WI0400110_Permit (Issuance)_20111017

ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7, Chapter 87, Article 21. Chapter 143, and other
applicable Laws, Rules, and Regulations
PERMISSION IS HEREBY GRANTED TO
High Point Regional -Health Systems
FOR THE CONSTRUCTION AND OPERATION OF G TYPE 5I INJECTION WELLS, defined
in Title 15A North Carolina Administrative Code 2C .0209(e)(3)(C), to inject Oxygen BioChem,
to chemically oxidize #2 heating oil contamination in soil. These injection wells/points will be
located at the Dynamic Capital Mortgage, Inc. office building. located at 133 South Main Street
in Kernersville, Forsyth County, North Carolina, and will be operated in accordance with the
application submitted May 28, 2009, and in conformity with the specifications and supporting
data submitted, all of which are filed with the Department of Environment and Natural
Resources and are considered a part of this permit,
This permit is for Construction and Operation only, and does not waive any provisions of the
Water Use Act or any other applicable Laws, Rules, or Regulations. Operation and use of an
injection well shall be in compliance with Title i SA North Carolina Administrative Code 2C
.0100 and .0200, and any other Laws, Rules, and Regulations pertaining to well construction and
UM
This permit shall be effective, unless revoked, from the date of its issuance until August 31,
2012, and shall be subject to the specified conditions and limitations set forth in Parts I through
X hereof.
Permit issued this the 17th day of October, 2011.
for Coleen H. Sullins, Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0400110 PAGE 1 OF 6
ver.6107 APIMC-6

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
1. The Permittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (15A NCAC 2C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided for
in N.C.G.S. 87-94.
2. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
"a. This permit is valid only for construction of the number of injection wells described in the
application and other supporting data. Construction of additional injection wells must be
approved in advance by the Aquifer Protection Section.
4. Each injection well shall not hydraulically connect separate aquifers.
5. Each injection well shall be constructed in such a manner that water from land surface cannot
migrate into the gravel pack or well screen.
6. Each injection well shall be secured to reasonably insure against unauthorized access and
use. Each well shall be permanently labeled with a warning that it is for injection purposes
and the entrance to each well must be secured with a locking cap.
7. Each injection well shall be afforded reasonable protection against damage during
construction and use.
8. Each injection well shall have permanently affixed an identification plate.
9. Within 30 days of completion of well construction, a completed Well Construction Record
(Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART II - WELL CONSTRUCTION SPECIAL CONDITIONS
At Ieast forty-eight (48) hours prior to constructing each injection well, the Permittee shall notify
the Aquifer Protection Section -Underground Injection Control (UIC) Central Office staff.,
telephone number [phone] and the Winston-Salem Regional Office Aquifer Protection
Section Staff, telephone number [phone].
Permit No. WI0400110 PAGE ? OF F
ver.8107 APIUIC-6

PART III - OPERATION AND USE GENERAL CONDITIONS
1. This permit is effective only with respect to the nature, volume of materials, rate of injection,
and number of injection wells as described in the application and other supporting data.
?. This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to change
ownership, or there is a name change of the Permittee, a formal permit amendment request
must be submitted to the Director, including any supporting materials as may be appropriate,
at least 30 days prior to the date of the change.
3. The issuance of this permit shall not relieve the Permittee of the responsibility of complying
with any and all statutes, rules, regulations, or ordinances which may be imposed by other
local, state, and federal agencies which have jurisdiction. Furthermore, the issuance of this
permit does not imply that all regulatory requirements have been met.
PART IV - PERFORMANCE STANDARDS
I . The injection facility shall be effectively maintained and operated at all times so that there is
no contamination of groundwater which will render it unsatisfactory for normal use. In the
event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
?. The Permittee shall be required to comply with the terms and conditions of this permit even
if compliance requires a reduction or elimination of the permitted activity.
3. The issuance of this permit shall not relieve the Permittee of the responsibility for damages to
surface or groundwater resulting from the operation of this facility.
PART V - ❑PERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times,
?. The Permittee must notify the Division and receive prior written approval from the Director
of any planned physical alterations or additions in the permitted facility or activity not
specifically authorized by the permit.
At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section-UIC. Central
Office staff, telephone number [phone]. Notification is required so that Division staff
can inspect or otherwise review the injection facility and determine if it is in compliance with
permit conditions.
Permit No. WI0400110 PAGE 3 OF 6
ver.810 7 AP/UIC-6

PART VI - INSPECTIONS
1. Any duly authorized officer, employee, or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained under
the terms and conditions of this permit, and may obtain samples of groundwater, surface
water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observation, and sampling associated with injection and any related facilities as provided for
in N.C.G.S. 87-90.
3. Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VII - MONITORING AND REPORTING REQUIREMENTS
1. The proposed monitoring plan included in the application shall be followed. All sample
results shall be submitted to the Aquifer Protection Section's Winston-Salem Regional Office
and the Raleigh Central Office. Any monitoring (including groundwater, surface water, or
soil sampling) deemed necessary by the Division of Water Quality to insure surface and
ground water protection, will be established and an acceptable sampling reporting schedule
shall be followed.
2. The Permittee shall submit an Injection Event Record within 30 days of completing each
injection.
3. The Permittee shall produce a final project evaluation within 9 months after completing all
injection -related activity associated with this permit or produce a project interim evaluation
before submitting a renewal application for this permit. This document shall assess the
injection projects findings in a written summary. The final project evaluation shall also
contain monitoring well sampling data, contaminant plume maps and potentiometric surface
maps.
4. The monitoring results and the final project evaluation shall be submitted to:
and to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Aquifer Protection Section
DENR-DWQ Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Permit No. WI040011 o PAGE 4 OF h
ver.8J07 APUIC-6

5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge
of the occurrence, to the Winston-Salem Regional Office. telephone number {336) 771-5000.
any of the following:
(A)Any occurrence at the injection facility which results in any unusual operating
circumstances:
(B) Any failure due to known or unknown reasons, that renders the facility incapable of
proper injection operations, such as mechanical or electrical failures.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to the
Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take
such immediate action as may be required by the Director.
PART VIII - PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose. the
Permittee must submit an application to renew the permit 120 days prior to its expiration date.
PART Ik - CHANGE OF WELL STATUS
The Permittee shall provide written notification within 15 days of any change of status of an
injection well. Such a change would include the discontinued use of a well for injection. If a
well is taken completely out of service temporarily, the Pen ittee must install a sanitary seal.
If a well is not to be used for any purpose that well must be permanently abandoned
according to 15A NCAC 2C .0113, Well Construction Standards.
?. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C A 113 (b), including but not limited to the following:
(A) All casing and screen materials may be removed prior to initiation of abandonment
procedures if such removal will not cause or contribute to contamination of the
groundwaters.
(S) The entire depth of each well shall be sounded before it is sealed to insure freedom
from obstructions that may interfere with sealing operations,
(C) The well shall be thoroughly disinfected, prior to sealing, if the Director determines
that failure to do so could lead to the contamination of an underground source of
drinking water.
Permit Na. W1040031 U PAGE 5 OF 6
Ver.8107 APIUIC-6

(D) Drilled wells shall be completely filled with cement grout, or bentonite grout which
shall be introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
(E) in the case of gravel -packed wells in which the casing and screens have not been
removed, neat -cement, or bentonite grout shall be injected into the well completely
filling it from the bottom of the casing to the top.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has
been created, each well shall be abandoned in such a manner that will prevent the
movement of fluids into or between underground sources of drinking water and in
accordance with the terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (1) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X - WORKER PRECAUTIONS DURING APPLICATION
Some effects reported to be associated with the product proposed to be used are as follows:
eye, skin, nose, throat, and lung irritation. If the product is released into the environment in a
way that could result in a suspension of fine solid or liquid particles (e.g., grinding, blending,
vigorous shaking or mixing), then proper personal protective equipment should be used. The
application process should be reviewed by an industrial hygienist to ensure that the most
appropriate personal protective equipment is used.
Persons working with these products should wear goggles or a face shield, gloves, and
protective clothing. Face and body protection should be used for anticipated splashes or
sprays.
3. Eating, drinking, smoking, handling contact lenses, and applying cosmetics should not be
permitted in. the application area during or immediately following application.
4. Safety controls should be in place to ensure that the check valve and the pressure delivery
systems are working properly.
5. The Material Safety Data Sheets should be followed to prevent incompatible or adverse
reactions and injuries.
Permit No. WI0400110 PAGE 6 OF b
ver.8/07 AP/MC-6

DIVISION OF WATER QUALITY
AQUIFER PROTECTION SECTION
October 11, 2011
MEMORANDUM
TO: Debra Watts
FROM: David Goodrich
RE: Renewal of August 27, 2009 Permit To Inject Oxygen BioChem
Dynamic Capital Mortgage, Inc. Office Building
1 recommend that Permit Number W10400110, issued to High Point Regional Health Systems to inject Oxygen BioChem
to remediate soils contaminated with #2 heating oil, be renewed.
PROPOSED INJECTION Injection has been completed.
MONITORING Post -injection monitoring at this site has not yet been completed. The Permittee has requested that the
permit be extended an additional 12 months to allow for the completion of post -injection monitoring activities, evaluation,
and reporting.
REGIONAL OFFICE COMMENTS Shuying Yang and Sherri Knight of the Winston-Salem Regional Office recommend
the renewal of this permit.

ORIGINAL PERMIT APPLICATION

DIVISION OF WATER QUAI.LITI
AQUIFER PROTECTION SECTION
August 26, 2009
MEMORANDUM
TO: Debra Watts
FROM: Thomas Slusser r j
RE: Permit To Inject Oxygen BioChem
Dynamic Capital Mortgage. Inc. Office Building
I recommend that Permit Number WI0400110 be issued to High Point Regional Health Systems to inject Oxygen BioChem to
remediate soils contaminated with #F2 heating oil.
SITE DESCRIPTION The site was developed as an office building in 1959, at which time a 550 gallon heating oiI UST was
installed. The UST was closed out in February 1996. at which time 13 tons of petroleum -contaminated soil was removed.
HVDROGEOLOGIC DESCRIPTION The site is located in a suburban mixed residential and commercial setting in the
central Piedinont physiographic province. As of October 2008, depth to groundwater is 28.6 feet, which is approximately 10
feet below the proposed injection zone.
EXTENT OF CONTAMINATION Contamination is limited to soils in the vadose zone approximately 10 feet above the
water table. The extent of contamination is approximately 10'x12' and 10' thick: this corresponds to a volume of 1200 fr or
8976 gallons of contaminated soil. Petroleum compounds have not been detected in groundwater from the onsite monitoring
well.
PROPOSED INJECTION 480 gallons of Oxygen BioChem will be injected via 6 temporary injection wells, only one
injection event is planned. The injection interval is 8-18 feet below land surface. The proposed injection volume represents
approximately 5% of the total volume of soil contamination.
HOW IT WORKS Oxygen BioChem is a chemical oxidizer that consists of calcium peroxide and sodium persulfate.
Reaction byproducts include water, carbon dioxide, oxygen, calcium, and sulfate. Oxygen and persulfate radicals are formed,
which are short-lived, highly oxidizing reaction intermediates that chemically destroy petroleum compounds. Residual oxygen
is also formed, which stimulates continued aerobic bioremediation.
MONITORING Soil samples will be collected from the sail contamination zone and analyzed approximately 60 days
after injection. No groundwater monitoring is proposed because contamination has not previously been detected, the water table
is approximately 10 feet below the zone of soil contamination, the proposed injection volume is approximately 5% of the total
volume of soil contamination, and is an even smaller percentage of the total soil volume above the water table.
EPIUEMIOLUGY On August 25, 2008, Dr. Sandy Mort provided comments on calcium peroxide and sodium persulfate
for groundwater remediatian. Dr.tnrsdid not present any information that would preclude the use of these products for
injection but did provide a health risk analysis and worker safety precautions, which are in Part X of the attached permit,
REGIONAL OFFICE COMMENTS Stephen Berry and Sherri Knight of the Winston-Salem Regional Office recommend
issuance of this permit.

NORTH CAROLINA
ENVIRONMENTAL MANAGEMENT COMMISSION
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
RALEIGH, NORTH CAROLINA
PERMIT FOR THE CONSTRUCTION AND OPERATION OF A WELL FOR INJECTION
In accordance with the provisions of Article 7. Chapter 87: Article 21, Chapter 143. and other
applicable Laws, Rules. and Regulations
PERMISSION IS HEREBY GRANTED TO
High Point Regional Health Systems
FOR THE CONSTRUCTION AND OPERATION OF 5 TYPE 51 INJECTION WELLS, defined in
Title 15A North Carolina Administrative Code 2C .0209(e){3}(C), to inject Oxygen BioChem, to
chemically oxidize #2 heating oil contamination in soil. These injection wells/points will be located
at the Dynamic Capital Mortgage. Inc. office building, located at 133 South Main Street in
Kemersville. Forsyth County. North Carolina, and will be operated in accordance with the
application submitted May 28, 2009, and in conformity with the specifications and supporting data
submitted. all of which are filed with the Department of Environment and Natural Resources and are
considered a part of this permit.
This permit is for Construction and Operation only, and does not waive any provisions of the Water
Use Act or any other applicable Laws. Rules, or Regulations. Operation and use of an injection well
shall be in compliance with Title 15A North Carolina Administrative Code 2C .0100 and .0200, and
any other Laws. Rules, and Regulations pertaining to well construction and use.
This permit shall be effective, unless revoked, from the date of its issuance until August 31.2011,
and shall be subject to the specified conditions and limitations set forth in Parts I through X hereof.
A'1i�
Permit issued this the day of . 2009.
Jr" '� ucws
Coleen H. Sullins. Director
Division of Water Quality
By Authority of the Environmental Management Commission.
Permit No. WI0400110 PAGE. 1 OF 6
ver.8/07 APIUIC-5

PART I - WELL CONSTRUCTION GENERAL CONDITIONS
The Penrnittee must comply with all conditions of this permit and with the standards and
criteria specified in Criteria and Standards Applicable to Injection Wells (I 5A NCAC ?C
.0200). Any noncompliance with conditions of this permit constitutes a violation of the
North Carolina Well Construction Act and is grounds for enforcement action as provided for
in N.C.G.S. 87-94.
?. This permit shall become voidable unless the facility is constructed in accordance with the
conditions of this permit, the approved plans and specifications, and other supporting data.
3. This permit is valid only for construction of the number of injection wells described in the
application and other supporting data. Construction of additional injection wells must be
approved in advance by the Aquifer Protection Section.
4. Each injection well shall not hydraulically connect separate aquifers.
Each injection well shall be constructed in such a manner that water from land surface cannot
migrate into the gravel pack or well screen.
6. Each injection well shall be secured to reasonably insure against unauthorized access and use.
Each well shall be permanently labeled with a warning that it is for injection purposes and the
entrance to each well must be secured with a locking cap.
7. Each injection well shall be afforded reasonable protection against damage during
construction and use.
8. Each injection well shall have permanently affixed an identification plate.
9. Within 30 days of completion of well construction, a completed Well Construction Record
(Form GW-1) must be submitted for each injection well to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART II - WELL CONSTRUCTION SPECIAL CONDITIONS
At least forty-eight (48) hours prior to constructing each injection well. the Permittee shall notify
the Aquifer Protection Section -Underground Injection Control (UIC) Central Office staff.
telephone number [phone] and the Winston-Salem Regional Office Aquifer Protection
Section Staff, telephone number [phone].
Permit No. W10400110 PAGE 2 OF 6
ver.8107 APIUIC-6

PART III - ❑PERATION AND USE GENERAL CONDITIONS
This permit is effective only with respect to the nature, volume of materials, rate of injection.
and number of injection wells as described in the application and other supporting data.
?_ This permit is not transferable without prior notice to, and approval by, the Director of the
Division of Water Quality (Director). In the event there is a desire for the facility to change
ownership, or there is a name change of the Permittee. a formal permit amendment request
must be submitted to the Director, including any supporting materials as may be appropriate,
at least 30 days prior to the date of the change.
The issuance of this permit shall not relieve the Permittee of the responsibility of complying
with any and all statutes, rules, regulations, or ordinances which maybe imposed by other
local, state, and federal agencies which have jurisdiction. Furthermore, the issuance of this
permit does not imply that all regulatory requirements have been met.
l . The injection facility shall be effectively maintained and operated at all times so that there is
no contamination of groundwater which will render it unsatisfactory for normal use. In the
event that the facility fails to perform satisfactorily, including the creation of nuisance
conditions or failure of the injection zone to adequately assimilate the injected fluid, the
Permittee shall take immediate corrective actions including those actions that may be
required by the Division of Water Quality such as the repair, modification, or abandonment
of the injection facility.
? _ The Permittee shall be required to comply with the terms and conditions of this permit even if
compliance requires a reduction or elimination of the permitted activity.
_ The issuance of this permit shall not relieve the Permittee of the responsibility for damages to
surface or groundwater resulting from the operation of this facility.
PART V - OPERATION AND MAINTENANCE REQUIREMENTS
1. The injection facility shall be properly maintained and operated at all times,
?. The Permittee must notify the Division and receive prior written approval from the Director
of any planned physical alterations or additions in the permitted facility or activity not
specifically authorized by the permit.
At least forty-eight (48) hours prior to the initiation of the operation of the facility for
injection, the Permittee must notify by telephone the Aquifer Protection Section-UIC. Central
Office staff, telephone number [phone]. Notification is required so that Division staff
can inspect or otherwise review the injection facility and determine if it is in compliance with
permit conditions.
Permit No. W104001 10 PAGE ; of 6
ver.8107 APIUIC-6

PART VI - INSPECTIONS
1. Any duly authorized officer, employee. or representative of the Division of Water Quality
may, upon presentation of credentials, enter and inspect any property, premises, or place on
or related to the injection facility at any reasonable time for the purpose of determining
compliance with this permit, may inspect or copy any records that must be maintained under
the terms and conditions of this permit, and may obtain samples of groundwater, surface
water, or injection fluids.
2. Department representatives shall have reasonable access for purposes of inspection,
observatiom and sampling associated with injection and any related facilities as provided for
in N.C,G.S. 87-90.
Provisions shall be made for collecting any necessary and appropriate samples associated
with the injection facility activities.
PART VIII - MONITORING AND REPORTING REQUIREMENTS
i . The proposed monitoring plan included in the application shall be followed. All sample
results shall be submitted to the Aquifer Protection Section's Winston-Salem Regional Office
and the Raleigh Central Office. Any monitoring (including groundwater, surface water, or
soil sampling) deemed necessary by the Division of Water Quality to insure surface and
ground water protection, will be established and an acceptable sampling reporting schedule
shall be followed.
2. The Permittee shall submit an Injection Event Record within 30 days of completing each
injection.
3. The Permittee shall produce a final project evaluation within 9 months after completing all
injection -related activity associated with this permit or produce a project interim evaluation
before submitting a renewal application for this permit. This document shall assess the
injection projects findings in a written summary. The final project evaluation shall also
contain monitoring well sampling data, contaminant plume maps and potentiometric surface
maps.
4. The monitoring results and the final project evaluation shall be submitted to:
and to:
Aquifer Protection Section-UIC Staff
DENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
Aquifer Protection Section
DENR-DWQ Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Permit No. WI0400110 PAGE 4 OF 6
ver.8107 APfUIC-6

5. The Permittee shall report by telephone, within 48 hours of the occurrence or first knowledge
of the occurrence. to the Winston-Salem Regional Office. telephone number [phone],
any of the following:
(A) Any occurrence at the injection facility which results in any unusual operating
circumstances;
(B) Any failure due to known or unknown reasons, that renders the facility incapable of
proper injection operations. such as mechanical or electrical failures.
6. Where the Permittee becomes aware of an omission of any relevant facts in a permit
application, or of any incorrect information submitted in said application or in any report to
the Director, the relevant and correct facts or information shall be promptly submitted to the
Director by the Permittee.
7. In the event that the permitted facility fails to perform satisfactorily, the Permittee shall take
such immediate action as maybe required by the Director.
PART VIII - PERMIT RENEWAL
In order to continue uninterrupted legal use of the injection facility for the stated purpose, the
Permittee must submit an application to renew the permit 120 days prior to its expiration date.
The Pei, ittee shall provide written notification within 15 days of any change of status of an
injection well. Such a change would include the discontinued use of a well for injection. If a
well is taken completely out of service temporarily. the Permittee trust install a sanitary seal.
If a well is not to be used for any purpose that well must be permanently abandoned
according to 1 SA NCAC 2C .0113, Well Construction Standards.
2. When operations have ceased at the facility and a well will no longer be used for any
purpose, the Permittee shall abandon that injection well in accordance with the procedures
specified in 15A NCAC 2C .0113(b). including but not limited to the following:
(A)All casing and screen materials may be removed prior to initiation of abandonment
procedures if such removal will not cause or contribute to contamination of the
groundwatem.
(B) The entire depth of each well shall be sounded before it is sealed to insure freedom
from obstructions that may interfere with sealing operations.
(C) The well shall be thoroughly disinfected, prior to sealing, if the Director determines
that failure to do so could lead to the contamination of an underground source of
drinking water.
Permit No. W10400110 PAGE 5 OF 6
ver.8/07 AP/UIC-6

(D ) Drilled wells shall be completely filled with cement grout, or bentonite grout which
shall be introduced into the well through a pipe which extends to the bottom of the
well and is raised as the well is filled.
t E 7 In the case of gravel -packed wells in which the casing and screens have not been
removed, neat -cement, or bentonite grout shall be injected into the well completely
filling it from the bottom of the casing to the top.
(F) In those cases when, as a result of the injection operations, a subsurface cavity has
been created, each well shall be abandoned in such a manner that will prevent the
movement of fluids into or between underground sources of drinking water and in
accordance with the terms and conditions of the permit.
(G) The Permittee shall submit a Well Abandonment Record (Form GW-30) as specified
in 15A NCAC 2C .0213(h)(1) within 30 days of completion of abandonment.
3. The written documentation required in Part IX (I) and (2) (G) shall be submitted to:
Aquifer Protection Section-UIC Staff
D ENR-Division of Water Quality
1636 Mail Service Center
Raleigh, NC 27699-1636
PART X — WORKER PRECAUTIONS DURING APPLICATION
1. Some effects reported to be associated with the product proposed to be used are as follows:
eye, skin, nose, throat, and lung irritation. If the product is released into the environment in a
way that could result in a suspension of fine solid or liquid particles (e.g., grinding, blending,
vigorous shaking or mixing), then proper personal protective equipment should be used. The
application process should be reviewed by an industrial hygienist to ensure that the most
appropriate personal protective equipment is used.
2. Persons working with these products should wear goggles or a face shield, gloves, and
protective clothing, Face and body protection should be used for anticipated splashes or
sprays.
3. Eating, drinking, smoking, handling contact lenses, and applying cosmetics should not be
permitted in the application area during or immediately following application.
4. Safety controls should be in place to ensure that the check valve and the pressure delivery
systems are working properly.
5. The Material Safety Data Sheets should be followed to prevent incompatible or adverse
reactions and injuries.
Permit No. W10400110 PAGE 6 OF 6
ver.8107 AP/MC-6

Shrestha. Shristi R
From: Shrestha, Shristi R
Sent: Friday, August 25, 2017 12:59 PM
To: '[e-mail]'
Subject: WI0400110 Dynamic Capital Mortgage Inc
Good afternoon,
We are in the process of closing our expired permit and it looks like dynamic Capital Mortgage Inc site with the
permit number WT0400110 is also in the list. Our records show that the permit expired 08/31/2012. While going
through our records I found a Status resort for August 2011. If you have any other reports or monitoring results for the
site please send it to me by email or regular mail. If you want to rescind the permit I would need a permit rescission
request from the owner which can be in the form of an email too.
Please contact me at the number below if you have any questions or concerns regarding this. Thank you for your
cooperation.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shresthaCci)-nedenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email cormspondence to and from this address is subjecr to the
North Carolina Pubtic Records Law and may be disclosed to third parties.

5I Final Project Evaluation (FPE) Checklist
Permittee/Applicant: 'tyl -ttt acid
Permit No.: WI 0 4 C) c> r 10
Reviewer: S
Date: V 1_2 5-1/2-0 ► -
1. Permit issued date: /G J 1?-/ J t f I Expiration date: F 3 f Z D 1
2. BIMS: Check to see if there is a current renewal Application for this permit number under
review or newer permit issued (search by facility address). if this is case, no FPE is needed at
this time. t�l
3. Intent of Permittee for this site (i.e., permit complete and no further injection activities planed,
future injection activities are planned, permit to be renewed,
etc.):
4. FPE or equivalent received? IF rec'd: S 1 Z 9 j 2- Q 1► . If FPE or Al is needed, date
sent: A f 2 S r . Date received: S f z q/ z U I l
5. Proposed monitoring reports received for most part?
6. Proposed sampling frequency complied with (e.g, monitored for 4 quarters)? D +V►�'�
7. Proposed parameters analyzed?
8. Any clear evidence of daughter products? MA If evident, RO may want to review.
9. GW-ls or equivalent received? `� Date: -e `As Built' well construction info
entered into BIMS. S t_, Date: ��,,,��r►e� J� � rt fie i�
14. Status of injection wells (i.e., active- to be use as monitoring wells, abandoned,
etc.)Afn Et.IU4�1�
11. if abandoned, GW-30s Records received? Date: Status entered/changed into
RIMS? Date:
12. (Note- if we have not received. GW- I s130s for DPT wells, and obtaining these records is
problematic, injection well status forms (GW-68) may suffice. Bottom line, we need some
kind of a record, even e-mail from the Permittee/consultant, with info on when the well points
were plugged.)
13. Any outstanding NOVs in BFMS? nl
14. Completion Letter Sent date: RIMS updated- `Permit Completed'_
Notes:
Revised 9-20-2016

Application Reviewer:
Pre -Review; Conducted? C!fj Yes ❑ No
O.K. to Process? JE Yes ❑ No
If No, What Action Is Needed? ❑ Pre -Review Return
❑ Hold, Pending Receipt of Addinfa.:
Dame/Affiliation of Person Contacted:
Date(s) of Contact: ❑ By Phone ❑ By E-Mail ❑ By Letter
Owner: EF Existing ❑ unknown Owner Tjpe JE Non -Gov't (D Ind. or © Org) ❑ Goy. -Municipal
Facilirv/Operation: ❑ Proposed ❑ Existing
Regulated Activities:
AnplicationfPermit:
Permit Type:
❑ Injection Water Only GSHP Well System (5QW)
❑ Injection Mixed Fluid GSHP Well System (5QM)
❑ Injection Tracer Well OT)
❑ Injection Experimental Technology (5X251
Project Type: ❑ New ❑ Major Mod.
Notes:
❑ Gov. -County ❑ Gov. -State ❑ Goy. -Federal
❑ Facility ❑ Operation
Injection In situ Groundwater Remediation Well (511
❑ Injection Heating/Cooling Water Return Well (5A7)
❑ Injection Other Wells (5Z)
❑ ln}ection Aquifer Recharge (5R.21)
❑ Minor Mod. ® Renewal ❑ Renewal w.' Mod.
FORM: BIMS 1010 '2007
'101 U y �)U I I
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