WI0400562_Permit (Issuance)_20210113

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ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
December 23, 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
Langley Tire Service
113 S. Staley Street
Staley, Randolph County, North Carolina
NCDEQ Incident #13623
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 the North Carolina Department of
Environmental Quality State -Lead Program. 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.
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Hassan Osman, Hydrogeologist for NCDEQ
Attachments

Notice of Intent to Construct or Operate Injection Wells
Langley Tire Service, Staley, North Carolina
NOTICE OF INTENT FORM
�ATC
E>tE�RONMEN1AL • OEUMMI011
N1111GISG iE1UM • WIMILMSI N6

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: December 23 , 20_20_ PERMIT NO. W 10400562 (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. WI
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: State Government
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 1

C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name: Hassan Osman — Hydrogeologist, North Carolina Department of Environmental Quality
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27699-1646
County: Wake
Day Tele No.: 919-707-8167 Cell No.:
Not Available
EMAIL Address: hassan.osman(&ncdenr.gov Fax No.: Not Available
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Theresa Robbins Ballew
Company Name Not Applicable
Mailing Address: 4305 Bridle Path Court
City: Fredericksburg State: VA Zip Code: 22408
County: Not Applicable
Day Tele No.: 540-710-1666 Cell No.:
Not Available
EMAIL Address: Not Available Fax No.:
Not Available
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name: Ashley M. Winkelman — ATC Associates of North Carolina, P.C.
Mailing Address: 2725 E. Millbrook Road, Suite 121
City: Raleigh State: NC_ Zip Code:27604
County: Wake
Day Tele No.: 919-871-0999 Cell No.: 919-830-3576
EMAIL Address: ashlev.winkelman(a.atcgs.com Fax No.: 737-207-8261
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Langley Tire Service
113 S. Staley Street
City: Staley County. Randolph Zip Code: 27355
(2) Geographic Coordinates: Latitude": ° " or 35 0.79577
Longitude": 0 1" or 79 0. 55112
Reference Datum: WGS84 Accuracy: 10-meter
Method of Collection: DOQ — Acme Mapper 2.2
"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
Land surface area of inj. well network:
square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 2

l"
I.
J.
1N
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
Included in the Figures section. Note that soil maps are not available.
(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.
Cross -sections have not been prepared for this site.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing and
proposed wells.
Included in the Figures section.
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 three Provect ORS sleeves in monitoring well MW-1 in order to aide in natural attenuation and
reduce compounds concentrations to below the North Carolina Groundwater Quality Standards (2L Standards).
Based on the most recent samplin event in March 2020, the following compounds exceeded the 2L
Standards: benzene at 1.3 micrograms per liter (Vg/Q. The sleeves come in 3-foot sections. ATC will install
three 3-foot section at the base of the well, across the well screen. The sock will release oxidizing solids into
the groundwater for approximately 6 months, at which point the chemicals in the socks will have depleted.
WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 1 Existing (provide NC Well
Construction Record (GW-1) for each well) Included in Appendix B
(2) Appx. injection depths (BLS): 31 -40
(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
INJECTION SUMMARY
NOTE: Only injectants approved by the epidemioloy section of the NC Division of Public Health, Department
of Health and Human Services can be injected. Approved iniectants can be found online at
http: //deq.nc. gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 3

Contact the UIC Pro am or more in�if you wish to get approval or a different additive However 1p ease
note it may take 3 months or loner
Injectant: Provect ORS Sleeves Total Amt. to be injected (gal)/event: 1,038 in3 (volume of sleevesZ
Amt. Water to be injected (gal/event):
Total Amt. to be injected (gal/event):
N/A
1,038 in3 (volume of sleeves)_
No. of separate injection events:l Est. Total Amt. to be injected (gal): 1,038 in3 (volume of
sleeves
Source of Water (if 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.
Approximately 6 months after the installation of the Provect ORS sleeve in MW-1 ATC will collect a sample
from the well for analysis of volatile organic compounds by EPA Method 6200B The sample will be shaped
to Pace Analytical in Mt. Juliet, Tennessee. ATC will also measure dissolved oxygen conductivity erp ature
pH, and oxygen reduction potential in MW-1 during the sampling event.
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 submittingfalse information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all •elated appurtenances in accordance with the I SA NCAC 02C 0200 Rules. "
Ashley Winkelman on behalf of Hassan Osman NCDEQ
Signature of Applicant Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection wells) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection wells) conform to the Well Construction Standards
(1 SA NCAC 02C . 0200). "
"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 A_p_pendix C Theresa Robbins Ballew
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.
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 4

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 Remediation NOI Rev. 2-14-2020 Page 5

Ashley Winkelman
From: Osman, Hassan <[e-mail]>
Sent: Monday, December 21, 2020 10:08 AM
To: Ashley Winkelman
Subject: [EXTERNAL] Langley Tire Service # 13623
[External Email] This email originated from outside of the Atlas mail system. Please use caution when
opening attachments.
Hi Ashley:
ATC Associates is granted/approved a permission to act as an agent for NCDEQ to sign a notification for UIC.
Thanks
Hassan
Has sari 0-sman
H'.0geo?ogistr LIST
�D
Worth Carohna Department ofETIV=i umennUd Quabty
D E
19.707. 167 (Office)
Hassan.Osm�@acdmu.gov
Erwk ca spored yr ce ro and from 1ho address is s bject tc Me
Nwh ft:dI as Pc.rbk Records Law -and may be dIsr o.Sed to owd wt e.s.

Notice of Intent to Construct or Operate Injection Wells
Langley Tire Service, Staley, North Carolina
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LEGEND
MONITOR WELL LOCATION
WATER SUPPLY WELL LOCATION
® TEMPORARY WELL LOCATION (FEB. 18, 2020)
IMAGE SOURCE: NC ONEMAP, DATED 2014
0 40
GRAPHIC SCALE
80
(IN FEET)
a
III S
SITE MAP
Site ID:13623
SCALE:
FIGURE NO.
AS SDHOWN
2
LANGLEY TIRE
113 S. STALEY STREET
STALEY, RANDOLPH COUNTY, NORTH CAROLINA
MARCH 2O20
PROJECT NUMBER
4305-18-077B

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LEGEND IMAGE SOURCE: NC ONEMAP, DATED 2014
MONITOR WELL LOCATION
(76.77) GROUNDWATER ELEVATION
- - -GROUNDWATER CONTOUR
GROUNDWATER FLOW DIRECTION
GROUNDWATER MEASURED MARCH 9, 2020
(NM) NOT MEASURED
0 40
80
GRAPHIC SCALE
(IN FEET)
a
GROUNDWATER ELEVATION MAP
Site ID: 13623
SCALE:
FIGURE NO.
AS SDHOWN
3
LANGLEY TIRE
MARCH 2O20
PROJECT NUMBER
Ill S
113 S. STALEY STREET
4305-18-077B
STALEY, RANDOLPH COUNTY, NORTH CAROLINA

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TW-1 p9/L
2—Butanone 13
Acetone 9.7 J
Benzene 0.18 J
Tetrachloroethylene 0.59
Toluene 0.32 J
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p9/L
1,2,4— Trim ethylbenzene
2.3 .
1,3,5— Trim ethylbenzene
2.0 M�
Benzene
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Ethylbenzene
17
Isopropylbenzene
3.8
Total Xylenes
4.8
Naphthalene
38
n—Butylbenzene 0.45
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n—Propylbenzene
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p—Isopropyltoluene
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sec—Butylbenzene
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Toluene
1.0
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• 77
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MW-2
No Results Detected
MW-3 p9/L �,� . .1• > .' • .. .
No Results Detected
LEGEND
® MONITOR WELL LOCATION
SAMPLES COLLECTED JANUARY 9, 2019
pg/L - MICROGRAMS PER LITER
J - ESTIMATED CONCENTRATION
NOTES:
• VALUES SHOWN IN BOLD EXCEED NCAC 2L STANDARDS
• ANALYTICAL METHOD: 6200B
• SAMPLE DATES: FEBRUARY 18, 2020 (TW-1)
MARCH 9, 2020 (MW-1, MW-2, MW-3, MW-4)
0 40 80
GRAPHIC SCALE (IN FEET)
IMAGE SOURCE: NC ONEMAP, DATED 2014
a
111 S
GROUNDWATER CONSTITUENT MAP
Site ID:13623
SCALE:
FIGURE NO.
AS SDH�OWN
4
LANGLEY TIRE
113 S. STALEY STREET
STALEY, RANDOLPH COUNTY, NORTH CAROLINA
MARCH 2O20
PROJECT NUMBER
4305-18-077B

Notice of Intent to Construct or Operate Injection Wells
Langley Tire Service, Staley, North Carolina
APPENDIX A
MSDS FORM
�ATC
E>tE�RONMEN1AL • OEUMMI011
N1111GISG iE1UM • WIMILMSI N6

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
Langley Tire Service, Staley, North Carolina
APPENDIX B
MONITORING WELL CONSTRUCTION DETAILS
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Notice of Intent to Construct or Operate Injection Wells
Langley Tire Service, Staley, North Carolina
APPENDIX C
ACCESS AGREEMENT FROM SITE PROPERTY OWNER
�ATC
E>tE�RONMEN1AL • OEUMMI011
N1111GISG iE1UM • YE1ENlNEFE5HN6

�NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WASTE MANAGEMENT
MICHAEL F. EASLEY, GOVERNOR NCDENR
William G. Ross Jr., SECRETARY NORTH CAROLINA DEPARTMENT OF
FNI-NMVNT - Ns Al RFcn1-111
Dexter R. Matthews, DIRECTOR
UNDERGROUND STORAGE TANK SECTION
Herb Berger Post -it® Fax Note 7671 Date 3 ��oQ pages►
To From
Hydrogeologist
DWM UST Section Co./Dept. Co. � (A—
s
1637 Mail Service Ctr Phone # f'Q r Phone #
Raleigh, NC 27699-1637 Fax# Fax#
=ern
RE: Former Langley Tire Service
113 South Staley Street
Staley, Randolph County NC
DWM Incident #13623
Dear Mr. Berger:
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and hereby
permit the Department of Environment and Natural Resources (Department) or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of G. S. 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and is
a public record, in accordance with North Carolina G.S. 132-1.
DIVISION OF WASTE MANAGEMENT/UST SECTION
1637 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA 27699-1637
PHONE: [phone] FAx: [phone]
INTERNET: htt,,://www.wastenot.enr.state.nc.us
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/10% POST -CONSUMER PAPER

6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the land owner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
I'hebbl /rev
Type/Print Name of Owner or Agent
Phone Number
Address
rea6en%�s dw� V� zz.�rag
City/State/Zip Code
�dd8 co `H,
Date,