LATITUDE 35 ° 45 56.6500 " DMS OR DD
LONGITUDE 80 55 ' 2.5700 " DMS OR DD
Latitudeilongitude source: V3PS Ofopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 38.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 38.0
12. REMARKS:
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
1 DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOORD%�S BEEN PROVIDED O THE LL OWNER.
V pp� g 01/17/13
SIGNATURE OF CERTIFIED WE TRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
I. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-2
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring 0 Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 9 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC /LAND SETTING:
❑ Slope 0 Valley 51 Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _° 45 • 56.6500 " DMS OR DD
LONGITUDE 80 ° 55 • 2.5700 ° DMS OR DD
Latitude/longitude source: V-3PS i]Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6. WELL DETAILS:
a. Total Depth 38.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypcchlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Sand Cement
Cement lb.
Water aal.
Bentonite 300.D lb.
Type: ❑ Slurry 0 Pellets
Water gal.
Other
Type material PORTLAND CEMENT
n,,,,.,,,,e 7.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of till materialstsed
11. DATE WELL ABANDONED 12/10/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a; THIS RECORD HAS BEEN PIDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.) \�
FACILITY ID # (if applicable) 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT SIGN TURF F CERTIFIED WELL AC'17OR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677 SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wbersonalhebandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONfWELL OWNER: VINCE FEDERLE
NAME NCDOT PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 114 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
-°� �:u��w-��,� w., „JaclV: ✓IV171Vu;V1;;YYgICI,,h(ugltL IIUVrrrldLIVII t'fVGe551n
Form GW-30
1617:MaihSelvfce Center, Raleigh, NC 271i99 1617 Phone [phone] Rev.5110

NON-RESIDENTIAL ON .ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
I. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 FT. Above Land Surface -
"Top of casing terminated at/or below land surface may require
a variance In accordance with I6A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
: Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-28
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection v
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/18/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY; STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope []Valley &(Flat ❑Ridge ❑Other
LATITUDE 35 ° 45 - 56.6500 " DMS OR
LONGITUDE 80 ^ 55 ' 2.5700 " DMS OR DID
Latitude/longitude source: 613PS Dropographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 36.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [J(
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" If Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 36.0
: 12. REMARKS:
Slot Size Material
In.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCA9,2C. WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECHAS,B� ((//KK�t VID.Fi�rO THE LL O NER.
GO� 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GWA b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina .Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-28
STATE WELL PERMIT# (ifapplicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)`.] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 1Z Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
s. WELL DETAILS:
a.Total Depth 36.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
G. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Sand Cement
Cement lb.
Water oal.
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 7.25 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley Vi Flat ❑ Ridge❑ Other
(Check appropriate setting) :
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 _= 45 56.6500 DMS OR DID
in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 _ - 55 2.5700 ' DM5 OR DO
types of fill materialslsed
Latitude/longitude source: 963PS []Topographic map
12/18/12
(location ofwell mustbe shown on a USGS topo map andattached to
11. DATE WELL ABANDONED
this form ifnot using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY - The name of the business where the well is located. Complete 4a:
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PEDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
Pit 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual wbersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONMELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

NON-RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
7( 04 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) ; Top Bottom Ft.
SITE WELL ID #(if applicable) B-3 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection
Irrigation[] Other ❑ (list use)
DATE DRILLED 12/19/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ✓(Flat ❑Ridge ❑Other
LATITUDE 35 .45 ' 56.6500 „DMS OR DID
LONGITUDE 80 ° 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: W3PS piopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
C. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
8. GROUT:
Depth
Material Method
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size Material
Top
Bottom
Ft. In. in.
Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Material
Formation Description
DIRECT PUSH
I DO HERE Y CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 75A NIrAG/C, WSTRUON STAAAAHHHHppppARDS, AND THAT A COPY OF THIS: RECO AS BEEN P VIDE THE OW ER.
!� 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-3
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)!] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial 0 Agricultural
❑ Recovery Z Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
0 Slope ❑ Valley p, Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _° 45 56.6500 " DMS OR DD
LONGITUDE 80 _ ° 55 2.5700 " DMS OR DD
Latitude/longitude source: 963PS ❑ropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter; in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. In.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite sao.o lb.
Type: ❑ Slurry 0 Pellets
Water gal.
Sand Cement
Cement lb.
Water gal.
Other
Type material PORTLAND CEMENT
n. nitnr 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of lheell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsysed
: 11. DATE WELL ABANDONED 12/19/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY - The name of the business where the well is located. Complete 4a +
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS EC�O�R�D_H/AAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
\
��?�
FACILITY ID # (if applicable)
�" —`J""" ' .
Y 2 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
4b. CONTACT PERSONIWELL OWNER:
in accordance with 15A NCAC 2C .0113.)
VINCE FEDERLE
NAME NCDOT
: PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

NON ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTI ICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-4
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Infection [�
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/11/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley (Flat ❑Ridge ❑Other
LATITUDE 35 -45 ' 56.6500 " DMS OR DO
LONGITUDE 80 ° 55 , 2.5700 " DMS OR DID
Latitude/longitude source: V.PS propographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 41.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E/
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS
0.0 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): N/A
METHOD OF TEST N/A
f. DISINFECTION: Type
N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
: 7. CASING: Depth
Diameter Weight Material
Top Bottom
Ft.
Top Bolcom
Ft.
Top Bottom
Ft-
8. GROUT: Depth
Material Method
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
: 9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0.0 / 41.0
DIRECT PUSH
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
IGA NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD H CS BEEN PROVIDED T THEW LLOOWNER.
/(
01DATE3
SIGNATURE OF CERTIFIED
WELL CO �G OR
VINCE FEDERLE
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

r-
r� WELL ABANDONMENT RECORD
l _..1<ew North Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIMCATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-4
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery Z Injection ❑ Irrigation
❑ Other (list use)
5. WELL DETAILS:
a.Total Depth 41.0 ft. Diameter: in.
b. Water Level (Below Measuring Paint): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
Length Diameter
N/A ft
N/A ft.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Benlonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.25 GALLONS
in.
in.
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
164 BOSTIAN BRIDGE DRIVE 28677
_TREMIE
(Streel/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley rL Flat ❑ Ridge❑ Other
(Check appropriate setting)
10. WELL DIAGRAM : Draw a detailed sketch of tlleell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 _^ 45 56.6500 ° DMS OR DID
in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 _ ^ 55 2.5700 ^DMS OR DD
types of fill materialsised
Latitude/longitude source: �iPS ❑Topographic map
12/11/12
(location of well must be shown on a USGS topo map andattached to
11. DATE WELL ABANDONED
this form if not using GPS)
100 HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY - The name of the business where the well is located. Complete 4a;
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PIDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable) :
\ / y 2� Uz 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
��n
SIG ERTI IE WELL DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

- a*
1. WELL CONTRACTOR:
VINCE FEDERLE
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) ; Top Bottom Ft.
SITE WELL 1D #(if applicable) B-5 ; Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 91
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/11/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY; STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley I/Flat ❑Ridge ❑Other
LATITUDE 35 ^ 45 56.6500 " DMS OR
0
LONGITUDE 80 ^ 55, 2.5700 " DMS OR DD
Latitude/longitude source: BPS pTopographic map
(location of well must be shown on a USGS topo map andattached to
this form /f not using GPS)
5. FACILITY (Name of the business where the well is located.)
MAYMEAD ASPHALT PLANT
NIA
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
C�
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 41.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [�
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
8. GROUT: Depth
Material Method
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
: Top Bottom
Formation Description
0.0 / 41.0
DIRECT PUSH
12. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC RD AS BVIDEJ�1jD
THEW LL OWNER.
01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

:sue :�;j .�� ,�-•�1�,:,. �•{;.
a
�y`fya at,:,r
WELL ABANDONMENT RECORD
North Carolina .Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Stale Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-5
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial 0 Agricultural
❑ Recovery ✓ Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley (-/, Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _° 45 • 56.6500 " DMS OR DID
LONGITUDE 80 ° 55 ' 2.5700 '- DMS OR DD
Latitude/longitude source: 03PS E fopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not usln GPS)
6. WELL DETAILS:
a.Totai Depth 41.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat .em -nt Sand Cement
Cement lb. Cement lb.
Water gal. Water cal.
Bentonite
Bentonite 390.0 lb.
Type:O Slurry 0 Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.25 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materiala,sed
11. DATE WELL ABANDONED 12/11/12
9
I DO HEREBY CERTIFY THATTHIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY - The name of the business where the well is located. Complete 4a :
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well, skip 4a: complete 4b, well owner information only.)
FACILITY ID # (if applicable)
�f 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIG ERTI IED WEL DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an Individual w ersonali bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
-- - t
`• Form GW-30
1617 MatlServtce Center, Rah:lgh; NC 27699 1617 Phone' (919}l807 6300 Rev. 5/10

._.��'4w_SrAT o�tyy
'nitt,)irn V� Y
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 FT. Above Land Surface -
`Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
; Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-6
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ar
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/11/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley IIFlat ❑Ridge ❑Other
LATITUDE 35 .45 - 56.6500 " DMS OR
LONGITUDE 80 ^ 55 , 2.5700 " DMS OR
Latitude/longitude source: VGPS Qfopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 41.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO IV
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
• 10. SAND/GRAVEL PACK:
Depth Size
: Top
Bottom Ft.
Top
Bottom Ft.
Top
Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 41.0
12. REMARKS:
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2 , WELL CONSTRUCTION STANDARDS, AND
/THAT A COPY OF THIS
REC0BEEN PROVIDEgg THE WE}LELi�—
01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolinn Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-6
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery J Injection ❑ Irrigation
❑ Other (list use) _
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
5. WELL DETAILS:
a.Total Depth 41.0
ft. Diameter: in.
b. Water Level (Below Measuring
Point): 21.0 ft.
Measuring point is 0.0
ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known):
N/A ft. in.
b. Casing Removed:
N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.25 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley fG Flat ❑ Ridge❑ Other
(Check appropriate setting)
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 _� 45 , 56.6500 ° DMS OR DD
in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 � 55 ' 2.5700 " DMS OR DD
types of fill materialstsed
Latitude/longitude source: RTGPS ❑Topographic map
12/11/12
(location of well must be shown on a USGS topo map andattached to
11. DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY - The name of the business where the well Is located. Complete 4a;
(If a residential well, skip 4a; complete 4b, well owner information only.)
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THI RE OR� BEEN P VIDED THE WELL OWNER.
FACILITY ID # (if applicable)
�� 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must bean individual w ersonall bandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONIWELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

4.
NONRESIDENTIAL WELL CONSTRUCTION RECORD
' :1 _r
�tJ oyp North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
: Top
Bollom
Ft.
OTHER ASSOCIATED PERMIT#(if anplicable)
: Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-7'
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection E/I
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/19/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley 5/Flat ❑Ridge ❑Other
LATITUDE 35 ° 45 - 56.6500 "DMS OR DID
LONGITUDE 80 ° 55 1 2.5700 " DMS OR DD
Latitude/longitude source: fXPS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 38.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E./
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0.0 / 38.0
: 12. REMARKS:
Slot Size Material
In.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• RE NC 2� NSTRS�CTION - RDS T A COPY OF THIS
: R O HAS BEEN OVI rg/(�C�t TO TH
01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-7
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery M Injection ❑ Irrigation
❑ Other (list use)
5. WELL DETAILS:
a.Tolal Depth 38.00 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water aal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
3. WELL LOCATION:
Amount 7.5 GALLONS
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
164 BOSTIAN BRIDGE DRIVE 28677 TREMIE
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting) 10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 245 56.6500 " DMS OR DO in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 o 55 • 2.5700 2. DMS OR DD types of fill materials,sed
Latitudetlongitude source: RfGPS ❑Topographic map 12/19/12
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED
this form if not using GPS)
4a. FACILITY -The name of the business where the well is located. Complete 4a
(If a residential well, skip 4a: complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY MAYMEAD ASPHALT PLANT
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
Clly or Town State Zip Code
4b. CONTACT PERSONIWELL OWNER:
NAME NCDOT
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
I DO HEREBY CERTIFY THATTHIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THATA COPY OF
THISiREC� S BEW PFDVI�D TO�r— OWNER.
01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an Individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
VINCE FEDERLE
PRINTED NAME OF PERSON ABANDONING THE WE LL
Form GW-30
Rev. 5/10

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
7( 04 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PER
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-6
d. TOP OF CASING IS 0.0 FT. Above Land Surface*
'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 5 Top Bottom Ft.
Irrigation❑ Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 12/12/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFIat []Ridge ❑Other
LATITUDE 35 ° 45 ' 56.6500 " DMS OR DD
LONGITUDE 80 ^ 55 1 2.5700 " DMS OR DD
Latitude/longitude source: W3PS Qfopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LEI
C. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft_
11. DRILLING LOG
: Top Bottom
0.0 / 42.0
12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
YY
RE�OF�HAS��OVIT TO THTIELL OWNER
-(f�(/xj� 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
.....,.. WELL CONTRACTOR CERTIFICATION It 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-8
STATE WELL PERMIT# (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring ❑ Residential
❑ M unlcipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery G Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
5. WELL DETAILS:
a.Tolal Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
Length Diameter
N/A ft. in,
NIA f(, in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Sand Cement
Cement lb.
Water oal.
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
: 9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley U Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 45 56.6500 " DMS OR DID
LONGITUDE80 55 2.5700 "DMS OR DD
Latitude/longitude source: &63PS pTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materlals,sed
11. DATE WELL ABANDONED 12/12/12
100 HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i
THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
( 01 /17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town Slate Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONIWELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

STATE
A�•
rt`)
I �ON ESIDENTIAL WELL CONSTRUCTION RECORD
`` Sk
North Carolina Department of Envirotmient and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION FERMI
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-9
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Lvf
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/12/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope ❑Valley &Flat []Ridge ❑Other
LATITUDE 35 .45 ' 56.6500 "DMS OR DD
LONGITUDE 80 * 55 , 2.5700 " DMS OR DD
Latitude/longitude source: V3PS E l"opographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑�
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING:
Depth
Diameter Weight Material
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
8. GROUT:
Depth
Material Method
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft, in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0.0 / 42.0
12. REMARKS:
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
ECD D HAS BEEN tPRO D TO THq WELL OWNER.
! /i lJf Oir 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GWA b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Slate Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-9
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (Lf applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 9 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) :
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _° 45 56.6500 " DMS OR DID
LONGITUDE 80 " 55 2.5700 '• DMS OR DID
Latitude/longitude source: RfGPS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Sand Cement
Cement lb.
Water gal.
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of lfegil on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill malerialsJsed
11. DATE WELL ABANDONED 12/12/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY -The name of the business where the well is located. Complete 4a i
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
�n 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SlOffATLIM9 OF CERTIF— IE�C�MUTRAC-rDATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town Slate Zip Code
(The private well owner must bean individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONIWELL OWNER:
VINCE FEDERLE
NAME NCDOT
: PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

NONRESIDENTIAL
3., Q
WELL CONSTRUCTION RECORD
North Carolina of Environment and Natural Resources- Division Water
.Department of Quality
WELL CON`rRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28626
City or Town Slate Zip Cade
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) : Top Bottom Ft.
SITE WELL ID #(if applicable) B-10 ; Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Cdj
Irrigation[] Other ❑ (list use)
DATE DRILLED 12/12/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley !(Flat ❑Ridge []Other
LATITUDE 35 .45 - 56.6500 "DMS OR DD
LONGITUDE 80 , 55 1 2.5700 " DMS OR DD
Latitude/longitude source: OPS Qfopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LJI
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: 8. GROUT:
Depth
Material Method
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
: 9. SCREEN:
Depth
Diameter Slot Size Material
Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
/
12. REMARKS:
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RE OR AVID§XOTHET O
' 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

tiya °Y STATE >�" <+
E
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality WELL CONTRACTOR CERTIFICATION# 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (If applicable) B-10
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'] Monitoring 0 Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery f Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(St(eet/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope 0 Valley V Flat 0 Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 ^ 45 ' 56.6500 " DMS OR DO
LONGITUDE 80 55 - 2.5700 "DMS OR DID
Latitude/longitude source: RJ�PS Qropographic map
(location of welt must be shown on a USGS topo map andattached to
this form if not using GPS)
6. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point Is 0.0 ft. above land surface.
6. CASING: Length
a. Casing Depth (if known): N/A ft.
b. Casing Removed: N/A ft.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Diameter
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
A.,,.,,,-+ 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
In.
In.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
In the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED 12/12/12
: I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY -The name of the business where the well is located. Complete 4a +
THIS RECORD HAS BEEN PFDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
-A
FACILITY ID # (if applicable)
. A— 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

�
�'� a STA ; %'
t4
_ _
NON- ESIDENTIAL
WELL CONSTRUCTION RECORD
^'" (".'` • 05
North Carolina Department of Environmentand Natural Resources- Division of Water Quality
'yrVr,v..v4va� u
WELL CONTRACTOR CCRTII+ICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
d. TOP OF CASING IS 0.0 FT. Above Land Surface -
"Top of casing terminated allor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NIA METHOD OF TEST N/A
If. DISINFECTION: Type N/A Amount NIA
Street Address
: g. WATER ZONES (depth):
STATESVILLE
NC 28625 : Top
Bottom
Top
Bottom
City or Town
State Zip Code ; Top
Bottom
Top
Bottom
70( 4 ) 872-7686
: Top
Bottom
Top
Bottom
Area code Phone number
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter
Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
; Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-11
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 5(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/13/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope []Valley VFlat ❑Ridge ❑Other
LATITUDE 35 ° 45 ' 56.6500 " DMS OR DID
LONGITUDE 80 ° 55 ' 2.5700 DMS OR DD
Latitude/longitude source: MPS E]Topographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO F/
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
8. GROUT:
Depth
Material Method
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
9. SCREEN:
Depth
Diameter Slot Size Material
Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
Top
Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
Tap Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Material
Formation Description
DIRECT PUSH
• 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCA9e2C, WELL CONSTRU TION STANDARDS, AND THAT A COPY OF THIS
: RECmRYHAS.Ba�VIDO ThIE LL O
YY `/j 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WILL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-11
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'D Monitoring ❑ Residential
❑ M uniclpal/Public ❑ Industrial/Commercial ❑ Agricultural
Recovery G Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley l7 Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _° 45 56.6500 „ DMS OR DO
LONGITUDE 80 55 2.57002 DMS OR DID
Latitude/longitude source: IMPS OTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
s. WELL DETAILS:
a.Total Depth 42.0
ft. Diameter: in.
b. Water Level (Below Measuring
Point): 21.0 ft.
Measuring paint is 0.0
ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known):
N/A ft.
b. Casing Removed:
N/A ft.
7. DISINFECTION: N/A
(Amount of 65%75% calcium
hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 30e.0 lb.
Type: ❑ Slurry 0 Pellets
Water gal.
Other
Sand Cement
Cement lb.
Water gal.
Type material PORTLAND CEMENT
Ar mmt 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theall on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials,sed
11. DATE WELL ABANDONED 12/13/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY - The name of the business where the well is located. Complete 4a i
(If a residential well, skip 4a; complete 4b, well owner information only.)
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF
` TW.S--R.E_C-ORDD HAS BEEN PD�ED T� OWNER.
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONIWELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 6110

i
t �;,• ?
1 V' ONESIDENTIAL WELL CONSTRUCTION RECORD
�g
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated allor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount NIA
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
; Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-12
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Ind ustrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection W
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
; Top
Bottom
Ft.
DATE DRILLED 12/13/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope ❑Valley NiFlat ❑Ridge pOther
LATITUDE 35 " 45 - 56.6500 " DMS OR DD
LONGITUDE 80 " 55 ' 2,5700 " DMS OR DID
Latitude/longilude source: V3PS DI-opographic map
(location of well must be shown on a USGS topo map andattached to
this form ff not using GPS)
5. FACILITY (Name of the business where the well Is located.)
MAYMEAD ASPHALT PLANT
NIA
Facility Name
Facility ID# (if
applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
9. SCREEN:
Depth
Diameter
Top
Bottom
Ft. in.
Top
Bottom
Ft. in.
Top
Bottom
Ft. in.
10. SAND/GRAVEL PACK:
Depth
Size
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2 ,WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RECORp H� BE�IDED_ATHE WE OWN/ER.
V 1P77(2n 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GWA b
Rev. 2109

41�> -
"r,�� WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
5.
WELL DETAILS:
VINCE FEDERLE
a.Total Depth 42.0 ft. Diameter: in.
Well Contractor (Individual) Name
b. Water Level (Below Measuring Point): 21.0 ft.
GEOLOGIC EXPLORATION, INC
Measuring point is 0.0 ft. above land surface.
Well Contractor Company Name
176 COMMERCE BLVD
6.
CASING: Length Diameter
Street Address
STATESVILLE NC 28625
a. Casing Depth (if known): N/A ft
City or Town State Zip Code
b. Casing Removed: N/A ft.
704 872 7686
N/A
Area code Phone number
7.
DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-12
8.
SEALING MATERIAL:
Neat Cement Sand Cement
STATE WELL PERMIT # (if applicable)
Cement lb. Cement lb.
COUNTY WELL PERMIT # (if applicable)
Water gal. Water oat.
Bentonite
DWQ or OTHER PERMIT # (if applicable)
Bentonite 300.0 lb.
WELL USE (Check applicable use)'] Monitoring ❑ Residential
Type: ❑ Slurry ❑ Pellets
❑ M unicipal/Public ❑ industrial/Commercial ❑ Agricultural
Water gal.
❑ Recovery 0 Injection ❑ Irrigation
Other
❑ Other (list use)
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
9.
EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
164 BOSTIAN BRIDGE DRIVE 28677
TREMIE
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 ° 45 56.6500 " DMS OR DID
LONGITUDE 80 _ ^ 55 2.5700 ,. DMS OR DD
Latitude/longitude source: W�3PS Ol opographic map
I (location of well must be shown on a USGS topo map andattached to
in.
in.
10. WELL DIAGRAM :Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED 12/13/12
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY The name of the business where the well is located. Complete 4a i
(If a residential well, skip 4a; complete 4b, well owner information only.)
_ : YI 113 HAS t}EEN P D TO WELL OWNER.
V Ix
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an Individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
;
Form GW-30
Rev. 5/10

NON ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department orEnvironment and Natural Resources- Division of Water Quality
*• <y;;;K,o .•f WELL CONTRACTOR CERTIFICATION # 3552
't"....
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-13
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/13/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley rw(Flat ❑Ridge ❑Other
LATITUDE 35 ^ 45 56.6500 " DMS OR DD
LONGITUDE 80 , 55 , 2.5700 " DMS OR DD
Latitude/longitude source: W3PS propographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 41.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E,/
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
7. CASING: Depth
Diameter
Weight Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
: 8. GROUT: Depth
Material
Method
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
: 9. SCREEN: Depth
Diameter
Slot Size Material
Top Bottom
Ft.
in.
in.
Top Bottom
Ft.
in.
in.
Top Bottom
Ft.
in.
In.
10. SAND/GRAVEL PACK:
Depth
Size
Material
Top Bottom
Ft.
Top Bottom
Ft.
m : Top Botto
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 41.0
1
12. REMARKS:
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR 1AS BEEN PPRtOVIDE TO THE�0. EEILL OWNER.
ii�u�.n/( /og��q 01/17/13
SIGNATURE OF CERTIFIED W LL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

f4
f4f ;�f WELL ABANDONMENT
RECORD
•�1al I At
North Carolina Department of Environment
and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
5. WELL DETAILS:
VINCE FEDERLE
a.Total Depth 41.0 ft. Diameter: in.
Well Contractor (Individual) Name
b. Water Level (Below Measuring Point): 21.0 ft.
GEOLOGIC EXPLORATION, INC
Measuring point is 0.0 ft. above land surface.
Well Contractor Company Name
176 COMMERCE BLVD
6. CASING: Length Diameter
Street Address
STATESVILLE NC 28625
a. Casing Depth (if known): N/A ft. in.
City or Town State Zip Code
b. Casing Removed: N/A ft. in.
704 ) 872-7686
NIA
Area code Phone number
7. DISINFECTION:
2. WELL INFORMATION:
(Amount of 65%75% calcium hypochlorite used)
SITE WELL ID # (if applicable) B-13
8. SEALING MATERIAL:
Neat Cement Sand Cement
STATE WELL PERMIT # (if applicable)
Cement lb. Cement lb.
COUNTY WELL PERMIT # (if applicable)
Water gal. Watergal.
Bentonite
DWQ or OTHER PERMIT # (if applicable)
Benlonite 300.0 lb.
WELL USE (Check applicable use)`] Monitoring ❑ Residential
Type:0 Slurry 0 Pellets
❑ Municipal/Public ❑ IndustriallCommercial ❑ Agricultural
Water gal.
0 Recovery f Injection ❑ Irrigation
Other
❑ Other (list use)
Type material PORTLAND CEMENT
Amni inf 8.25 GALLONS
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley LG Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 ^ 45 56.6500 ^ DMS OR DD
LONGITUDE 80 55 2.5700 2 DMS OR DD
Latitude/longitude source: 963PS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of dwell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialarsed
: 11. DATE WELL ABANDONED 12/13/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i
(if a residential well, skip 4a; complete 4b, well owner information only.)
: THIS R CORD HAS BEEN F7VIDED TO THE WELL OWNER.
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONIWELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

,. � � SiAif q •e.
��d �,•. ,�,ry f''a
1 '@` ONA.ESID.ENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
n� V"""""" • �rY WELL CONTRACTOR CERTIFICATION # 3552
"R•i bk Nu�� v4�d p.
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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 (gpin): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thicknessl
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
: Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-14
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Mf
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/19/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley g(Flat ❑Ridge ❑Other
LATITUDE 35 .45 56.6500 "DMS OR DD
LONGITUDE 80 ^ 55 , 2.5700 " DMS OR DD
Latitude/longitude source: V3PS OT'opographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if
applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
Slate
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Slate
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 38.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO L/
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 38.0
12. REMARKS:
Slot Size Material
in.
in.
in. —
Material
Formation Description
DIRECT PUSH
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 H S BEEN PROVIDED T THEW L OWNER.
d— 1 �. 01/17/13
SIGNATURE OF CERTIFIED WEL TOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2109

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-14
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (tf applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley U Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 ^ 45 56.6500 " DMS OR DID
LONGITUDE 80 _ " 55 • 2.5700 " DMS OR DD
Latitude/longitude source: RTSPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
7
5. WELL DETAILS:
a.Total Depth 38.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (If known): N/A ft.
b. Casing Removed: N/A ft.
7. DISINFECTION: NIA
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonile 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Sand Cement
Cement lb.
Water gal.
Other
Type material PORTLAND CEMENT
Amount 7.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
In the well, gravel interval, intervals of casing perforations, and depths and
types of fill malerialstsed
11. DATE WELL ABANDONED 12/19/12
this form l not using GPS)
100 HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i
THIS EC_ORD-aHAS BEEN POVIDED TO/THE OWNER.
(If a residential well, skip 4a; complete 4b, well owner Information only.)
/WELL
�X�t
FACILITY ID # (if applicable)
�iri Cam✓` GO 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONIWELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

e
srnr"�.,
NON ESIDENTIAL WELL CONSTRUCTION RECORD
P. G- ��� o, North Carolina Department of Environment and Natural Resources- Division of Water Quality
.• """:�'.A' WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Stale Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount NIA
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
; Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-15
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection g
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/13/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFIat ❑Ridge []Other
LATITUDE 35 .45 ' 56.6500 " DMS OR
21!
LONGITUDE 80 ' 55 ' 2.5700 " DMS OR DD
LatitudeAongitude source: (3PS aopographic 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.)
MAYMEAD ASPHALT PLANT
NIA
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 39.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E/
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 39.0
: 12. REMARKS:
Slot Size Material
in.
in.
In.
Material
Formation Description
DIRECT PUSH
' 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR FtAS BEEN PROVIDED TO THE WELL OWNER.
// 01/17/13
SIGNA E'Cl=-RTlrlr=D WEL N eYR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

STA
rV. WELL ABANDONMENT RECORD
3r
(; �,. North Carolina Department of Environment and Natural Resources- Division of Wafer Quality
_11`` WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR: 5. WELL DETAILS:
VINCE FEDERLE a.Total Depth, 39.0 ft. Diameter: in.
Well Contractor (Individual) Name b. Water Level (Below Measuring Point): 21.0 ft.
GEOLOGIC EXPLORATION, INC Measuring point Is 0.0 ft. above land surface.
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-15
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring 0 Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery rl Injection 0 Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
6. CASING:
Length Diameter
a. Casing Depth (if known):
N/A ft.
b. Casing Removed:
N/A ft.
7. DISINFECTION: N/A
(Amount of 65%75% calcium
hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type:O Slurry ❑ Pellets
Water gal.
Sand Cement
Cement lb.
Water Qal.
Other
Type material PORTLAND CEMENT
n— ­1 7.75 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
in.
in.
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC I LAND SETTING:
0 Slope ❑ Valley U Flat ❑ RidgeO Other
(Check appropriate selling) : 10. WELL DIAGRAM : Draw a detailed sketch of lheell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 45 56.6500 DMS OR DD in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 55 2.5700 " DMS OR DIDtypes of fill materialsrsed
Latitude/longitude source: VGPS Qfopographic map 12/13/12
(location of well must be shown on a USGS topo map andattached to 11. DATE WELL ABANDONED
this form if not using GPS)
4a. FACILITY - The name of the business where the well is located. Complete 4a;
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY MAYMEAD ASPHALT PLANT
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
City or Town State Zip Code
4b. CONTACT PERSONIWELL OWNER:
NAME NCDOT
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
lit EC�S BPFDVIgFO TO TOWNER.
X 01/17/13
: SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual whgmprialhebandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
• mmr.p FFIIFRI F
PRINTED NAME OF PERSON ABANDONING THE WE LL
Form GW-30
Rev. 5/10

j
STAre2.
NON ESIDENTIAL
WELL CONSTRUCTION RECORD
Norlh Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(ir applicable) B-16
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 9(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/13/12 - 12/14/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFlat ❑Ridge ❑Other
LATITUDE 35 " 45 56.6500 " DMS OR DD
LONGITUDE 80 " 55 1 2.5700 " DMS OR DD
LatiludeAongitude source: W3PS Qfopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if
applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [J(
c. WATER LEVEL Below Top of Casing: 21.0 FT,
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness!
: 7. CASING: Depth
Diameter
Weight Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
: 8. GROUT: Depth
Material
Method
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter
Slot Size Material
Top Bottom
Ft.
in.
in.
Top Bottom
Ft.
in.
in.
Top Bottom
Ft.
in.
in.
10. SAND/GRAVEL PACK:
Depth
Size
Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Formation Description
DIRECT PUSH
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
REC\ORrAS BEEN PROVIDED TO THE WELL OWNER.
01/17/13
SIG A OF CERTIFIED WE CC CQIVTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-16
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)`] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
0 Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley U Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _° 45 56.6500 „ DMS OR DD
LONGITUDE 80 55 2.5700 " DMS OR DD
Latitude/longitude source: Uf3PS pfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL DETAILS:
a.Tolal Depth 42.0 ft. Diameter., in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): NIA ft. in.
b. Casing Removed: N/A ft. In.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type:0 Slurry ❑ Pellets
Water gal.
Other
Sand Cement
Cement lb.
Water gal.
Type material PORTLAND CEMENT
Amni int 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM :Draw a detailed sketch of thwe l on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialaised
11. DATE WELL ABANDONED 12/14/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
4a. FACILITY - The name of the business where the well is located. Complete 4a i
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS RECORD HAS BEEN PIDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
-A
FACILITY ID # (if applicable)
vj-'7'� , /, 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
a 'I J
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must bean individual w ersonall bandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE ILL.
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5110

srnr "y:�
NON ESIDENTIAL WELL CONSTRUCTION RECORD
' `..�
_ � •�cs North Carolina Department oPCnvironmenf and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70�4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) : Top Bottom Ft.
SITE WELL ID #(if applicable) B-17 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Id
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/14/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley &(Flat ❑Ridge ❑Other
LATITUDE 35 ° 45 • 56.6500 "DIVISOR DD
LONGITUDE 80 ° 55 1 2.5700 " DMS OR DO
Latitude/Iongitude source: V3PS [3Topographic map
(location of well must be shown on a USGS topo map andattached to
this form /f not using GPS)
5. FACILITY (Name of the business where the well is located.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E/
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: 8. GROUT: Depth Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
m Top BottoFt. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0.0 / 42.0
: 12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• I6A NCAC 29 WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
H9fS RECORR DEEr�JK,lln'r/i DEDJKHE W OWNER.
\1(/ UK1�p� 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

5. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point Is 0.0 ft. above land surface.
6. CASING:
a. Casing Depth (if known):
b. Casing Removed:
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorile used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Bentonite 300.0 lb.
Type:O Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of lheall on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
: 11. DATE WELL ABANDONED 12/14/12
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualit)l
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-17
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'J Monitoring ❑ Residential
❑ Municipal/Public 0 Industrial/Commercial ❑ Agricultural
❑ Recovery rM Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley LZ Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 45 56.6500 " DMS OR DD
LONGITUDE80 55 2.5700 "DMS OR DD
Latitude/longitude source: 563PS Qfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i THIS RECORD HAS BEEN PEDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable) �� �A 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT SIG AT OF CERTIFIED WE R DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677 SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wpersonalhebandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONANELL OWNER: VINCE FEDERLE
NAME NCDOT PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Length Diameter
N/A ft.
N/A 0.
Form GW-30
Rev. 5/10

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(If applicable)
SITE WELL ID #(if applicable) B-18
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
: Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑✓ Top Bottom Ft.
Irrigation❑ Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 12/19/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley FFlat ❑Ridge ❑Other
LATITUDE 35 ° 45 56.6500 "DMS OR DD
LONGITUDE 80 ° 55 , 2.5700 " DMS OR DD
Latitude/longitude source: VGPS pTopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 40.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
9. SCREEN:
Depth
Diameter
Top
Bottom
Ft. in.
Top
Bottom
Ft. in.
Top
Bottom
Ft. In.
10. SANDIGRAVEL PACK:
Depth
Size
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 40.0
: 12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
f17GtKI&li;ill 2"]
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 7C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: REC RD AS BEEN PR VIDEp/Tj0 THE �L OWNER
"(/f (\ 01 /17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GWA b
Rev. 2/09

na STA7£ q 11
� 4 `;.,i
WLr'LL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
5. WELL DETAILS:
VINCE FEDERLE
a.Total Depth 40.0 ft. Diameter: in.
Well Contractor (Individual) Name
b. Water Level (Below Measuring Point): 21.0 ft.
GEOLOGIC EXPLORATION, INC
Measuring point is 0.0 ft. above land surface.
Well Contractor Company Name
176 COMMERCE BLVD
6. CASING: Length Diameter
Street Address
STATESVILLE
NC 28625 a. Casing Depth (if known): N/A ft.
City or Town
State Zip Code b. Casing Removed: N/A fl.
872-7686
N/A
Area704
code Phone number
7• DISINFECTION:
(Amount of 65%75% calcium hypochlorite used)
2. WELL INFORMATION
SITE WELL ID # (if applicable) B-18
8. SEALING MATERIAL:
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley G Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 ^ 45 56.6500 '• DMS OR DID
LONGITUDE 80 _ = 55 2.5700 ° DMS OR DID
Latitude/longitude source: S63PS E fopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gaL
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.0 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
in.
in.
10. WELL DIAGRAM :Draw a detailed sketch of tiveell on the back of this
farm showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel Interval, intervals of casing perforations, and depths and
types of fill materialtused
11. DATE WELL ABANDONED
12/19/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a;
THJA RECORD HAS BEF.N POV ED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner Information only.)
FACILITY ID # (if applicable)�'�
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must bean individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28577
Form GW-30
Rev. 5/10

NONRESIDENTIAL WELL CONSTRUCTION RECORD
(, r o North Carolina Department of Environment and Natural Resources- Division of Water Quality
A.
WELL CONTRACTOR CERTwICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(Inapplicable)
; Top
Bottom
Ft.
SITE WELL ID #(in applicable) B-19
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
IndustriaVCommercial ❑ Agricultural ❑ Recovery ❑ Injection gf
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/14/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope []Valley ,(Flat ❑Ridge []Other
LATITUDE 35 ^ 45 56.6500 " DMS OR DD
LONGITUDE 80 ° 55 1 2.5700 " DMS OR DD
Latitude/longitude source: MPS ❑Topographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 41.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [�
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 41.0
/
12. REMARKS:
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
' 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NC C 2,e, WELL CONSTRUC�T��-JJ}JJIQQQQQN STAN-1AARDS, AND THAT A COPY OF THIS
RECOR F S BEEN PR DEC) ?jYTHEWE
LU9WN R.
oolf T 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

STA Fn�.-- .
WELL ABANDONMENT RECORD
r.�cy� North Carolina Department of Gnvironnlent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Stale Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-19
STATE WELL PERMIT# (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)D Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery :Z Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley rG Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 " 45 56.6500 " DMS OR DID
LONGITUDE 80 55 2.57002 DMS OR DD
Latitude/longitude source: Rj 3ps aopographic map
(location of well must be shown on a USGS topo map andattached to
this farm if not using GPS)
5. WELL DETAILS:
a.Total Depth 41.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Sand Cement
Cement lb.
Water gal.
Other
Type material PORTLAND CEMENT
A 8.25 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of thee[] on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials,sed
11. DATE WELL ABANDONED 12/14/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i
THI RECORD HAS BEEN PfDVIDED TO THE WELL OWNER.
��%�
(If a residential well, skip 4a; complete 4b, well owner Information only.)
: \
/_ /%
Y �10&/
FACILITY ID # (if applicable)
C�Zvtl{ 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must bean individual w grsonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

f�
p=�„srnrt•4 �
NONRESIDENTIAL ESID.E'NTIAL WELL CONSTRUCTION RECORD
North Carolina Department orEnvironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
FL _
OTHER ASSOCIATED PERMIT#(if applicable)
: Top
Bottom
FL _
SITE WELL ID #(if applicable) B-20
: Top
BottonL
Ft. _
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 5
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/14/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope ❑Valley ,VFlat ❑Ridge []Other
LATITUDE 35 .45 56.6500 " DMS OR DO
LONGITUDE 80 " 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: 03PS ❑Topographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 38.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES❑ NO[/
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth
Diameter
Top Bottom
Ft. In.
Top Bottom
Ft. in.
Top Bottom
Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 38.0
/
: 12. REMARKS:
Method
Slot Size Material
In.
In.
in.
Material
Formation Description
DIRECT PUSH
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOR H BEEN PROVIDED T THEW OWNER.
��aCQ�t 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department orEnvironnlent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-20
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
Cl Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) :
TOPOGRAPHIC / LAND SETTING:
❑ Slope ❑ Valley pp Fiat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 45 56.6500 ^ DMS OR DD
LONGITUDE 80 ^ 55 • 2.5700 ^ DMS OR DID
Lalilude/iongitude source: 9f3PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
6. WELL DETAILS:
a.Total Depth 38.0
ft. Diameter in.
b. Water Level (Below Measuring
Point): 21.0 ft.
Measuring point is 0.0
ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known):
N/A ft.
b. Casing Removed:
N/A ft,
7. DISINFECTION: N/A
(Amount of 65%75% calcium
hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Sand Cement
Cement lb.
Water pal.
Other
Type material PORTLAND CEMENT
Amount 7.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of th¢ell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materiaisised
11. DATE WELL ABANDONED 12/14/12
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well Is located. Complete 4a;
THIS CORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
'A' ��
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONANELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE ILL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

SrAr,
T ' NONRESIDENTIAL ONESIDENT.IAL WELL CONSTRUCTION RECORD
North CarolinaDepartmentorEnvironntentandNaturalResources-DivisionorWnterQuality
""°� WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Slate Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION:
: 7. CASING:
Depth
Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
; Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-21
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ff(
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/17/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFW ❑Ridge []Other
LATITUDE 35 ^ 45 - 56.6500 "DMS OR DID
LONGITUDE 80 " 55 1 2.5700 " DMS OR DC
Latitude/longitude source: WGPS pfopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E/
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
9. SCREEN:
Depth
Diameter
Top
Bottom
Ft. in.
Top
Bottom
Ft. in.
Top
Bottom
Ft. in.
10. SAND/GRAVEL PACK:
Depth
Size
Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
ECO D HAS BEEN PROVIDED TOT WELL OWNER.
• ����� 01/17/13
SIGNATURE OF CERTIFIED LL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

f Y i WWELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-21
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring ❑ Residential
0 Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery Ji Injection ❑ Irrigation-
❑ Other (list use)
S. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft, in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Sand Cement
Cement lb.
Water gal.
Type material PORTLAND CEMENT
A...,,.,.,r 8.5 GALLONS
3. WELL LOCATION:
_
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
164 BOSTIAN BRIDGE DRIVE 28677
TREMIE
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope 0 Valley rG Flat ❑ Ridge❑ Other
(Check appropriate setting)
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE _35_ _° 45 56.6500 ° DMS OR DID
in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 _ ° 55 2.5700 ^ DMS OR DD
types of fill malerials,sed
Latilude/longitude source: Rj3PS ❑Topographic map
12/17/12
(location of well must be shown on a USGS topo map andattached to
11. DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
:
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a ;
THIS RECORD HAS BEEN PEDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
-A,
FACILITY ID # (if applicable)
�L'tj 116, 16, 1, 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677 :
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must bean individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5110

- : srnrfn 4
a'V� ♦��wy ro � �'4
P'S
NON ArTIESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department oPEnvironment and Natural Resources -.Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Slate Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(ir applicable)
SITE WELL ID #(If applicable) B-22
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated atior below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A
METHOD OF TEST N/A
f. DISINFECTION: Type
N/A
Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top
Bottom
Top Bottom
Top
Bottom
Top Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth
Diameter
Weight Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection gf Top Bottom Ft.
Irrigation[] Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 12/17/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley F/Flat []Ridge []Other
LATITUDE 35 "45 - 56.6500 "DMS OR DD
LONGITUDE 80 ° 55 1 2.5700 " DMS OR DD
Latitude/longitude source: 03PS aopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L/
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11, DRILLING LOG
: Top Bottom
0.0 / 42.0
/
12. REMARKS:
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NC,AC 2C, WELL CONSTUCTION SJANDARDS, AND THAT A COPY OF THIS
R4CORD HARO TO TNENyEL
V T 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2109

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Stale Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-22
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'—] Monitoring 0 Residential
❑ Municipal/Public 0 Industrial/Commercial ❑ Agricultural
❑ Recovery Z Injection ❑ Irrigation
❑ Other (list use)
S. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Sand Cement
Cement lb.
Water aal.
Bentonile 300.0 lb.
Type: 0 Slurry 0 Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEAREST TOWN: STATESVILLE
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
164 BOSTIAN BRIDGE DRIVE 28677
TREMIE
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
0 Slope ❑ Valley iZ Flat ❑ Ridge❑ Other
(Check appropriate setting)
10. WELL DIAGRAM : Draw a detailed sketch of tt►eell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 _° 45 56.6500 ° DMS OR DD
in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 _ ° 55 2.5700 °DMS OR DD
types of fill materialsrsed
Latitude/longitude source: �PS Uopographic map
12/17/12
(location of well must be shown on a USGS topo map andattached to
11. DATE WELL ABANDONED
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i
THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
�� �
/ 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNAT F"CERT
FIfJED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town Slate Zip Code
(The private well owner must be an individual wbersonalltabandons his/her residential well
In accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677 ;
Form GW-30
Rev. 5110

NON-RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
"Top of casing terminated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST NIA
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#
: Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
: Top
Bottom
Ft. _
SITE WELL ID #(if applicable) B-23
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection @r
Top
Bottom
Ft.
Irrigation[] Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/17/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley @(Flat ❑Ridge []Other
LATITUDE 35 ^ 45 56.6500 "DMS OR DD
LONGITUDE 80 ° 55 r 2.5700 " DMS OR DD
Latitude/longitude source: W3PS pTopographic map
(location of well must be shown on a USGS topo map andattached to
this form ff not using GPS)
5. FACILITY (Name of the business where the well is located.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CV(
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
:9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 142.0
12. REMARKS:
Slot Size
in.
in.
in.
Material
Formation Description
DIRECT PUSH
Method
Material
• I DO HEREBY CERTI THAT THIS WELL WAS CONSTRU DIN ACCORDANCE WITH
15A NCAC 2C, WE ONSTRUCT�I JJ S DARDS, AN AT A COPY OF THIS
RECORD HAS B PROVIDED-'T( THELL QI�NER
{fY� 01/17/13
SIGNA E OF CERTIFIED WELL CONTRACTOR DATE
JA ES HESS
. PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

�k WELL ABANDONMENT RECORD
North Carolina Department oPl;nvironment and Natural Resources- Division of Water Quality
��•4Y Pu„'rm�c�.�=•
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-23
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use):] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) :
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley U Flat 0 Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 0 45 56.6500 " DM5 OR DD
LONGITUDE 80 __ 55 2.57002 DMS OR DO
Latitude/longitude source: RTGPS ❑topographic map
(location of well must be shown on a USGS topo map andattached to
5. WELL DETAILS:
a.Tolal Depth 42.0
ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0
ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known):
N/A ft. in.
b. Casing Removed:
N/A ft. in.
7. DISINFECTION: N/A
(Amount or 65%75% calcium
hypochlorite used)
8. SEALING MATERIAL:
Neat Cament Sand Cement
Cement lb. Cement lb.
Water gal. Wateral.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED 12/17/12
thrs form r not using GPS)
I DO HEREBY CERTIF THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C ELL CONSTRUCTION STANDAOS, AND THAT COPY OF
4a. FACILITY - The name of the business where the well Is located. Complete 43 1
(If a residential well, skip 4a: complete 4b, well owner information only.)
THIS RECORD H EEEN B"ED fq THHEE WELL NER.
Y
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATLOXOF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must bean Individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
JAMES HESS
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5110

t%
NON ESIDENTIAL WELL CONSTRUCTION RECORD
K-As
North Carolinst Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Slate Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-24
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection d Top Bottom Ft.
Irrigation[]Other [I(list use) :Top Bottom Ft.
DATE DRILLED 12/17/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Coda)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley I(Flat []Ridge []Other
LATITUDE 35 ^ 45 - 56.6500 " DMS OR
WE
LONGITUDE 80 ' 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: V3PS ETopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if
applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ❑v/
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Method
Slot Size Material
in.
in.
In.
Material
Formation Description
DIRECT PUSH
I DO HEREBY �f�TIFY THAT-�NISW AS CONST CTED IN ACCORDANCE WITH
• 15A NCAC 2 (' 1 TRU�TJON� 5, IT A COPY OF THIS
RECORD IDE TO TH R.
01/17/13
SIG TURE OF CERTIFIED WELL CONTRACTOR DATE
JAMES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department ol'Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Natne
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-24
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use), Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery M Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 ^ 45 56.6500 " DMS OR DID
LONGITUDE 80 _ " 55 2.5700 ° DM5 OR DD
Latitude/longitude source: RiPS ElTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft.
b. Casing Removed: N/A ft.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Sand Cement
Cement lb.
Water gal.
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
n— —f 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED 12/17/12
1 DO HEREBY CE IFY THAT THIS WELL WAS ABAN ONED IN ACCORDANCE
WITH 15A NCAC , WELL CONSTRUCTION STAN)3ARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a;
THIS RECORD S BEEN PrEr�rp THE WE OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGN RE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONANELL OWNER:
JAMES HESS
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
;
Form GW-30
Rev. 5/10

I \
,a�srntl:•, �,,
..^' r
a 'Jim
1 i' -r!? ONESr�DEIVT'IAL WELL CONSTRUCTION RECORD
,rL .. �• s
�o! North Carolina Department of Environment and Natural Resources- Division of Water Quality
�k p,,,,„ad `rt WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS 0.0 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): NIA METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft. _
OTHER ASSOCIATED PERMIT#(if applicable)
: Top
Bottom
Ft. _
SITE WELL ID #(if applicable) B-25
: Top
Bottom
Ft. —
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material
Industrial/Commercial ❑ Agricultural ❑ Recovery❑ Injection Mr
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/17/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope ❑Valley 5JIFlat ❑Ridge ❑Other
LATITUDE 35 " 45 156.6500 " DMS OR DO
LONGITUDE 80 " 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: IMPS Dibpographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO LJ(
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORR HAS BEEN PROVIDED TO THE WELL OWNER.
01/17/13
SIGNATURE Ur CERTIFIED ( R DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

re
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
l
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2, WELL INFORMATION:
SITE WELL ID # (if applicable) B-25
STATE WELL PERMIT# (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)7 Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery Z Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Streel/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
i
TOPOGRAPHC / LAND SETTING:
I
❑ Slope ❑ Valley FZ Fiat ❑ Ridge❑ Other
(Check appropriate setting)
I •
LATITUDE 35 - 45 56.6500 " DMS OR DD
LONGITUDE 80 _ o 55 2.5700 " DM5 OR DO
Latitude/longitude source: [J-PS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A R. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water nal.
Bentonite
Bentonite 300,0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
10. WELL DIAGRAM : Draw a detailed sketch of theeli on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill malerialsised
: 11. DATE WELL ABANDONED 12/17/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH i5A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a; THIS RE�+ORD HAS BEEN POVIDED TO THE WELLLLL OWNER.
(IFa residential well, skip 4a; complete 4b, well owner information only.) ` /� � ' �-
FACILITY ID # (if applicable) V �1* [f� 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT : SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677 SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town Slate Zip Code (The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONMELL OWNER: VINCE FEDERLE
NAME NCDOT PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5110

NONE.S`IDENTIAL
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
'�*'�•""""'"" ai`
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#
: Top
Bottom
Ft.
OTHER ASSOCIATED PERMIT#(if applicable)
: Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-26
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection 9(
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/17/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope []Valley V(Flat ❑Ridge ❑Other
LATITUDE 35 ^ 45 ' 56.6500 " DMS OR DD
LONGITUDE 80 ° 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: Q(GPS pTopographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO L�
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 8. GROUT: Depth
Material Method
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
: 9. SCREEN: Depth
Diameter
Slot Size Material
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0.0 / 42.0
DIRECT PUSH
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
: RE VORAS'f/J(�
VIDFp1T0 THEktlfLL OWNER. ljLp 01/17/13
: SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

I
"tea STATt'"'�+t
� t•tW WYN'et N ,� V Air
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Stale Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) 13-26
STATE WELL PERMIT# (Lfapplicable)
COUNTY WELL PERMIT # (If applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'J Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery Z Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley G Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 ° 45 56.6500 " DMS OR DD
LONGITUDE 80 ° 55 2.5700 1' DMS OR DO
Latitude/longitude source: Rf3PS Qfopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY - The name of the business where the well is located. Complete 4a i
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY MAYMEAD ASPHALT PLANT
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
6. WELL DETAILS:
a. Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
: 7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Sand Cement
Cement lb.
Water gal.
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED 12/17/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
THIS CORD HAS BEEN PtDVIDED TO THE WELL OWNER.
7-z''`� �""" �GrJ� 01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STATESVILLE NC 28677 SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual wbersonallsbandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER: VINCE FEDERLE
NAME NCDOT PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

w
,ad;;: srAreo,.
NON-RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
3552
WELL CONTRACTOR CERTIFICATION #
Chrv,nxr�
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-27
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection F(
Irrigation[] Other ❑ (list use)
DATE DRILLED 12/17/12 - 12/18/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope []Valley Flat []Ridge ❑Other
LATITUDE 35 0 45 - 56.6500 " DMS OR DD
LONGITUDE 80 ^ 55 , 2.5700 " DMS OR DD
Latitude/longitude source: IJJ3PS ❑ropographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ei,✓
C. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0.0 FT. Above Land Surface`
"Top of casing terminated aYor below land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth
Diameter Weight Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
8. GROUT: Depth
Material Method
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter
Slot Size Material
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
r
12. REMARKS:
Formation Description
DIRECT PUSH
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 AS BEEN PROVIDEDPROVIDEDA
O THE LL OWNER.
l dv? pp� � 01/17/13
SIGNATURE OF( WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town Stale Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-27
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'1 Monitoring ❑ Residential
❑ Municipal/Public 0 Industrial/Commercial ❑ Agricultural
0 Recovery 0 Injection 0 Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) :
TOPOGRAPHIC / LAND SETTING:
❑ Slope 0 Valley Z Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE _35 _° 45 56.6500 " DMS OR DD
LONGITUDE 80 ° 55 2.5700 " DMS OR DO
Latitude/longitude source: Wf.PS Qropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. WELL DETAILS:
a.Total Depth 42.0
ft. Diameter: in.
b. Water Level (Below Measuring
Point): 21.0 ft.
Measuring point is 0.0
ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known):
N/A ft. in.
b. Casing Removed:
N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium
hypochlorite used)
: 8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Bentonile 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED 12/18/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT ACOPY OF
4a. FACILITY -The name of the business where the well is located. Complete 4a I
(If a residential well, skip 4a; complete 4b, well owner information only.)
THIS S VCORD HAS, BEEN el@VIDEO THE WELL OWNER.
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must bean individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
;
Form GW-30
Rev. 5/10

�'E
NON
frM
.ESIDLNTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTI ACTOR CL'RTIT[CATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-28
d. TOP OF CASING IS 0.0 FT. Above Land Surface"
"Top of casing terminated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .0118,
e. YIELD (gpm): N/A METHOD OF TEST N/A
L DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
: Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection R( Top Bottom Ft.
Irrigation❑ Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 12/17/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY; STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley g(Flat ❑Ridge []Other
LATITUDE 35 ^ 45 ' 56.6500 "DMS OR DD
LONGITUDE 80 ° 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: 03PS propographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if
applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
Slate
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO [�
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11, DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
100 HE CE FY THAT THIS WELL WAS CONST TED IN ACCORDANCE WITH
• 15A NCAC 2C, L CONST ON NDARDS, THAT A COPY OF THIS
RECORD HA DE TO TH 1!�'VN
01/17/13
: SIG IV
URE OF CERTIFIED WELL CONTRACTOR DATE
JAMES HESS
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) 13-28
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'-1 Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery Z Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
5, WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Sand Cement
Cement lb.
Water pal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
(Slreel/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley (7 Flat 0 Ridge❑ Other
(Check appropriate setting)
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
LATITUDE 35 _� 45 56.6500 " DMS OR DID
in the well, gravel interval, intervals of casing perforations, and depths and
LONGITUDE 80 — 55 2.5700 " DMS OR DD
types of fill matedalaised
Latitude/longitude source: RTSPS DTopographic map
12/17/12
(location of well must be shown on a USGS topo map andattached to -
11. DATE WELL ABANDONED
this form if not using GPS)
100 HEREBY CE TIFY THAT THIS WELL WAS AB DONED IN ACCORDANCE
WITH 15A NCA C, WELL CONSTRUCTION ST ARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a;
RE
THIS COR AS BEEN,�iC11 O THEW L OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGN T RE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town Stale Zip Code
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER:
JAMES HESS
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

i
„a ST�Ar�.� +
1. WELL CONTRACTOR:
JAMES HESS
NONRESIDENTIAL ON ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS 0.0 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 (gpin): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
: g. WATER ZONES (depth):
: Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
Ft. _
OTHER ASSOCIATED PERMIT#(inapplicable)
: Top
Bottom
Ft. _
SITE WELL ID #(If applicable) B-29
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection C(
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/18/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope ❑Valley I'Flat ❑Ridge []Other
LATITUDE 35 ^ 45 ' 56.6500 "DMS OR DID
LONGITUDE 80 ^ 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: BPS ❑Topographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Code
L-)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 32.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C3�
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
9. SCREEN: Depth Diameter
Top Bottom Ft. in
Top Bottom Ft. in
Top Bottom Ft. in
10. SAND/GRAVEL PACK:
Depth Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
: Top Bottom
0.0 / 32.0
12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
I DO HEREBY CER Y THAT THIS WELL WAS CONSTR ED IN ACCORDANCE WITH
• 15A NCAC 2C1W CONSTR_U�JANAjJDARDS, A HAT A COPY OF THIS
RECORD HAS N PRO IDE r0 THE t t. 0)(VNEI .
/�vY, 01/17/13
SIGN RE OF CERTIFIED WELL CONTRACTOR DATE
JA ES HESS
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2/09

>'y r 4
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE
City or Town
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-29
STATE WELL PERMIT # (if applicable)
5. WELL DETAILS:
a.Total Depth 32.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point Is 0.0 ft. above land surface.
6. CASING:
NC 28625 a. Casing Depth (if known):
State Zip Code b. Casing Removed:
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)7 Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection 0 Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No.. Parcel, Zip Code) :
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 " 45 56.6500 " DMS OR DID
LONGITUDE 80 " 55 2.5700 " DMS OR DD
Latitude/longitude source: &!f3PS []Topographic map
(location of well must he shown on a USGS topo map andattached to
this form if not using GPS)
4a. FACILITY - The name of the business where the well Is located. Complete 4a
(If a residential well, skip 4a; complete 4b, well owner Information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY MAYMEAD ASPHALT PLANT
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
City or Town State Zip Code
4b. CONTACT PERSONAMELL OWNER:
NAME NCDOT
Length Diameter
N/A ft.
N/A ft.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Qement
Cement lb.
Water gal.
Bentonite
Bentonite 360.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Sand Cement
Cement lb.
Water oal.
Other
Type material PORTLAND CEMENT
n,.,, —i 6.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials,sed
11. DATE WELL ABANDONED
12/18/12
: I DO HEREBY RTIFY THAT THIS WELL WAS A NDONED IN ACCORDANCE
WITH 15A N 2C, WELL CONSTRUCTIONS NDARDS, AND THAT A COPY OF
THIS REGqW HAS A�BE�IDVtqEpTO HE LLOWNER.
lIXX��JJ %� 01/17/13
SIYATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677 :
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
JAMES HESS
PRINTED NAME OF PERSON ABANDONING THE WE LL
Form GW-30
Rev. 5110

.M'J ., 4
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
" WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(if applicable) :Top Bottom Ft.
SITE WELL ID #(if applicable) B-30 : Top Bolcom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Cvf
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/18/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope []Valley Q(Flat ❑Ridge ❑Other
LATITUDE 35 ^ 45 - 56.6500 " DMS OR DD
LONGITUDE 80 ° 55 ' 2.5700 " DMS OR DO
Latitude/longitude source: VGPS 01-opographic map
(location of well must be shown on a USGS tope map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
MAYMEAD ASPHALT PLANT N/A
Facility Name Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE NC 28677
City or Town State Zip Code
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE NC 28677
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 38.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO CV
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
8. GROUT: Depth
Material Method
: Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
9. SCREEN: Depth
Diameter
Slot Size Material
Top Bottom
Ft.
In. in.
Top Bottom
Ft.
in. in.
Top Bottom
Ft.
in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 38.0
/
/
12. REMARKS:
Formation Description
DIRECT PUSH
I DO HEREBY CVAIFY THAT THIS WELL WAS CONST CTED IN ACCORDANCE WITH
15A NCAC 2C,XALL CONS rTION [ANDARDS, D THAT A COPY OF THIS
RECORD HA EEN PRO%&JD).TO TFiEINLEl&WW
// 01 /17/13
WELL CONTRACTOR DATE
NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2109

t'ai --
-
WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
RH,..:,;�• WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
s. WELL DETAILS:
JAMES HESS
a.Total Depth 38.0 ft. Diameter: in.
Well Contractor (Individual) Name
b. Water Level (Below Measuring Point): 21.0 ft.
GEOLOGIC EXPLORATION, INC
Measuring point is 0.0 ft. above land surface.
Well Contractor Company Name
176 COMMERCE BLVD
6. CASING: Length Diameter
Street Address
STATESVILLE
NC 28625 a. Casing Depth (if known): N/A ft. in.
City or Town
State Zip Code b. Casing Removed: N/A ft. in.
704 872-7686
7. DISINFECTION: N/A
Area a code Phone number
(Amount of 65%75% calcium hypochlorite used)
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-30
8. SEALING MATERIAL:
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable usefl Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGIE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Streel/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley U Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 45 56.6500 " DMS OR DD
LONGITUDE 80 _ " 55 2.5700 '• DMS OR DD
Latitude/longitude source: 03PS Oropographic map
(location of well must be shown on a USGS topo map andattached to
this to if not usin GPS)
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Watergal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
A..,..-f 7.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
In the well, gravel interval, intervals of casing perforations, and depths and
types of rill materialsised
11. DATE WELL ABANDONED
12/18/12
9 I DC HEREBY ERTIFY THAT THIS WELL WAS ANDONED IN ACCORDANCE
WITH 15A C 2C, WELL CONSTRUCTION ANDARDS, AND THAT COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 42; THIS RE C 0 HAS B -POT �D nO TH ELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner Information only.) /--�{,
FACILITY ID # (if applicable) 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT SOKATURE OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677 SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONfWELL OWNER: DAMES HESS
NAME NCDOT PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of L'•nvironnlent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
2. WELL INFORMATION: : 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# Top Bottom Ft.
OTHER ASSOCIATED PERMIT#(il applicable) : Top Bottom Ft.
SITE WELL ID #(if applicable) B-31 : Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Ed
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/18/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel. Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
[]Slope ❑Valley &(Flat ❑Ridge ❑Other
LATITUDE 35 -45 - 56.6500 " DMS OR DID
LONGITUDE 80 , 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: 03PS ElTopographic 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.)
MAYMEAD ASPHALT PLANT
NIA
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 27.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E/
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 8. GROUT: Depth Material
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
9. SCREEN:
Depth
Diameter
Top
Bottom
Ft. in.
Top
Bottom
Ft. in.
Top
Bottom
Ft. -in.
10. SANDIGRAVEL PACK:
Depth
Size
: Top
Bottom
Ft.
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
Top Bottom
0.0 / 27.0
/
12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
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.
01/17/13
SIGU019P,910111 CERTIFIED ACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

3". WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
r" WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-31
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'] Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
0 Recovery M Injection ❑ Irrigation
0 Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley FJ Flat 0 Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _- 45 56.6500 " DMS OR DO
LONGITUDE 80 55 2.5700 " DMS OR DD
Latitude/longitude source: RJ�PS pl-opographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL DETAILS:
a.Total Depth 27.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Cement lb.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type:O Slurry ❑ Pellets
Water gal.
Sand Cement
Cement lb.
Water aal.
Other
Type material PORTLAND CEMENT
n,r,,,—f 5.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
_TRREMIE
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill malerialmsed
: 11. DATE WELL ABANDONED 12/18/12
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i
THIS`RECC RD HAS BEEN POVIDED TO THE
(If a residential well, skip 4a; complete 4b, well owner information only.)
/�WELL
\ /� � �ja�Cit!X/tXX�
FACILITY ID # (if applicable)
_ /�/OWNER.
�( 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual w ersonall bandons hisfher residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONIWELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5110

• \\6 sTAre b"S.
f� .7I�11!U�,51T•rT, Y�
NoN E`�SIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department orEnvironment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
If. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT#
Top
Bottom
FL
OTHER ASSOCIATED PERMIT#(If applicable)
: Top
Bottom
Ft.
SITE WELL ID #(if applicable) B-32
: Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
: 8. GROUT:
Depth
Material
Industrial/Commercial ElAgricultural ElRecovery [IInjection
Top
Bottom
Ft.
Irrigation❑ Other ❑ (list use)
: Top
Bottom
Ft.
DATE DRILLED 12/18/12
: Top
Bottom
Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY; STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley 9'Flat []Ridge ❑Other
LATITUDE 35 ° 45 r 56.6500 "DMS OR DD
LONGITUDE 80 55 ' 2.5700 " DMS OR DD
Latitude/longitude source: V3PS ❑topographic 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.)
MAYMEAD ASPHALT PLANT
N/A
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
U
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ede
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth _ Size
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Slot Size
In.
in.
in.
Material
Formation Description
DIRECT PUSH
Method
Material
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC,2C� STRUCTION STWDARDS. AND THAT COPY OF THIS
: RECpOVVfIyyHASAEEN P VID O THE L O NER.
01/17/13
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1 b
Rev. 2109

1 `�,d �,� o ,... •i�r`Y
,r . •3•��'° WELL ABANDONMENT RECORD
North Carolina Department of Environment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR: 6. WELL DETAILS:
VINCE FEDERLE a.Total Depth 42.0 ft. Diameter: in.
Well Contractor (Individual) Name b. Water Level (Below Measuring Point): 21.0 ft.
GEOLOGIC EXPLORATION, INC Measuring point is 0.0 ft. above land surface.
Well Contractor Company Name
176 COMMERCE BLVD
Sheet Address
STATESVILLE NC 28625
City or Town Stale Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-32
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)'] Monitoring ❑ Residential
0 Municipal/Public 0 Industrial/Commercial 0 Agricultural
0 Recovery ✓ Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Slreel/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
0 Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 _" 45 56.6500 " DMS OR DD
LONGITUDE 80 55 2.57002 DMS OR DO
L ' d /1 'l d lc -A,
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Bentonite 300.0 lb.
Type:O Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
nm m i t 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill malerialsised
atitu a ongl u e source. PS pfopographlc map
(location of well must be shown on a USGS topo map andattached to
11. DATE WELL ABANDONED 12/18/12
this form if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a;
THIS RECORD HAS BEEN PIDVIDED TO THE WELL OWNER.
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
d ,/f ( 4z— 01/17/13
CZ
NAME OF FACILITY MAYMEAD ASPHALT PLANT
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code
(The private well owner must be an individual wbersonall abandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSONANELL OWNER:
VINCE FEDERLE
NAME NCDOT
PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

.NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina .Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Cade
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-33
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth Diameter Weight Material
Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ 8. GROUT: Depth Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ .Injection (af Top Bottom Ft.
Irrigation❑ Other ❑ (list use) : Top Bottom Ft.
DATE DRILLED 12/18/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley &Flat ❑Ridge ❑Other
LATITUDE 35 ^ 45 - 56.6500 " DMS OR DID
LONGITUDE 80 ° 55 • 2.5700 " DMS OR DD
Latitude/longitude source: W3PS pTopographic 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.)
MAYMEAD ASPHALT PLANT
NIA
Facility Name
Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE
NC
28677
City or Town
Stale
Zip Cade
NCDOT
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE
NC
28677
City or Town
State
Zip Code
L�
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO C}�
c. WATER LEVEL Below Top of Casing: 21.0 FT.
(Use "+" if Above Top of Casing)
Method
9. SCREEN: Depth Diameter Slot Size Material
Top Bottom Ft. in. in.
Top Bottom Ft. in. In.
Top Bottom Ft. in. in.
• 10. SAND/GRAVEL PACK:
Depth Size Material
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
I
12. REMARKS:
Formation Description
DIRECT PUSH
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
• 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECOEA
S BEEN PROVIDED TO THE WELL OWNER.
r d,q ' 01/17/13
SIG Rr-OF CERTIFIED W 1TOR DATE
VINCE FEDERLE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-lb
Rev. 2/09

4 vL
�41hs,.c.� 3• -,2 WELL ABANDONMENT RECORD
North Carolina Department orEnvironment and Natural Resources- Division or Water Quality
WELL CONTRACTOR CERTIFICATION # 3552
1. WELL CONTRACTOR:
VINCE FEDERLE
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-33
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable usey7 Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
Recovery J Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEAREST TOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Street/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code) ;
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 245 56.6500 ^ DMS OR DID
LONGITUDE 80 _ ^ 55 2.5700 " DMS OR DD
Latitude/longitude source: 03PS ❑Topographic map
(location of well must be shown on a USGS topo map andettached to
6. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter; in.
b. Water Level (Below Measuring Point): 21.00 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING: Length Diameter
a. Casing Depth (if known): N/A ft. in.
b. Casing Removed: N/A ft. in.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
A..,,,,,..f 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materialsised
11. DATE WELL ABANDONED 12/18/12
this form if not using GPS)
: I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF
4a. FACILITY - The name of the business where the well is located. Complete 4a i THIS RECORD HAS BEEN POVIDED TO THE WELL OWNER,
(If a residential well, skip 4a; complete 4b, well owner information only.) /�On�L�
FACILITY ID # (if applicable) \z//� 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677 SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
City or Town State Zip Code (The private well owner must bean individual wl a nalltebandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
4b. CONTACT PERSON/WELL OWNER: VINCE FEDERLE
NAME NCDOT PRINTED NAME OF PERSON ABANDONING THE WE LL
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
Form GW-30
Rev. 5/10

`4•Sln7E�
-
NON
ESIDENTIAL WELL CONSTRUCTION RECORD
( o'
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTII+ICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(it applicable)
SITE WELL ID #(ir applicable) B-34
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated atlor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): N/A METHOD OF TEST N/A
f. DISINFECTION: Type N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top
Bottom
Top
Bottom
Top
Bottom
Thickness/
:7. CASING: Depth Diameter Weight Material
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑ : 8. GROUT: Depth Material
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection u� Top Bottom Ft.
Irrigation[] Other ❑ (list use) : Top Bottom Ft,
DATE DRILLED 12/18/12 : Top Bottom Ft.
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley VFlat ❑Ridge ❑Other
LATITUDE 35 ^ 45 56.6500 " DMS OR DID
LONGITUDE 80 ^ 55 , 2.5700 2 DMS OR DD
Latitude/longitude source: 03PS ElTopographic 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.)
MAYMEAD ASPHALT PLANT N/A
Facility Name Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE NC 28677
City or Town State Zip Code
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address
STATESVILLE NC 28677
City or Town Stale Zip Code
L)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO EV
c. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
: 9. SCREEN: Depth Diameter
Top Bottom Ft. in.
Top Bottom Ft. in.
Top Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
: Top Bottom Ft.
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 / 42.0
12. REMARKS:
Method
Slot Size Material
in.
in.
in.
Material
Formation Description
DIRECT PUSH
100 HEREBY CE THAT THIS WELL WAS CONSTR ED IN ACCORDANCE WITH
• 15A NCAC 2C, L CONST��Rttj�GGTT110 NDARDS, A THAT A COPY OF THIS
RECORD HAS NPR VIDEq,TO TH l ELI„r,I,WNE .
�� �� {fY� 01/17/13
SIGN RE OF CERTIFIED WELL CONTRACTOR DATE
JAMES HESS
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2/09

4a. FACILITY - The name of the business where the well is located. Complete 4a;
(If a residential well, skip 4a; complete 4b, well owner information only.)
FACILITY ID # (if applicable)
NAME OF FACILITY MAYMEAD ASPHALT PLANT
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
City or Town State Zip Code
4b. CONTACT PERSON/WELL OWNER:
NAME NCDOT
STREET ADDRESS 164 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
rr ` ,3• ���r WELL ABANDONMENT RECORD
17
North Carolina Department of Environment and Natural Resources- Division of Water Quality
C �
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR: 6. WELL DETAILS:
JAMES HESS a.Total Depth 42.0 ft. Diameter: in.
Well Contractor (Individual) Name b. Water Level (Below Measuring Point): 21.0 ft. .
GEOLOGIC EXPLORATION, INC Measuring point is 0.0 ft. above land surface.
Well Contractor Company Name
176 COMMERCE BLVD 6.
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number 7'
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-34 8.
STATE WELL PERMIT # (if applicable)
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)❑ Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(Streef/Road Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley V Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 45 56.6500 " DMS OR DID
LONGITUDE80 _ 55 2.5700 "DMS OR DID
Latitude/longitude source: Vf3PS pfopographic map
(location of well must be shown on a USGS topo map andauached to 11. DATE WELL ABANDONED
this to if not using GPS)
I DO HEREBY CERTIFY THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC 2 . ELL CONSTRUCTION STAND ^ S, AND THAT A COPY OF
THIS RECORD H BEEN PRaUtBED�QITHE WELL NER.
VI
01/17/13
SIGNATr OF CERTIFIED WELL CONTRACTOR DATE
CASING:
a. Casing Depth (if known):
b. Casing Removed:
Length Diameter
N/A ft
N/A ft.
DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
SEALING MATERIAL:
Neat Cement Sand Cement
Cement lb. Cement lb.
Water gal. Water gal.
Bentonite
Bentonite a00.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
A.,,.,—f 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TRFMIE
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
In the well, gravel interval, intervals of casing perforations, and depths and
types of fill materiais;sed
12/18/12
: SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must be an individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
JAMES HESS
PRINTED NAME OF PERSON ABANDONING THE WE LL
Form GW-30
Rev. 5/10

�, I'•^�
1. WELL CONTRACTOR:
JAMES HESS
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
70( 4 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) B-35
3. WELL USE (Check One Box) Monitoring ❑ Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection Ed
Irrigation❑ Other ❑ (list use)
DATE DRILLED 12/18/12
4. WELL LOCATION:
164 BOSTIAN BRIDGE DRIVE 28677
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: STATESVILLE COUNTY IREDELL
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope []Valley i'Flat ❑Ridge []Other
LATITUDE 35 * 45 56.6500 " DMS OR DD
LONGITUDE 80 * 55 , 2.5700 " DMS OR DD
Latitude/longitude source: BPS pTopographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPSI
5. FACILITY (Name of the business where the well is located.)
MAYMEAD ASPHALT PLANT N/A
Facility Name Facility ID# (if applicable)
164 BOSTIAN BRIDGE DRIVE
Street Address
STATESVILLE NC 28677
City or Town State Zip Code
: d. TOP OF CASING IS 0.0 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): N/A
METHOD OF TEST N/A
f. DISINFECTION: Typo
N/A Amount N/A
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Thickness/
7. CASING: Depth
Diameter Weight Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
8. GROUT: Depth
Material Method
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
: 9. SCREEN: Depth
Diameter Slot Size Material
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
Top Bottom
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth
Size Material
Top Bottom
Ft.
Top Bottom
Ft.
Top Bottom
Ft.
11. DRILLING LOG
Top Bottom
Formation Description
0.0 / 42.0
/
Contact Name
164 BOSTIAN BRIDGE DRIVE
Mailing Address /
STATESVILLE NC 28677
City or Town Stale Zip Code
12. REMARKS:
l)
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 42.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO Ede
C. WATER LEVEL Below Top of Casing: 21.0 FT
(Use "+" if Above Top of Casing)
DIRECT PUSH
I DO HEREBY CPITIFY THAT THIS WELL WAS CONSTJ3UCTED IN ACCORDANCE WITH
• 15A NCAC 2C LL CONSTTITANDARDS D TI4AT A COPY OF THIS
RECORD H EEN P OV1q�D TO T}1¢ WELL OW R.
I 01117/13
Si TURE OF CERTIFIED WELL CONTRACTOR DATE
JAMES HESS
: PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GW-1b
Rev. 2109

WELL ABANDONMENT RECORD
North Carolina .Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3550
1. WELL CONTRACTOR:
JAMES HESS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
704 ) 872-7686
Area code Phone number
2. WELL INFORMATION:
SITE WELL ID # (if applicable) B-35
STATE WELL PERMIT # (if appli
COUNTY WELL PERMIT # (if applicable)
DWQ or OTHER PERMIT # (if applicable)
WELL USE (Check applicable use)D Monitoring ❑ Residential
❑ Municipal/Public ❑ Industrial/Commercial ❑ Agricultural
❑ Recovery 0 Injection ❑ Irrigation
❑ Other (list use)
3. WELL LOCATION:
COUNTY IREDELL QUADRANGLE NAME
NEARESTTOWN: STATESVILLE
164 BOSTIAN BRIDGE DRIVE 28677
(StreeNRoad Name, Number, Community, Subdivision, Lot No., Parcel, Zip Code)
TOPOGRAPHC / LAND SETTING:
❑ Slope ❑ Valley G Flat ❑ Ridge❑ Other
(Check appropriate setting)
LATITUDE 35 45 56.6500 " DMS OR DD
LONGITUDE80 55 2.5700 "DMS OR DD
Latitude/longitude source: 03PS ❑Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. WELL DETAILS:
a.Total Depth 42.0 ft. Diameter: in.
b. Water Level (Below Measuring Point): 21.0 ft.
Measuring point is 0.0 ft. above land surface.
6. CASING:
Length Diameter
a. Casing Depth (if known):
NIA ft.
b. Casing Removed:
N/A ft.
7. DISINFECTION: N/A
(Amount of 65%75% calcium hypochlorite used)
8. SEALING MATERIAL:
Neat Cement
Sand Cement
Cement lb.
Cement lb.
Water gal.
Water gal.
Bentonite
Bentonite 300.0 lb.
Type: ❑ Slurry ❑ Pellets
Water gal.
Other
Type material PORTLAND CEMENT
Amount 8.5 GALLONS
9. EXPLAIN METHOD OF EMPLACEMENT OF MATERIAL:
TREMIE
in.
in.
10. WELL DIAGRAM : Draw a detailed sketch of theell on the back of this
form showing total depth, depth and diameter of screens (if any) remaining
in the well, gravel interval, intervals of casing perforations, and depths and
types of fill materials,sed
11. DATE WELL ABANDONED 12/18/12
I DO HEREBY CERT Y THAT THIS WELL WAS ABANDONED IN ACCORDANCE
WITH 15A NCAC WELL CONSTRUCTION STAN DS, AND THAT A COPY OF
4a. FACILITY - The name or the business where the well is located. Complete 4a; THIS RECORD V66 BEEN I�'d't8E13`iQ THE WE WNER.
(if a residential well, skip 4a; complete 4b, well owner information only.) �!1 �r��1111
FACILITY ID # (if applicable) 01/17/13
NAME OF FACILITY MAYMEAD ASPHALT PLANT SIGNAT E OF CERTIFIED WELL CONTRACTOR DATE
STREETADDRESS 164 BOSTIAN BRIDGE DRIVE
STATESVILLE NC 28677
City or Town State Zip Code
4b. CONTACT PERSONfWELL OWNER:
NAME NCDOT
STREET ADDRESS 114 BOSTIAN BRIDGE DRIVE STATESVILLE, NC 28677
SIGNATURE OF PRIVATE WELL OWNER ABANDONING THE WELL DATE
(The private well owner must bean Individual w ersonall bandons his/her residential well
in accordance with 15A NCAC 2C .0113.)
• _IAMFC 1-IFCS
PRINTED NAME OF PERSON ABANDONING THE WE LL
Form GW-30
Rev. 5/10

Application Reviewer:
Pre -Review: Conducted? Yes ❑ No
O.K. to Process?
Yes [ No � Ls
C�� �'�'✓
If No, What Action Is Needed? ElPre-ReviewReturn -�I
El Hold, Pending Receipt of Addinfo.: b r I
Name/Affiliation of Person Contacted: 2 W
.. r
_ 7
Lxisting Li Unknown 0mier Y e Non -Gov't YP I� (❑ Ind. or ❑ Org) ❑Gov. -Municipal
❑ Gov. -County Jr Gov. -State
❑ Gov. -Federal
Faci Regulated
Activities:
❑ Proposed Existing Facility
Regulated Activities; � 3 ®Operation
T�
App1_1 cati on/Permit:
Permit Type:
❑ Injection Water Only GSHP Well System (5QW)
❑ Injection Mixed Fluid GSHP Well System (5QM)
❑ Injection Tracer Well (5T)
Project Type: New ❑ Major Mod.
Notes:
Injection In situ Groundwater Remediation Well (5I)
❑ Injection Heating/Cooling Water Return Well (5A7)
❑ Injection Other Wells (5Z)
i_ � inje�.cu�i Aquner z�ecilu.be (�IZ21)
❑ Minor Mod. ❑ Renewal ❑ Renewal w/ Mod.
FORM: BIMS 10/04/2007

IN Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
1. Article Addressed to:
Sharon Ghiold
Former NCDOT Asphalt Testing Site #2-66
1557 Mail Service Center
Raleigh, NC 27699-1557
11111111111111111111111111111111111111111111111111
9590 9402 3665 7335 1548 66
2. Article Number (rransfer from service label)
7012 1640 0000 9792 3230
A. Signature
X ❑ Agent
❑ Addressee
B. Received by (Printed Name) Lp. Date of Delivery
D. Is delivery address different from item 1? ❑ Yes
If YES, enter delivery address below: ❑ No
3, Service Type
❑ Priority Mail Express®
❑ Adult Signature
❑ Registered MailTM
❑ Adult Signature Restricted Delivery
❑ Registered Mail Restricted
❑ Certified MaIIO
Delivery
❑ Certified Mail Restricted Delivery
❑ Return Receipt for
❑ Collect on Delivery
Merchandise
❑ Collect on Delivery Restricted Delivery
❑ Signature ConfirmationT
'-isured Mail
❑ Signature Confirmation
isured Mail Restricted Delivery
Restricted Delivery
)ver 5500)
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
i

USPS TRACKING 4 IIIIIIIIIIIIIIIIIUId
llllllllllllllllll
9590 9402 3665 7335 1548 66
United States
Postal Service
Co
First -Class Mail
Postage & Fees Paid
USPS
Permit No. G-10
0 Sender: Please print your name, address, and ZIP+40 in this box*
NCDEQ - DkVR
W' ,IN'T Quality Regional Operations Section
ATTN: SHRISTI SHRESTHA
1636 Nlail Servile Center
Raleigh, NC 2—/(,),
t, _)�,9_1636

o
(Domestic Mail Only; Provide
M
ru
For delivery information visit our website at www.uspsxonn�,
m
ru
Cr
r� Postage
$
Er
Certified Fee
0
Postmark
O Return Receipt Fee
Here
O (Endorsement Required)
M Restricted Delivery Fee
1:3 (Endorsement Required)
Total Postage
a Sent To Sharon Ghiold
ti Former NCDOT Asphalt Testing Site #2-66
C3 Sfreet,Apt No.; 1557 Mail Service Center
or PO Box No.
City state,ziP+: Raleigh, NC 27699-1557
PS Form :00 August 2006 See Reverse for Instructions

Certified Mail Provides:
■ A mailing receipt
■ A unique Identifier for your mailpiece
■ A record of delivery kept by the Postal Service for two years
important Reminders:
■ Certified Mail may ONLY be combined with First -Class Maile or Priority Mail®.
■ Certified Mail is not available for any class of international mail.
■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For
valuables, please consider Insured or Registered Mail.
■ For an additional fee, a Return Receipt may be requested to provide proof of
delivery. To obtain Return Receipt service, please complete and attach a Return
Receipt (PS Form 3811) to the article and add applicable postage to cover the
fee. Endorse mailpiece'Return Receipt Requested'. To receive a fee waiver for
a duplicate return receipt, a LISPS® postmark on your Certified Mail receipt is
required.
■ For an additional fee, delivery may be restricted to the addressee or
addressee's authorized agent. Advise the clerk or mark the mailpiece with the
endorsement "Restricted Delivery".
■ If a postmark on the Certified Mail receipt is desired, please present the arti-
cle at the post office for postmarking. If a postmark on the Certified Mail
receipt is not needed, detach and affix label with postage and mail.
IMPORTANT: Save this receipt and present it when making an inquiry..
PS Form 3800, August 2006 (Reverse) PSN 7530-02-000-9047