WI0600228_Permit (Issuance)_20210219

RECEIVED
FEB 0 5 2021
1&ina Department of Environmental Quality — Division of Water Resources
F'!R7'mtJn'R+�.
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. This forma shall be submitted at least 2 WEEKS prior to iniectiion.
AQUIFER TEST WELLS (isit 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 .122Sl or TRACER WELLS (I5A NCAC 02C. 0229):
1) Passive Injection Systems - In -well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small -Scale Injection Operations — 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 Was - 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: 1-18 20 21
PERMIT NO. W I0600228 (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well..: , ,,,,...:..<;..,;.;..,,,..... ....Complete sections B through F, K, N
(2) Aquifer Test Well.;. ,.,,. e., .Complete sections B through F, K, N
(3) X Passive Injection System..... .Complete sections B through F, H-N
(4) 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
B. STATUS OF WELL OWNER: Business/Organization
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(s): SECU RE Southeast : Attn: Michael Canadv
Mailing Address: 651 Executive Place
City: Fayetteville State: NC Zip Code: 28305 County: Moore
Day Tele No.: [phone] Cell No.: .: [phone]
EMAIL Address: [e-mail] _ Fax No.:
Deemed Permitted GW Remediation NO! Rev. 3-1-2016 Page 1

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: same
Company Name
Mailing Address:
City: Raeford State: NC Zip Code: County
Day Tele No.: Cell No.:
EMAIL Address; Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Finn)
Name -and .Title: Thomas W. Witner. P.G. Environmental Group Leader..
Company Name Shield Engineering, Inc,,._
Mailing Address: 4301 Taggart Creek Road
City: Charlotte State: NC Zip Code:.28208 County: Mecklenburg
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address: twitnerAshieldengineering.com Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: 4994 Philippi Church Road
City: Raeford:
County: Hoke Zip Code: 28376
(2) Geographic Coordinates: Latitude**: " or 34 °.9700- :N
Longitude**: ° " or 79 °.0985 S
Reference Date: Accuracy:
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: 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)
H. INJECTION ZONE MAPS — Attach the following to the notification. (Figures 1, 2, and 3)
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
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.
Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 2

I. 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.
A release -of approximately 110 gallons of home _heating, oil from :i damaged suPp v line froth an exterior ho nie>
heating oil aboveground storage tank located on the property has impacted subsurfacegroundwater above the
15A NCAC 2L .0202:groundwater _quality standards, The use of OSOXTM (Calcium peroxide or equivalent).
in MW-1 is planned to enhance the degradation of petroleum contaminant levels in the groundwater.
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:"httpf/deg:ne:gov/about/divisions/water-
resourcesfwaterresources-permit/wastewater-branehlgroundywater rotection//round-water-approved4n[ectants..
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info
(919-807-6496).
Injectant:. Calcium Peroxide .in solid .fprrn .by sock of chemical in.monitor wells, for oxygen
Volume of injectant: Varies, by diffusion. .1.74...lb:EHC-OTM or. 0.261.lb-.Oxygen . per well ..-.....:.
Concentration at point of injection: 10-40 mg/1..
Percent if in a mixture with other injectants: Calcium peroxide 45 70%, Calcium I3v ll'oxide .`10 20%n,
Sodium, Calcium Aluminosilicate.. Hydrated 20-30%
Injectant:
Volume of injectant::
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: Proposed 1 Existing (provide GW-1s) (A
(2) For Proposed wells or Existing wells not having GW-1 s, 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
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 3

Well
MW-1
Date
Installed
2/8/2008
Grout
Type (ft-bls)
Permanent
Monitoring
Well
0-1ft
Portland
Bentonite
Screen
(ft-bls)
5-15ft
Casing -
Length
(ft-bls)
2in PVC
0-5ft
Well
Contractor
Geologic
Exploration,
INC.
Cert. #
28625
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Passive oxygen releasing 0S0XsTM will be placed into the existing well MW-1 following receipt of the
notification permit .number from NCDEO to prornote efforts: in elevating D0: levels.
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.
The injection of oxygen is not expected to result in violations of the 2L Standards. The monitor wells will be.
.samgied on.a regular basis:..
N. SIGNATURE OF APPLICANT AND PROPERTY 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 ar urIerzances in, ance with the 1 SA MCA' 02C 0200 Rules." 't!P So.rf'l,2es.
C6-w44E /h. �� SEC w-
Signature of Appli t Print or Type Fidi Name and Title
Pl OPERTY OWNER (if the propel is hammed by the permit trppldarft) ;
"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 (ISA 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.
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 ofa signature on this form.
RECEIVED
FEB 0 5 2021
NC DEQ/DWR
Central Office
Submit the completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 4

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RECEIVED
aFEB 0 5 2021
/
MW-5
(NS)
WATER SUPPLY WELL
(ABANDONED)
MW-4
— (NS)
MW-1
(23:3)
MW-3®
(t4S)
Si•
MW-6,
(Ns)
ATER
ETER
x—�
HEATING \013
OIL AST
rt
MW-Z4
(NS)
LEGEND
• MONITORING WELL
TEMPORARY MONITORING WELL
WATER SUPPLY WELL - ABANDONED
us&L MICROGRAMS PER LITER
23.3 RED VALUE EXCEEDS NCDEQ
NCAC 2L STANDARDS
(NS) NOT SAMPLED
NAPHTHALENE ISOCONCENTRATION.
(ug/L)
NOTE:
1. GROUNDWATER SAMPLES COLLECTED ON 09/03/2020.
2. ALL LOCATIONS ARE APPROXIMATE.
3. MW-1 TO BE USED AS INJECTION WELL.
GRAPHIC SCALE
SCALE: Yin. = 20 R.
SHIE
ENGINEERING, INC.
(*MK ROAD
akr:ngraienv com
CONTAMINANT OF CONCERN CONCENTRATION
MAP - GROUNDWATER:
KRIS KELTON RESIDENCE
4994 PHILIPPI CHURCH ROAD
RAEFORD, NORTH CAROLINA
'SHIESILD11 40728S0
DATE : ___ 11/13/20
DRAWN BY : KJC
SCALE : AS SHOWN
FIGURE : 1
NC DEQ/DWR
Central Office

0
z
0
J
W
m
3
0
A MW-6
GROUND SURFACE
MW-3
MW-1
•
—•TD 15'
TAN# BROWN FINE TO MEDDIUM:SAND •
GRAY, ORANGE, TAN CLAYEY SAND
TAN, ORANGE FINE TO MEDIUM SAND
WATER SUPPLY WEIL
(ABANDONED)
A -A' PROFILE LOCATION
14 ETER
GRAPHIC SCALE
10 10' 30 40
SCALE: 1 In. > 40 It.
TD 15'
•
TD 15'
LEGEND___
. STATIC WATER LEVEL (9.3-20)
MW-1 MONITORING WELL LOCATION
SCREENED INTERVAL
EXTENT OF NAPHTHALENE PLUME
NOTE:
1. MONITORING WELL MW-1 IS PROPOSED INJECTION
WELL.
10'
10'
SCALE
A'
gilt SHIELD N4 CREEK
ENGINEERING, INC., �w.n roQao, G,wum
CROSS SECTION A -A'
KRIS KELTON RESIDENCE
4994 PHILIPPI CHURCH ROAD
RAEFORD, NORTH CAROLINA
SHIELD # 4072B50
DATE : 12/01/20
DRAWN BY :
KJC
r
SCALE : AS SHOWN
FIGURE :
2

GROUNDWATER
MW-5 •
(95.24)
WATER SUPPLY WELL
(ABANDONED)
MW-6
(93.21)
MW-4
(97.46)
W3"�•
(94.97)
1
ATER
ETER
/ MW-2
(94.56)
/
x
HEATING
OIL AST -13
l P�
V.
N
LEGEND
(19 MONITORING WELL
TEMPORARY MONITORING WELL
FENCE
WATER SUPPLY WELL - ABANDONED
0
(98.40)
(NM)
GROUNDWATER ELEVATION (FEET)
GROUNDWATER ELEVATION CONTQUF
LINE (FEET)
GENERAL GROUNDWATER FLOW
DIRECTION
NOT MEASURED
NOTE:
1. INJECTION WELL LOCATIONS MEASURED BY SHIELD
PERSONNEL IN THE FIELD.
2. ALL LOCATIONS ARE APPROXIMATE.
3. CONTOUR INTERVAL - 1 FOOT.
4. GROUNDWATER ELEVATIONS MEASURED 09/03/20.
GRAPHIC SCALE
SCALE: 1 in. = 20 ft.
I
illitSHIELD1041044013
8CREEK ��
ENGINEERING.INC. 704-304•0114e ma
"" 0101denottoesin°°^
GROUNDWATER ELEVATION CONTOUR MAP
t09/03/20)
KRIS KELTON RESIDENCE
4994 PHILIPPI CHURCH ROAD
RAEFORD, NORTH CAROLINA
SMEW it 4072850
DATE : 09/11/20 DRAWN BY : KJC
SCALE : AS SHOWN FIGURE 3