WI0400556_Permit (Issuance)_20201105

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ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
October 26, 2020
Ms. Shristi Shrestha
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Circle K Store #7930 (RM #2681)
3700 Groometown Road
Greensboro, Guilford County, North Carolina
NCDEQ Incident No. 15707
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of Phillips 66 Company. The permit application
covers the performance of passive remediation in one monitoring well associated with the above
referenced site
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
cYP9 r
Robert Broda, P.G. Gabriel Araos, P.E.
Project Geologist Senior Project Manager
cc: Ed Kuhn, Contract Program Manager for Phillips 66 Company
Attachments

Notice of Intent to Construct or Operate Injection Wells
Circle K Store #7930 (RM #2681), Greensboro, NC
NOTICE OF INTENT FORM
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NC Department of Environmental Quality — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of I5A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .02251 or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small -Scale Injection Operations — Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a remediation
strategy in order to develop a full scale remediation plan for future implementation, and where the surface area of the
injection zone wells is 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.
5) In -Situ Thermal Wells (IST) — Used to `heat' contaminated groundwater to enhance remediation
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: October 16 , 20_20_
PERMIT NO. W10400556
(to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
Permit No.
Issued Date:
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well.......................................Complete sections B through F, J, M
(2) Aquifer Test Well.......................................Complete sections B through F, J, M
(3) x Passive Injection System...............................Complete sections B through F, H-M
(4) Small -Scale Injection Operation ......................Complete sections B through M
(5) Pilot Test.................................................Complete sections B through M
(6) In -Situ Thermal (IST) Well...........................Complete all sections except K
B. STATUS OF WELL OWNER: Choose an item.
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 1

C.
D.
E.
F.
G.
WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): Ed Kuhn — Contract Manager for Phillips 66 Company
Mailing Address:
— PB 141
City: Bartlesville State: OK Zip Code: 74003 County: Washington
Day Tele No.
704-676-0502
EMAIL Address: ed.kuhn(&eontractor.p66.com
PROPERTY OWNER(S) (if different than well owner/applicant)
Cell No.: Not Available
Fax No.: Not Available
Name and Title: Cecil S. and Patricia J. Little
Company Name Triad Holding Co. LLC
Mailing Address: 6318-A West Market Street
City: Greensboro State: NC Zip Code: 27409 County: Guilford
Day Tele No.
336-299-4500
Cell No.: Not Available
EMAIL Address: Unavailable Fax No.: Not Available
PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Gabriel Araos, P.E., Senior Project Manager
Company Name ATC Associates of North Carolina, P.C.
Mailing Address: 2725 East Millbrook Road, Suite 121
City: Raleigh State: NC Zip Code: 27604 County: Wake
Day Tele No.: 919-871-0999 Cell No.: 919-816-7915
EMAIL Address: gabe.araoskatc,gs.com
PHYSICAL LOCATION OF WELL SITE
Fax No.: 737-207-8261
(1) Facility Name & Address: AAA Self Storage at Groometown Rd
3702 Groometown Road
City: Greensboro County: Guilford Zip Code: 27407
(2) Geographic Coordinates: Latitude": " or 360. 01508697267033
Longitude":
Reference Datum:
°
WGS84
Method of Collection: Google Earth
" or -790. 86614651738763
Accuracy:
+/- 10 feet
"FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
TREATMENT AREA
Land surface area of contaminant plume: N/A square feet
Land surface area of inj. well network: N/A square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: N/A (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 2

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.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
See Figures I through 8 for site location, injection zone maps, and cross sections.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
ATC will install Provectus Oxygen Releasing Substrate (ORS) sleeves in monitoring wells GW-13 in order to
aide in natural attenuation and reduce compound concentrations to below the North Carolina Groundwater
Quality Standards (2L Standards). Based on the most recent samplingevent in September 2020,
methyl tertiary -butyl ether (MTBE) exceeded 2L Standards in GW-13. The socks come in 3-foot sections. ATC
will install four 3-foot sections at the base of the well, across the well screen. The socks will release oxidizing
compounds into the groundwater for approximately 6 months, at which point the chemicals in the socks will
have depleted. ATC will also measure dissolved oxygen, conductivity, specific conductance, temperature, pH,
and oxygen reduction potential in monitoring well GW-13 during quarterly sampling events. ATC will change
the ORS sleeves periodically as determined by the laboratory results.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 0 Proposed 1 Existing (provide NC Well
Construction Record (GW-1) for each well) — See Appendix A
(2) Appx. injection depths (BLS): 20 feet
(3) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for multiple
wells with the same construction details. Well construction details shall include the following
(indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division of Public Health, Department
of Health and Human Services can be injected. Approved injectants can be found online at
hlt 2:Hdeg.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-watgr-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program for more info if wish to get approval for a deferent additive. However, please
note it may take 3 months or loner.
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 3

Injectant: Provectus-ORS(See Appendix B for MSDS) Total Amt. to be injected (gal)/event:
Amt. Water to be injected (gal/event): 0 gallons
Total Amt. to be injected (gal/event):
No. of separate injection events: Est. Total Amt. to be injected (gal):
Source of Water (if applicable): Not Applicable
L. 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.
Quarterly sampling events of select monitoring wells are performed ATC's next sampling event will occur in
December 2020. During the sampling event, ATC will collect a sample from monitoring well GW-13 for analysis
of volatile organic compounds by EPA Method 6200B including MTBE. The sample will be shipped to SGS
North America Inc. in Scott, Louisiana.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby cert�, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
/ fDtw1,0/� Mt. 1<v dd . PGl I Le ,1°1S (i6 lone CAM
Signature of Applicant f Print or Type Full Name
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .0200). "
"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.
SEE ATTACHED
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send 1(one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Rem--diation NOI Rev. 2-14-2020 Page 4

WILLIAM BECK
Eastern Region Manager
Remediation Management
PHILLIPS 66
420 S. Keeler Avenue, P13-174700-01
Bartlesville, OK 74003-6670
Phone [phone]
Email Bili.E.Becl<@p66.com
April 28, 2017
North Carolina Department of Environment and Natural Resources
Division of Water Quality - Aquifer Protection Section
3800 Barrett Drive
Raleigh, NC 27609
RE: Authorization to Sign on Behalf of Phillips 66
Monitoring Well Permit Application
To Whom It May Concern:
PHILLIPS
CW0
Remediation Management (RM - a department within the Phillips 66 Health, Safety, and
Environment Department) is authorized to sign documents on behalf of Phillips 66 within its scope of
responsibility and financial authority. These authorities may be delegated for specific transactions
by the person holding that authority with the delegation sent to the RM Manager. Phillips 66
Company also authorizes third -party agents to sign certain documents oil its' behalf according to the
same prescribed process. According to our "Document Signature Authorities - Remedlatio►l
Management" (Effective May 1, 2012), a Program Manager Is authorized to sign Permit and Licenses
(Well Permits and Similar) on behalf of the Company.
Accordingly, this letter delegates authority to our Charlotte, North Carolina- based Program Manager,
Ed Kuhn, of GHD, Inc. to sign well permit applications on our behalf. This delegation shail be
effective for as long as Mr. Kuhn remains in the position of Program Manager for Phillips 66.
Thank you for assuring that only authorized agents sign documents submitted on our behalf. If you
have any questions, please do not hesitate to contact me at the phone number listed above.
Res ctfully submitted,
W� V-1-
William E. Beck
East Region Manager
Phillips 66 Remediation Management
Cc: Steve Belin, RM Manager

AOC site #: 2681
Acquisition #: 7930
LICENSE AGREEMENT
THIS LICENSE AGREEMENT (the "Agreement") is made as of May 10, 2014, by and between
CECIL S. LITTLE and PATRICIA J. LITTLE (together "Licensor") and PHILLIPS 66
COMPANY ("Licensee"); Licensor and Licensee, together, shall sometimes hereinafter be
referred to as the "Parties."
RECITALS
A. Licensor is the legal and rightful owner of a certain parcel of real property located
at 3702 Groometown Road, Greensboro, North Carolina, further identified by the Guilford County
Assessor as Parcel No. 0140842 (the "Property"), and in the vicinity of the former Circle K Store
No. 7930, located at 3700 Groometown Road, Greensboro, North Carolina;
B. Licensee, in cooperation with the North Carolina Department of Environment and
Natural Resources ("NCDENR"), now desires to enter the Property to continue its various
environmental investigation and/or remediation activities, including, but not limited to, the
following, as may be shown on the site plan labeled Exhibit "A," attached hereto and incorporated
herein (the "Work");
1. Continued periodic monitoring, sampling and maintenance of the six (6)
previously installed groundwater monitoring wells labeled as "GW07, GW08,
GW10, GWl1, GW12 and GW13";
2. Possible one-time relocation of two (2) groundwater monitoring wells, "GW07"
and "GW13," as may be required to allow for Licensor's new building
construction, which relocation will include the following:
a. Proper groundwater monitoring well abandonment, in accordance with
state and/or local protocols; and
b. Re -installation of the two (2) groundwater monitoring wells in the
approximate proposed locations, as noted on Exhibit "A";
3. Installation and periodic monitoring, sampling and maintenance of any new
groundwater monitoring wells and/or remedial wells; and
4. Eventual proper well abandonment in accordance with state and/or municipal
protocols.
C. The Parties desire to enter into this Agreement so that the soil and/or groundwater
can continue to be assessed pursuant to environmental laws and regulations;
NOW THEREFORE, in consideration of the granting of the foregoing, the mutual premises,
covenants, conditions and agreements hereinafter set forth, and other good and valuable
consideration, the receipt and adequacy of which are acknowledged, the Parties hereby agree as
follows:
1. Grant of License - Licensor hereby grants to Licensee, and its employees, representatives
and/or contractors an irrevocable, non-exclusive license (the "License") to enter upon the Property
from time to time to conduct the activities described in Recitals Paragraph B and C above.
Further, Licensor shall cause any tenants or lessees of the Property, not a party hereto, to provide
Page I of 5
License Agreement PTRRC12v.1

AOC Site #: 2681
Aequisition #: 7930
Licensee, including its consultant(s), and/or contractor(s), same License. This License shall
commence on May 10, 2014 (Effective Date), and shall end on May 10, 2019, unless the Parties
agree in writing to extend the term of the License. If Licensee is required by a government agency
to maintain a well or other equipment on the Property beyond the term of this License, then the
License shall, on notice of such requirement to Licensor, be extended until thirty (30) days after
such requirement ceases. Prior to the expiration of the License, Licensee shall, at its sole cost and
expense, (a) cause any excavations to be returned to the original gradient, (b) remove all
equipment placed on the Property, (c) fill and level all ditches, ruts and depressions, if any, caused
by the closure of the Licensee's excavation operations on the Property and (d) remove all debris
resulting therefrom.
2. Compliance with Laws - Licensee shall conduct all operations which are the subject of
this License in compliance with all federal, state, and municipal statutes and ordinances, and with
all regulations, orders, and directives of appropriate governmental agencies, as such statutes,
ordinances, regulations, orders and directives now exist or provide.
3. Permits - Licensee, at no cost or expense to Licensor, shall be responsible for obtaining
any and all governmental permits and approvals which may be necessary for it to conduct any
work or activities under this Agreement. Licensor shall coordinate and cooperate with Licensee in
Licensee's activities to obtain all necessary government permits and permissions.
4. Liens and Claims - Licensee will not permit any mechanics', materialmen's, or similar
liens or claims to stand against the Property for labor or material furnished in connection with any
work performed by Licensee under this Agreement. Upon reasonable and timely notice of any
such Iien or claim delivered to Licensee by Licensor, Licensee may bond and contest the validity
and the amount of such lien, but Licensee will immediately pay any judgment rendered, will pay
all proper costs and charges, and will have the lien or claim released at its sole expense.
5. Cooperation - Licensee agrees to coordinate its activities with Licensor to minimize any
impairment of access by customers or business invitees of Licensor to the Property and any
inconvenience to or disruption of Licensoe's business on the Property.
6. Indemnity, - Licensee agrees that it will indemnify and hold Licensor harmless from and
against any claims, demands, actions, suits, judgments, losses, damages, costs, or expenses
incurred as a result of personal injury, property damage, civil penalties, or fines to the extent
proximately caused in whole or in part by the negligent acts or omissions of Licensee or its
authorized contractors and employees in conducting the Work. However, this indemnity and hold
harmless obligation shall not apply to any such claims, demands, actions, suits, judgments, losses,
damages, costs, or expenses to the extent caused by the sole negligence, gross negligence, or
willful misconduct of Licensor. This indemnity is expressly conditioned on the following:
(a) In the event Licensor shall identify any matter to which this indemnity may apply or
receive a notice or claim from any third party of such matter, it shall immediately, and in every
case within thirty (30) days of said notice or claim, notify Licensee in writing of such matter.
(b) Licensor shall cooperate with Licensee by allowing Licensee, its agents,
representatives, contractors and consultants prompt and ready access to the Property for the
Page 2 of 5
License AV-eement PTRRC12v.1

AOC Site M 2681
Aequisitlon 8. 7930
purpose of investigating any matter to which this indemnity may apply. Licensor shall provide
Licensee with copies of all investigative reports, data, or other information in any form which
Licensor, its consultants or attorneys may have pertaining to any such matter, upon request of
Licensee.
(c) Notwithstanding anything in this Agreement to the contrary, in no event shall
Licensee be liable for any special, indirect or consequential damages, including, but not limited to
claims for loss of use, rents, anticipated profit or business opportunity, or business interruption, or
punitive damages or exemplary damages.
7. Severabili - In case any one or more of the provisions contained in this Agreement shall
be invalid, illegal or unenforceable in any respect, the validity, legality, and enforceability of the
remaining provisions contained herein shall not in any way be affected or impaired thereby.
8. Notices - Any notice provided for herein or otherwise required to be given hereunder shall
be deemed received when personally served or three (3) days after mailing by certified or
registered United States mail, return receipt requested, postage prepaid, or by facsimile machine,
with transmission and receipt confirmed, or by nationally recognized overnight delivery service,
addressed as follows:
To Licensor: Cecil S. and Patricia J. Little
c/o Triad Holding Co. LLC
6318-A West Market Street
Greensboro, North Carolina 27409
Telephone: [phone]
Facsimile: L.....) _-
To Licensee: Phillips 66 Company
1232 Park Street, Suite 300
Paso Robles, California 93446
Attention: Colleen S. Hagemann
Telephone: [phone]
Facsimile: [phone]
With Copies to: Phillips 66 Company
c/o Steve Belin
420 South Keeler, PB-1760
Bartlesville, Oklahoma 74004
Attention: Ed Kuhn; Contract Program Manager
Telephone: [phone]
The person and the place to which notices are to be mailed may be changed by either party
by providing written notice of same to the other.
9. Assignment - This Agreement may not be assigned by any Party without the prior written
consent of the non -assigning Party, which consent shall not be unreasonably withheld, provided,
however:
Page 3 of 5
License Agreement PTRRCI2v I

ADC Site #: 2681
Acquisition #: 7930
(a) Licensee may assign or transfer this Agreement to a successor in interest
("Assignee") which assumes the responsibility of conducting the Work, without consent of
Licensor. Automatically upon such assignment or transfer, Licensee shall be released from all
obligations and liabilities hereunder accruing after the effective date of such assignment or
transfer, provided that, Assignee assumes all of the obligations and liabilities hereunder accruing
after the effective date of such assignment or transfer.
(b) Licensor understands and acknowledges that should Licensor assign this Agreement
to an assignee {"Licensor's Assignee") without the prior written consent of Licensee, acceptance
of this Agreement by Licensor's Assignee is with recourse to Licensor, and failure of Licensor's
Assignee to fulfill its obligations under this Agreement will constitute a material breach of this
Agreement by Licensor and Licensor's Assignee,
10. Change in Ownership - Licensor shall notify Licensee of any change in Property
ownership within five (5) days of the close of Property's escrow or the recordation of a deed
indicating Licensor has transferred the Property to another person(s) or entity(ies) by providing
Licensee at a minimum, the new Property owner's name and contact information. Should Licensor
fail to notify Licensee of Licensor's transfer of the Property, Licensor agrees to indemnify
Licensee for any cause of action asserted against Licensee for trespass to the Property.
11. Governing Law - This Agreement shall be construed and interpreted and governed by and
in accordance with the local law of the State of North Carolina without reference to any choice of
law, rules or policies which may refer the resolution of any dispute arising hereunder to the laws of
any other jurisdiction.
12. Entire Agreement — Except as expressly provided herein to the contrary, this Agreement
represents the full, complete and entire agreement between the Parties with respect to the subject
matter hereof, and the rights and remedies of the Parties shall be solely and exclusively those
herein contained, and in lieu of any remedies otherwise available at law or in equity.
13. Execution of Agreement - Each of the undersigned hereby represents and warrants that
they are authorized to execute this Agreement on behalf of the respective Parties to the Agreement,
and that this Agreement, when executed by those Parties, shall become a valid and binding
obligation, enforceable in accordance with its terms. Upon execution, this Agreement shall be
binding as to the Parties' respective parent companies, subsidiaries, affiliates, successors, heirs and
assigns.
[THE REMAINDER OF THIS PAGE INTENTIONALL Y LEFT BLANK]
Page 4 of 5
License Agreement PTRRC12v I

AOC Site #: 2681
AcquisUlon #: 7930
14. Counterparts - This Agreement may be executed in one or more counterparts, each of
which shall be deemed an original, and all of which, taken together, shall constitute one and the
same Agreement.
THE PARTIES have executed this Agreement in two (2) duplicate originals on the dates
set forth below.
LICENSOR
CECIL S. LI1TL �-
By: C
Name: Z;/ t:-
Title: e-'2'1z4yF Z
Date:
LICENSOR
PATRICIA J. LITTLE l
By:
Name: C;In�
Title: -/ 11�elev '/, Z'r—'r
Date: h •• /
Page S of S
License Agreement PTRRC12v.I
LICENSEE
PHILLIPS 66 COMPANY
Name: Bill A. Hallett
Title: Attomey-in-Fact
Date:

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Notice of Intent to Construct or Operate Injection Wells
Circle K Store #7930 (RM #2681), Greensboro, NC
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SOURCE: 1994 TOPOGRAPHIC MAP - MSRMAPS.COM. m rGu 300
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� 2725 E. Millbrook Road, Ste 121
(Raleigh, NC 27604 FIGURE 1: SITE TOPOGRAPHIC MAP
ENVIRONMENTAL • GEOTECHAICAL [phone]
BUILDING SCIENCES • MATERIALS TESTING Circle K Store No. 7930 (RM No. 2681
PROJECT NO: P662681019 3700 Groometown Road
SCALE: SEE ABOVE DATE: 12/2019 REVIEWED BY: BB Greensboro, Guilford County, North Carolina

LEGEND:
MONITORING WELL — - - — PROPERTY BOUNDARY WELL INSTALLED
BY S&ME RITE AID
VERTICAL DEFINITION -MW- - MUNICIPAL WATER
ON 05/15/2012 I o DRUGSTORE
MONITORING WELL - -SAN- SANITARY SEWER SCREEN 21 ID 1
• MONITORING POINT - -UE— UNDERGROUND ELECTRIC NO -
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AIR SPARGE WELL -UT- - UNDERGROUND TELEPHONE i - MW
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MONITORING WELL
— - - —
PROPERTY BOUNDARY
VERTICAL DEFINITION
—71.10—
GROUNDWATER ELEVATION
CONTOUR (ft.)
MONITORING WELL
•
MONITORING POINT
(71.13)
GROUNDWATER ELEVATION
(ft.)
AIR SPARGE WELL
INFERRED GROUNDWATER
FLOW DIRECTION
VAPOR EXTRACTION WELL
— — — — —
ESTIMATED GROUNDWATER
CONTOUR LINE
(NM)
NOT MEASURED
s
0
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PAD �
VENT
GRASS GW10 N
(74.65) ol
GW07
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(75.75)
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75.64
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STORAGE � � Gj
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GW12
DRIVEWAY "lh(74.03)
E STORAGE
h
/ WELL INSTALLED
BY S&ME
ON 05/15/2012
GW06 / SCREEN 21'-31'
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MONITORING WELL
VERTICAL DEFINITION
MONITORING WELL
•
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AIR SPARGE WELL
VAPOR EXTRACTION WELL
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Notice of Intent to Construct or Operate Injection Wells
Circle K Store #7930 (RM #2681), Greensboro, NC
APPENDIX A
MSDS FORM
.-ITC
d1WeIWlNMI • kllfltlptA

provectus
ENVIRONMENTAL PRODUCTS`
1.
2.
3.
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 1 of 5
PRODUCT IDENTIFICATION:
PRODUCT USE:
MANUFACTURER:
PROVECTUS ENVIRONMENTAL
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
PROVECT-ORS
Soil and water treatment.
EMERGENCY PHONE:
USA: (S15) 650-2230
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide), Class 5.1, PG II, UN1479
WHMIS CLASSIFICATION:
Oxidizer
COMPOSITIONANFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Inorganic Nutrients
PHYSICAL DATA
Appearance -----------------------
Physical state_____________________,
Odor threshold,___________________
Bulk Density______________________
Solubility in Water --------------
pH------------------------------------
Decomposition Temperature.
4. HAZARDS IDENTIFICATION
Chemical Formula CAS No. Percentage
Ca02 1305-79-9 75%-85%
15%-25%
White & brown granules
Solid
_None
500-650g/L
Insoluble
III
Self -accelerating decomposition with oxygen release starting from 275
degrees Celsius
Emergency overview
Oxidizing agent, contact with other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product contains <1 % non -respirable crystalline
silica. The NTP and OSHA have not classified non -respirable crystalline silica as carcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (silicosis). ORS does not
contain respirable crystalline silica.
Potential Health Effects:
0 General_________________________ Irritating to mucous membrane and eyes.

Provectus
ENVIRONMENTAL PRODUCTS"
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 2 of 5
• Inhalation_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
• Eye contact May cause irritation to the eyes; Risks of serious or permanent eye
lesions.
• Skin contact__________________ May cause skin irritation.
• Ingestion Irritation of the mouth and throat with nausea and vomiting.
5. FIRST AID MEASURES
• Inhalation Remove affected person to fresh air. Seek medical attention if effects
persist.
• Eye contact___________________ Flush eyes with running water for at least 15 minutes with eyelids
held open. Seek specialist advice.
• Skin contact Wash affected skin with soap and mild detergent and large amounts of
water.
• Ingestion ----------------------- If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Point
• Not applicable
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• Water
Fire Hazards
• Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,

Provectus
ENVIRONMENTAL PRODUCTS}
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 3 of 5
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution. Pressurization if confined when heated or
decomposing. Containers may burst violently.
Fire Fighting Measures
• Evacuate all non -essential personnel
• Wear protective clothing and self-contained breathing apparatus.
• Remain upwind of fire to avoid hazardous vapors and decomposition products.
• Use water spray to cool fire- exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper, oils,
etc.). Do not return product to container because of risk of contamination.
8. HANDLING AND STORAGE
Storage
• Oxidizer. Store in a cool, well -ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
• Keep away from incompatible materials. Keep containers tightly closed. Do not store in
unlabeled or mislabeled containers.
• Protect from moisture. Do not store near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Store separately from organics and reducing materials. Avoid contamination that may lead to
decomposition.
Handling
• Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
• Do not swallow. Avoid breathing vapors, mists, or dust. Do not eat, drink, or smoke in work
area.
• Prevent contact with combustible or organic materials.
• Label containers and keep them tightly closed when not in use.
• Wash thoroughly after handling.

provectus
ENVIRONMENTAL PRODUCTS'
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 4 of 5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no respiratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
• Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
• Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC, neoprene or rubber)
Other Protective Equipment
• Eye -wash station
• Safety shower
• Impervious clothing
• Rubber boots
General Hygiene Considerations
• Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
Stable under normal conditions
Condition to Avoid
• Water
• Acids
• Bases
• Salts of heavy metals
• Reducing agents
• Organic materials
• Flammable substances
Hazardous Decomposition Products
0 Oxygen which supports combustion

Provectus
ENVIRONMENTAL PRODUCTS}
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
• LD50 Oral: Min.2000 mg/kg, rat
• LD50 Dermal: Min. 2000mg/kg, rat
• LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological Information
• Hazards for the environment is limited due to the product properties of no bioaccumulation, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste Treatment
• Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations.
Package Treatment
• The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Class: 5.1
• Labels: 5.1 (Oxidizer)
• Packing Group: II
15. REGULATORY INFORMATION
• SARA Section ------------------------------------------
Yes
• SARA (313) Chemicals
No
• EPA TSCA Inventory --------------------------------
Appears
• Canadian WHMIS Classification
C, D2B
• Canadian DSL..........................................
Appears
• EINECS Inventory
Appears

Notice of Intent to Construct or Operate Injection Wells
Circle K Store #7930 (RM #2681), Greensboro, NC
APPENDIX B
MONITORING WELL CONSTRUCTION DETAILS
Rff,TC
d1WeIWlNM� • k�lfltllntA

L4
LUL
TYPE II MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
PROTECTIVE CASING AND CONCRETE PAD
L1
� CASING MATERIAL steel
. m'
CASING DIAMETER 8 inches
a:co:tw:
:aa:ao-:ao-.
aa:
.a:•w:aax.: CASING LENGTH 12 inches
ao- ao-
r}:¢ aa:a}
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 15 feet
L2
BACKFILL AROUND CASING
MATERIAL cement -sand grout
THICKNESS 10.5 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #1 silica sand
DISTANCE ABOVE SCREEN 2 feet
L3
WELL SCREEN
SCREEN MATERIAL sch 40 PVC
DIAMETER 2 inches
LENGTH 20 feet
SLOT SIZE 0.010 inches
L1 =
0.5
FT.
L2 =
15
FT.
L3 =
20
FT.
L4 =
35
FT.
DEPTH TO BOTTOM OF
MONITORING WELL 35 feet
DEPTH TO BOTTOM OF
BOREHOLE 35 feet
DIAMETER OF BOREHOLE 8.25 inches
TITLE WELL CONSTRUCTION DETAILS
Monitoring Well GW13
V
Circle K Store #7930
3700 Groometown Road
6512 Falls of Neuse Road, Suite 100
Greensboro, North Carolina 27407
Raleigh, North Carolina 27615
FILE
PREP. BY
REV. BY
DATE
PROJECT NO.
RAK
I GA
2/11 /2002
45.75000.7930