WI0300453_Permit (Issuance)_20210422

CES NC:
April 7, 2021
Michael Rogers
DWR — UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
RE:
Notification of Intent to Operate Injection Wells
Kerr's Hickory Ready Mixed Concrete
1126 1st Avenue SW
Hickory, Catawba County, North Carolina
NCDEQ UST Incident No.: 20025
Dear Mr. Rogers:
CES of NC, PLLC
5104 Reagan Drive, Suite 7
Charlotte, North Carolina 28206
980.819.9333 [office]
540.343.6259 [facsimile]
On behalf of the responsible party/applicant, CES of NC, PLLC is submitting the enclosed Notification of
Intent to Operate Injection Wells. The document details "deemed permitted" small-scale injection activities
utilizing existing monitoring wells for the purpose of groundwater remediation associated with the
referenced incident number. Following review should you have any questions or require additional
information, please do not hesitate to contact me by phone at [phone] or email at
awi I iamso ni@crawfordenvi ronmental.com.
Sincerely,
CES of NC, PLLC
/162"Livz._
Aaron Williamson, GIT
Project Manager
Enclosure
AEG 13
APR
-Central ;Juice

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 NC,1C' 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (I;A \('.1C 02C .0225j or TRACER WELLS (15.X NC.tC 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: March 18 ,2021
PERMIT NO. W10300453 _(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. '.VI
(3) Passive Injection System Complete sections B through F. H-M
(4) X Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (IST) Well Complete sections B through M
B. STATUS OF WELL OWNER: Business/Organization
Deemed Permitted Gob' Remediation NO1 Rev. 2-17-2020
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(s): Mr. Roger S. Kerr, Vice President / Kerr's Hickory Ready Mixed Concrete. Inc.
Mailing Address: 1126 1" Avenue Southwest
City: Hickory — State: NC Zip Code: 28602 County: Catawba
Day Tele No.: 828-322-7276 Ce1I No.: 828-322-3157
EMAIL Address: rskerrakerrsconcrete.com Fax No.:
D. PROPERTY OWNER(rrS) (if different than well owner/applicant)
Name and Fine: _ } 1':t <1 prrr'rYl Lif � �'a.1C��•;
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Company Name Southern Concrete Materials. Inc.
Mailing Address:
City: Salisbury
Day Tele No.: 1-800-288-6421 Ce11 No.:
EMAIL Address: 1 a t'Tt t' i ! .s( r-t u A . L_J r'v Fax No.:
PO Box 1040
State: NC Zip Code: 28145 _County: Rowan
Name and Title: Aaron Williamson, Project Manager
Company Name CES of NC. PLLC
Mailing Address: 5104 Reai an Drive. Suite 7
Day Tele No.: 980-819-9333 Cell No.: 910-280-2974
City: Charlotte State: _ NC Zip Code: 28206 County: Mecklenburg
EMAIL Address: awilliatnson:i crawfordenvirolimental.coin Fax No.: 540-343-6259
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Kerr's Hickory Ready Mixed Concrete
1126 I" Ave Southwest
City: Hickon County: _ Catawba Zip Code: 28602
(2) Geographic Coordinates: Latitude**: "or 35.730973
G. TREATMENT AREA
Land surface area of contaminant plume: 8.500 ,square feet
Land surface area of inj. well network: 1,800 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 21 (must be < 5% of plume for pilot test injections)
Longitude**: " or °.-81.358009
Reference Datum: WGS84 Accuracy: 2 meters
Method of Collection: Goole Earth
**FOR AIR INJECTION AND AQI LIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
Deemed Permitted GW Remediation NOI Rev 2-17-2020
'age 2

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.
I• 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:
UST system removed in December 1998. release indicated. Active remediation from 2000 to 2020 removed
much free product. but product Generally persists in two site wells MW-4 and RW-5. Purpose of injection is to
remediate free product in subsurface detected in wells MW-4 and RW-5. 50 gallons of PetroSolvTM surfactant
will be mixed with 950-gallons of potable water to create an approximately 5% surfactant solution injected into
the wells. Iniection of surfactant followed by vacuum extraction to recover groundwater on the order of at least
1.5 to 2 times to volume injected is proposed to liberate. mobilize. and recover free product in the subsurface
vicinity of these two wells. Once free product is no longer present, natural attenuation may be pursued for
incident closure. See NCDEO UST incident Number 20025.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 2 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 25 — 35 feet
(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
K. INJECTION SUMMARY
NOTE Only iniectants approved by the epidemiolotry section of the NC Division of Public Health,Departnrent
of Health and Human Services can be infected. Approved iniectants can be
found online at
bttp: deq.nc.goviabout divisions; water-resources;w ater-resources-ttermits, wastewater -branch ground -water -
protection uround-water-approved-iniectants. All other substances must be reviewed bp the DHHS prior to use.
Contact the UJC Program for more info Jt you wish to get approval for a d erent additive. However please
note it snap lake 3 months or longer. If no iniectants are to be used use N/A.
Injectant_ ETEC, LLC PetroSolvTM _ — Total Amt. to be injected (gal)/event: 50
lnjectant: Potable Water Total Amt. to be injected
1 (gal)/event: 950
Deemed Permitted GW Remediation NOI Rev.2-17-2020
Page 3

Injectant: Total Amt. to be injected (gal)/event:
lnjectant: Total Amt. to be injected (gal)/event:
injectant: Total Amt. to be injected (gal)/event:
Total Amt. to be injected (gal/event): 1.000
No. of separate injection events:1 Total Amt. to be injected (gal): 1,000
Source of Water (if applicable): Potable on -site
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.
Site currently exhibits violations of2L Standards for petroleum hydrocarbons and is monitored on a semi-annual
basis which will continue post injection, reduction is expected post injection. Wells will be measured for
presence of free product and groundwater samples will be collected and analyzed for PAHs by EPA Method
625. See NCDE0 UST Incident Number 20025.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well OwneriApplicant: "1 hereby certif •, under penally of law, that 1 am familiar with the information
submitted in this document and all attachments thereto and that, based on my ingu/ry of those individuals
immediately responsible f r obtaining said information, 1 believe that the information is true, accurate and
complete. 1 cnn aware that there are significant penalties, including the possibility of fines and imprisonment.
for submitting false information. 1 agree to construct, operate. maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 1 iA NC4C 02C 0200 Rules."
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of 1ppiicant 4'
pQR
Deemed
Pen emediatiun NO1 Rey. 2-17-2020coo
Signature
Print or Type Full Name and Title
Proper;\ Owner (if the property is not owned by the Well Owner/Applicant):
"As oitwner of -the property on which the injection well(s) are to he 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
(15.1 NC'.4C 02C .0. 01D..,
"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 Propert thsner (if different from applicant) Print or Type Full Name and Title
*An n 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 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
�Ee+� 1636 Mail Service Center
Raleigh, NC 27699-1636
V7.1 Telephone: [phone]
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TERRAINE, inc.
ENVIRONMENTAL SERVICES
INSTALLATION METHOD
DRILLING COMPANY: GEOTEK Drilling Co.
EQUIPMENT:
Ingersoll-Rand T-3
AUGER SIZE (SOIL): _
BIT SIZE (ROCK): 6" 00 Air Hammer
DRILLING FLUID (SOIL): - _
DRILLING FLUID (ROCK):
DRILLER:
HELPER:
DIMENSIONS lft)
L1 12.50
L2 2.00
L3 12.50
L4 17.00
10.00
27.00
L5
L6
ELEVATIONS (ft msl0
El 0.00
E2 95.74
E3 -20.99
E4 -30.99
E5 -30.99
L6
CALCULATED MATERIALS NEEDED‘
2.1_ /00 # bags filter material
1 bucket(s) bentonite pellets
2.1 94# bags cement
0.0 pounds granular bentonite
0.0 pounds powdered bentonite
2_0 80# bags concrete/sakrete
ACTUAL MATERIA SUS .n
1100 100 # bags filter material
GOO bucket(s) bentonite pellets
0A0 94# bags cement
0,00 pounds granular bentonite
0.00 pounds powdered bentonite
0.00 80# bags concrete/sakrete
MONITORING WELL
INSTALLATION REPORT
PROJECT NUMBER:
PROJECT NAME:
FACILITY ID NO.:
PROJECT LOCATION;
52952
Kerr's Ready -Mixed LSA
Hickory
NC
WELL IDENTIFICATION #: MW-04
WELL LOCATION: See Site Map
DRILLING DATE/TIME: start: 01/07/00
finish: - 01/07:00 /
LOGGED BY: OPK Phil Kimbrell
00:00
00:00
NOT TO SCALE
DIA. OF BORING 6.25-in OD (Air Hammer)
El - TOP OF COVER ELEVATION
E2 - TOP OF WELL ELEVATION
WELL • locking expansion plug
❑ flush joint PVC
C3 other
WELL CASING 2-Inch Diameter PVC
ANNULAR SEALANT
FILTER PACK SEALANT
E3 - TOP OF SCREEN ELEVATION
FILTER MATERIAL -
WELL SCREEN 2-Inch Diameter PVC
SLOT SIZE
E4 - BOTTOM OF SCREEN ELEVATION
E5 - TOTAL DEPTH ELEVATION

r
TERRAINS inc.
ENVIRONMENTAL SERVICES
MONITORING WELL
INSTALLATION REPORT
INSTALLATION METHOD
DRILLING COMPANY: _ SAEDACCO
EQUIPMENT: Gus Pech 1300AXR
AUGER SIZE (SOIL):
BIT SIZE (ROCK): 9" OD Air Hammer
DRILLING FLUID (SOIL): None
DRILLING FLUID (ROCK): NIA
DRILLER: Steve
HELPER:
PROJECT NUMBER: 52952
PROJECTNAME: Kerr's Ready -Mixed LSA
FACILITY ID NO.:
PROJECT LOCATION: Hickory NC
WELL IDENTIFICATION #: RW-04
WELL LOCATION: See Site Map
DRILLING DATE/TIME start: 0330101 >/
finish: 03/30/01 /
LOGGED BY.
DIMENSIONS (ft)
L1
0.00
L2 0.00
L3 35.00
L4 0.00
L5 35.00
L6 35.00
ELEVATIONS (ft msf)
El
0.00
E2 98.64
E3 0.00
E4 -35.00
E5 -35.00
CALCULATED MATERIAL NE n1D
9S 100 # bags filter material
bucket(s) bentonite pellets
0.0 94# bags cement
0.0 pounds granular bentonite
0.0 pounds powdered bentonite
20 80# bags concretersakrete
ACTUAL MATERIALS USED
10.00 100 # bags filter material
0.00 bucket(s) bentonite pellets
0'06 94# bags cement
0.00 pounds granular bentonite
n° pounds powdered bentonite
1.00 80# bags concrete/sakrete
MJP Michael Pressley
t l:35
12::00
DIA. OF BORING 9-in OD (Air Hammer)
El - TOP OF COVER ELEVATION
E2 - TOP OF WELL ELEVATION
WELL ■ locking expansion plug
❑ flush joint PVC
C other
WELL CASING
0-Inch Diameter
ANNULAR SEALANT
FILTER PACK SEALANT
E3 - TOP OF SCREEN ELEVATION
FILTER MATERIAL
#2 Coarse Silica Sand
WELL SCREEN 4-Inch Diameter PVC
gli
=_=i
i=girSLOT SIZE 0.010 Inch
NOT TO SCALE
E4 - BOTTOM OF SCREEN ELEVATION
E5 - TOTAL DEPTH ELEVAT'ON

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CES@NM
April 7, 2021
Michael Rogers
DWR — UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
RE:
Notification of Intent to Operate Injection Wells
Kerr's Hickory Ready Mixed Concrete
1126 1st Avenue SW
Hickory, Catawba County, North Carolina
NCDEQ UST Incident No.: 20025
Dear Mr. Rogers:
CES of NC, PLLC
5104 Reagan Drive, Suite 7
Charlotte, North Carolina 28206
980.819.9333 [office]
540.343.6259 [facsimile]
On behalf of the responsible party/applicant, CES of NC, PLLC is submitting the enclosed Notification of
Intent to Operate Injection Wells. The document details "deemed permitted" small-scale injection activities
utilizing existing monitoring wells for the purpose of groundwater remediation associated with the
referenced incident number. Following review should you have any questions or require additional
information, please do not hesitate to contact me by phone at [phone] or email at
[e-mail].
Sincerely,
CES of NC, PLLC
761,Go/L-461/1442-r_,
Aaron Williamson, GIT
Project Manager
Enclosure

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 15A NCAC 02C.0200 (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS is NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15:‘ NC 1C 02C .0225) or TRACER WELLS (15A NC:uC 02(' .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: March 18 , 2021 PERMIT NO.
(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) Passive Injection System .. Complete sections B through F,
(4) X Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (IST) Well ... Complete sections B through M
B. STATUS OF WELL OWNER: Business/Organization
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 1

Day Tele No.: 980-819-9333 Cell No.: 910-280-2974
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): Mr. Roger S. Kerr, Vice President / Kerr's Hickory Ready Mixed Concrete, Inc.
Mailing Address: 1126 1" Avenue Southwest
City: Hickory State: NC Zip Code: 28602 County: Catawba
Day Tele No.: 828-322-7276 Cell No.: 828-322-3157
EMAIL Address: rskerrAkerrsconcrete.com Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Jr �� �J - L e 4 f S! clr 1 c�
Company Name Southern Concrete Materials, Inc.
Mailing Address: PO Box 1040
City: Salisbury State: NC Zip Code: 28145 County: Rowan
Day Tele No.: 1-800-288-6421 Ce11 No.: U- ' - 7 f 3- - 77 3 4
EMAIL Address: a 1 A e. t 14 c l. t- Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Aaron Williamson, Project Manager
Company Name CES of NC, PLLC
Mailing Address: 5104 Reagan Drive, Suite 7
City: Charlotte State: NC Zip Code: 28206 County: Mecklenburg
EMAIL Address: awil]iamsonrricrawfordenvironmental.com Fax No.: 540-343-6259
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: _ Kerr's Hickory Ready Mixed Concrete
1126 1st Ave Southwest
City: Hickory
(2) Geographic Coordinates: Latitude**:
Longitude**:
G. TREATMENT AREA
Land surface area of contaminant plume: 8,500 square feet
Land surface area of inj. well network: 1,800 square feet (< 10,000 ftz for small-scale injections)
Percent of contaminant plume area to be treated: 21 (must be < 5% of plume for pilot test injections)
County:
°
°
Catawba Zip Code: 28602
" or 35.730973
" or °.-81.358009
Reference Datum: WGS84 Accuracy: 2 meters
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.
Deemed Permitted GW Remediation NOl Rev. 2-17-2020
Page 2

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.
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:
UST system removed in December 1998, release indicated. Active remediation from 2000 to 2020 removed
much free product, but product generally persists in two site wells MW-4 and RW-5. Purpose of injection is to
remediate free product in subsurface detected in wells MW-4 and RW-5. S0 gallons of PetroSolvTM surfactant
will be mixed with 950-gallons ofpotable water to create an approximately 5% surfactant solution injected into
the wells. Injection of surfactant followed by vacuum extraction to recover groundwater on the order of at least
1.5 to 2 times to volume injected is_proposed to liberate, mobilize, and recover free product in the subsurface
vicinity of these two wells. Once free product is no longer present, natural attenuation may be pursued for
incident closure. See NCDEQ UST Incident Number 20025.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 2 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 25 — 35 feet
(3) 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
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division of Public Health, Department
of Health and Human Services can be infected Approved injectants can be found online at
http: deq.nc. iovrabout:'divisions/water-resources,'water-resources-permits/wastewater-branchiground-water-
protectioniaround-\rater-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program for more info if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no injectants are to be used use NIA.
Injectant: ETEC, LLC PetroSolvTM Total Amt. to be injected (gal)/event: 50
Injectant: Potable Water _Total Amt. to be injected (gal)/event: 950
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 3

Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
lnjectant: Total Amt. to be injected (gal)]event:
Total Amt. to be injected (gal/event): 1,000
No. of separate injection events:1 Total Amt. to be injected (gal): 1,000
Source of Water (if applicable): Potable on -site
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.
Site currently exhibits violations of 2L Standards for petroleum hydrocarbons and is monitored on a semi-annual
basis which will continue post injection, reduction is expected post injection. Wells will be measured for
presence of free product and groundwater samples will be collected and analyzed for PAHs by EPA Method
625. See NCDEQ UST Incident Number 20025.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "1 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, 1 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. / agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and rrII related appurtenances in accordance with the 15A .VCAC 02C 0200 Rules."
r •_ ( �-, 14 Lcar,t,, • 1l ite fres;c,��,,,�-.
Si na a of Applicant Print or Type Full Name and Title
Property Owner (if theproperty 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, 1 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
(15.4 VC. -IC 02C . 0?00). "
"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 of a signature on this form.
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 — U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 4

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TERRAINIn�.
ENVIFIONMENTAL SERVjC€S
INSTALLATION METHOD
DRILLING COMPANY
• GEOTEK Drilling Co.
EQUIPMENT:
Ingersoll-Rand T-3
AUGER SIZE (SOIL).
BIT SIZE (ROCK):
6" OD Air Hammer
DRILLING FLUID (SOIL):
DRILLING FLUID (ROCK):
DRILLER::
HELPER:
DIMENSIONS (ft)
Li 12.50
L2 2.00
L3 12.50
L4 17.00
L5 10.00
L6 27.00
ELEVATIONS (ft msl)
El 0.00
E2 95.74
E3 -20.99
E4 -30.99
ES -30.99
CA£CUATERIALS NEEDED
2.1 100 # bags filter material
bucket(s) bentonite pellets
2.1 94# bags cement
0.0 pounds granular bentonite
20 pounds powdered bentonite
2.0 80# bags concrete/sakrete
ACTUAL. MATERIALS USED
0.00 100 # bags filter material
0,00 bucket(s) bentonite pellets
0.00 94# bags cement
0,00 pounds granular bentonite
0.00 pounds powdered bentonite
0.00 80# bags corcrete/sakrete
L1
L4
L6 L2
L5
L3
MONITORING WELL
INSTALLATION REPORT
PROJECT NUMBER: 52952
PROJECT NAME: Kerr's Ready -Mixed LSA
FACILITY ID NO.:
PROJECT LOCATION:
Hickory M1)C
WELL IDENTIFICATION #: MW-04
WELL LOCATION: See Site Map
DRILLING DATE/TIME: start Q1ro7O0/
finish: 01/D7/00
LOGGED 8Y: OPK Phil Kimbrell
00,00
00:00
DIA. OF BORING 6.25-in OD (Air 1-Jammer)
ET - TOP OF COVER ELEVATION
E2 - TOP OF WELL ELEVATION
WELL ■ tucking expansion plug
❑ flush joint PVC
© other
WELL CASING
2-1nch Diameter PVC
ANNULAR SEALANT
FILTER PACK SEALANT
P3 - TOP OF SCREEN ELEVATION
FILTER MATERIAL
WELL SCREEN 2-Inch Diameter PVC
SLOT SIZE
E4 - SOTTQM OF SCREEN ELEVATION
E5 - TOTAL DEPTI-/ ELEVATION
NOT TO SCALE

.TERRAINS, inc.
EIV1/4/IRONMEN1PL SEFZVICES
INSTALLATION METHOD_
DRILLING COMPANY. SAEDACCO
EQUIPMENT.: Gus Pech 1300AXR
AUGER SIZE (SOIL):
BIT SIZE (ROCK): 9" OD Air Hammer
DRILLING FLUID (SOIL): None
DRILLING FLUID (ROCK): N/A
DRILLER: Steve
HELPER:
DIMENSIONS (ft)
L I 0.00
L2 0.00
L3 35.00
L4 0.00
L5 35.00
L6 35.00
ELEVATIONS (ft msi)
El 0.00
E2 98.64
£3 0.00
E4 -35.00
E5 -35.00
ti
CALCULATED MATERIALS NEEDED
SS 100 # bags filter material
1 bucket(s) bentonite pellets
0.0 94# bags cement
0•0 pounds granular bentonite
0.0 pounds powdered bentonite
80# bags concrete/sakrete
ACTUAL MATERIALS USED
10.00 100 # bags filter material
0-00 bucket(s) bentonite pellets
0.00 94# bags cement
0.00 pounds granular bentonite
0.00 pounds powdered bentonite
1.OQ 80# bags concrete/sakrete
L6
L4
L5
V
MONITORING WELL
INSTALLATION REPORT
PROJECT NUMBER: 52952
PROJECT NAME: Kerr's Ready -Mixed LSA
FACILITY ID NO.:
PROJECT LOCATION: Hickory NC
WELL IDENTIFICATION r!_ RW04
WELL LOCATION.- See Site Map
DRILLING DATFJTIME.: start: 01 / it35
finish: C3r30/01 / 12 00
LOGGED 8Y MJP Michael Pressley
DIA. OF BORING 9-in OD (Air Hammer)
E1 - TOP OF COVER ELEVATION
E2 - TOP OF WELL ELEVATION
WELL ■ locking expansion plug
❑ flush joint PVC
G other
WELL CASING
0-Inch Diameter
ANNULAR SEALANT
FILTER PACK SEALANT
E3 - TOP OF SCREEN ELEVATION
FILTER MATERIAL
#2 Coarse Silica Sand
WELL SCREEN 4-Inch Diameter PVC
SLOT SIZE 0.010 Inch
E4 • BOTTOM OF SCREEN ELEVATION
ES - TOTAL DEPTH ELEVATION
NOT TO SCALE
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