WI0100221_Electronic_File_20201105

s y = s NON RESIDENTIAL WELL CONSI'RUMON RECORD
North Carolina Department of Environment and Natural Resonrecs- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3307
1 , WELL CONTRACTOR: d. TOP OF CASING IS FT. Aboe Land Surface'
Tommy BOtyard 'Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .011 B.
Well Contractor ( Indi„idual) Name
Environmental Drilling 8 Probing Services, LLC (EDPS) Is. YIELD (gpm): METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Amount
STREET ADDRESS 17536 Greenhill Road g. WATER ZONES (depth):
From To From To
Charlotte NC 28278 From To From To
City or TOimn State Zip Code
70( 4 } 607 7529 From To From To
Area code- Phone number 6. CASING : Thidmessl
2. WELL INFORMATION: From 55.5 Depth 0 Ft Di�er WWW Material
SITE WELL ID #(H apphc ble) AS-1 rvV�C•
From To Ft.
STATE WELL PERMIT#(d applicable) From To Ft
DWO a OTHER PERMIT Mir applicable)
WELL USE Check (cable Box Montroi 7. GROUT: Depth Material Method
( al Ll ) ca Munnjecti Public ❑ From 53'5 To 51 .5 Ft Bentorute Tremle
IndustriaUCanmeraal ❑ Agricultural ❑ Recovery ❑ Injection ❑ From 51 .5 To""' Ft Grout Pump
Irrgationp Other 2) (list use) Arc Sparge
DATE DRILLED 12f30/13-t/IS/14 From To Ft
B. SCREEN: Depth Diameter Slat size Material
TIME COMPLETED AM ❑ PM ❑ From 58 To 55.5 Ft 2 la 0.01 in. PVC
3. WELL LOCATION: From TOI Ft in. _ in
CITY- tenor COUNTY From To Ft In. in.
1990 Connelly Springs Road, Lenior, NC
9, SAND/GRAVEL PACK:
(Brest Name. Numbers. Community, SubrSWsion, Lo! No., Parcel,'Zip Depth Site Material
TOPOGRAPHIC / LAND SETTING:
From 58 To 53.5 FL 1Y2rtled Sand
❑ Slope ❑ Valley ❑ Flat [] Ridge ® Other X
From To Ft
(check aPMWriate box)
LATITUDE 3 _
May be In degea, From To Ft.
minutes. ssrnds or 10. DRILLING LOG
LONGITUDE _ _ inadwmaltamdt From To Formation Description
Latitudeflongtude source: ❑ GPS ❑ Topographic map
(Aeration of "I must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY- K ma ,ate a me «. wn� m< wee R waned.
FACILITY ID #(if applicable)
NAME OF FACILITY Cajah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lenior NC
City or Twin State Zip Code
CONTACT PERSON Cary Ot Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 . REMARKS:
City or Twin State Zip Cade
F
Area code - Phone number
00 HEREBY CERTIFY IHATTRS WELL WAS 00MTRUCTED IN AtS� CCF OAN NTH
5. WELL DETAILS: 15n N c 2C,
a ' i wU - STRIjo` ON STuoMDS. a vT A COPY CF IM
TOTAL DEPTH: Ca+D oBEE*PR 0 owLL
1 /2CJ74
In. DOES WELL REPLACE EXISTING WELL? YES ❑ NO E SIGNATURE O D WELL CONT�LTOR DATE
c. WATER LEVEL BelrmiTop of Casing: FT o Mm H � Q�d-
(Use '+• If Abax Top of Casing) PRINTED NAME OF PERSON ONSTR TING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Form GW_1b
1617 Mail Service Center — Raleigh , NC 27 6 99-1 61 7 Phone No. (919) 7334015 ezt 568, Ron. 7/05

nArE ;
s ;•r NONRESIDENTIAL WELL CONSTRUCTION RECORD
h
t ' . ' -,I • px . North Carolina Department of Environment and Natural Resolsrces- Division of Water Quality
�`r • " � • d WELL CONTRACTOR CERTIFICATION # 3307
1 , WELL CONTRACTOR: d. TOP OF CASING IS FT. Above Land Surface
Tommy Bolyard 'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
Wen Contractor (Individual) Name
Environmental Drilling & Probing Services, LLC (EDPS) e. YIELD (gpm)� METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Amount
STREET ADDRESS 17538 Greenhill Road g. WATER ZONES (depth):
From To From To
Charlotte NC 28278
From To From To
City or Tarn State Zip Code
From To From To
7( O4 } 607 .7529
Area code- Phone number 6. CASING : ThiclmBss/
2. WFII INFORMATION: 5 Depth D FL Diameter WeioM Material
SITE WELL ID #p From 55. p
f applicable) AS-2
STATE WELL PERMIT#(i/ appNcable) From To Ft
From To Ft
DWQ or OTHER PERMIT #(If applicade) 7, GROUT : Depth Material Method
WELL USE (Check Applicable Box) Monitonng ❑ Muniapbl/PUNIC ❑
lidustrial/Commeraal ❑ Agricultural ❑ Recovery O Injection ❑ From 53. 5 To 51 . 5 Ft. Bentadte Trerrtie
IrTigatian❑ Oilier ® (fist use) Air Sparge
From 51 .5 T'fr — Ft Grout Pump
DATE DRILLED
12/30/13-1 /15/14 From Ta Ft
8, SCREEN: Depth Diameter Sld See Material
TIME COMPLETED AM ❑ PM ❑ From 58 To 55.5 Ft 2 in 0.01 in, PVC
3. WELL LOCATION: From To Ftin. _ in.
CITY Lenlor COUNTY From To Ft in. IR
1990 Connelly Springs Road, Lentor, NC
9. SANDJGRAVEL PACK :
(Street Name, Nrmbers, Community, Subd%ision, Lot No., Parcel, by Coda) Depth See Material
TOPOGRAPHIC / LAND SETTING: From 58 To 53.5 Ft #2rned Sand
❑Slope ❑ Valley ❑Fiat ❑ Ridge IsT Other X From To Ft
(deck appropriate box) From To Ft
LATITUDE May be in degre¢
mumtes. seconds a 10. DRILLING LOG
LONGITUDE ma decunnl format From To Formation Description
Latitude/longitudesauce: ciGPS ❑ Topographicmap
(bcatun of wet must be shown on a USGS topo map and
attached to this form it not using GPS)
4. FACILITY- is tna „ame d me cusk,� vme.e u, overt n wdtea.
FACILITY ID #(if applicable)
NAME OF FACILTY Cajah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Leruor NC
City a Town State To Code
CONTACT PERSON Cary Ot Company
MAIUNG ADDRESS 110 Mackenan Drive
Cary NC 11 . REMARKS:
City or Town State Zip Cade
Area code - Phone number
5. W EI I SAILS: I DO HEREBY CERTIFY THAT THS WELL WAS CONSTRUCTED IN ACCORDANCE W17H
1SA NCAC 2C, WELL CCdlSTRUCTIONI STANDARDS, AND THATA COPY OF m45
a. TOTAL DEPTH: 581 RECORD HAS BEEN P [HOED TO THE WELL MNPLn
V26114
h. ODES WELL REPLACE EXISTING WELL7 YES ❑ NO 91 SIGNATU IP D WELL CONTRACTOR DATE
a. WATER LEVEL Below Top of Casing: FT. TM N•1 U L'0 l Ada
(Use '+' if Above Top of Casing) PRINTED NAME OF PERSON tONSTRU TING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn : Information Mgt , Form GW-lb
1617 Mail Service Center — Raleigh , NC 27699-1617 Phone No. (919) 733-7015 ext 568. Rev. 7/05

`r 1 1 r ONRESLOENTL4L WELL CONSTRUCTION RECORD
s , n
Noah Carolina Department of Envvortmeot and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION k 3307
1 . WELL CONTRACTOR: d. TOP OF CASING IS FT. Above Land Surface
Tommy Bolyard 'Top of casing terminated alla belowland surface may require
Contractor ( IndiHdual) Name
a variance in accordance Y&h 15A NCAC 2C .0118.
We0
Environmental Drilling & Probing Services, LLC (EDPS) e. YIELD (gpm): METHOD OF TEST
Wdl Cmtractor Company Name f, DISINFECTION: Type Amount
STREET ADDRESS 17538 Greenhill Road g. WATER ZONES (depth):
From To From To
Charlotte NC 28278
From To From To
City a Town State Zip Code
701 4 1. 607 .7529 From. To Fran To
Area coda Phone number 6. CASING: TNclmess/
2, WELL INFORMATION: From 67"5 Depth 0 Ft Dir eta WeiDM Material
SITE WELL ID. #(if appGeable) AS-3 sch_4�
STATE WELL PERMIT da From To Ft
#( applicable) From To Ft
DWQ a OTHER PERMIT #(if applicable)
WELL 115E ( Check Applicable Bore) Monuonng ❑ MunidpaNPuhlic ❑
7. GROUT: Depth Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑ From 85. 5 To 83.5 Ft Bentaite Trenie.
IrrigatimO Other ® (Nst use) Air Sparge
From $3. 5 To""" Ft. Grout Pump
DATE DRILLED 12/30/13- 1/Li/I4 From To Ft.
8, SCREEN: Depth Diameter Stet Size Material
TIME COMPLETED AM ❑ PM Q From 90 To 87.5 Ft 2 in. 0.01 in. PVC
3• WELL LOCATION: From To Ft. in. _ in.
CITY Lenlor COUNTY From To Ft_in. in
1990 Connelly Springs Road, Lenlor, NC g, SANDIGRAVEL PACK :
(Street Name, Numbers, Community, SubdrmvDn, Lot No., Parcel, Zip Code)
Depth 5¢e Material
TOPOGRAPHIC / LAND SETTING: From 90 To 85.5 Ft 92med Sand
❑Slope ❑ Valley ❑ Flat ❑ Ridge R) Other X From To Ft
(d,eck appropnate box) From To Ft
LATITUDE 3 _ May be m dcgr i •
nurotes, s=owis or 10, DRILLING LOG
LONGITUDE _ _ ur a decimal format From To Formation Description
Latitude/longitudesource: ❑ GPS ❑ Topographic map
(bcatiwl of wel must be shown on a USGS topo map and
attached to this form 6not using GPS)
4. FACILITY- a me name ate wsmas caner, me w n m wc.tea.
FACILITY ID #(if applicable)
NAME OF FACILITY Calah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lenkx NC
City a Town State Zip Code
CONTACT PERSON Cary Oil Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 . REMARKS:
City a Town State Zip Code
Area code - Phone number
5. WELL DETAILS: 100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, MiE . CONSTRUC130N STANDAkM, AND THAT A COPY CF THIS
RECORD HAS a F1d PROVIDED 101HE NER.
a. TOTAL DEPTH: d
1/26114
lx DOESWELL REPLACE EIOSTING WELL? YES [INO ® SIGNATUj2 CERTIFIED WELL kdPNTRACTOR DATE
/ � , /
c, WATER LEVEL Below Top of Casing FT. tor✓Lrvll 3 1JakA
(Use '+' if Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Form GW-lb
1617 Mail Service Center — Raleigh , NC 276990617 Phone No . (919) 7334015 ext 568, Rev. 7105

nT
NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
b
WELL CONTRACTOR CERTIFICATION 4 M07
1 . WELL CONTRACTOR: d. TOP OF CASING IS FT. Above. two Surface
Tommy Bolyard 'Top of casing tern mated at/or heJaw land surface may require
a variance m accordance with 15A NCAC 2C . 0118.
Well Contractor ( Individual) Name
Environmental Drilling & Probing Services, LLC (EDPS) e. YIELD (gprn): METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Amount
STREET ADDRESS 175W Greenhill Road g. WATER ZONES (depth)_
From To From To
Charlotte NC 28278
City or Tw.n Stave Zip Code From To From To
From. To From To
7( 04 } 607.7529
Area coda Phone number 6. CASING : Thickness/
2 WELL INFORMATION: Frorr1 55.5 Depth efRh Diameter Weuo MataW
at
SITE WELL ID #(if applicable) AS-4 0 Ft sch:40
STATE WELL PERMIT#(i applicable) To Ft) From To Ft
DW Q a OTHER PERMIT #(if applicable) Method al
7, GROUT : Depth Material
WELL USE (Check Applicable Box) Monitoring [IMunicipal/Pubbc ❑ 53.5 To 51 .5 FL B Tremie
Industrial/Ccmmacial [IAgricuttural ❑ RecoveryO Injection ❑ From 51 �— Grout ImgationCl Other T (W use) Arc SParge From Tc Ft Puna
DATE DRILLED
12/30113-1/15/14 Fran To Ft.
8. SCREEN: Depth Diameter Slot Size Material
TIME COMPLETED AM ❑ PM ❑ From 58 To 55.5 FL 2 in 0.Of in. PVC
3. WELL LOCATION: Fran To Ft�in. _ in
CITY. Lena COUNTY From To Ft�in. _ in.
1990 Connelly Springs Road, Lenim, NC
9, SANDIG PACK :
(Brest Name, Nunbers, Community, Subdivision, Lot No. , Parcel, Zip Code)
Depth 5¢e Material
TOPOGRAPHIC / LAND SETTING. From 58 To 53,5 Ft #2med Send
❑ Slope ❑ Valley ❑ Flat ❑ Ridge © Other X From To R.
(check appropriate bey)
LATITUDE 3 May be ms e em, From Tc Ft.`_
mvmtes. �nds « 10. DRILLING LOG
LONGITUDE ma decimal tunnat From To Formation Description
Latitude/longitude source ❑ GPS ❑ Topographic map _
(bcaton of "I must be shown on a USGS topo map and
attached to this form A not using GPS)
4. FACILITY- : u,e e.me or me cu.m wk me wet R gym.
FACILITY ID #(if applicable)
NAME OF FACILITY Calah's Mountain Superefte
STREET ADDRESS 1990 Connelly Springs Road
Lanka NC
City or Toxr1 State Zip Code
CONTACT PERSON Cary Oil Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 , REMARKS:
City or ToAn State Zip Cade
Area code - Phone number
S. WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE W11H
15A NCAC 2C2 WELL CONSTRUCTION STANDARDS, AND THATA COPY OF THIS
58, RE.CORD HAS BE R ED E ni
a TOTAL DEPTH:
f2fi/14
In, DOES WELL REPLACE EXISTMG WELL? YES ❑ NO ® SIGNATURE RTIFIED WFd l Oa R TOR DATE
c. WATER LEVEL Below Top of Casing: FT. /Cq ^2m `i & `d/ya�
(Use '+° if Abo✓e Top of Casing) PRINTED NAME OF PERSONCONS R CTIN11� G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: 4hformation Mgt, Form GW-1b
1617 Mail Service Center — Raleigh , NC 27699.1617 Phone No, (919) 7334015 eut 568. Rev_ 7tO5

r NONRESIDENTIAL WELL, CONSTRUCTION RECORD
sP North Carolina Department of Environment and Naf ual Resources- Division of Water Quality
�d WELL CONTRACTOR CERTIFICATTON 4 3307
1 . WELL CONTRACTOR: d.. TOP OF CASING IS FT. Above Land Surface'
Tommy Bogard • p of casing terminated
ermil accordance with 1 � rface 2C . 0119. rei
a
Well Contractor ( Individual) Name
Environmental Drilling & Probing Services, LLC (EDPS) e. YIELD (gpm): METHOD OF TEST
Weil Contracts Company Name I. DISINFECTION: Type Amount
STREET ADDRESS
17538 Greenhill Road g• WATER ZONES (depth):
From To From To
Charlotte NO 28278
From To From To
Clty or Town State Zip Code From To From To
704 } 607,7529
Area code- Phone number 6. CASING: Thickness/
2, WELL INFORMATION: Depth Diameter W �( at
SITE WELL ID #(8 appfcabk) AS-5 From 92. 5 To 0 Ft 20 SPA W
STATE WELL PERMIT#(rt appNcaNe) Fran To Ft
From To Ft
DWO. or OTHER PERMIT #(if applicable) 7. GROUT: Depth Material Method
WELL USE (Check Applicable Box) Monitoring ElMmidpallPublic ❑
From 90.5 To 88.5 Ft Bentanite Tremie
Ir dung flonE]eret ❑ Agricultural ❑ RecoveryO Injection ❑ Fran 88. 5 Tom- Ft Grout Pump
Irrigadm❑ Other ® (fist use) Air Spurge
From To Ft
DATE IX2ILLE0 12J30/13-1/15/ I4
8, SCREEN: Depth Diameter Sid Size Material
TIME COMPLETED AM ❑ PM ❑ From 95 To 92.5 Ft 2 in. 0.01 is PVC
3. WELL LOCATION: From To Ft. n._in. i
CITY.- Lenbr COUNTY From Ta Ft_in. in
1990 Connelly Springs Road, Lemor, NO 9, SANDIGRAVEL PACK:
(Street Name. Numbers, Community, Subdimsion. Lot No.. Parcel, Zip Code) Depth Size Material
TOPOGRAPHIC / LAND SETTING: From 95 To 90.5 Ft. #2med Send
❑ Slope ❑ Valley ❑ Flat ❑ Ridge 91 Other From To FL
(check appropriate box) From To Ft.
LATITUDE
r"'m'tes, sec°"ds "r 10. DRILLING LOG
LONGITUDE 'anadaunattbnnm From To Formation Description
Latitude/longitudesotuce: ❑ GPS ❑ Topographic map
(braton of wee must be shown a a USGS topo map and
attached to this form # not using GPS)
4. FACILITY- ;. me �,me a ma ewn� wrier, u,e wee warm ,
FACILITY ID #(if applicable)
NAME OF FACILITY Cajah's Mountain Superette
STREET ADDRESS 1990 Connelky Springs Road
Lenior NC
City or Town State Zip Cade
CONTACT PERSON Cary Oil Company
MAILING ADDRESS 110 Mackenan Ddve
Cary NC 11 . REMARKS:
City a Town State Zip Code
Area code - Phone number
S. WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS ¢ONSTRt1CTEO 14 ACCORDANCE WITH
I NCAC ]C, WELL CCNSTRI 0114 STANDMIDS, MID THAT A COPY 11FT
a TOTAL DEPTH: 95' RECORD Hss7
�// .�'��ii%I / / 1f26114
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® r
SIGNATUPWQFTIFIRbWEIL LONTRACfOR DATE
c. WATER LEVEL Below Top of Casing: FT. B0 ak'j
�G rH1Y✓ N
(Use •+• R Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn : Information Mgt, Form GW-1b
1617 Mail Service Center — Raleigh , NC 27699-1617 Phone No , (919) 7334015 ext 568. Rev. 7/05

�r.>r
NONRESIDENTIAL WELL CONSTRUCTION RECORD
s`
North Carolina Department of Environment and Natural Resources- Division of Water Quality
ka �r WELL CONTRACTOR CERTIFICATION H 3307
'I . WELL CONTRACTOR: d. TOP OF CASING IS FT. Above Land Surface
Tommy Bolyard `Top of casing terminated altior below lard surface may require
a variance in accordance With 15A NCAC 2C .0118.
Well Contractor (Individual) Name
Environmental Drilling & Probing Services, ULC (EDPS) e. YIELD (gpm): METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Amount
STREET ADDRESS 11538 Greenhill Read g. WATER ZONES (depth):
From To From To
Charlotte NC 28278 From To Fran To
City or Tovn Stele Zip Code
7( 04 } 607 ,7529 From T❑ Fram To
Area code- Phone number 6. CASING : ThiGmessi
2. WELL INFORMATION: From 77.5 Depth To 0 Ft Diameter20 W�gg� rIC Material
SITE WELL ID #3(HappGwde) ASS
STATE WELL PERMIT rf a From To Ft
#( applicable) From To Ft.
DWQ or OTHER PERMIT #(it applicable)
WELL USE (Check Applicable Box) Monitoring ❑ MunicipalfPublic E 7, GROUT: Depth Material Method
From 75.5 To. 73.5 Ft. Bentonite Tremie
Industrial/Commercial ❑ Agricultural ❑ Recovery E Injection ❑ From 73.5 Tp—� Ft G P MP
Irrigation❑ Other 91 (list use) Air Sparge
To. Ft.
DATE DRILLED 12/30/I3-1/15/14 From
a. SCREEN: Depth Diameter Slit Sae Material
TIME COMPLETED AM ❑ PM ❑ 80 77.5 2 0.01 PVC
From To Ft. in.
3. WELL LOCATION: From To Ft_in. _ in.
CITY: Lenior COUNTY Fram To Ft in. _ im
1990 Connelly Springs Road, Lemon, NC 9., SANDIGRAVEL PACK '
(Street Name, Numbers, Community, SubdrNsion, Lot No., Parcel, Zip Code) Depth Sae Material
TOPOGRAPHIC I LAND SETTING: From 80 To 75.5 Ft. 92rted Sand
❑ Stope EValley [I Flat ❑ Ridge 91 Other x From To Ft
(olhe k appropnate box)
LATITUDE
1,Taahe m degras. From To Ft.
ram. xro its or 10. DRILLING LOG
LONGITUDE _ _ in adairnW format From To Formation Description
Latitude/longitude solace: ❑ GPS ❑ Topographic map
(bcabon of wet must be shown on a USGS topo map and
attached to this form i/ not using GPS)
4. FACILITY- m ine name a one m as wnere me w m eaed .
FACILITY ID #(if applicable)
NAME OF FACILITY Cajah'S Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lerror NC
City or Torn State Zip Code
CONTACT PERSON Cary Od Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 , REMARKS:
City or Town State Zip Code
(
Area code - Phone number
DO HEREBY CERTIFY THAT T45 WELL WAS CCNSTRUCTEON ACCORDANCE Wr[H
5. WELL DETAILS : 1 SA NDAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF R4S
a. TOTAL DEPTH: AS�, RECORD H MENP TO TH
E HE WELL UNDER.
lfzr>t1a
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 91 SIGNATURE/ C TIFIED WELL 11514TRAt6TOR DATE
c. WATER LEVEL BelmTop of Casing: FT.
(Use '+• if Above Top of Casing) PRINTED NAME. OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Form GW-1b
1617 Mail Service Center — Raleigh , NC 2711 Phone No . (919) 733=7015 ext 56& Rev. 7105

s
r ' NONRESIDENTIAL WELL. CONSMUCTION RECORD
Noah Carolina Department of F_nvvonment and Natural Resources- Division of Water Quality
a WELL CONTRACTOR CERTIFICATION 4 3307
1 . WELL CONTRACTOR: d. TOP OF CASING IS FT. Above Land Surface'
Tommy Bdyard 'Top of casing terminated at/or below lad surface may require
a variance in accordance oath 15A NCAC 2C . 0118.
Wdl Contractor (Indndual) Name
Environmental Drilling & Probing Services, LLC (EDPS) a YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount
Wen Contractor Comfy Name
STREET ADDRESS 175M Greenhill Road 9• WATER ZONES (depth):
From To From To
Chariotte NC 28278 From To FronrL. To
City or Town State Zip Code
From TO Ram To
70( 4 } 617 . 7529
Area code- Phone number 6. CASING: Thidmess/
Z WELL INFORMATION: From 47.5 Depth 0 Ft Di
�stet W�g MPvc
allimal
SFFE W ELL ID #(ir applicable) AS-7 To
From To. Ft.
STATE WELL PERMIT#Crf applicable) From To Ft.
DWO or OTHER PERMIT #(if applicable)
WE USE (Check Applicable Box) Monftoring ElMunicipal/Public ❑ 7 GROl1 Depth Material method4 5
LL
IrdushiaUCommercial [I Agricultural ❑ Recovery (.3 Injection 11 From 5.5 Tc 43.5 Ft 9entanRe TrerMe
Irrigation❑ Other XI (W use) Av Sparge
From 43.5 T J� Ft Grout Pump
From To Ft.
DATE DRILLED 12/30/13-1/15/14
8, SCREEN: Depth Diameter Slat Sae Material
TIME COMPLETED AM ❑ PM ❑ From 50 To 47.5 EL 2 in. O.oi in. PVC
3. WELL LOCATION: From To Ft in. in
CITY. Lenlor COUNTY From To Ft.in. in.
1990 Connelly Springs Road, Lenity, NC 9, SAND/GRAVEL PACK:
(Weer Name, Nu berg, Community, Subdivision., Lot No., Parcel. Zip Code) Dew Stze Material
TOPOGRAPHIC / LAND SETTING: From 50 To 45.5 Ft. #2med Sand
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ID OtherX From To Ft
(check appropriate box) From To Ft,
LATITUDE 3 — NJgnuun �coiers,
n
�, ' iR` or 10. DRILLING LOG
LONGITUDE in a deam.d lom'at From To Formation Description
LatitudeAcingitudesotuce: ❑ GPS ❑ Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not Using GPS)
4. FACILfTY- � ma name a n,e eusinaawnera me weu k wUrm.
FACILITY ID iltif applicable)
NAME OF FACILITY Cajah's Mountain Superatte
STREET ADDRESS 1990 Connelly Springs Road
Lenor NC
City a Twin State Zip Code
CONTACT PERSON C01Y OB Company
MAIUNG ADDRESS 11O Mackenan Drive
Cary NC 11 . REMARKS:
City or Town .State Zip Code
Area code - Phone number
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRIICTEDIN ACGWDPNCE WITH
5. WELL DETAILS: IM NCAC 2C4 WELL CqNSTRUCTION STANDARDS, AND THATA COPY OF trss
RECORD HAS BEE D THE LL OWNER.
a TOTAL DEPTH: 1r2H14
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO91 SIGNATURE WELL CON AQ R DATE
ofc. WATER LEVEL Belau Top Casing: FT. / N41,� D Qtj
(Use'+ H Above Top of Casing) PRINTED NAME OF PERSON CO TRUCTI G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Form GW-1b
1617 Mail Service Center — Raleigh , NC 27699-1617 Phone No, (9191 733.7015 ext 568. Rev. 7MS

c*� NONRESIDENTIAL WELL. CONSTRUCTION RECOIRD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
`16 ar WELL CONTRACTOR CERTIFICATION H 3307
1 . WELL CONTRACTOR: d, TOP OF CASING IS FT. Above Land Surface'
Tommy Botyard 'Top of casing terminated aQ/or balm land surface may require
Well Contractor ( Indiidual) Name
a variance in accordance with 15A NCAC 2C .0118.
Environmental Drilling 8 Probing Services, LLC (FOPS) e. YIELD (gpm). METHOD OF TEST
Wdl Contractor Company Name I. DISINFECTION: Type Amount
STREET ADDRESS
17538 Greenhill Road g. WATER ZONES (depth):
From To From To
Charlotte NC 28278
City or Torn State Zip Code Frain To From To
7( 04 }.807 7529 From To From To
Area code- Phme number 6, CASING : Thiclmess/
Z WELL INFORMATION: 47. 5 Depth 0 Diarnetc WttinM Material
From
SITE WELL ID #tH applicable) AS-8 Ft 2- scn_40 PVC
From To Ft
STATE WELL PERMIT#(d applicable) From To R. ~_
DW Q or OTHER PERMIT #(if applicable)
7. GROUT : Depth Material Method
WELL USE (Check Applicable Box) Monitoring ❑. MunicypallF'udic ❑ From 455 To 43.5 FL Bdnbnite Trerrtie
Industrial/Commerclal D Agricultural ❑ Recovery ElIn m .
)ecO ❑ From 4 5 To—� Ft. G , to Pump
InigationO Other n (lest use) Air Sparge
GATE DRILLED
12/30/13-1/15114 From Tc Ft.�
B. SCREEN: Depth Diameter Skt Sae Maternal
TIME COMPLETED AM ❑ PM ❑ 50 47.5 2 0.01 PVC
From To Ft in. in.
3, WELL LOCATION: From . To. Fti_in. in.
CITY: Lenior COUNTY From To Ftin. _ in.
1990 Connelly Springs Road, Lenior, NC 9, SAND/GRAVEL PACK:
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code) Depth Sae Material
TOPOGRAPHIC / LAND SETTING: From 50 To 45.5 Ft #2med Sand
❑ Slope ❑ Valley ❑ Flat ❑ Ridge IL OtherX From To Ft
(check appropriate box),
be in deer From . To Ft.__
LATITUDE _ -
tes. scond, °r 10. DRILLING LOG
LONGITUDE _ _ Fm ,rdWtm;>! la),mat From To Formation Description
latitude/longitude source: ❑ GPS ❑ Topographic rnap
(location of wet must be shown on a USGS topo map and
attached to this form it not using GPS)
4. FACILITY- . the mme a me uwmcae .mere the weli m located.
FACILITY ID kif applicable)
NAME OF FACILITY Cajah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lenlcr NC _
City a Town State Zip Code
CONTACT PERSON Cary Oil Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 , REMARKS:
City or Town State Zip Code
I Area code - Phone number
I DO HEREBY CER71FY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE Wm1
5. WELL DETAILS: 15ANCAC2C, WE s"RO S �V ar ins
oARDs. ANDTHATACa
�, RECORD HAS BE PR OED
a TOTAL DEPTH; 126H4
b. DOES WELL REPLACE EXISTING WELL7 YES ❑ NOR] SIGNATURE OF f2 IFIED WELL CONTRA TOR DATE
c. WATER LEVEL Below Top of Casing: FT..
(Use '+' H Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days, Attu: Information Mgt, Form GW_1b
1617Mail Service Center - Raleigh , NC 27699-1617 Phone No. i919i 733-7015 ext 568, R v 7105

_ Sf4rI., � T D �
r 1 r ONR SIDENTIAL WELL CONSTRUCTION RECORD
3 `p�gF ^ S i
S 3 North Carolina Department of Environment and Natural Resources- Division of Water Quality
� : k. . � WELL CONTRACTOR CERTIFICATION 4 3307
1 . WELL CONTRACTOR: d. TOP OF CASING IS FT. Above Land Surface
Tommy Bolyard 'Top of casing terminated aVa land surface may require
a variance in accordance vith 15A NCAC 2C .0118.
Wall Contractor (Indmdual) Name
Environmental Drilling & Probing Services, LLC (EDPS) e. YIELD (gpm): METHOD OF TEST
Well Contractor Canpany Name f. DISINFECTION: Type Amount
STREET ADDRESS 17538 Greenhill Road g. WATER ZONES (depth):
From. To From To
Chadotte NC 28278 Fran To From To
City orToAfl State Tip Code
From To From To
704 } 607 .7529
Area coda Phone number 6. CASING : Thickness/
2. WELL INFORMATION : Depth Difneter Weght al
SITE WELL ID #(da ble AS-9. From 69.5 To 0 Ft sr#r:40 • C
��� ) Fran To Ft.
STATE WELL PERMiT#(AappNcable) From TO Ft
DW O or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Baer) Montoring ❑ MunicipaltPuaic ❑ 7. GROUT: Depth Material Method
From 6T5 To 65.5 Ft Beratinhe Trerrie
IndusinaVCanmercial ❑ Agricultural ❑ Recovery ❑ Injectlm [I From
65.5 Tom— Fl Gr 'nq R
Irrigation[] Other EJ ( W use) Air Sparge
From To Ft
DATE DRILLED 12/3 011 3-1/1 5/1 4
8, SCREEN: Depth Diameter Sid Size Material
TIME COMPLETED AM ❑ PM [] From 72 To 69.5 Ft 2 in. 0,01 in PVC
3. W EI_l. LOCATION: From TD Ft_in. in.
CRY Lena COUNTY From To Ftin. in.
1990 Connelly Springs Road, Lenfot NC 9. SANDIGRAVEL PACK:
(Street Name, Nunbers, Community, Subdlusion, Lot No., Parcel, Code) Depth Size Material
TOPOGRAPHIC / LAND SETTING: From 72 To 67.5
Ft #tined Sand
❑ Slope [] Valley ❑ Flat ❑ Ridge 91 Other
From To Ft
(check appropriate box) From To Ft.
LATITUDE 3 May be m depreca'
rN les. scunuLs x 10. DRILLING LOG
LONGITUDE _ _ in a dmirnal turmat From To Formation Description
latitude/longitudesource. ❑ GPS ❑ Topographic map
(bcation of we/ must be shown on a USGS topo m P and
attached to this form it not using CPS)
4. FACILITY. s the „emu a the n n� where the wen is kicated_
FACILITY ID #(if applicable)
NAME OF FACILITY Cajah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lenior NC
City or Tmn State Zip Code
CONTACT PERSON Cary Oil Company
MAILING ADDRESS 110 Mackenan Drive
Cary NO 11 . REMARKS:
City a Tmvn State Zip Code
Area code - Phme number
I DO HEREBY OERTFY THAT DiS WELL WAS CONSTRUCTED M ACCORDANCE WrlH
S. WELL DETAILS: 1 S NcAo zc, we�L coNs non srANoraos. Al+o nun A cF iris
a TOTAL DEPTH: 72' RECORD HAS seENRR a nrt MXL owNeR.
1/26114
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® SIGNATURE OF TI I ELL CT/O DATE
c. WATER LEVEL Beim Top d Casing: FT , In yi �BU�lQ2�
(Use `+' if Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTINU THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attu: Information Mgt., For GW-1b
1617 Mail Service Center — Raleigh , NC 27699A617 Phone No, (919) 7334015 ext 569, Rev. 7105

nAn ,
N =r NON ONRESIDENTW WELL CONSTRUCTION RECORD
S
- North Carolina Departm on( of EnNironri and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION H 3307
1 . WELL CONTRACTOR: d. TOP OF CASING IS FT. Above (and Surface
Tommy Bofyard 'Tap of casing terminated allot below land surface may require
a variance in accordance vith 15A, NCAC 2C . 011 &
Well Contractor ( Individual) Name
Environmental Drilling & Probing Servlces, LLC (EDPS) e. YIELD (gprn)t METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Arnount
STREET ADDRESS 17538 Greenhill Road g. WATER ZONES (depth):
Charlotte NC 28278 From To From To
City or Town Stale Lip Cade From. To From To
704 y 607 7529 Fran To. Fram To
Area code- Phone number 6. CASING: Thiclmessl
2. WELL INFORMATION: From 57 5 Depth 0 FL Diameter W Manorial
SITE WELL ID #W applicable) AS-10 WC
STATE WELL PERMIT#(A applicable) From To Ft
From To Ft
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitmng ❑ Municipal/pUblic ❑ 7, GROUT: Depth Material Method
Industrial/Commercial ❑ Agncuttural ❑ Recovery ❑ Injection ❑
From 55.5 To 53.5 Ft Bantonite Tpenye
Irrigabonp Other M ( list use) Air Sparge From 53.5 Tom— Ft. Grout Pump
DATE DRILLED
12/30/13-1/I5p4 From To Ft
8. SCREEN: Depth Diameter Slat Size Material
TIME COMPLETED AM ❑ PM From 60 To. 57.5 Ft 2 in. 0.01 in, PVC
3. WELL LOCATION: From Ta Ft in. in.
CRY: Lenior COUNTY from To. Ft�in. _ in.
19W Connelly Springs Road, Lenior, NC 9, SANDlGRAVEL PACK :
(Sheet Name, Number, Community, Subdivision, Lot No. , Parcel, Zip Code) Depth Size Material
TOPOGRAPHIC 1 LAND SETTING:
❑ Slope ❑ Vailey El Fla El Ridge ID OtherX From 80 To 55.5 Ft #2med Sand
(check appropriate box) From To Ft
May be in degrees From To Ft
LATITUDE 3 _ °
m161te`, '9COLds "` 10. DRILLING LOG
LONGITUDE _ _ in admimal Immat From To Formation Description
Latitude/longitudesonace: ❑ GPS ❑ Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form if not using CPS)
4. FACILITY. is the mina err me easiness where me wea is w ted.
FACILITY ID #(if applicable) .
NAME OF FACILITY Cajah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lector NC
City or Town State Zip Code
CONTACT PERSON Cary 00 Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 , REMARKS:
City or Town state Zip Code
Area code • Phone number
S. WELL DETAILS: 100 HEREBY CERTIY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2c, WE CCt15TRUCTION STANflARDS, A THAT A COPYOFills
60, RECORD HAS B PROVIDED TD THE WELL QINER.
a TOTAL DEPTH: 126/14
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO ® SIGNA E OF .2 TIFIED CO TOR DATE
c WATER LEVEL Below Top of Casing: FT. L �m
(Use '+' if Above Top of Casing) PRIMED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Farm GW-1b
1617 Mail Service Center — Raleigh , NC 27649-1617 Phone No . (919) 733-7015 ext 568, Rev 7/05

r ` NONRESIDENTIAL WELL CONSTRIIM0NRECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
I
WELL CONTRACTOR CERTIFICATION # 3307
1 . WELL CONTRACTOR : d. TOP OF CASING IS FT. Abooe Land Surface`
Tommy Bogard 'Top of casing terminated ado belm land surface may require
a variance in accordance Mh 1SA NCAC 2C . 0118.
Well Contractor ( Indmdual� Name
Environmental Drilling & Probing Services, LLC (EOPS) e. YIELD (gprm) METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Amount
STREET ADDRESS 17538 Greenhill Road g• WATER ZONES (depth):
Charlotte NC 28278 From To From To
Fran To Fran To
City orTuu1 State Zip Code
704 } 6077529
From To. From To
Area code- Phone number 6. CASING : Thidalessf
2, WELL INFORMATION: Depth Diameter Wr a Matriial
SITE WELL ID #(if applicable) AS- 11 From 72.5 To 0 Ft Y PVC
From To Ft
STATE WELL PERMIT#(m applicable) From To Ft
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box.) Monitoring ❑ MuniciPat Public. ❑ 71 GROUT : Depth Material Method
Industriad/Commerciai ❑ Agricultural ❑ Recovery ❑ Injection ❑. From 70.5 To 68-5 FL Bentonite Tremie
Inigaton❑ Other ® ( list use) Air Sparge
From 68.5 Tom FL Gran Pump
From To Ft.
DATE DRILLED 12/30/13-1/15/14
8, SCREEN: Depth Diameter Slat Size Material
TIME COMPLETED AM ❑ PM ❑ From 75 To 72. 5 Ft 2 in 0.01 in, PVC
3. WELL LOCATION: From Ta Ft_in, in
CITY Lenior COUNTY From To Ft in. in.
1990 Connelly Springs Road, Lanior, NC
9. SANDfGpth PACK:
(Street Name, Numbers, Community, Subdi.ision, Lot No., Parcd, 7'p Code) Deem Size Material
TOPOGRAPHIC / LAND SETTING. From 75 To 70.5 Ft #2med Sand
❑ Slope ❑ Valley ❑ Flat ❑ Ridge ® OtherX From To Ft
(check appropriate box) From To Ft.
LATITUDE 3 _ May be in degrees,
minutes, s onds a 10. DRILLING LOG
LONGITUDE _ _ inad? anal tormat From To Formation Description
LatitudeAongitudesource: ❑ GPS ❑ Topographic map
(bcation of "I must be shown on a USGS topo map and
attached to this form it rid using GPS)
4. FACILITY- is u.e na,oe a me n oess wneee the wen is woared.
FACILITY ID #(if applicable)
NAME OF FACILITY Ca)ah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lenty NC
City or Tmvm State Zip Code
CONTACT PERSON Cary Oa Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 , REMARKS:
City or Toe en State Zip Code
Area code - Phone number
5. WELL DETAILS: I DO HEREBY CER71FY THAT THIS WELL WAS CONSTRUCTED IN AanMANCE WITH
1 SA NCAC 2C, WELL
a TOTAL DEPTH: 75' necoRo rtes eaa [:OILST/IiII ON STANDARDS, AND TIAt A COPY OF 1lLS
ee1`T7Ttl\
h. DOES WELL REPLACE EXISTING WELL2 YES [I NO ri 1126114
SIGNATURE OF IFIED WELL CONTRACTCR DATE
c. WATER LEVEL Blow Top of Casing: FT. a1Q /(tl-
(Use,•+ if Above Top of Casing) PRINTED NAME OF PERSON CONSTRUCTING THE WFI I
Submit the original to the Division of Water Quality within 30 days. Attn : Information Mgt, Form GW-1b
1617 Mail Service Center . Raleigh , NC 276 99-1 61 7 Phone No. (919) 733-7015 ext 568. Ron. 7105

R ;
r: J 1 s 1 V ONRE,SIDENTUL WELL CONSTRUCTION RECORD
5 North Carolina Department of Environment and Natural Resources- Division of Water Quality
s
WELL CONTRACTOR CERTIFICATION 4 3307
1 . WELL CONTRACTOR: d. TOP OF CASING IS FT. Abow Land Surface
Tommy Bolyard 'Top of casing terminated allay belwi land surface may require
a Variance in accordance wdh 15A. NCAC 2C .0118.
Well CaRractor ( IndrAdual) Name
Environmental Drilling 8 Probing Services, LLC (EDPS) e. YIELD (gpm): METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Amount
STREET ADDRESS
17538 Greenhill Road g• WATER ZONES (depth):
From To From To
Charlotte NC 28278 From To From To
City or Tovn State Zip Code
7 � 607,7529( Oq From To From To
Area code- Phone number 6. CASING : Thericokhntess/
2. WELL INFORMATION: From 62.5 Depth 0 Ft Di7 erer eOh'40 Material
VC el
SITE WELL ID #(if appficable) AS-12
STATE WELL PERMIT#fd applicable) To. Ft') From To Ft
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) MonRaing ❑ Municipal/Pudic ❑
7. GROUT : Depth Material Method
Industrial/Commercial ❑ Agricultural ❑ Recovery [I Injection ❑
From 60. 5 To 58.5 Ft Benton@e Tremle
Irrigation❑ Other ® (Nst use) Air SPar9e
From 58.5 Tom Ft' Grout Pump
DATE DRILLED
12/30/13-1115/ 14 From To Ft
B. SCREEN: Depth Diameter Slat 5¢e Material
TIME COMPLETED AM ❑ PM ❑ Fran 65 To 62.5 Ft 2 in. 0.01 In PVC
3. WELL LOCATION: From . To Ft in. _ in.
CITY Lenox COUNTY From To Ft in _ in.
1990 Connelly Springs Road, Lenior, NC 9., SANDIGRAVEL PACK :
(Street Name, Numbers, Community, Subdivslon, Lot No., Parcel, Zip Code) Depth Size Material
TOPOGRAPHIC / LAND SETTING: From 65 70 60.5 Ft 92med Sand
❑Slope ❑ Valley ❑ Flat ❑ Ridge ® OtherX From To Ft
(check appropriate box)
Y
L 3 From T o Fr
-
LATITUDE
Res, s"""d'z or 1n. DRILUNG LOG
LONGITUDE _ _ ,na a«,,mat rbnaal From To Formation Description
latitudeAcingitude sotuce: ❑ GPS ❑ Topographic map
(location of wel must be shown on a USGS topo map and
attached to this form if not using GPS)
4. FACILITY. is mr, nerve a u,e one we me was ie brim.
FACILITY ID #(if applicable)
NAME OF FACILITY Calah's Mountain Superette
STREET ADDRESS 1990 Connelty Springs Road
Lenox NC
City a Town State Zip Code
CONTACT PERSON Cary Oil Company
MAJLUNG ADDRESS 110 Mackenan Drive
Cary NC 11 . REMARKS:
City a Town State Zip Cade
I }
Area code - Phone number
5, WELL DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W ACCORDANCE WITH
1 SA NCAC 20, WELL g0lZTRUCTION STANDARDS, AND THAT A COPY OF ILS
a TOTAL DEPTH: 65' RECORD HAS BE. ROv1DED T E WELL OWNER.
h. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 91 1/26/14
SIGNATUR " FF CAE TIFIED h L / RACTOR DATE
c. WATER LEVEL Below Top of Casing: FT. `�
(Use '+' d Above Top of Casing) PRINTED NAME OF PERSON' CONSTRUCTING THE WELL
Submit the original to the Division of Water Duality within 30 days. Attn : Information Mgt, Form GW-1b
1617 Mail Service Center — Raleigh , NC 27 6 9 9-1 61 7 Phone No . (919) 733-7015 ext 568. Rye 7105

k'= NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of FinNitomnent and Natural Resources- Division of Water Quality
« WELL CONTRACTOR CERTIFICATION 11 3307
1. WELL CONTRACTOR: d, TOP OF CASING IS FT. Aba+e Land Surface
Tommy Botyam 'Top of casing terminated Wor belnwland surface may require
We Contractor ( Indimduai) Name a vanance in accordance With 15A NCAC 2C .0118.
Environmental Drilling a Probing Services, LLC (EDPS) a YIELD (gpm): METHOD OF TEST
Well Contractor Company Name f, DISINFECTION: Type Amount
STREET ADDRESS 17538 Greenhill Road g• WATER ZONES (depth):
From To From To
Charlotte NC 28278 From To From To
City a Town .State Zip Code
From To From To
7704 1- 607 . 7529
Area code- Phone number 6. CASING : Thickness!
2. WELL INFORMATION: Depth Diameter W
Material
SITE WELL ID An applicable)
AS- 13 From 62.5 To 0 Ft r NO PVC
From To FL
STATE WELL PERMIT#Cif applicable)
From To FL
DINO Or OTHER PERMIT #(If applicable)
p
WELL USE (Check Applicable Bar) Monrtonng ❑ Municipal/Public 7 GROIfT: Depth Material MAhod
Industrial/Commercial ❑ Agricultural ❑ Recavay ❑ Injection ❑. From 60.5 To 5&5 Ft. Bentonite Tremie
Air S are From 58.5 To—� Ft Grout
IrrigAion❑ Other ® (Nst use) P 9
From To Ft
DATE DRILLED L2730/13-1/l5/lA
8. SCREEN: Depth Diameter Shot Size Material
TIME COMPLETED AM ❑ PM ❑ From To 65 62.5 Ft in. in.2 0.01 PVC
_ _
3, WELL LOCATION: From To Ft in. _ In
CITY: Lenior COUNTY From To. Ft_in. in.
1990 Connelly Springs Road, Lenior, NC 9. SAND)GRAVEL PACK:
(Street Name, Nunbem, Community, Subdi%ision, Lot No., Parcel, Zip Code) Depth Size Material
TOPOGRAPHIC / LAND SETTING: From 65 To 60.5 Ft, #2med Sand
[] Slope ❑ Valley ❑ Flat ❑ Ridge ®Other X Fran Tc Ft
(check appropriate box)
y be in degr� From To Ft.
LATITUDE 3 _ muartes seconds or
10, DRILLING LOG
LONGITUDE _ _ in a decimal formal From To Formation Description
LatitudeAongitude source: ❑ GPS ❑Topographictnap
(location of wen must be shown on a USES topo map and
attached to this firm d not using GPS)
4. FACILITY- is a came a ffie evainess whe.e ue wee is Fred.
FACILITY ID #(if applicable)
NAME OF FACILITY Cajah's Mountain Supefette
STREET ADDRESS 1990 Connelly Springs Road
Lenior NC
City or Town State Zip Code
CONTACT PERSON Gary Otl Company
MAJUNG ADDRESS 110 Mackeaan Done
Cary NC 11 , REMARKS:
City or Town State Zip Code
Area code - Phone number
I DO HEREBY cERTFy THAT THs WELL WAS ccNsTRUC1ED IN ACCORDANCE WITH
5. WELL DETAILS: I SA rrcac 2C, WELL cDN9TRucTION STANDARDS, AND THATA C07Y dF IM
65' RECORD HAS aE B D
a. TOTAL DEPTH: 1/26114
b. DOES WELL REPLACE EXISTING WELL? YES Li NO 91 SIGNATURE Q R�TTIFIED W L C1'O�NT CTOR DATE
c. WATER LEVEL BeiowTop of Casing- FT . `� /p 'M' 13D a
(Use -+� if Abmre Top of Ca lag) PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality Within 30 days- Attn: Information Mgt, Form GW-lb
1617 Mail service Center — Raleigh , NC .27699-1617 Phone No . (919) 7334015 ext 568. Res- 7105

rr { NONRESIDENTIAL WELL, CONSTRUMON RECORD s + I
,p North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION H 3307
1 . WELL CONTRACTOR: d. TOP OF CASING IS FT. Above land Surface`
Tommy Bolyard 'Top at casing terminated avor below land surface. may require
Well Contractor (IndMdual) Name a variance in accordance with 15A NCAC 2C .0118.
Environmental Drilling & Probing Services, LLC (EDPS) e. YIELD (gpm). METHOD OF TEST
Well Contractor Company Name f. DISINFECTION: Type Amount
STREET ADDRESS 17538 Greenhill Road g. WATER ZONES (depth):
Charlotte NC 26278 From To From. To
CityorTwm State Zip Code From. To From To
L 7( 04 } 607. 7529 Fran Tc From. To
Area Code- Phone number 6. CASING: Thickness/
2. WELL INFORMATION: Depth Diameter W �t ABC tat
SITE WELL ID *(if applicabie) AS- 14 Fran 59-5 To 0 Ft 2w scel�i.40
STATE WELL PERMIT#(il applicable) From To Ft.
From To Ft
DWQ or OTHER PERMIT #(if applicable)
WELL USE (Check Applicable Box) Monitoring ❑ Municipal/Public ❑ 7• GROUT: Depth Material Method
Industnal/Canmercial ❑ Agricultural ❑ Recovery ❑ Injection ❑ From 57-5 To 55.5 Ft Bentonite Tremie
Air S Fran 55.5 To _� Ft Gnwt Pump
Irrgation0 Olherp (6st use) parge
DATE DRILLED 1L30/13-1/15/14 From To Ft
TIME COMPLETED AM ❑ PM ❑ B, SCREEN: Depth Diameter SIB Size Material
3. WELL LOCATION:
From 62 TO 59.5 R 2 in. 0.01 in. PVC
Frain To Ft_in. in.
CITY; Lenar COUNTY From To Ft in. _ in
19W Connelly Springs Road, Lenior, NC
9.. SANDIGRAVEL PACK:
(6heet flame. Numbers, Community, SubdWsion, Lot tJo. , Parcel, Zip Code) Dew Size Material
TOPOGRAPHIC / LAND SETTING;
[] Slope ❑ Valley ❑ Flat ❑ Ridge R1 Other From 62 To 57.5 FL #Zoned Sand
(check appropriate box) From To Ft
be m de Fran TO Ft
LATITUDE 3 Y ��T:
v11Il11Cz seconds " 10. DRILLING LOG
LONGITUDE _ _ ma decimal tormat From To Formation Description
LatitudeAongitudesotrce: ❑ GPS ❑ Topographic map
(location of "I must be shown on a US GS topo map and
attached to this form Anat using GPS)
4. FACILTTY- R its, name or m, w�,aaa where. ono well .a located. _
FACILITY ID #(if applicable)
NAME OF FACILITY Calah's Mountain Superette
STREET ADDRESS 1990 Connelly Springs Road
Lenior NC
City or Twin State Zip Code
CONTACT PERSON Cary oil Company
MAILING ADDRESS 110 Mackenan Drive
Cary NC 11 . REMARKS:
City Or Town State Zip Code
Area code --Phone number
5. WPI I DETAILS: I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORORNCE WITH
1 SA NCAC 2C, WELL C NSTRUCR� N STANDARDS, AND 7HATA COPY OF THIS
a TOTAL DEPTH: 62' RECORD 1vs nee o�4o u a
1f26/14
b. DOES WELL REPLACE F_7(ISTING. WELL? YES ❑ NO 91
SIGNAT C F C IFIEDATLL CONTRACTOR DATE
c. WATER LEVEL Below Top of Casing: FT. l0 min
( Use '+• if Above Top of Casing) - / Ly IItNNN
PRINTED NAME OF PERSON CONSTRUCFrING THE WELL
Submit the original to the Division of Water Quality Within 30 days. Attn: Information Mgt, Form GW-1b
1617 Mail Service Center - Raleigh , NC 27 699-1 61 7 Phone No. (919) 733-7015 ext 568_ Rev 7/05

INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
Permit Number WI010022
Were any wells abandoned during this injection
1 . Permit Information event?
Cary Oil Company ❑ Yes No
Pernittee If yes, please provide the following information:
Former Caiah's Mountain Superette
Number of Monitoring Wells
Facility Name
1990 Connelly Springs Rd, Lenoir, NC Number of Injection Wells
Facility Address Please include two copies of the GW-30 for each
well abandoned.
2. Injection Contractor Information
ATC Associates of North Carolina, P.C. 4. Injectant Information
air
Injection Contractor / Company Name
4020 Old Pineville Road Injectant Type
Street Address
Charlotte NC 28217 Concentration
City State Zip Code If the injectant is diluted please indicate the source
704 529-3200 dilution fluid.
Area code — Phone number Total Volume Injected
3 . Well Information Volume Injected per well
Number of wells used for injection 2 5. Injection History
Well names
DMW-1 , DMW-2 Injection date(s) 9/10/12 (pilot test)
Were any new wells installed during this injection Injection number (e.g. 3 of 5)
event?
❑ Yes ❑- No is this the last injection at this site?
❑ Yes ❑E No
If yes, please provide the following information:
Number of Monitoring Wells I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
Number of Injection Wells THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
Type of Well Installed (Check applicable type) : STANDARDS LAID OUT IN THE PERMIT.
❑ Bored ❑ Drilled El Direct-Push
❑ Hand-Augured ElOther (specify) 9 - n � 1vAnfv' � � & I2Ilz_ � 12
�GNA OF WJECTION CONTRACTOR
Please include two copies ofform GW-I b for each Christine E. Dupuis
well installed. PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Quality within 30 days of injection. Form UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699- 1636, Phone No. 919-733-3221 Rev. 07/09

State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
STATUS OF INJECTION WELL SYSTEM
Permit Number: WI0100221
Pelnnttee Name: Cary Oil Company
Address: 110 McKennan Drive, Suite 300, Cary, NO 27511
Please check the selection which most closely describes the current status of your injection well system:
I ) ❑ Well(s) still used for injection activities, or may be in the future.
2) 1 Well(s) not used for injection but is/are used for water supply or other purposes.
3 ) ❑ Injection discontinued and : a) ❑ Well(s) temporarily abandoned
b) ❑ Well(s) permanently abandoned
c) ❑ Well(s) not abandoned
4) ❑ Injection well(s) never constructed
Current Use of Well
If you checked (2), describe the well use (potable water supply, irrigation, monitoring, etc), including pumping rate and other
relevant information.
wells currently used for groundwater monitoring
Well Abandonment
If you checked (3)(a) or (3)(b), describe the method used to abandon the injection well . (Include a description ofhow the well
was sealed and the type of material used to fill the well ifpermanently abandoned) :
Permit Rescission:
If you checked (2), (3), or (4) and will not use a well for injection on this site in the future, you should request rescission of the
permit. Do you wish to rescind the permit?
Yes ❑ No
Certification :
"T hereby certify, under penalty of law, that I have personally examined and am familiar with the information submitted
in this document, and that to the best of my knowledge the information is true, accurate, and complete. "
L � J Cam.
�1LS G -�-� )_ . �..2 2AT by C'u-U C 2 7 - I14
Signature Date '
Revised 5/05 GW/UIC-68

�<Ceidrq Ekr'�z�a., 11l tt/1w A?
s a
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS '..
The following are `permitled by rule"and do not require an individual permit when constructed in accordance
with the rules of ISANCAC 01C.0200. This form shall be submitted at least 2 weeks prior to construction.
AQUIFER TEST WELLS(15A NCAC 02C.0227)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
INSITU REMEDIATION(15A NCAC 02C10225)or TRACER WELLS(15A NCAC 02C.0229):
1) Passive Injection Systems -In-well delivery systems to diffuse injectams into the subsurface. Examples include
ORC socks,iSOC systems,and other gas infusion methods.
2) Small-Scale Injection Operations - Contaminant plumes located entirely within a land surface area not to
exceed 10,000 square feet. For tracer tests in uncontaminated areas the area of influence of the injection well(s)shall
be entirely within a land surface area not to exceed 10,000 square feet. An individual permit shall be required for
test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for f num,implementation,and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume. -
4) Air Injection Wells-Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: November 20 2013 PERMITNO. WT010022.( (to be filled in by DWQ)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) _X Air Injection Well......................................Complete sections B-F,K,N
(2) Aquifer Test Well.......................................Complete sections B-F,K,N
(3). Passive Injection System...............................Complete sections B-F,H-N
(4) Small-Scale Injection Operation......................Complete sections B-N
(5) Pilot Test.................................................Complete sections B-N
(6) Tracer Injection Well...................................Complete sections B-N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER — State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: Cary Oil Company/Glenn Petri
Mailing Address: 110 McKenan Drive Suite 300
City: Cary State:_NC_Zip Code:27511 County:Wake
Day Tele No.: [phone] Cell No.: Unknown
EMAIL Address: elenn(a),carvoil.com Fax No.: [phone]
DWQNIC//n Snu Reined.Notification(Revised 426/2012) Page l

F
D. PROPERTY OWNER(if different than well owner)
Name: Caiah's Mountain Park LLC
Mailing Address: PO Box 1114
City: Hudson State: NC Zip Code:28638 County:Caldwell
Day Tele No.: [phone] Cell No.: Unknown
EMAIL Address: Unknown Fax No.: Unknown
E. PROJECT CONTACT-Person who can answer technical questions about the proposed injection project.
Name: Christine Schaefer
Mailing Address: 7606 Whitehall Executive Center Drive,Suite 800
City: Charlotte State:_NC_Zip Code:28273 County:Mecklenburg
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address:[e-mail] Fax No.: [phone]
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 1999 Connelly Springs Road
County:Caldwell
City: Lenoir State:NC Zip Code: 28645
(2) Geographic Coordinates: Latitude**: o "or 35 837065 N
Longitude**: "or 81 538152 W
Reference Datum: Accuracy:
Method of Collection: Gooele Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: square feet(< 10,000 fl for small-scale injections)
Land surface area of treatment area/radius of influence: square feet
Percent of contaminant plume area to be heated: (must be<5%of plume for pilot test injections)
BE INJECTION ZONE MAPS—Attach the following to the notification.
(1) Contaminant plume maps) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater,existing and proposed monitoring wells,and existing and
proposed injection wells;and
i
(2) Cross-section(s) to the (mown or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells,and existing and proposed injection wells.
DWQNIC/Id Situ Pureed.Notification(Revised 4/262012) Page 2

I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — Provide a brief narrative regarding the
purpose,scope,and goals of the proposed injection activity. -
J. INJECTANTS—Provide a MSDS and the following for each injectant.Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
hhp.11aortal.nedenr.orglweh/wo/anslkworo. All other substances must be reviewed by the Division of Public
Health,Department of Health and Human Services. Contact the UIC Program for more info(919-807-6496).
Injectam:
Volume of inject int:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectt:
Volume of injectant:
Concentration at point of injection: —
Percent if in a mixture with other injectants:
Injectam:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
IC WELL CONSTRUCTION DATA
(1) Number of injection wells: 8 Proposed 0 Existing
(2) Provide well construction details for each injection well in a diagram or table format. A single
diagram or line in a table can be used for multiple wells with the same construction details. Well
construction details shall include the following:
(a) well type as permanent,direct-push,or subsurface distribution system(infiltration gallery)
(b) depth below land surface of grout,screen,and casing intervals
(c) well contractor time and certification number
DWQ/DIC/In Situ Remed.Notifinben(Revised 42612012) Page 3

L. SCHEDULES—Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN—Describe below or in separate attachment a monitoring plan to be used to determine
i£violations of groundwater quality standards specified in Subchapter 02L result from the injection activity. _
N. CERTIFICATION(to be signed as required below or by that person's authorized agent)
I5A NCAC 02C.0211(e)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;
5. for any other person authorized to act on behalf of the applicant: documentation shall be submitted
with the notification that clearly identifies the person, grants them signature authority, and is signed
and dated by the applicant.
"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 thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and '..
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Signature of Applicant Print or Type Full Name '..
See attached access agreement
Signature of Property Owner(ifdifferent from applicant) Print or Type Full Name L,
Signature of Authorized Agent,if any Print or Type Full Name
Submit one copy of the completed notification package to:
DWQ-Aquifer Protection Section
1636 Mail Service Center
Raleigh,NC 27699-1636
Telephone: [phone] Fax: [phone]
DWQNIGln San Remed,Notifiva[ion(Revieed 4/26/2012) Page 4

PROPOSED AIR SPARGE WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL CAP
PROTECTIVE CASING AND CONCRETE PAD
L1 CASING MATERIAL Steel
CASING DIAMETER 8 inches
CASING LENGTH 12 inches '..
PAD DIMENSIONS 2feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches -
JOINT TYPE flush threaded
LENGTH 72.5 feet
L2 BACKFILL AROUND CASING
MATERIAL cement-sand grout
THICKNESS 68.5 feet
L4
SEAL
TYPE OF SEAL bentonite
THICKNESS T
FILTER PACK(42 silica sand)
DISTANCE ABOVE SCREEN 2-
WELL SCREEN(sch 40 PVC)
DIAMETER 2 inches
LENGTH 2.5 feet
SLOT SIZE 0.010 inches
L3
DEPTH TO BOTTOM OF
AIRSPARGEWELL 75.0 feet
u = 005 FT, DIAMETER OF BOREHOLE 8 inches
L2= 72.5 FT,
L3= 2.6 FT.
L4= 75 FT.
TITLE Air Sparge Well Diagram ��/�/y -
(Example of proposed air sparge well installation displayed �1T�'ASSMAM INC.
above(
7606 Whitehall Executive Center Drive
Charlotte,North Carolina 28273
FILE PREP. BY REV. BY DATE PROJECT NO.

V( ) �
} lmgn
§ {
w
jE
2 _. _
` _ , _,_KL : ;

t
OFF-SITFACCWSB AARUMMT
Bacot Amil 25, 2013
Name., Steve:Hamby,Caiah's Mountain Park LLC:+
Address: PO Sox 1114
Hudsoli,NC4g638
REI Itightof Entry Request,
Parcel 111DI I -LegalDescription(ifavailable)NC PIN,A 2748g903i1S'
Addt0'as and/or ParcelDreaorigiloy 1999C 11y Sin `- Rad -
Lpnoih'NdYth Carolkrya
The FormerCajah'sMountain$operetta Gas Statioa.1990 Connally springs Road,Lenoir,North Carolina �
T4 Mr.Hamby, t
Cary oil Company,un$brsmods thatayon are the olvnorjslof the property,sefina nced above,which is located it the
vicinity-gfthe former Ca)ah'aMountom Stamens gas Station located-at 1990 Connelly Springs ltoa 1,Lenoir.North
Cargllt9;.
Cary Oil has conducted ad investigation of subsurface environmental conditions in the vicinity of your property at the
fmflwr.C®ah's ivl`oanfain 0apamneepo$m1b,az the direction of the North Carolina l7cpadwcntgfkavuomoenfant%
Natural Resources(NCAENRS.The inupstigationwasyvnduam4 ac esdlumemaypeirolewn-related impacts ofthasoil
- sndgrypndwator,9eyedOnihe5n8ing'ap£1h9sv vesttg'aiidi;NCDEIUF.d[rZcted'Comp104ion ofaCouechLeAc bnPl6(i
(CAP), the CAP hag been approved hY the NCD&k add consists of hf,B atla och of an air sparge and soul vapor
extractionremediadbnsysm=
As Part ofthe approved borreodyeimion adtiviiles,(ary Oti taquesm your imnmssinpto mseall remediado welle(am
spporfe,slid soil vaporwaracdon wells)onyeariaQperty at the location{5)shown onehe''eoolq'sed map,datddAmill25,
2t113, thesemedladn awellawill beoommeW underground with pbty'Vmyl of teride OVQ piping which Wilt require
aurtatre trenching artd snkssquentxaplagem�rt of tbeexGtling surface aovec Q e.grass,asphalt,conermo) The PVC
piping will be-Installed underground andoomemad in§.system smopo tehostmilek located at the eastern bom dw'y of
ydcrpsgperty,as ajmDhgdmap,dated April 25,2013 Pieaseaotethvt monfia ,
offheprdposed remedtadon wet[s,treneliing/piaing,andsyetom naileraro appreximateandihay requirevWisiou.hased-
ansifacandidons,adlides,obeinmt(nnsrntc. Wowilikeemmingomo your property periodically to condae4operation
and maintenance(O&kTYactivities associated with themrspmgeandsoilvapor exaacdpntemediadon system. Wevid
hnaskjpgournebeultagtsATC Asdnoiateg9£Notth Ca?g1t�,P,C,lpoated§14�0 O1dPmeGll0 k4ad,ChaYlotCk,,N9fifl
Catotinatc do this wortconom h0helg
Io poeterming this work, Cary Od will take all iomemable measures to void damage to your property and/or
pnteasdpabieinterferenfewhhih0 prasddmieanfyounptopgtty. CaryO➢l will depend,ind0tubil4 andhaldyoudt8rmiass.
from.epdagainst any lg33,co;f,dyanape tlf gxpansearisipg;but dfouC work;6nybuYPropery4 Opon amgplento ntth
ourroofs•o action aahrfities,Cary bit will close all wells in accordance with state regulations,removealtequfpmemmul

F
rostoreypnrproperty t2azneaeits origindl condidon(Immediately pour to d6mmencammutq#Yha work)as reasonably
possible.
Whether you wnsenttaurrafnse Cary OiPsregssk please Gheatetheappropeiate box,srgn(nftspaaeprevidod below,
aid mium this leNer iaihoanvelopapcovided or fax this Leer to AfC se Won aspossible(ATC irnt hambpr 704-52q-
3272)L If you check the appropriate,box and sign,yom sigratum will serve to glaut Cary Oil(including its employees
_ andagnots)pennissionto biter onto your property for the pmpwoofpeeforlLingthe work described above. You:m2y _
revoke this permission m any time by giving dwy Oil at least Sixty(dtl)days written notice of your intent to revoke.
Please respond wdhia 14 dayaofthe datc,4this letter
If you have any t aestiong abour the obtain of this latter,qr would Like further infarmatton about Carry oils proposed
wOYk,plaese da not Ne%data to eodYaotrtt8'atdd266tdPineVille R6ad,Chartarta,North Carritina28217 drat{'!OA}5'✓5: I
Sore emlya
Christina M Dupuis,ATC Associates ofNonh C-rohnE)P.C.
6hvimnmantaY Ropresentadvefor. CaryOil Companyy
rrbllosubcsm
act Ran Murphy; Cazolina Department ol'finri£onment and Nabuil Resources
'- I have the preaedmg lettterandrepresantro d weranbthat I live full nurbnrlty to enternuo this
Aameaa Agreement witorvnaka it binding on any,entity baying-valid olaam of an interest it my
probably,Iherebygra tCary011 Company avd(prrepresentsNv"hurCary DilCampany purrossibo
to'eroW onto my property under the hoona deau dyad above..
n 1havo road thepmediusletteraud hereby de.not ggraat Cary OilCompary aneVormpmsaniartvesfor
Csry f A� n buy to�i'piopetty pnda thaterms deacnhed above,
Signatunu Date
T
Rota
Attachments: Sitepiwilhle atingprbposed/approximateremediatiomweils;rceftaingiplpingaanditaildeiai tons l
j

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule"and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C.0200. This form shall be submitted at least 2 weeks Prior to construction.
AQUIFER TEST WELLS(15A NCAC 02C.0227)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
INSITU REMEDIATION(15A NCAC 02C.0225)or TRACER WELLS(15A NCAC 02C.0229):
1) Passive Injection Systems - In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks,iSOC systems,and other gas infusion methods.
2) Small-Scale Injection Operations - Contaminant plumes located entirely within a land surface area not to
exceed 10,000 square feet. For tracer tests in uncontaminated areas the area of influence of the injection well(s)shall
be entirely within a land surface area not to exceed 10,000 square feet. An individual permit shall be required for
test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation,and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Infection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: November 20 2013 PERMIT NO. W L o\oo l2.t (to be filled in by DWQ)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) _X_Air Injection Well......................................Complete sections B-F,K,N
(2) Aquifer Test Well.......................................Complete sections B-F,K,N
(3) Passive Injection System...............................Complete sections B-F,H-N
(4) Small-Scale Injection Operation......................Complete sections B-N
(5) Pilot Test.................................................Complete sections B-N
(6) Tracer Injection Well...................................Complete sections B-N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER — State time of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: Cary Oil Company/Glenn Petti
Mailing Address: 110 McKenan Drive Suite 300
City: Cary State:_NC Zip Code:27511 County:Wake
Day Tele No.: [phone] Cell No.: Unknown
EMAIL Address: elennAcaryuiLcum Fax No.: [phone]
DWQ/UIC/In Son Round.Notification(Revised 4/26/2012) Page l

- D. PROPERTY OWNER(if different than well owner)
Name: Mary Lindsay
Mailing Address: 127 Dell Circle
City: Hudson State:_NC Zip Code:28630 County: Caldwell
Day Tcle No.: [phone] Cell No.: Unknown
EMAIL Address: Unknown Fax No.: Unknown
E. PROJECT CONTACT-Person who can answer technical questions about the proposed injection project.
Name: Christine Schaefer
Mailing Address: 7606 Whitehall Executive Center Drive Suite 800
City: Charlotte State:_NC Zip Code:28273 Country:Mecklenburg
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address:[e-mail] Fax No.: [phone]
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 1990 Connelly Springs Road
County:Caldwell
City: Lenoir State:NC Zip Code: 28645
(2) Geographic Coordinates: Latitude**: "or 35 837424 N '..
Longitude**: "or 81 538733 W
Reference Datum: Accuracy: I.
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED M LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: square feet(< 10,000 ftr for small-scale injections)
Land surface area of treatment area/radius of influence: square feet
Percent of contaminant plume area to be treated: (must be<5%of plume for pilot test injections)
H. INJECTION ZONE MAPS—Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater,existing and proposed monitoring wells,and existing and
proposed injection wells;and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells,and existing and proposed injection wells.
D WQ/UIC/In Saa gained.Notification(Revised 4/262012) Page 2

L DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — Provide a brief narrative regarding the —
purpose,scope,and goals of the proposed injection activity. -
J. INJECTANTS—Provide a MSDS and the fallowing for each injectant.Attach additional sheets if necessary. —
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://nortalncdc,nr.ore/iveblwolaps/mvmro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info(919-807-6496).
Injectant:
Volume of injectant
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant.
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants
K WELL CONSTRUCTION DATA
(1) . Number of injection wells: 5 Proposed 0 Existing
(2) Provide well construction details for each injection well in a diagram or table format. A single
diagram or line in a table can be used for multiple wells with the same construction details. Well
construction details shall include the following:
(a) well type as permanent,direct-push,or subsurface distribution system(infiltration gallery)
(b) depth below land surface of grout,screen,and casing intervals
(c) well contractor name and certification number
D VAyU10In Situ Reued.Notification(Revised 4126/2012) Page 3

L. SCHEDULES—Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN—Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
N. CERTIFICATION(to be signed as required below or by that person's authorized agent)
15A NCAC 02C .021Ile)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;
5. for any other person authorized to act on behalf of the applicant: documentation shall be submitted
with the notification that clearly identifies the person, grants them signature authority, and is signed
and dated by the applicant.
"I hereby certjy, under penalty of law, that I have personally examined and am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the 154 NCAC 02C 0200 Rules."
Signature of Applicant Print or Type Full Name
See attached access agreement
Signature of Property Owner(if different from applicant) Print or Type Full Name
Signature of Authorized Agent,if any Print or Type Full Name
Submit one copy of the completed notification package to:
DWQ-Aquifer Protection Section
1636 Mail Service Center
Raleigh,NC 27699-1636
Telephone: [phone] Fax:[phone]
DWQNIC/m Situ Remed.Notification(Revised 4/26MI2) Page 4

PROPOSED AIR SPARGE WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW -
NOT TO SCALE
LOCKABLE WELL CAP -
PROTECTIVE CASING AND CONCRETE PAD
L1 CASING MATERIAL Steel
CASING DIAMETER 8 inches
CASING LENGTH 12 inches
PAD DIMENSIONS 2 feet x2feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 72.5 feet
L2 BACKFILL AROUND CASING
MATERIAL cement-sand grout
THICKNESS 68.5 feet
L4
SEAL
TYPE OF SEAL bentonite
THICKNESS 2'
FILTER PACK(#2 silica sand)
DISTANCE ABOVE SCREEN 2'
WELL SCREEN (sch 40 PVC)
DIAMETER 2 inches
LENGTH 2.5 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
AIR SPARGE WELL 75.0 feet
-1 = 0.5 FT. DIAMETER OF BOREHOLE 8 inches
L2= 72.6 FT.
L3= 2.5 FT.
L4= 75 FT.
TITLE Air Sparge Well Diagram ��y�/�(
(Example ofpmposed alrspergewell installation displayed AMASSMATW INC
above)
7606 Whitehall Executive Center Drive
Charlotte, North Carolina 28273
FILE PREP. BY REV. BY DATE PROJECT NO.

� o
4
k
�k a'
S�ti am I.
�N I
�?yp
=YE
m� f
�scw° 0 rvPPil uONI—cwzu uaxuorxc way �a PnoPweosol�vnPon Pxnacmxvmu I�'
----.PROPeercuee PROPMEnuawmoeweu o zn so 1Do
naw wcnrorwnv 4 rcPe m
CI II BIIIL�IXG OVIIIIrt

S AGREEMENT
'..'OFF-SITE ACCESS A
Date: December 14. 2012
Name: Mary Lindsay
Address: 127 Dell Cr
Hudson,NC 28630
RE: Right of Entry Request
Parcel# 1122 1 12A -Legal Description(if available)NC PIN 9 2746795343
Address and/or Pawl Description 1990 Connelly Sprinss Road
Lenoir,North Carolina
The Former Cajah's Mountain Superette Gas Station,1990 Connelly Springs Road,Lenoir,North Carolina
To Ms Lindsay :
Cary Oil Company understands that you are the owner(s)of the property referenced above,which is the former Cajah's
Mountain Superette gas station located at 1990 Connelly Springs Road,Lenoir,North Carolina.
Cary Oil has conducted aninvestigation of subsurface environmental conditions on and in the vicinity ofyouproperty at
the former Cajah's Mountain Superette gas station at the direction of the North Carolina Department ofBnvironment and
Natural Resources(NCDENR). The investigation was conducted to evaluate any petroleum-related impacts of the soil
andgroundwater. Based on the findings ofthis investigation,NCDENRdirected completionofa ConectiveActionPhm
(CAP). The CAP has been approved by the NCDENR and consists of installation of an air sparge and soil vapor
extraction remediation system. '..
As part of the approved corrective action activities,Cary Oil requests your permission to install remediation wells(air
sparge and soil vapor extraction wells)on yourproperty,at the location(s)shown on the enclosed map. Theremediation
wells will be connected underground with polyvinyl chloride(PVC)piping which will require surface trenching and
subsequent replacement of the existing surface cover(i,e.grass,asphalt,concrete). The PVC piping will be installed
underground and connected to a system components trailer at a proposed location on yaw property,as indicated on the
attached map. Please note that locations of the proposed remediation wells,trenchingipiping,and system trailer are
approximate and may require revision based on site conditions,utilities,obstructions,etc. We will be entering onto your
property periodically to conduct operation and maintenance(O&M)activities associated with the air sparge and sail
vapor extractionremediation system. We will be asking ow consultant,ATC Associates ofNorth Carolina,P.C.located -
at 4020 Old Pineville Road,Charlotte,North Carolina to do this work on ow behalf.
In performing this work, Cary Oil will take all reasonable measures to avoid damage to your property and/or
unremonableinterferencewiththepreseutuseofyowproperly. Cary Oil will defend,indemnify andhold you harmless
from and against any lass,war,damage or expense arising out of ow work on you property. Upon completion ofthe
corrective action activities,Cary Oil will close all wells in accordance withstate regulations,remove all equipment and
restore your property to as now its original condition(firmediately prior to commencement ofthe work)as reasonably -

possible.
Whether you consent to or refuse Cary Oil's request,please check the appropriate box,sign in the space provided below,
and return this letter in the envelope provided or fax this letter to ATC as soon as possible(ATC faxnumber 704-529-
3272). Ifyou check the appropriate box and sign,your signature will serve to grant Cary Oil(including its employees
and agents)permission to enter onto your properly for the purpose ofperforming the work described above. You may
revoke this permission at any time by giving Cary Oil at least sixty(60)days written notice of your intent to revoke.
Please respond within 10 days of the date of this letter.
Ifyou have any questions about the terms ofthis letter,or would like further information about Cary Oil'sproposedwork,
please do not hesitate to contact me at 4020 Old Pineville Road,Charlotte,North Carolina 28217 or at(704)529-3200.
Sincerely,
Christine E,Dupuis,ATC Associates of North Carolina,P.C.
Environmental Representative for Cary Oil Company
Enclosures:
cc: Dan Murphy,North Carolina Department of Environment and Natural Resources
�/77k1 I have read the preceding letter and represent and warrant that I have full authority to enter into this
Access Agreement and to make it binding on any entity having a valid claim of an interest in my
property. I hereby grant Cary Oil Companyand/orrepresenmtives for Cary Oil Compauypermission
to enter onto my property under the terms described above.
[] l have read the preceding letter and hereby do not grant Cary Oil Company andfor representatives for
Cary Oil Company permission to enter onto my property under the terms;described above.
Signature: �
Date: A.
,aO73
Attachments: Site lanillustratingproposed/approximateremediation wells,trenching/piping,and trailer locations

RCcn'Je.l Eltc ean.lo. t(r 111ZP115
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule"and do not require an individual permit when constructed in accordance
with the rules of I5ANCAC 02C.0200. This form shall be submitted at least 2 weeks Prior to construction.
AQUIFER TEST WELLS(15A NCAC 02C.0227)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
INSITU REMEDIATION(15A NCAC 02C.0225)or TRACER WELLS(1sA NCAC 02C.0229):
1) Passive Injection Systems -In-well delivery systems to diffuse injections into the subsurface. Examples include
ORC socks,iSOC systems,and other gas infusion methods.
2) Small-Scale Injection Operations -Contaminant plumes located entirely within a land surface area not to ',
exceed 10,000 square feet. For tracer tests in uncontaminated areas the area of influence of the injection well(s)shall
be entirely within a land surface area not to exceed 10,000 square feet. An individual permit shall be required for
test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation,and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land -
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Blegible Submittals Will Be Returned As Incomplete.
DATE: November 20 , 2013 PERMIT NO. W V o c D ozz t (to be filled in by DWQ) '..
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) _X_Air Injection Well......................................Complete sections B-F,K,N
(2) Aquifer Test Well.......................................Complete sections B-F,K,N
(3) Passive Injection System...............................Complete sections B-F,H-N
(4) Small-Scale Injection Operation......................Complete sections B-N
(5) Pilot Test.................................................Complete sections B-N
(6) Tracer Injection Well...................................Complete sections B-N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER — State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: Cary Oil Company/Glenn Petri
Mailing Address: 110 McKenna Drive Suite 300
City: Cary State:_NC_Zip Code:27511 County:Wake
Day Tele No.: [phone] Cell No.: Unknown
EMAIL Address: elemudicaryoil.com Fax No.: [phone]
DWQ/UIC/In See Reined.Notification(Revised 4/26/2012) Page I

D. PROPERTY OWNER(if different than well owner)
Name: Walter and Carolyn Moore
Mailing Address: 2915 Dry Ponds Road
City: Granite Falls State:_NC Zip Code:28630 County:Caldwell
Day Tele No.: [phone] Cell No.: Unknown
EMAIL Address: Unknown Fax No.: Unknown
E. PROJECT CONTACT-Person who can answer technical questions about the proposed injection project.
Name: Christine Schaefer
Mailing Address: 7606 Whitehall Executive Center Drive,Suite 800
City: .Charlotte State:_NC_Zip Code:28273 County:Meeklenbure
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address:christine.schaeferGdatcassociates.com Fax No.: [phone]
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 1998 Connelly Shrines Road
County:Caldwell
City: Lenoir State:NC Zip Code: 28645
(2) Geographic Coordinates: Latitude**: "or 35 837135 N
Longitude**: "or 81 " 538788 W
Reference Datum: Accuracy:
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAYBE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: square feet(< 10,000 ftr for small-scale injections)
Land surface area of treatment area/radius of influence: square feet
Percent of contaminant plume area to be heated: (must be<5%of plume for pilot test injections)
H. INJECTION ZONE MAPS—Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration Hoes that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells,and existing and
proposed injection wells;and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells,and existing and proposed injection wells.
DWQ/UIC/In Situ Remed Notification(Revised 4126/2012) Page 2

I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — Provide a brief narrative regarding the
purpose,scope,and goals of the proposed injection activity.
J. INJECTANTS—Provide a MSDS and the following for each injection.Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remedlalion additives) can be found online at
httn/portal ncdenr orn/web/wa/ansl�,pro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info(9/9-807-6496).
Injectant: _
Volume of inject int
Concentration at point of injection:
Percent if in a mixture with other injections:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injections:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: ____I_Proposed 0 Existing
(2) Provide well construction details for each injection well in a diagram or table format. A single
diagram or line in a table can be used for multiple wells with the same construction details. Well
construction details shall include the following:
(a) well type as permanent,direct-push,or subsurface distribution system(infiltration gallery)
(b) depth below land surface of grout,screen,and casing intervals
(c) well contractor name and certification number
DWQNIC/1a Situ Remed.Notification(Revised 4/26/2012) Page 3

L. SCHEDULES—Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN—Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
N. CERTIFICATION(to be signed as required below or by that person's authorized agent) _
15A NCAC 02C.021l(e)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;
5. for any other person authorized to act on behalf of the applicant: documentation shall be submitted
with the notification that clearly identifies the person, grants them signature authority, and is signed
and dated by the applicant.
"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 thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon
the injection well and all related appurtenances in accordance with the I5A NCAC 02C 0200 Rules."
Signature of Applicant Print or Type Fall Name
See attached access agreement
Signature of Property Owner(if different from applicant) Print or Type Full Name
Signature of Authorized Agent,if any Print or Type Full Name
Submit one copy of the completed notification package to: �i
D WQ-Aquifer Protection Section
1636 Mail Service Center
Raleigh,NC 27699-1636
Telephone:[phone] Fax:[phone]
DWQNIC/In Sim Remed.Notification(Revised 4/26MD) Page 4

PROPOSED AIR SPARGE WELL CONSTRUCTION DETAILS _
FLUSH GRADE MANHOLE _
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL CAP
/ PROTECTIVE CASING AND CONCRETE PAD
L1 ✓ CASING MATERIAL Steel
CASING DIAMETER 8 inches
CASING LENGTH 12 inches
71 PAD DIMENSIONS 2 feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING '..
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 72.5 feet
L2 BACKFILL AROUND CASING
MATERIAL cement-sand grout
THICKNESS 68.5 feet
L4
SEAL
TYPE OF SEAL bentonite
THICKNESS 2'
FILTER PACK(#2 silica sand)
DISTANCE ABOVE SCREEN 2'
WELL SCREEN(sch 40 PVC)
DIAMETER 2 inches
LENGTH 2.5 feet
SLOT SIZE 0.010 inches
L3
DEPTH TO BOTTOM OF
AIR SPARGE WELL 76.0 feet
u = 0.5 FT, DIAMETER OF BOREHOLE 8 inches
L2= 72.5 FT,
L3= 2.5 FT.
L6= 75 FT.
TITLE Air Sparge Well Diagram �M����/y/�/A� Q INC
(Example of proposed air sparge well Installation displayed AWMAM IN
above)
7606 Whitehall Executive Center Drive
Charlotte, North Carolina 28273 ',
FILE PREP. BY REV. BY DATE PROJECT NO.

� e
s "
P; uo I
e{
P
�p<
,Ec�D
P IYPEXNDNIIDPNDWELL �E EXDPoSED901LVPpOfl IXIWCINNIWELL Ili
------PPDPENIY FINE Q ppEIIIMMIIGXN l' I PRCRRFGPIP&PMGEWE0.
PWDWOMINE D R5®
[C.I BAD
II

i '
OFF-SITE ACCESS AGREEMENT
Dam: December 14. 2012
Name: Walter and Carolyn Moore
Address: 2915 Dry Ponds Road
Granite Falls,NC 28630
RE: Right of Entry Request
Parcel# 1122112 -Legal Description(if available)NC PIN#2746795237
Address and/or Parcel Desaiption 1998 Connelly Springs Road
Lenoir,North Carolina
The Former Cajah's Mountain Superette Gas Station,1990 Connelly Springs Road,Lenoir,North Carolina
To Mx.and Mrs Moore
Cary Oil Company understands that you are the owner(s)of the property referenced above, which is located in the
vicinity of the former Cajah's Mountain Superette gas station located at 1990 Connelly Springs Road,Lenoir,North
Carolina.
Cary Oil has conducted an investigation of subsurface environmental conditions in the vicinity of your property at the
former Cajah's Mountain Superette gas station at the direction of the North Carolina Department of Environment and
Natural Resources(NCDENR). The investigation was conducted to evaluate any petrolemn-related impacts of the soil
andgroundwater. Based onthefmdings ofthis investigation,NCDENR directedoompletion ofaCorrective Action Plan
(CAP). The CAP has been approved by the NCDENR and consists of installation of an air sparge and soil vapor
extraction remediation system.
As part of the approved corrective action activities,Cary Oil requests yaw permission to install remediation wells(air
sparge and soil vapor extraction wells)on your property at the locations)shown on the enclosed map. The remediation
wells will be connected underground with polyvinyl chloride(PVC)piping which will require surface trenching and
subsequent replacement of the existing surface cover(i.e.grass,asphalt,concrete). The PVC piping will be installed
underground and connected to a system components trailer at a proposed location north ofyour property,as indicated onI,
theattachedrnap. Please note that locations of the proposedremediation wells,trenching/piping,and system trailer are
approximate andmayrequirerevision based on site conditions,utilities,obstructions,etc. We will be emeringowayour
property periodically to conduct operation and maintenance(O&M)activities associated with the air sparge and soil
vaporextractionremediationsystem. We will be asking our consultant,ATC Associates of North Carolina,P.C.located
at 4020 Old Pineville Road,Charlotte,North Carolina to do this work on our behalf.
In performing this work, Cary Oil will take all reasonable measures to avoid damage to you property and/or
unreasonable interference withthe presentuse ofyourproperty. Cary Oilwiil defend,indemnify andholdyouharmless
from and against any loss,cost,damage or expense atising out of our work on your property. Upon completion of the
corrective action activities,Cary Oil will close all wells in accordance with state regulations,remove all equipment and ',

restore your property to as near its original condition(immediately prior to commencement of the work)as reasonably
possible.
Whether you consent to or refuse Cary OR'srequest,please check the appropriate box,sign in the space provided below, -
and return this letter in the envelope provided or fax this letter to ATC as soon as passible(ATC fax number 704-529-
3272). If you check the appropriate box and sign,your signature will serve to grant Cary Oil(including its employees
and agents)permission to enter onto your property for the purpose of performing the work described above. Youmay
revoke this permission at any time by giving Cary Oil at least sixty(60)days written notice of your intent to revoke.
Please respond within 10 days of the date of this letter.
Ifyou have any questions aboutthe terms of this letter,or wouldlike further information about Cary Oil'sproposed worky
please do not hesitate to contactme at 4020 Old Pineville Road,Charlotte,North Carolina28217 or at(704)529-3200.
Sincerely,
6 U
C
Christine E.Dupuis,ATC Associates of North Carolina,P.C.
Environmental Representative for Cary Oil Company
Enclosures:
cc: Dan Murphy,North Carolina Department of Environment and Natural Resources
[� I have read the preceding letter and represent and warrant that I have full authority to enter into this
Access Agreement and to make it binding on any entity having a valid claim of an interest in my
property. I hereby great Cary Oil Company and/orrepresentatives for Cary Oil Companypennission
to enter onto my property under the terns described above.
[] I have read the preceding letter and hereby do not grant Cary Oil Company and/or representatives for
Cary ''IC EI L o pany ermission to enter onto my property under the terms described above.
�v1a Signature: U
Date: J" J? �7
Attachments: Site plan illushatingproposed/approxhnate remediation wells,trenching/piping,andlmiler locations