WI0100507_DEEMED FILES_20181017

1)~ vvi.t>JOOSO~
hart ;! hickman
Via FedEx Overnigh t
October 15, 2018
NCDEQ
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Attention: Ms. Shristi Shresthar
Re: Injection Event Record
Former Sugar Hill Truck Stop
2855 Sugar Hill Rd
Marion, North Carolina
Incident No. 41115
Injection Permit WI0100507
H&H Job No. CEI-002
Dear Ms. Shresthar:
SMARTER ENVIRONMENTAL SOLUTIONS
,t.CE\VED/NCDEQIO~ ·
OCT 1 7 2018
Water Quality Regional
Operations SectioT'
On behalf of Carolina Energies, Inc., Hart and Hickman, PC (H&H) is submitting the enclosed
Injection Event Record for the referenced facility.
If you have any questions or need further information, please do not hesitate to contact me at
704-887-4606.
Sincerely,
Hart & Hickman, PC
~2
Stephen R. Libbey, PG
Project Manager
Enclosure
2923 South.Tryon Street, Suite 100
Charlotte, NC 28203
704.586.0007 main
3334 Hillsborough Street
Raleigh, NC 27607
919.847 .4241 main
www.harthickman.com
.D~ V\)-::u}/0050}-
Via US Mail
October 10, 2019
NCDEQ
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Attention:· Ms. Shristi Shrestha
Re: Injection Event Record
Former Sugar Hill Truck Stop
2855 Sugar Hill Rd
Marion, North Carolina
Incident No. 41115
Injection Permit WIOl 00507
H&H Job No. CEI-002
Dear Ms. Shrestha:
hart '$ hickman
SMARTER ENVIRONMENTAL SOLUTIONS
R~rlBfri~R
:PCT1lti2MJJ -~
On behalf of Carolina Energies, Inc., Hart and Hickman, PC (H&H) is submitting the attached
Injection Event Record for the referenced facility.
If you have any questions or need further information, please do not hesitate to contact me at
704-887-4606.
Sincerely,
Hart & Hickman, PC
~?
Stephen R. Libbey, PG
Project Manager
Enclosure
2923 South Tryon Street, Suite 100
Charlotte, NC 28203
704.586.0007 main
3921 Sunset Ridge Rd, Suite 301
Raleigh, NC 27607
919.847.4241 main
www.harthickman.com
North Carolina Department of Environmental Quality - Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0100507
I. Permit Information
Carolina Energies, Inc
Permittee
Former Sugar Hill Truck Stop
Facility Name
2855 Suvar Hill Road, Marion, McDowell
County, NC
Facility Address (include County)
2. Injection Contractor Information
Hart & Hickman, PC
Injection Contractor / Company Name
Street Address 2923 South Trvon Street
Charlotte
City
NC
State
[phone]
Area code - Phone number
28203
Zip Code
3. Well Information
Number of wells used for injection 6
Well IDs AS-1 throuF: iAS-6
Were any new wells installed during this injection
event?
❑ Yes No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
LI Hand -Augured ❑ Other (specify)
Please include a copy of the GW-J formfor each
well installer
OM 14 2019
,.
Were any wells abandoned dg,1; 4ectiqn
event?
•
❑ Yes
No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include a copy of the GW-30 for each well
abandoned.
4 Injectant Information
Ambient Air
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration NA
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal) NA
Volume Injected per well (gal) continuous ca 2.6 to
2.8 cfin per well durint event
5. Injection History
Injection date(s) 9/23/19-9/27/19
Injection number (e.g. 3 of 5) 4 of 6
Is this the last injection at this site?
❑ Yes ® No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON TI-IIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
SIGNATURE OF INJECTION CONTRACTOR
Stephen Libbev for Hart & Hickman. PC
DATE
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection_
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Forrn UIC-IER
Rev. 3-1-2016

Via Email
March 20, 2019
NC DEQ
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Attention: Ms. Shristi Shrestha
Re: Injection Event Record
Former Sugar Hill Truck Stop
2855 Sugar Hill Rd
Marion, North Carolina
Incident No. 41115
Injection Permit WI0100507
H&H Job No. CEI-002
Dear Ms. Shrestha:
111
hart sNE hickman
SMARTER ENVIRONMENTAL SOLUTIONS
csuitqi
MAR 2 is2019
9�i�'i►rysl LAALvtr
ar.rfbn
On behalf of Carolina Energies, Inc., Hart and Hickman, PC (H&H) is submitting the attached
Injection Event Record for the referenced facility.
If you have any questions or need further information, please do not hesitate to contact me at
704-887-4606.
Sincerely,
Hart & Hickman, PC
Stephen R. Libbey, PG
Project Manager
Enclosure
2923 South Tryon Street, Suite 100
Charlotte, NC 28203
704.586.0007 main
3921 Sunset Ridge Rtl, Suite301
Raleigh, NC 27607
919.847.4241 main
www.harthickman.epm

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0lO0507
l ,
2.
3.
Permit Information
Carolina Enersies. Inc
Permittee
Former Sugar Hill Truck Stop
Facility Name
2855 Sugar Hill Road. Marion, McDowell
County. NC
Facility Address (include County)
Injection Contractor Information
Hart & Hickman, PC
Injection Contractor / Company Name
Street Address 2923 South Tryon Street
Charlotte NC 28203
City State Zip Code
[phone]
Area code — Phone number
Well Information
Number of wells used for injection 6
Well I.Ds AS-1 throe th AS-6
Were any new wells installed during this injection
event?
❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
0 Hand -Augured ❑ Other (specify)
Please include a copy of the GW-J form for each
well installed
Were any wells abandoned during this injection
event?
■ ❑ Yes ® No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Please include a copy of the OW-30 for each well
abandoned.
4. lnjeetant Information
Ambient Mr
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration NA
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal) NA
Volume Injected per well (gal) continuous ii' 2,610
2.8 cfm per well during event
5. Injection History
Injection date(s) 2118119-3/1/19
Injection number (e.g. 3 of 5) 3 of 6
Is this the Iast injection at this site?
❑Yes No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
SIGNATURE OF INJECTION CONTRACTOR
DATE
Stephen Libbev for Hart & Hickman. FC
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form tJIC-IER
Rev. 3-1-2016

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0100507
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Sugar Hill Truck Stop
Location Address
2855 Sugar Hill Rd
Marion
Owner
Owner Name
Carolina Energies Inc
Dates/Events
NC
Orig Issue
9/24/2018
App Received
9/12/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28752
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/24/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Asheville
County
McDowell
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Joseph Joplin
PO Box 1569
Forest City
Issue
9/24/2018
Effective
9/24/2018
NC 28043
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Via FedEx Overnight
September 10, 2018
NCDEQ
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Re: NOI Application
Former Sugar Hill Truck Stop
2855 Sugar Hill Rd
Marion, North Carolina
Incident No. 41115
H&H Job No. CEI-002
Dear Sir or Madam:
hart ~ hickman
SMARTER ENVIRONMENTAL SOLUTIONS
On behalf of Carolina Energies, Inc., Hart and Hickman, PC (H&H) is submitting one copy (hard
and on CD) of the Notification of Intent (NOI) to Construct or Operate Injection Wells
application for the above-referenced site.
If you have any questions or need further information, please do not hesitate to contact me at
704-887-4606.
Sincerely,
Hart & Hickman, PC
~?
Stephen R. Libbey, PG
Project Manager
Enclosure
2923 South Tryon Street, Suite 100
Charlotte, NC 28203
704.586.0007 main
3334 Hillsborough Street
Raleigh, NC 27607
919.847.4241 main
www.harthickman.com
North Carolina Department of Environmental Quality-Division of Water Resources
NOTIFICATION OF INfENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitJed by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NC4C 02C. 0200 (NOTE: This form must be received at least 14 DAYS p rior to injection)
AQUIFER TEST WELLS USA N CAC 02c .0220)
These wells are used to inject wicontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .022fil 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 In· ection O perations -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.
Prlnt'Clearly or Type Information. Illegible Suhmitta/s Will Be Returned As Incomplete.
DATE: Sl;Pr JO, .20_!_8_ PERMIT NO. wJ-f)j Oo50r (tobefilledinbyDWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
____ Air Injection Well ...................................... Complete sections B through F, K, N
___ .Aquifer Test Well ....................................... Complete sections B through F, K, N
--~Passive Injection System ............................... Complete sections B through F, H-N
X Small-Scale Injection Operation ...................... Complete sections B through N
-~-Pilot Test ................................................. Complete sections ·B through N
___ Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: Choose an item.
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): {'~<,11vt1 ~'Jt-6 ,GS , :Z..,,C.. .41,v/ do er J i:>1''4/
Mailing Address: ,Zo. (/oY L St? -J
City: Fo/l.£".sr C. /1'-/ State: M-:_ Zip Code: U o c/3 County: tlvrJt,.."&fi>~
Day Tele No.: fz.0-Z ffC-K,Z,.I Cell No.: ________ _
EMAIL Address: JJo euN IP ll~ .. l.PM Fax No.: fL6 --z. 9 8 .. 2,, 3 ,,
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 Page 1
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: -~~/4~--------------------------
CompanyName ____________________________ _
Mailing Address: ____________________________ _
City: ____________ State: __ Zip Code:, ______ County: _____ _
Day Tele No.: __________ _ Cell No.: _________ _
EMAIL Address: ____________ _ FaxNo.: _________ _
E. PROJECT CONT ACT (l'ypically Environmental Engineering Firm)
Name and Title: S77EPH9'.I l,J (/4$( , I-'~ I' /tN Fc:.r MAIV&f ~)'l_
Company Name /./1/(l,r I: t-ft4CAttA:N /J t:.
Mailing Address: Z 9 Z. 3 S r,vn{ TIY/tuJ S T ./ltfl:f1':
City: __c_11/M,""'1[ State: M,. Zip Code: 2 8 z,,o 3 Cowity: .M,t£(J4.,a,y&,11..fit
Day Tele No.: ~-1187 -C( '10~ Cell No.: :Zo 'f--Jt>2 -'-l'-,o't
EMAIL Address: Sl,1:>'"1., ~ hc,Jl,t,~. ~M Fax No.: ________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) FacilityName&Address: ~ l:>U4,'b't. H1,...t_ D(u:.L S,f"b/J
2,~ >"S: Su~.-,...t. Hlt...t-12.o,lf D
City: MA: Pdod County: Mc-Do l.cU::tL Zip Code: 2-8 is 2-
(2) Geographic Coordinates: Latitude**: 1> S"" 0 ~8 '51.''i "or __ 0 • ______ _
Longitude**: CZ.. 0 12.L.' S,.~J"or __ 0 • ______ _
Reference Datum: TA~ e,tc;SJ,J Accuracy:_,MJ-~i...~----
Method of Collection: 4~1£ l:"k:1!-1l-f
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP Willi PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume:_ 2~1 '-/'f~
Land surface area of inj. well network: 3, S: 3 I
Percent of contaminant plume area to be treated: / 3
square feet
square feet 05 10,000 fl:2 for small-scale injections)
(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, 3-21-2018 Page2
L DESCRIPTION OF PROPOSED INIlECTION 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.
Ewa t e r Gb4A I110 41 Ce' tin—Pw+ser 6xrr +c iestl (MMPE )
elekirs Gait bud eV (AR.4MJ A s) , 6t14
CaMinu vary) cam . W ILe 2e rM 01-re c S c-tta-vu to-.
`fl - R-c wi nig A— irk c NNA Ta f2'kc s �7
G acuiD wAti1 itcrrtio 1- (4 Otto CArk4oAci mac'-e.ot.t) Ros s
C b1 JT %M t,►h4i1 a+I] r
J. APPROVED INJE TANTS — 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 htgxlldeq.tte. ovlabouddivisionsiwater-
resourceslwater-resources- errnits/wtiste'ater-branch/ round-water-pt tection4ground-water-approved-injectants.
Alt other substances must be reviewed by the DIMS prior to use. Contact the UIC Program for more info (9I9.-
807-6496).
Injectant: A446104. 4112
Volume of injectant: ^- 3 c fj Pot kiat-
Concentration at point of injection: Ivf i�
Percent if in a mixture with other injectants: Afji4
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 ofinjection welts: Proposed 6 Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having CW-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)
(b)
(c)
Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
Depth below land surface of casing, each grout type and depth, screen, and sand pack
Well contractor name and certification number
Deemed Permitted OW Remethation NO1 Rev. 3-21-2018 Page 3

L. SCHEDULES — Briefly describe the schedule for well constriction and injection activities,
5ePt674i0.ro Ner-eiftis ekel- , AA b Qu#,' rb-n..y
Tlttar�F L 1\ S . —
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 front the injection activity.
r2 iwiDmisd-pot- 5k , &WI- vex-5 CeAravezer2 A5 PA-er
OF el/Les 61 Alit 5 I Tt / 1 W t Th iL i !4 . 51i^ P Lefil f S e-*NDoer
A]PiL r 1Lz Y ave- Apiant 193cLawr / 67I-C L.# Ati/' 1, 4S
arAi de en 1.2.J A-c.11u kJ° -r cr A4T09 ra
tit C4Q S IAA; ti to Le#1144A4 OP 4,trev0 w -iefL
QtPub4r Cr
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Weil Owner/Applicant: "I hereby certify, under penalty of law, that I can familiar with the information
submitted in this docwnent 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 offines 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 !SA NCAC 02C 0200 Rules."
Joseph N. Joplin, President
c t Print or Type Full Name end, Title
Property Owner (tithe property is not owned by the Well Owner/ApplicantZ
"As owner of the property on which the rejection 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 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.
Signature* of Property Owner (if different from applicant) Print or Type Fun 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 -- WC Program
1636 Mall Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted OW Remediation NOI Rev. 3-21-2018 Page 4

70
•MW-1 (SAMIR)
SAMIR'S QUICK
STOP #2
- -- — — _ _ RETALNINQ WALL
MW7�"i3
73 (73.53) AS-1 Siw
AS-2
72 Z
FORMER GAS DISPENSERS
CANOPY
ASPHALT -
LEGEND
SITE PROPERTY BOUNDARY
ADJACENT PARCEL BOUNDARY
APPROXIMATE EXTENT OF UST
EXCAVATION
APPROXIMATE LOCATION OF UST
SYSTEM ON ADJACENT PROPERTY
• MONITORING WELL LOCATION
, GROUNDWATER ELEVATION
05/7118 (FT)
GROUNDWATER ELEVATION
CONTOUR (FT)
NOTE:
APPROXIMATE GROUNDWATER
FLOW DIRECTION
ftew RMG` 1'!o F'/Y►Q
fig
e
FORMER STORE
0
APPROXIMATE
50
FORMER DIESEL
DISPENSERS CANOPY
100
SCALE IN FEET
SHALLOW GROUNDWATER
POTENTIOMETRIC MAP
FORMER SUGAR HILL TRUCK STOP
2855 SUGAR HILL ROAD
MARION, NORTH CAROLINA
hart 'Ns hickman
SMARTER 23i'JIAONMFNTAL SOLUTIONS
2923 South Tryon Stccct-Suite 100
Charlotte, North Carolina 28203
704-586-0007(p) WM-586-0373(f)
License # C-1269 / #C-245 Geology
DATE: 5-29-18
REVISION NO. 0
MONITORING WELLS GAUGED ON 9/21/17.
JOB NO. CEI-002
FIGURE NO. 4

FORMER GAS DISPENSERS
CANOPY
1
t
ASPHALT
▪ -7
LEGEND
SITE PROPERTY BOUNDARY
ADJACENT PARCEL BOUNDARY
• MONITORING WELL LOCATION
® AIR SPARGE WELL LOCATION
(1000) BENZENE CONCENTRATION 05/07/18 (NgfL)
(1,350') BENZENE CONCENTRATION 07/18/17 ()1g/L)
—100— BENZENE ISOCONTOUR OWL)
(DASHED WHERE INFERRED)
AAw�
MW-1
SAMIR'S QUICK
STOP #2
- RETAINING WALL_
1 '
FORMER STORE
APPROXIMATE
50
FORMER DIESEL
DISPENSERS CANOPY
100
SCALE IN FEET
BENZENE CONCENTRATIONS IN SHALLOW
GROUNDWATER MAP
FORMER SUGAR HILL TRUCK STOP
2855 SUGAR HILL ROAD
MARION, NORTH CAROLINA
SMARTER ENVT3.01 1WfalL SOLUTIONS
DATE: 5-29-18
2933 South Tryon Strcct-Suite 100
Charlotte, North Carolina 282203
701-566-0007(p) 704-586.0373M
License it C-12691 11C-2+5 Geology
REVISION NO. 0
JOB NO. CEI-002 FIGURE NO. 5

LEGEND
SITE PROPERTY BOUNDARY
ADJACENT PARCEL BOUNDARY
MONITORING WELL LOCATION
(s,600) MTBE CONCENTRATION 05107I48 (NIL)
(2370') MTBE CONCENTRATION 07I18I17 44L0
—200— MTBE ISOCONTOLIR (nit.)
(DASHED WHERE INFERRED)
1'
1
1
FORMER GAS DIS
ER5�^
OPY
{7en
/
MW-7
AS-10 (''•FOfl ]
-1
AS-20 14.5u01
` AS-50
A 11;,000Y
iD
ASPHALT-
0
APPROXIMATE
50
1
? ? S1
1 (SkMIR)
4
FORMER STORE
100
SCALE IN FEET
MTBE CONCENTRATIONS IN SHALLOW
GROUNDWATER MAP
FORMER SUGAR HILL TRUCK STOP
2855 SUGAR HILL ROAD
MARION, NORTH CAROLINA
hart hickman
SMARTER ENVIRONMENTAL Sot.V110NS
2923 South Tryon Street -Suite 100
Charlotte, North Carolina 20203
701-586.0007(p) 704586-0373(I)
license # C-1269 / #C-2 i Geology
DATE: 5-29-18
REVISION NO. 0
JOB NO. CEI-002
FIGURE NO.6

P4
JJ
co
AS-3 0
W-6
i.
AS-
/ AS-5
AS-6
MW-ID
FORMER GAS DISPENSERS
CANOPY
—ASPHALT--
LEGEND
SITE PROPERTY BOUNDARY
-- ADJACENT PARCEL BOUNDARY
APPROXIMATE EXTENT OF UST
EXCAVATION
APPROXIMATE LOCATION OF UST
L SYSTEM ON ADJACENT PROPERTY
MONITORING WELL LOCATION
A 1 CROSS-SECTION TRANSECT LINE
SAMIR'S QUICK
STOP #2
_ RETAINING WALL
\-FORMER STORE
APPROXIMATE
0 50
FORMER DIESEL
DISPENSERS CANOPY
100
SCALE IN FEET
eawty
CROSS-SECTION LOCATIONS MAP
FORMER SUGAR HILL TRUCK STOP
2855 SUGAR HILL ROAD
MARION, NORTH CAROLINA
hart hickman
SMARTER ENVMONNIENTAL SOLUTIONS
29 5 South Tryon Street -Suite 100
Charlotte, North Camlimr 28203
704-586.0007 W 704-586.0373(
License # C-1269 / #C: 245 Cieo ogy
DATE: 5-29-18
REVISION NO. 0
JOB NO. CEI-002
FIGURE NO. 10

WELL CONSTRUCTION RECORD
This form can be used for single or multiple wells
I. Well Contnctor Information:
MARK IRELAND
Well Contractor Name
A-4163
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Nan1e
2. Well Con~truction Permit#:
Lisi all applit:ab/e well ~m1.r1ntt:lion permil !i (i.e. Co1111(v. s·1a1e, VaJ";ance , etcJ
3. Well Use (check well use);
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Res idential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
OAquifor Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal (Heatin g/Cooling Return) el Other ( explain under #21 Remarks)
,t Date Well(s) Completed: 03/14/18 WelllD# AS-1
~a. Well Loeation:
SUGAR HILL TRUCK STOP
facility/Owner ~ame Facility ID// (ifappli"ableJ
2855 SUGAR HILL ROAD MARION 28752
Physical Address. City, and Zip
MARION
County Paree) Ideutitication No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decill1lll degrees:
(if well field, one lat/long 1s sutlic,ent)
35° 38' 53.83" 82° 01' 59.70" ___________ N ______________ W
6. Is (are) the well(s): 121Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or tnNo
lflhis iJ a repair.fill nut known well ~on.vtruclivn infan,mticm and e.r:plain the nalurl:! of1hc
repair under ;i 21 remarks section or m, the back of th,:i; fm·m.
8. Number of wells constructed: ___ 1 ____ ~----
Por mu//iple in}icliun or non-water .mpply wells ONl Y wilh 1he .\ame cnnstrllcJian. yo11 can
submic am: fi>rm ..
I For Internal Use UNL Y:
14. WATER-.ZONE:S
FROM TO DESCRIPTION
ft. fl.
ft. ft.
15, OUTER CASING (for )Dulti-castd wells I OR LINER (if annlicableJ
FROM I TO I DIAMETER I TIUCK.'iESS I MATERIAL
ft. ft. in.
16. INNER CASING-OR TUBING l•eothermal clused-10011)
JiRO,>I TO DIAME'Tf;R THICKNESS MATERIAL
0.0 ft. 40.0 ft. 2.0 in. SCH40 PVC
ft. ft. in.
J7. SCREEN
FROM TO DIAMETER SLOTSIZE llflCKNESS MATERIAL
40.0 ft. 45.0 ft. 2.0 in. .010 SCH40 PVC
rt. rt. in.
IS. GRO:C,T
FRO'.\! TO MATERIAL EMPLACEMENT METHOD & Al!OUNT
0.0 ft. 36.0 ft. PORTI.ANO 8ENTONrre SLURRY
ft. ft.
ft. rt.
1!1. SAND/GR."' VEL PACK tif applicahl•J
FROM TO MATERIAL EMPLACEI\.I ENT METHOD
38.0 rt. 45.0 ft. 20-40 FINE SILICA SAND
ft. ft.
20. DRJLUN'G LOG (attach additional sfu:ets i:I' r,i,cessa,-)
FROM TO DESCRlr"rJON (('oln1•, hatdness.soA'rock hM, ior.ain size, eh.·.I
0.0 ft. 5.0 ft. RED/BROWN SILT
5.0 It. 45.0 ft. BROWN SILT
ft. ft.
fl. It.
rt. fl.
rt. ft.
ft. rr.
i.1.REMAQKS
BENTONITE SEAL FROM 36.0 TO 38.0 FEET
... AIR SPARGE***
27fC:~d ~ 03/23/18
Signature ofCcni:ficd Well Contractor Date
By .rigning /hi.,• Ji:Jrm, I hert!b)' certify that lh~ wef/(s) 1110s (were) ,·ons1ru~·1ed in ,1cr:ordan,·,:
with 15A NCA<' 02C 0100 or 15A N<'AC 02C .0200 Well Comtruclio11 Siai1d,ml., and 1/,a, o
copy oflhi.'; record has been pro,·idecf 10 /he well 011~ner.
Z3. Site diagram or additional wrll details:
You may use the back of this page to provide additional well site detail~ or well
construction details. You may also attach addih<Hlal pages if necessary.
SUBMITTAL INSTUCTJONS
9. TotJI well depth below land surfacr:· ___ ..,....4_5_· O ________ .(ft.) Z.fa. For All Wells: Submit this fonn within 30 days of completion of well
J-"(lr 11mlliple ll'ell, li.,t a// depths ifd/Qerent (e.wmple-J@JOO' and 2@/01/') construction to the following:
10. Static water level below top of casing: ___ 2_7_-_0 _______ (ft.)
lfworcr Je, el is ahm·e tYJSing. use "-"
11. Borehole dia.rrn,ter: __ 8_._0 ____ (in.)
12. Well construction method: __ A_U_G_E_R __________ _
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SL"PPLY WELLS ONL V:
13a. Yield (gpm) ______ Method oftest: ______ _
Division of Water Quality, Jnformation Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
Z4h. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
constmct,on to the following:
Division of Water Quality, Underground lnjrction Control Program.
1636 Mail Servicr Center, Ralrigh, NC 27699-1636
24c. For Water Supt;lv & Iojution Wells: In addition to sending the form to
the address(es) above. also submit one copy of this form within 30 days of
J3b. Disinfntion type; Amount:_________ completion of well construt.'tion to the cowny health department of the county L~..=..:=::..:..:::..:..::...::::..::..:::..:=======-...:.:::::::.::.::..:=========..l where constructed.
FormGW-1 North Carolina Depmtment of Environment and Natural Resources-Division ofWotcr Quality Rc•isodJan. 2013
WELL CONSTRUCTION RECORD
This furm can be 11sed for single or multiple wells
I For Internal Use ONLY:
I. Well Contraclor Information:
14. WATER ZONES
MARK IRELAND FROM TO DESCIUPTION I
ft. ft.
Well Contractor Name
ft. ft. A-4163
JS. OUTER CASING (for multi-ca$ro.wells) OR.LINER lif aooUcablel
NC Well Contractor Certification Number FROM I TO DIAMETER I TIUCKNESS I MATERIAL
GEOLOGIC EXPLORATION, INC ft. ft. in.
16, INNER CASING OR TUBING teeothennal closed-loonl
Compau)' Name FROM TO DIA'1ETER TH!CK.~F.SS MATERIAL
0.0 ft. 40.0 rt. 2.0 in. SCH40 PVC 2. Well Construction Permit#:
!_.1st all app/icafJlt! well comuruc11011 permits (i.c, County, State, Varitmce, eJc.) ft. ft. in.
3. Well Use (check well use}: J7.SCREEN
FROM TO DIAMETER SLOTSll.E TJIICKNESS MATERIAL
Water Supply Well: 40.0 ft. 45.0 ft. 2.0 in. .010 SCH40 PVC
D Agricultural OMumcipal/Public
ft. rt. in.
;JGeothermal (Heating/Cooling Supply} □Residential Water Supply (single)
□Residential Water Supply (shared} UtGROUT
O Industrial/Commercial FROM TO MATERIAL EMPLACEMENTMETIIOD & AMOUNT
Olrrie.ation 0.0 ft. 36.0 ft. PORTI.ANOB~TONJTE SLURRY
Non-Water Supply Well: ft. ft.
□Monitoring □Recovery
ft. ft.
Injection Well:
□Aquifer Recharge □Groundwater Remediation J9. SAND/GRAVEL PACK lif ;tpplicableJ
FROM TO MATERHI.. EMPLACEMENT METHOD
□Aquifer Storage and Recovery □Salinity Barrier 38.0 ft. 45.0 ft. 20-40 FINE SILICA SAND
□Aquifer Test OStormwatcr Drainage ft. ft.
□Experimental Technology □Subsidence Control 20. DRILLING LOG lalfurb oddilio,10 1 •"'-·•IS if nec.,.sarv)
□Geothermal (Closed Loop} □Tracer FROM TO rn.sc."RlP"l'I ON h'UliJ,, bn,·dnr:S) ,u-iVnid, "-, r..ra11r:,1in. r t'",l
□Geothermal {Heating/Cooling Return) .:JOlher (exp lain under #21 Remarks} 0.0 ft. 5.0 ft. RED/BROWN SILT
03/14/18 AS-2 5.0 ft. 45.0 rt. BROWN SILT
4. Date Well(s) Completed: Well ID# ft. ft.
Sa. Well Location: ft. ft.
SUGAR HILL TRUCK STOP ft. ft.
FacjlitylOwner Name Facilily ID# (if applicable) fL ft.
2855 SUGAR HILL ROAD MARION 28752 ft. ft.
Physical Address, City, and Zip 21,REMARKS
MARION BENTONITE SEAL FROM 36.0 TO 38.0 FEET
Cmuity PaJccl ldonlification No. (PIN) -•AIR SPARGE***
Sb. Latitude and Longitude in degrees/minutes/secondN or dedmal degrees; 22 ( •ri • ~
(if well field. ono Jal/long is sunicient) ,hi 1
:ati~nL ~
35• 38' 53.83" 82° 01' 59.70" /~/C ___________ l'-. ______________ W SignruureoJ'Cerficd We~or 03/23/18
6. ls (arr) the well(s): IL!Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or lllNo
Jj this is a ntpair. fill out known we.II cons1ruclion injbrma1ion am_l explain lhe naurre of the
repair imdt•r ~21 remarks .iec1;011 or on 1he back of ihi:l'ji:>rm. ·
8. Number of wells constructed: --,--,.,.1....,..------,--------
Fm· mull.iple hy·ec:tion·or non-waler supply u•ells ONLY wilh the same crm,\tructUm, you can
.rnbmit one jiJr,~J.
Dale
By si1:,rning lhis form, I hereby ,·ertif.V that the well(s) n·c1s (w~re) constru,·lecl in ue<·ordm,c-,:
with /SA NCAC 01C .OJ/JO or /SA NCAC 0:JC .0200 Well Co11.vm,,·1ion Standarcls an,/ 1ht11 o
copy aflhfa-record has been prol'ided to the n-e/1 owner
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details You may also attach additional pages if necessary.
Sl!BMIJTAL INSTUCTIONS
9. Total well depth below land surface: ___ 4....,...,5_-_0 _______ (ft.) 24a. For All Wells: Submit this fom1 within 30 days of completion of well
FtJr multiple wells list all depths if d/fferenl (e.rnmp/e. 3@200' a11d 1@100') construction to the following:
JO. Static water level below top of casing: ___ 2_?_._0 _______ (ft.)
lj water Je,;e/ t.,· c,bo\-'e ca,;ing. use · -t "
I I. Borehole diameter: __ 8_._0 ____ (in.)
12. Well construction mrthod: __ A_U_G_E_R __________ _
(i.e. auger. rotary, cable, dire,;t pus!~ etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield {gpm) ______ Method oftest: ______ _
Di\'ision of Water Quality, lnformution Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: ln addition to sending the form to the address in 24a
above, also submit a .;opy of this fbrm within 30 days of completion of wdl
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
2-k For Water Supul & Injection Wells; In addition to sending the form to
the address(es) above, also submit one copy of this torm within 30 days of
13b. Disinfection type:________ ·• t completion of well construction to the county health department of the county
L:..:.:..:.:.:.:...:.::..:.:.::.::.::..:~:.:..:=======-......:.:.-,.:::0
::.
10
:_:
0:n:.:.:_: =========..! where constructed.
FormGW-1 North Carolina Department ofEnvironment and Natuml Re-sources-Division ofWnter Quality Revised Jan. 20 I 3
WELL CONSTRUCTION RECORD
This Form cAn be need for single or multiple welts.
1. Wr11 ContreernrInformation:
MARK IRELAND
Well C7oatrnetol' Name
A-4163
NC Well Contractor Ccrtifiication Number
GEOLOGIC EXPLORATION, INC
Company Yams
2. Well Construction Permit d:
).email applinahle mall evaurattrarr peragls (Le rota*: *: Slow. YurktnCt. ere)
3. Well Use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (HeatindCoolirig Supply)
DIndustrialVCornmeteiai
Dlrrteation
Non -Water Supply Well:
°Monitoring
Injection Well:
❑Aquifer Recharge
()Aquifer Storage and Recovery
❑Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
°Geothermal{Hearin_ ooli Return)
❑MunicipaUPubIlc
❑ Residential Water Supply (single)
❑Residential Waster Supply (shared)
❑ Recovery
❑ Groundwater Rem ediation
❑Salinity Barrier
CJStormwater Drainage
❑Subsidence Control
❑Tracer
ElOther (ex r Iain under 1i21 lte-marks)
4. Date Wedt(s) Completed: 03114118 Well 119N AS-3
Se. Well Location'
SUGAR HILL TRUCK STOP
Facility/Corner Name Facility IAIi tirapplicabtej
2855 SUGAR HILL ROAD MARION 28752
Physical Address, City, sad Zip
MARION
Comity Parcel tdatttification NO. [I1N1
Sb. Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
(if welt field, one larllcmK is surlicieui)
35" 38' 53.83" N 82' 01' 59.70"
b. Is (art) the we l(s). 12lPermanent or ❑Temporary
W
7. Is this o repair to an existing well: °Yes or Ebro
perm u a repair, till ow blown. i rfl co t lrutiouu Irrfornraaron and exploit+ the nature tithe
repair under o'21 renw rkr secuan or an the hark aphis Jam
6. Nnmlier of wells constructed: 1
r•err andiiple lrrteurtati nr min -wirer supply nrtlx ONLY will: rite .rpme construction. }eau awn
vhmt t nr+c form
9, Toted well depth below land surface: 45.0 [ft.)
Itnr aaelapia weal ',Wail depths tf if/faw i jerwlgdr..1 00' and 2@lrm7
In. Stacie water level below top of CRAWZ7.0 {ft,)
t/ ware, ked rr above easing t re " r •
I. Borehole diameter: 8.0 (in.)
12. Well construction method: AUGER
[i. e. auger, rotary, untie, direct yush, eta)
FOR WATER SUPPLY WELLS DNVLY:
132. Yield (gpm) Method of test:
lib. Disinfection type: Amount:
For lntcrnal 1]se ONLY:
14 WATER Z0N S
FROM
FL
TO
uescRtratO:s
ft.
rt.
15. OUTER CASINO (for mWti-earcdwells OR MLR lirxplr'cats)
FROM TO DIAMETER l TR1C ItNESS MATERIAL
ft.
R.
is
16. INNER CASING OR TUBING [=enihermsf dosed -loop)
FRDM
0.0
TO
DIAM$TER
TRICICSESS
ktATE.RJA 1.
40.0 I•
2.0
an,
SCH 40
PVC
It.
17. SCRBF.N
n.
is
FROM
TO
nia.mErER
SLOT SIZE
MATERIAL
40.0 R-
45.0 rt
2.0 is
.010
SCH 40
PVC
h.
rr.
in.
IE. GROUT
FROM
0.0 R
r1.
TO
36.0 R•
FCAPARCISENTOWIR
MATERIAL EMrIACEMENZ' METHOD & AMOUNT
SLURRY
R.
ft.
h.
19. SANDIGAAYEL PACKj!Farliiicsbll•J
FROM
TO k7ATERUAL
EMYLAC 1u&Tr .METHOD
38.0 h
45.0 h•
20-40
FINE SILICA SAND
rt.
rt.
20. DRILLING LOC;enxb xdditionui shorts if necessary)
FROM
0.0 h.
5,0 h.
R.
TD _ ov.cRlrf r0.. rroly , halloos, seiliroc f pg�r+iu vzc. rrt.l
5.0 R• RED/BROWN SILT
45.0 D, BROWN SILT
R.
h.
ft.
21. RF.111ARIC5
BENTONITE SEAL FROM 36.0 TO 38.0 FEET
AIR SPARGE*"
22. Certification:
S cure wr Corti ficd Glwrn�ivr
03/23/18
Dnro
rtp .srRrtrtrg this. Farm. I hereby arra!'" Nrot rile hell{,) leas jurrei mrulrueied lee aeranlrinre
w h 154 NCAC Olt',0100 or /54 AR:.4C O2C,0200 Wei Coasrratrtion-Saaridonir amrf than u
Cgpy aftht.V rrxwer her barn iruortded ro rlir well owner,
23. Site diagram or additional well detatls:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary
SUlMr1TAL INSTUCTIONS
24a_ For All.Wells: Submit this form within 30 days of completion of well
constriction to the following
Division of Water Quality, information Processing Unit,
1617 Mail Service Center, Raleigh, NC 276994617
24b. For lr'iection Wells: 1n addition to sending Me form ro lire atirdress in 24n
above, also submit a copy of this farm within 30 days of completion or well
construction to the following.
Division of Water Quality, 1 IIderground Injection Control program,
1636 Mail Service Center, Raleigh, NC27699-1636
24r. for Water Sapid & ltllection Wells: In addition tit sending the form to
the addressees) above, also submit one copy of Ibis Form vothm 30 days ul
completion of well construction to the county health department of the county
where constructed.
rarni Gw_t
North Carotin* Depnrtnam of EnVironrnenl and;luurat Rem lames - Division of Woicr Qualify Revi5et7 law- 2GI3

WELL CONSTRUCTION RECORD
This fo rm oa n be ,ised fut sinj_ll e or multiple well s
I.Well C I t onlractor n ormlltion:
MARK IRELAND
"w'ell Conlractor Name
A~ 4163
NC Well Contractor Cert ificatiort Number
GEOLOGIC EXPLORATION, INC
Compru1y Name
2. Well Construction Pennit#:
Lb:t all applil'able we/I constrm,'lic,n purmils (i..e. Coumy, S1a,e, Variance, etc.)
3. Well Use (check well use}:
Water Supply Well:
□Agricultural □Munic,pal/Publ ic
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
Olrn.aation
Non-W:iter Supply Well:
□Monitoring □Recovery
lnjectio11 Well:
OAquiter Recharge . □Groundwater Remediation
□Aquifor Storage and Recovery □Salinity Barner
□Aqutfor Test □Stormwater Drainage
□Experimental T~chnology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal (Heating/Cooling Return) IZ!Other (explain under #21 Remarks)
4. Date Well(s) Completed: 03/15/18 WelllD# AS-4
5a. Well Location:
SUGAR HILL TRUCK STOP
F.1cilityiOwaer Name Facility ID# (if applicable)
2855 SUGAR HILL ROAD MARION 28752
Physical Address, City, and Zip
MARION
C-ounty P0rcef ldcn1ifica1ion No. (PINJ
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient)
35° 38' 53.83" 82° 01' 59.70" -----------"' ______________ w
6. Is (are) the well(s): @Permanent or □Temporary
7. Is this u repair to ao existing well: □Yes ur IZJNo
If this i1· a repair, fill ,1111 knf111'n well consm,ction lnfam,at/on and explain the nalurc of the
repair under#]/ remarks section or on 1he back of1hisfm·m.
8. Number of wells constructed: ....,. __ 1 ___ -,. ____ _
For multiple ir,jec1io11 or uon~u·ater supp{v we/fs ONL1' with the ;mme construction, you can
submil one form.
I For Internal Use ONLY.
14. WATER ZONES
FROM TO Dt:SClllPTION
rt. ft.
ft. ft.
IS. OUTER CASING (for muljkased wells\ OR LINER (ifanmicable)
FROM I TO I DIAMCTER I THICk'NES!;" MATERIAL
ft. ft. in.
16 .. INNER CASING OR TUBING l~eothero,al dos,cUoopl
FROM TO DIAMETER TlllCKNESS MATERIAL
0.0 ft. 40.0 ft. 2.0 in. SCH40 PVC
ft. ft. in.
17,SCREEN
FROM TO DIAMETER SLOT Sil.£ TIIICKNESS MATERIAL
40.0 fl. 45.0 ft. 2.0 in. .010 SCH40 PVC
ft. ft. .in.
JS.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
0.0 ft. 36.0 ft. ~avm,•,.re SLURRY
r,. r1.
ft. ft.
i9. S~NDIGRA VEL.PACK tifannlitablel
FR0,'11 TO MATERIAL EMPLACEMENT M€T110D
38.0 ft. 45.0 ft. 20-40 FINE SILICA SAND
fl, ft.
20. DRILLING LOG (~n•~h odd itionol ,h<tl> If nctra,11.TV)
FROM TO lJ I.SCRIPTJO!\ fC'ulor. hardness soiVro,ck tv"""~ at'DUI siu:. e1c.)
0.0 ft. 5.0 ft. RED/BROWN SILT
5.0 ft. 45.0 ft. BROWN SILT
ft. ft.
ft. ft.
ft. ft,
ft. ft,
ft. ft.
.21. RE~fARKS
BENTONITE SEAL FROM 36.0 TO 38.0 FEET
***AIR SPARGE" ..
2f(;j ~
S;gnah,re of Certified Well~
03/23/18
Date
By signing thi.v form. J hereby cerrif.v (/l(JI the we/1(.i;) was (were) cou.ttroc·tccl m accurdono!
with 15A NC'A( 1/]C .0100 or 15A NCAC (J]C .Q20/J Well Co11s1r11clion Srandard.1· a11,J 1h01"
copy of this rec:m·d ho.-. berm pro,•rckcl la the well OH'ner.
23. Sitt diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional page~ ifnccessary.
SUBMITTAL INSTUCTJONS
9. Total well depth below land surfare: ___ 4,..,....5_._0 _______ (ff.} 24a. For All Wells: Submit this form within 30 days of completion of well
Por multiple ..-ells list all depths ifclijfcrcn1 (example-J@]O<J · and 2@/00') construction to the foUowmg :
J 0. Static water level below top of casing: ___ 2_7_.0 ________ (ft.)
~fwa,er /11.vt!I !.f ahnve co.dng. use "+"
11. Borehole diumeter: __ 8_._0 ____ (in.}
12. Well construction method: __ A_U_G_E_R __________ _
(i.e. auger. rotary. cable, direct push1 cfc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _______ Method of test: ______ _
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC27699-I6J7
24b. For lnj«tion Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of wdl
construction to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail St.rvice Centn, Rafoigli, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the form to
the address( es) above, also submit one copy of this form within 30 ,.fays of
13b. Disin.fection type: Amount: completion of well constn1ction to the county health department of the county L.:::.::..:.::=:.:::.:=~~-=-======.......'.::.::::::.::..:========..l where constructed.
FormGW-1 Noctb Carofina Department of Environment and Natural Resources-Division ofWatcr Quality Revised Jon. 2013
WELL CONSTRUCTION RECORD
This form can be used for smgry or multiple wells
I. Well Contractor information:
MARK IRELAND
H eta Conrraelor Name
A-4163
NC Well Caner/mew Corti ficaridn Nurnbcr
GEOLOGIC EXPLORATION, INC
Cumpa y Name
Z. Welt Construction Permit rr:
l.i.sr ail applicable meta rnnsirrirrrun perdue f.e. Como', Sieger'urRurre, rrn�
3. 'Nell Use (check well use):
Water Supply Well:
°Agricultural
DGe•orhennal (Heating/Cooling Supply)
D IndustriaUCommereial
C7lmgnrion
© Municipal/Publ
QResidential Water Supply (single)
GResidential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring C IRecavery
injection Weil:
LIAquifur Recharge
°Aquifer Storage and Recovery
°Aquifer Test
❑Experimernni Technology
C]Geothermal (Closed Loop)
❑Geothermal (Hearing/Cooling Return)
❑Groundwater Remediation
°Salinity Barrier
❑ Storrinveter Drainage
OSubsidence Control
DTraccr
JQther {explain under 1121 Remarks)
4. Dote Well(s) Completed: 03/15f $ Well Mir AS-5
5a. 1Ye11 Location:
SUGAR HiLL TRUCK STOP
Frx:iiity'N}wrre+ Name Faeil;ty III+ (if:epplicable)
2855 SUGAR HILL ROAD MARION 28752
i'liy5ical .Adikrrs. City, and Z1p
MARION
County Parcel irreniiiiration No (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
of wen field_ one leVlonp rs auffietenll
35' 38' 53.83" 82e 01' 59.70"
6. Is (are) the scents): G]Perrnxncol or L7Temporary
W
7. Is Ibis a repair to an existing well: COYea or Mt
// h a fs c rep*. fill alit know +veil romatruniuur ir+Ttlregni3Ol rind mpkrin the rrawre iy doe
repair order r2I remurkr aerriorr fir wr the Fr+r l rf lion firm.
S, Number of wells constructed: 1
For pm' rlple nt/rCrirrrt nr rn+r-,iwrrrsiylpi)' ,rr/!s ONLt t, itrt +Irr sumo rxrrer[rveilan, you roar
xubrriir ,rive' firm,.
9. Total well depth below land sedate: 45.0
1•or multiple helix 7isi all &prhr Ijr!!_Qvrrnl (exwllle- @178' ri12rroo)
to. Static water level below tap of casin g: 27' a (0,)
If II-Wier/e'er/ is above sdshrg. urn "-"
! 1. Borehole diameter: 8'0
(in.)
It. Well construction method:AUGER
(M.)
(Le. eager, Fat:vy, rabic, direct pushy orc.)
YOB WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type:
A me ant:
Form UM!
For IMemel Use ONLY.
id. WATFR ZONES
room
TO
Dt'4C61rr1QTV
re
h.
R.
fi.
IS. OUTER
CASING tfor
multi -rased walk) ORLINER {if on ' cable r
FROM
TO
mot
TguCKPicSS l MATERIAL
ft.
R,
in.
I`
1d, INNER
CASIPlC ORTUHINC
leeelbermnl closed -loom
?ROM
r To
owor at
Tit Ccicr si
!OATMEAL
0.0 r`•
40.0 n.
2.0 'n'
SCH 40
PVC
fi,
ft.
irL
17. SCREEN
FROM
-To
ouMURA
SLOTsrts
lilicxriess
mo.ncrAr..
40.0 fl_
45.0 ft-
2.0 11'
.010
SCH 40
PVC
fr.
it
in.
ta. Grimm
PERIM
TO
MATERIAL
EMPLACEMENT METHOD& AMOUNT
SLURRY
0.0 fe.
36.0 f'
oORA-MD BENTONITE
fe.
Pr.
R.
R.
to. SANDICRAVEL
PACK
Iif appiit bieI,
FROM
TO
MATERUAI.
E.MPLACE.MENTIHETHQD
38.0 "•
45.0 ft-
20-40
FINE SILICA SAND
fr.
D_
20, PRILLUNVC
LOC IRRuch
additional !heels if necessary I
FROM
TO
DESCRIPTION lender. Aerdueu soillsael: t.y..grain sire, ere.,
0.0 R•
5.0 n
RED/BROWN SILT
5.0 ':• _
45.0 n-
BROWN SILT
R.
ft.
It
ft.
1t
fr.
h.
R.
2.1. REMARKS
BENTONITE SEAL FROM 36.0 TO 38.0 FEET
'**AIR SPARGE1e
22. Certification:
=ima a of Cenifred Well & sn n,o,
03/23/18
Dato
Ry .rignbrg ebbs forme. I hrtxbr r'rrrfs' Niai the went) u+ar Isere) alomiliord it acrwrlalrcr
with 1SA cif A 021.'.l161I w /-tl t .t(: W('. U208 )Yell (iirsirirrnnn $rnnr/mr(A rod that ii
ropy alibis neon, has been provided to he Aril! owner-
23. Site diagram or additional wdl details:
You may use the back of this page to provide additional well site details or welt
Construction details. You may also attach additional pages Ifnecessttry.
SUBMITTAL INSTULf ONS
24s. For All Wells: Submit this farm within 30 days of complexion of well
canstnic1ion t0 the following,.
Division of Water Quality, Information Processing L'nit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24h. For injection Weli4: in addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
c,n#nrehon to the Following-
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC Z7699-1636
24r, For Water Supply & hijcction Wfl loadditioii to sending thatorn to
the address(cs) -above, also submit urn copy of this form within 30 days of
completion or well construction to the county health department vI the county
where constructed,
Mural Carolina I/rparmese of EnriwnincnT and Natural RosoarceF - DN'isiun of Water p,mriry Revised Jan. Z0 t3

WELL CONSTRUCTION RECORD
This kern :so Ise used for single or multiple wens
I. Well Contractor Infornlatlon-
MARK IRELAND
wet! Constrictor Niue
A- 4163
NC Well Consular Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
.rn ail appiire Ate +i ell enmenrcreott (warm ii.ee. ream% Mare, Variative, err)
3. Well Use (cheek well use):
Water Supply Well:
❑Agricultural
❑ Geolltermal Morning/Cooling Supply)
° Industrial/Commercial
❑ Irrigration
°Municipal/Public
❑Residential Water Supply (single)
O Residenriai Water Supply tsltarctl)
Non -Nato Supply Well:
°Monitoring ❑Recovery.
Injection Well:
OAq liter Recharge
❑ Aquifer Storage and Recovery
❑ Aquifer Test
❑Experimental Technology
DG ulhermal(Closed Luop)
❑Geothermal (Heating Cooling Return)
❑ Groundwater Remediat ion
°Salinity Harrier
°Stormwater Drainage
°Subsidence Control
o Tracer
VOther (explain under 112 t Remarks)
4. Date Well(s) Completed: 03/15I18 Well PEW AS-6
Sec Well Location:
SUGAR HILL TRUCK STOP
Facility/Owner Name Facilil± Ip# (if applicable)
2855 SUGAR HILL ROAD MARION 28752
Physrpnl Address, City, sod Zip
MARION
County Parcel ldeutig atioaro IPfN}
Sb. Li Made Plod Longitude in degrceslmiautcslseconds or derimid degrees:
of well field, nor Wong is sw frcieal.l
35° 38' 53.83" N 82° 01' 59.70"
6. Is (are) ffsewell(e): fdPermanent or 10Temparary
W
7. Is this a repair to an existing well: °Yes or FiNo
Irht,is !r o repair, foil ni,r kugwrr Hall constrtnVh,! 1*rxraliun wed rxplaia due iArrurr the
repair titular U1 rcmark..+Taw ar era the hall ❑fells for'
1. Number olwells constructed:
Far nrulltple faietdnq ur Jion.ii.atersuly ly arltf ONLY s i111 rho swna ermarnefion. )vu ran
subtali ante farm
9. Total well depth below land rface: 45.0
unlace: (ft.)
Far rnalilple wells liar all depth rf'dl?ereno s rw,rple- JI 2OO' one{ 3®100'1
Id. Static water level below top of casing: 27.0 (n-)
tt $rater fere7 is ohm, a rosy, rue " •
11. Borehole diameter: $.0 {in.)
12. Well construction method: AUGER
(i.e. auger. rotary. eat±la, direct push etc.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield igpm) llelbod of test:
13bs Disinfection type: Amount:
Form GW-I
For Internal Use ONLY:
l9. WATER ZONES
miens
TO
LLSCTtIFrPOet
ft.
fr_
n.
ff.
15. OUTER
CA$I?VG flat
multi -cased wells) art UNER of aoglicablei
FROM
TO
DIAMETER
TlnCENESS
MATERIALft.
I
It.
Is.
16. INNER
CASING OR TUl,1NG
jaeotbermal closed-hll!a
PROM
TO
DIAMETER
TRIMNESS
MATERIAL
0.0 rt. l
40.0 't-
2.0
SCH 40
PVC
ft.
ft.
is
17. SCREEN
PROM
TO
DIAMETER
SLOT star
THICKNESS MA7T.RIAL
40.0 'r•
45.0 fL
2.0 I'
010
SCH 40 PVC
ft.
rt.
is
1& CRO[1'r
FROM
1s0
MATWAL
EMPLACEMENT METHOD d Aa1 OUNT
0.0 ff•
36.0 n'
PORAJ"ea0.T"rr'e
SLURRY
fc
f►.
ft.
rl.
19. SAND/GRAVEL PACK Or spinitablel
PROM
TO
MATERIAL.
EMPLACEMEN?METHOD
38.0 h
45.0 n
20-40
FINE SILICA SAND
ft.
R.
20. DRMLLUNC
LOG lafterh
additional sheers if wecaine,1
PROM
Tu
DESCRIPTION Inner, SerMrssr, svimexe hp, pain Mo. etc.}
0.0 ft
5.0 rl•
RED/BROWN SILT
5.0 ft-
45.0 R•
BROWN SILT
ft.
f1,
ft,
It
b.
ft.
ft.
ft.
ft.
R.
21. REMARKS
BENTONITE SEAL FROM 36.0 TO 38.0 FEET
"'AIR SPARGE"'
22. C.ertilicafian:
idsnaS rwcofCertifed WdCi:w.rt'odor
03/23/18
ease
.trgoiirg rh:.. form. 1 hereby eenrjy that the wants.) arcs raere) cnrrrtr,reeed la aernrdunc't
with Isri Ni AIL 02C,1110a or 15A Mr-iAC tl?( .070d W.•77 CnrrxrFrrc•r+an Slamktrat aaa tlrn.I
crpy nfr/i.r mart, beet, provided en the +PM owner
23, Site diagram or Additional well details:
You may use the back of this page to provide additional well site details or well
construction derails. You may also attach addition} pages if necessary_
SUBMITTAL 1NSTUCTIONS
24a. per All Welly: Submit this forte within 30 days of completion of well
construction to thefollowing
Division of Water Quality, Information Processing Licit,
1617 Mail Service Center, Raleigh, NC27699-1617
24b. For lniection Wells: in addition to sending the farm to the address in 24a
above, also Subunit a copy of this Form within 30 days of completion or well
canslnrction to the following
Division of Water Quality, L'stde around Injection Control Peugeots'.
1636 Mail Service Ceafer, Raleigh, NC 27699-1636
24c, For Water Sunnis & Injection Wells: In addition to 9endrng the form to
the addresses) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the count).
where constructed.
North Carolina Department of En+riroumen I and Natural Resources - Division Uf Water finality
Revised ion nil

A
rrolxni
(Fr.)
110 —
100 —
90 -
80 —
70-
60-
50-
40--
30 —
20 —
RETAINING WALL
N
2 Q
-UST EXCAVATION LIMITS (6-1T)
}
- ? 1:3,600)
_.,..:SANDY _..- _
-- SILT --
(9,f 00)7-.
1-
0
w
D
EL
co et
`.�.. --_...:SANDY;—'t...r�..
— SILT . .... __
(12,00
� -- -• �._ o - - _
�.....�.. ._ —. ....—..�... —...4 .. —- -- .- —.. .—.. — - -- --—�_
•
10--
LEGEND
n
MONITORING/AS WELL DEPICTING SCREEN INTERVAL
— MTBE CONCENTRATION IN GROUNDWATER (pg/L) (051-7115)
4,600)
Y
coco
L....._______---- SOIL BORING DEPICTING SAMPLE INTERVAL
--- 200
▪ la
24
\+►yp
a�>. iy i.
b
hh
• pA� '.r 41.
a v-!R�:
akab{j'a ■
a RA
05/07/18 SHALLOW GROUNDWATER ELEVATION
MTBE ISOCONCENTRATION CONTOUR (pg/L)
(DASHED WHERE INFERRED)
E11771 SANDY SILT
PARTIALLY WEATHERED ROCK (PWR) NOTES:
/
a .•
If
�a ►• \
1. REFER TO FIGURE 10 FOR CROSS-SECTION
TRANSECT.
ra *da a . a. V•.
A'
[mod
1i0
— 100
— 90
- 80
— 70
- 50
—40
10
1— 20
- 10
20 —
APPROXIMATE
SCALE IN FEET
20
CROSS-SECTION A -A.
FORMER SUGAR HILL TRUCK STOP
2855 SUGAR HILL ROAD
MARION, NORTH CAROLINA
hart rA.hickman
5MARfEl{ ENVinoNMENrAL SOWT1ON5
2923 South Tryon Street -Suite 100
Charlotte, North Carolina 28203
704-586-0007(p) 704-586-0373(0
License # C-1269 / #C-245 Genic)*
DATE: 5-29-18
JOB NO. CEI-002
REVISION NO. 0
FIGURE NO. 11

eAst
tFTJ
110
— - —fi- —
-•
—...
LEGEND
— MONITORING/AS WELL DEPICTING SCREEN INTERVAL
MTBE CONCENTRATION IN GROUNDWATER (ij JL) (05+07I18)
(4,600T
SOIL BORING DEPICTING SAMPLE INTERVAL
;UST EXCAVATION LIMITS (6-17172-..-.___-.,....�,_
•
—.-
—
--A—._" "- SILT �...—...�.,._.._
�_.._...,..., ..,...... ,,..-,......-. .,,--,.- .- ..—.. —...
ti..
4600— . — — — —
■ r i ; lk..• . C a a 6- r�• rpc-.r�G.
r�o.s A.r.yyoo��• 5 I. . ••• Ab b p P • o..
b Pr.$'.P-:-•.I7' .t7 i� s P•r�E� b 0 O• �' • -•.D• , r ,0
01.
r•y� y, gf�4 sm. qArA?: 1. ►.r C 6 i. P o c -
_'=A
aa g.
1ai;i°: ;c •rp••yv :i
ou: Y o-._P%.KA.■'4=. r,cQot o:
r:y. .■*C
ti.r
'r.� d .0. .6 d co'''r5�+Or f:: o' onne .
9121f17 SHALLOW GROUNDWATER ELEVATION
MTBE ISOCONCENTRATION CONTOUR (NgfL)
(DASHED WHERE INFERRED)
SANDY SILT
PARTIALLY WEATHERED ROCK (PWR)
NOTES:
AlZe
■ a■
1. REFER TO FIGURE 10 FOR CROSS-SECTION
TRANSECT
AESr
irr.l
— id
APPROXIMATE
I +
20
SCALE IN FEET
FORMER SUGAR HILL TRUCK STOP
2855 SUGAR HILL ROAD
MARION, NORTH CAROLINA
SMARTER EI4iVIRn NMINTA. SQLLtt1o145
2)23 Snush'1'syon St:act Suitt 100
Charlotte, North CarolinaZ3203
704.586-1)007(p) 704-586-0373(f)
Licenx 4 C-12591 #C-245 Grolog-•
DATE: 5-29-18 REVISION NO. 0
JOB NO. CEI-002 FIGURE NO. 12