WI0400563_Permit (Issuance)_20210129

North Carolina Department of Environmental Quality — Division of Water Resources
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 15A 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 .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (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 are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: Jan 18 , 20_21 PERMIT NO. W10400563 (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(1) Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well .Complete sections B through F, K, N
(3) Passive Injection System Complete sections B through F, H-N
(4) X Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through N
(6) Tracer Injection Well Complete sections B through N
STATUS OF WELL OWNER: State Government
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): NCDEQ-DWM, UST Section, Federal & State Lead Program Attn: Linda Blalock
Mailing Address: 1646 Mail Service Center
City: Raleigh
State: NC Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8165
EMAIL Address:
linda.blalock(&,,ncdenr. gov
Cell No.: NA
Fax No.: 919-571-4718
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title:
Company Name
Mailing Address:
William S Newman (deceased 1-11-2020) and Dana Newman Sigmon
2100 Oak Ridge Road
City: Oak Ridge State: NC_ Zip Code: 27310 County: Guilford
Day Tele No.: Cell No..
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: G. Matthew James, P.G., Project Manager
Company Name WithersRavenel, Inc.
Mailing Address: 115 MacKenan Drive
City: Cary State: NC Zip Code:27511 County: Wake
Day Tele No.: 919-238-0335 Cell No.:
EMAIL Address: [e-mail] Fax No.: 919-467-6008
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Oak Ridge Gas Mart; 2105 Oak Ridge Road
City: Oak Ridge County: Guilford Zip Code: 27310
(2) Geographic Coordinates: Latitude**: " or 36.170565 °
Longitude**: " or -79.993835 °
Reference Datum: Google Earth Accuracy: +/- 5m
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: 100,000 square feet
Land surface area of inj. well network:—10,000 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 30-50% (must be < 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 2

DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
Purpose: Elimination of free -phase petroleum product on groundwater surface at site
Scope: Injection of EnviroClean surfactant into six existing monitoring wells (MW-1, MW-2, MW-9, MW-24,
MW-25, MW-26) followed by the performance of a surfactant enhanced recovery event (Mobile Multi -Phase
Extraction).
Goals: Reduction of source area contamination through removal of free -phase and dissolved -phase petroleum
contamination with the aid of surfactants.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-inj ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: EnviroClean Surfactant
Volume of injectant: 2,800 Gallons (55 gallons EnviroClean diluted with water to 2% solution)
Concentration at point of injection: 2% Mixture with potable water
Percent if in a mixture with other injectants: 2% EnviroClean, 98% potable water
Inj ectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: 0 Proposed 6 Existing (provide GW-1s)
(2) 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):
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
1) Following gauging of free product thickness in monitoring wells MW-1, MW-2, MW-9, MW-24, MW-25,
and MW-26 complete injection of EnviroClean Surfactant into each well.
2) Approximately 1-week following injection activities, perform surfactant enhanced 96-hr MMPE event on
monitoring wells MW-1, MW-2, MW-9, MW-24LMW-25, and MW-26.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
1) Gauge and sample monitoring wells MW-1, MW-2, MW-9, MW-24, MW-25, and MW-26 four months
following completion of injection/MMPE event
2) If Free Phase Product is detected following the injection and MMPE event, additional surfactant enhanced
recovery events will be conducted.
3) Monitor site annually until incident closed.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: `I hereby certify, 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."
d'o/tio th_pty(-
Laura Elliott, Agent for NCDEQ-DWM
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 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 NCDEQ STATE -LEAD ACCESS AGREEMENT FOR PROPERTY
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 his 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. 1-06-2021 Page 4