WI0300322_DEEMED FILES_20160721

cl,e.e.~. w_r o 3 o o :!> 2-2.
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources -Division of Water Rei'dJ.rcJsJ 20/6 Permit Number WI0300322 W.
. ate .-------------------------, naton,,._ y
Were any wells abandoned during t lTIS''f~~-
1. Permit Information
S&ME, Inc.
Permittee
TF-22887 Tip's Inc.
Facility Name
1515 Old Hickory Grove Road, Mt. Holly, NC 28120
Facility Address
2. Injection Contractor Information
S&ME, Inc.
Injection Contractor/ Company Name
Street Address 9751 Southern Pine Blvd.
Charlotte NC 28273
City State Zip Code
(.zM__J 523-4726
Area code -Phone number
3. Well Information
Number of wells used for injection ----=2=----
W ell names MW-1 and MW-4
Were any new wells installed during this injection
event?
D Yes 1K] No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
event? 10n
D Yes IB] No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number oflnjection Wells _______ _
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Calcium Peroxide
lnjectant Type
Concentration 10-40 mg/L ------------
If the injectant is diluted please indicate the source
dilution fluid. ------------
Varies, by diffusion. 1.75 lb EHC-0
Total Volume Injected or 0.2625 lb Oxygen per well
Varies, by diffusion. 1. 75 lb EHC-0
Volume Injected per well or 0.2625 lb Oxygen per well
5. Injection History
Injection date( s ) __ 07_1_14_1_16 ________ _
Injection number (e.g. 3 of 5) 1 -------
Is this the last injection at this site?
D Yes D No
Unknown, depends of water quality changes from the one event.
To be determined by NCDENR, UST Section, Sharon Ghiold
1 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 _i~¢~~ :::RMl:~/2:A~E
Scott Young
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 UIC-IER
Rev. 8/5/2013
Central Files: APS SWP _
6/30/2016
P-:r.-rit t(t:rt►mr WI0300322 Permit Tracking Slip
Fragrant Category
Deemed Ground Water
Permit Type
Injection Deemed In -situ Groundwater Remediation Weil
Primary Reviewer
shri sti.shrestha
Goastal SWRuIe
Permitted Flow
Facility
Status Project Type
Active New Project
Version Permit Classification
1.00 Individual
Permit Contact Affiliation
Facility Name
Tips incident # 22887
Location Address
1515 Old Hickory Grove Ra
Mt Holly
Owner
NC 28120
Major/Minor Region
Minor Mooresville
County
Gaston
Facility Contact Affiliation
Owner Name
Ncdeq Dwm List Section
Dates/Events
Owner Type
Government - State
Owner Affiliation
Sharon Ghiold
1637 Mail Service Ctr
Raleigh
NC 27699
Orig Issue
6/30/2016
App Received
6/27/2016
Draft initiated
Scheduled
Issuance Public Notice Issue Effective
6/30/2016 6/30/2016
Renulated Activitie. Requested /received Events
Groundwater remediation
OuttaII
Expiration
Waterbody Name Streamindex Number
Current Class Subbasin

Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Thursday, June 30, 2016 1:03 PM
To: 'Scott Young'
Cc: Al Quarles; Michael Pfeifer; Rogers, Michael; Basinger, Corey; Pitney, Andrew
Subject: WI0300322 RE: NOI to Construct or Operate Injection Well - TF-22887 Tip's Inc.
Thank you for submitting the Notice of intent to Construct or Operate Injection Wells (NOI) for the above referenced
site.
Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies of
the GW-1s and GW-30s if not already submitted (originals go the address printed an the form). NOTE: Direct
push or Geoprobe wells are considered wells and require construction (GW-1) and abandonment forms (GW-
30). If well construction/abandonment information is the same for the wells, only one form needs to be
completed- just indicate total number of injection paints in the Comments/Remarks section of form. These forms
can be found on our website at
http:Jdeq_nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch /ground-water-
protectio n/groun d-water-reoorting-forms
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g,, air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these farms directly to me at Shristi.shrestha:: ncdenr.L.ov or via regular mail to address
below. When submitting the above forms, you will need to enter the nine -digit alpha -numeric number on the form
(i.e., WIOXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number W10300322. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in reply to this email, as it will already have the assigned deemed permit
number- in the subject line.
Thank you for your cooperation.
Shristi
Shristi R. Shrestha
Hydrageologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
sh risti. shresthaO ncdenr.qov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
t 9Corr.�rr
taliPt �.4J1dtjk1rlt,a 16! ot+ti i,Lia• u JfJ t :J Li PC
North Cart Ilns r'rl1Gl t Recur :is Law 041 !; rav 6o► o+s.4..7I()A�t' !t MOP] purrn_pL

From: Scott Young [mailto:[e-mail]]
Sent: Wednesday, June 22, 2016 11:36 AM
To: Shrestha, Shristi R <[e-mail]>
Cc: Al Quarles <[e-mail]>; Michael Pfeifer <[e-mail]>
Subject: NOi to Construct or Operate Injection Well -TF-22887 Tip's Inc.
Shristi,
Please find attached a Notification of Intent to Construct or Operate Injection Well for the installation of O-SOXs at
our TF-22887 Tip's Inc. site. The installation of these O-SOXs is scheduled for July 14, 2016. A hard copy of the
Notification has been mailed to you. If you have any questions regarding or wish to discuss this submittal,
please contact me at your convenience.
Thank you,
Scott Young
M. Scott Young
Project Professional
S&ME
S&ME, Inc.
9751 Southern Pine Boulevard
Charlotte, NC 28273 ,,,.,.
Ph: 704-523-4726 ex. 11675
Fax: [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Thursday, June 30, 2016 1;05 PM
To: Basinger, Corey; Pitner, Andrew
Cc: Rogers, Michael
Subject: WI0300322 NOI Tips Inc
Attachments: TF-22887 Tips Inc NOI O6-22-16.pd#
Please find the attached NOI.
Sh risti
Shrlsti R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shresthancdenr. ov
512N. Salisbury Street
1 636 Mail Service Center
Raleigh, NC 27699 1636
Nothing C sn•
Email corrr!spondence to and from this address is subject to thv
North Caroiirra Public Records Law and rnav be disciosed to third parties.

S&ME
June 22, 2016
NCDEQ
DWQ — Aquifer Protection Section
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
ECOVENNCDEClDWR
JUN 2 7 2016
Water Quality Regional
Operations Section
Reference; Notice of Intent to Construct or Operate Injection Wells
Passive Injection Well
Tip's Inc., Gaston County, NC
S&ME Project No. 4305-14-127B
S&ME, Inc. (S&ME), on behalf of the North Carolina Department of Environmental Quality (NCDEQ),
Division of Waste Management, UST Section submits the attached Notice of Intent to Construct and/or
Operate Injection Wells to the NCDEQ, Division of Water Quality, Aquifer Protection Section_ The risk
classification of the referenced UST Incident is High based on the groundwater quality_
S&ME is scheduled to install two O-SOXs in each of monitoring well MW-1 and MW-4 on July 14, 2016. A
figure showing the location of the site is attached as Figure 1 and the location of the monitoring wells on
the site is shown on the attached Figure 2. Historical analytical results of samples collected from the
monitoring wells are available if necessary.
If you have any questions concerning this Notice of Intent, feel free to contact us at 704-523-4726.
Sincerely,
S&ME, Inc.
Scott Yount{
Project Professional
MSY/waq
Attachment
Notice of Intent to Construct or Operate Injection Wells
At Qrtes, E.G.
Senior Geologist
T:1...1TF-22887 Tips inc. DWQ-APS Cover Letter June 2016 dory
S&ME, Inc. 19751 Southern Pine Boulevard j Charlotte, NC 28273E p 704,523.4726 J f 704.525,3953 I www,smeinc.com

FIGURE NO.
1
1,500'.-
REFERENCE: MOUNT HOLLY [NC] 1:24,000 USGS TOPOGRAPHIC QUAD SHEET
THE PROJECT LOCATION AS INDICATED IS APPROXIMATE.
SCALE
1_ DATE:
DRAWN 134
= 1,000'
07-31-14
PRoJEcr No
4305-14-127
litS&ME
WWW.SMEINC.COM
ENGINEERING LICENSE NO: F-0176
PYright 2013 Wall
USGS TOPOGRAPHIC MAP
Project Location
TIPS, INCIDENT #22887
1515 OLD HICKORY GROVE ROAD
MOUNT HOLLY, GASTON COUNTY, NORTH CAROLINA
SIo1 u5GS roPo
❑:W 3051141127

REFERENCE:2010 AERIAL PHOTOGRAPH
BASE LAYERS WERE OBTAINED FROM NC ONEMAPAND GASTON COUNTY GI3 WEBSITE. LOCATIONS Of ADDED
FEATURES (MONITOR WELLS, SUPPLY WELLS. TANKS & DISPENSERS) WERE NOT SURVEYED BY A LAND SURVEYOR
BUT WERE APPROXIMATED BASED ON PREVIOUS REPORTS AND RELATIONS TO EXISTING STRUCTURES.
SCALE:
1 "=30'
DATE:
07-31-14
DRAWN BY:
DDH
PROJECT NO.
4305-14-127
*S&ME
WWW.SMEINC.COM
ENGINEERING LICENSE NO: F-0176
lai Monitor Well
Supply Well
Project Parcel
SITE MAP
TIPS, INCIDENT #22887
1515 OLD HICKORY GROVE ROAD
MOUNT HOLLY, GASTON COUNTY, NORTH CAROLINA
FIGURE NO.
2
CO430514 127 TIPS103 SITE

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT 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. This fo rm shall be submitted at least 2 weeks prior to construction.
AQUIFER TEST WELLS (15A NCAC 02C .0227)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITUREMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02c .0229):
1) Passive Injection S ystems -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 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.
Print Clearly or Type Information. Rlegible Submittals Will Be Returned As Inco'!]R,_lete.
_ RECt\VED/NCDEQ/DWR
DATE:June22,2016 PERMITNO. Nj_0'3D0322-(tobefilledinbyDWQ)
JUN 2 7 2016
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED Water Quality Regional
Operations Section
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B-F, K, N
--~Aquifer Test Well ....................................... Complete sections B-F, K, N
X Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
---'Pilot Test ................................................. Complete sections B-N
___ Tracer Injection Well ................................... Complete sections B-N
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Sharon Ghiold, NCDEO, DWM, UST Section
Mailing Address: 163 7 Mail Service Center
City: Raleigh State: NC Zip Code: 27699 County:_W_ak_e ______ _
Day Tele No.: 919-707-8166 Cell No.:
EMAIL Address: sharon.gh [e-mail] Fax No.: __________ _
DWQ/UIC//n Situ Remed. Notification (Revised 7/9/2012) Page I
D. PROPERTY OWNER (if different than well owner)
Name: Ridgeview Baptist Church
Mailing Address: -=-10=5"'---"-P=in=e'---'R=o=a=d=-------------------------------
City: Mt. Holl y State:~ Zip Code:=2=8=12=0=---______ County:.----'G=a=s=to=n"--------
Day Tele No.: Unknown Cell No.: __________ _
EMAIL Address: Unknown Fax No.: ___________ _
E. PROJECT CONTACT -Person who can answer technical questions about the proposed injection project.
Name: Al Quarles
Mailing Address: 97 51 Southern Pine Boulevard
City: Charlotte State:N ~-=-C-Zip Code: 28273 County: Mecklenburg
Day Tele No.: 704-523-4726 Cell No.: 803-984-6764
EMAIL Address: [e-mail] Fax No.: 704-525-3953
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 1515 Old Hickory Grove Road County:_G_a_s_to_n ___ _
City: Mt. Holly State: NC Zip Code:..,,2,,,,8--"-'12,e,0"-----------
(2) Geographic Coordinates: Latitude**: ___ 0 --__
11 or 0
Longitude**: 0 "or 0
Reference Datum: ________ Accuracy: _______ _
Method of Collection: _________________ _
**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 ofinj. 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.
(1) Contaminant plume map{s) with iso-concentration 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.
DWQ/UIC/In Situ Remed. Notification (Revised 7/9/2012) Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity.
A release of gasoline and diesel from an underground stora ge tank system located on the prop e rty has impacted
groundwater above the 15A NCAC 2L .0202 groundwater quality standards. The use of O-SOX (Calcium
peroxide or EHC-O chemical) usin g monitorin g wells MW-1 and MW-4 is p lanned to enhance the de gradation
of petroleum contaminant levels in the gr oundwater to below the 2L Standards. Two 3-ft long O-SOX to be
installed in each of monitoring wells MW-1 and MW-4
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/weblwq/aps/gwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
Injectant: Calcium Peroxide and Calcium Hydroxide in solid granular form contained in a permeable
sock. for releasing oxygen into the water within the well.
Volume of inj ectant: Varies , b y diffusion. 1.75 lb EHC-O (0.2625 lb Oxyg en) per sock,
Concentration at point of injection: ___ 1~0~-~40~m_g_._/L~----------------
Percent if in a mixture with other injectants: Calcium peroxide >75%, Calcium H ydroxide <25%
K.. WELL CONSTRUCTION DATA
(1) Number of injection wells: --------'Proposed __ ~2----' __ Existing
(2) 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:
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
( c) well contractor name and certification number
Well Type Grout Screen Casing Well Contractor Cert# (ft-bis) (ft-bis) (ft-bis)
MW-1 Permanent 0-2 5-35 0-5 S&ME Unknown
MW-4 Permanent 0-11 15 -30 0-15 Mad Dawg, Inc. 2907
Well Construction Records/Boring Logs attached.
DWQ/UIC/ln Situ Remed. Notification (Revised 7/9/2012) Page 3
L. SCREDULES — Briefly describe the schedule for well construction and injection activities.
Passive oxygen releasing: O-SOXs will be placed into the wells on approximately May 3. 2016. Groundwater
samples will be collected semi-annually. Depending on changes in petroleum contaminant concentrations, new
O-SOXs may be installed during a separate event.
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. Monitoring wells will be
sampled semi-annually until contaminant concentrations decrease to below 2L Standards. This may be followed
by post-remediation sampling without the use ofO-SOX to check for rebound of contaminant levels.
N. CERTIFICATION (to be signed as required below or by that person's authorized agent)
15A NCAC 02C .0211(e) requires that all permit applications shall be signed as follows:
1. for a corporation: by a responsible corporate officer;
2_ for a partnership or sole proprietorship: by a general partner or the proprietor, respectively;
1 for a municipality or a state, federal, or other public agency. by either a principal executive officer or
ranking publicly elected official;
4. for all others: by the well owner;
5. for any other person authorized to act on behalf of the applicant: documentation shall be submitted with
the notification that clearly identifies the person, grants them signature authority, and is signed and dated
by the applicant.
"I hereby certify, under penalty of law, that I have personally examined and 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. 1 am aware that there are significant penalties, including the possibility chines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
signature of Applicant
5c e •f4 de e5s ,i7 f-e. oster`
Signature of ro y Owners! diiferen#from applicant)
Signature a uthorized Agent, if any
Print or Type Full Name
Print or Type Full Name
Al Quarles. L.G. (S&ME. Inc.}
Print or Type Full Name
Submit one copy of the completed notification package to:
DWQ - Aquifer Protection Section
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone] I Fax: [phone]
DWQ/U1C//n Situ Reined. Notification (Revised 7/9/2012) Page 4

PAT MCCRORY
Goven,or
DONALD R. VAN DER V AART
Waste Management
ENVIRONMENTAL QUALITY
May 24, 2016
Ridgeview Baptist Church
105 Pine Road
Mt. Holly, NC 28120
RE: Site Access Request
Related to former Tips
1515 Old Hickory Grove Road
Mt. Holly, Gaston County, North Carolina (MRO)
FTF Incident #22887
Risk/Rank: Bi~ H360D
Dear Church Members:
Secretary
MICHAEL SCOTT
Director
In December 2000, a petroleum release was documented at your referenced property during the
removal of two gasoline underground storage tanks (US Ts). One soil sample collected beneath
the north end of tank #1 showed Total Petroleum Hydrocarbons at 13,000 mg/kg, and its risk-
based analysis exceeded residential soil cleanup standards. Residual petroleum compounds also
remain in the groundwater at the site. The incident was recommended to the State-Lead Cleanup
Program in 2001, and has been monitored since then as a Federal Trust Fund site.
I couldn't find a current Site Access Agreement in our file, so please sign the attached Agreement
which gives us and our contractors permission to go on the property and work (sample the monitor
wells, etc.).
Thank you for your cooperation,
Sharon Ghiold, Hydrogeologist
Division of Waste Management, NCDEQ
Enclosure
State ofNorth Carolina I Environmental Quality I Waste Management
1646 Mail Service Center ' 217 West Jones Street Raleigh, NC 27699-1646
919 707 8200 T
Mrs. Sharon Ghiold
DWM UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Mrs. Ghiold:
RE: Site Access Agreement
Related to former Tips
1515 Old Hickory Grove Road
Mt. Holly, Gaston County, North Carolina (MRO)
FTF Incident #22887
Risk/Rank: High, H360D
I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby permit the Department of Environmental Quality (Department) or its contractor to enter
upon said property for the purpose of conducting an investigation of the groundwaters under the
authority of G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
I . The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department orits contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.
3 . Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.
6. The activities to be carried out by the Department or its contractor are fodhe primary benefit of
the Department and of the State of North Carolina. Any benefits accruing to the owner are
incidental. The Department or its contractor is not and shall not be construed to be an agent,
employee, or contractor of the land owner.
Tips
Incident No. 22887
May24, 2O115
Page 2
20116 JUN 20 PM t: 0t+
IIWe agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Signature
Type/Print Name of Owner or Agent
Phone Number
y
_lin Oki //�k�
Address
Ci State/Zip Code
— /to —
Date

t
1
r
N•
PROJECT: TIPS
PROJECT NO: 1354-01-480
PROJECT LOCATION: Mt. Holly. NC
DRILLING CONTRACTOR S&ME
DRILLING METHOD: 414" H.S.A
DATE DRILLS 6/20/01
WATER LEVEL 22.25 tt bi.
LA71iJ0E:
LQNGflUDE:
TOP OF CASING ELEVATION:
DATUM:
LOGGED BY: KJS
STRATA
WELL
z
DESCRIPTIONDETAILS
g
11
a
WELL CONSTRUCTION DETAILS
0.170
GS
PROTECTIVE CASING
Diameter. S"
Red Slightly Clayey Slit
with Micaceous
Granules and
Manganese Staining
/ j
//f
°
-Fie;..
/A:
ker '
%
0.10
2130
4.00
Noe: Steel
interval: 0-0.5
RISER CASING
.ti.
Diameter. Z"
;'•
Two: Soh 40 PVC
Brown Slightly Clayey
61It with Micaceous
t ranuiee and
,,,///G
-
-- .
—
-
-
•-�
interval: 0$ BLS
Manganese Staining
ism
:
GROUT
1G
•.
=
Types: Type I Portland CemenU
/f
�..-
Interval: 0-2' BLS
..::
—'
�:..
SEAL
is
••
�.:
��~ •
Type: Bentonite Pellets
Interval: 2-4' BLS
FILTERPACK
2D•
'• :
-
r,
Type: No 2 Well Gravel
Interval: 496' BLS
,r
-III
'
:',
SCREEN
Diameter. Z"
' -'
Brown lied Sit
airy Bat t'
Micaceous Granules
=
: a :
ch
Type: S40 PVc
Interval: 5-3'S' BLS
and Mannese
ga
V
• :,.
Staining
''-::�
—
•-
so
'--
LEGEND
rf
:
ID FILTER PACK 'fOC TOP OF CASING
GS GROUND SURFACE
=
Barromm
III BS BENTONITE SEAL
;• '- �. •• ;
3b.DD
t� CEMENT (BUT FP FILTER PACK
TSC TOP OF SCREEN
=" CUTTINGS! BACKFI L BSC BOTTOM OF SCREEN
T. STATIC WATER LEVEL ca CE G�r
COMPLETION REPORT OF
S&ME WELL No. MW-1
lR�iO' Sheet 1 of 1

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resourmcs- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # Dr
?0- 7
',WELL CONTRACTOR:
well {Indlwidtd�
Well Name
59t
Sheet Address
Ciy sr Town
U0Y) 73 c 1
Area code Phone number
2. WELL INFORMATION: y�
WELL CONBTRUC11ON PERMIT# ft.) / Tl
iLr.:_ c$t)
Slate Zip Code
OTHER ASSOCIATED PERMInN ) tilA
SITE WELL ID I v appaoa6lel �
3. WELL USE (Check One Box) Monitoring kMuniripellPublir Q
Industrial/Commerclai ❑ Agricultural t7 Recovery0 ln]ecxion p
Irrigation° Other Ef (Bat
DATE DRILLED 1 CCI
4 IL LOGTI01
MW-4
d. TOP OF CASING IS 6 I) FT. Above Land Surface'
'Top of casing terminated etior below land surface may require
a variance in accordance with NCAC 2C .fl/ 1B.
!. YIELD (gm): fDf fl METHOD OF TEST
f. DISINFECTION: Type 14 V\ Amount
0. war ZONES (depth):
Top Bottom Top Beduin
Tap Bottom Top Bottom
m Bottom Top Botto
Top
1. CASING: Depth Diameter
Top i"> Bottom t CJ Ft 111
Top Bottom Ft
Top Boom Ft.
8. GROUT: Depth
Top I I Bottom 11 Ff.,
TopBottom } ( Ft. Cart 1.C.,-u�
Top Bottom Ft
Thickness)
SCLAWeight �r.a1
40
[� ors S. SCRREEN: Depth Diameter Slot
�` eeoarlal
1�v ❑l �lCk� c 7C *• c l�n .Top Bottum, Se'lFt in. J)0 in. Fl.Z
(She.( N.roe, tWure.rs, $ t.el Na.. PEereel, �p
Material
y 3 pammui ty (t� Code)
7 CITY: + - e) li +A COunr r LJ�-x C�
TOPOGRAPHIC 1 LAND Sr 1 ING: (cheek appropriate bat)
CI Slope ❑Valleyyy ❑Flat °Ridge ❑Other
LATITUDE 36 35'1' r " DMS OR 3X.XXI000[XXX OD
LONGITUDE 75� °(53. 0 % " DMS OR 7x_x}oocicxxxlE DD
Latitude/longitude source: 3PS [(Topographic rnap
(location of well must be Sho one CUSGS ropy map endattachpd ro
this Ibrm Knot using GPS)
& FAC1U Y (Name of the business where the well is located.)
tr a\d IA ickc,v-F`'rz'
nes,Add(
nii,6 'W;
Clty or TowiZ C
Nc ary / Q4 Lees Shoe Prays;ade
HeStfaa a Obi ,irli R1 • . Su►-,
AEdmas
`'� r Slats 7Jp Cade { � 19
1 401
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH:
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOk
c. WATER LEVEL Below Top of Casing: I \VA FT.
(Use "+• if Above Top of Casing)
a-7(1,01)
Top Bottom Ft. . in. in.
Top Bottom Ft. in. in.
10. SAHDfGRAVEL PACK:
Depth rS�h�oe litas.rleR 1 Top t.3 Bottom 4> F1,Lir1.te St 11
Top Bottom FL, _ _
Top Bottom FL
1. DRILLING LOG
Top Bottom
r
►
12. REMARKS:
Formation Description
G
� Sid LF+, '
i CO HERESY CERTIFY THATTHS wets. was
r 6A NCAC 2C, WELL COWSTRUCT1ON STA$
RECORD y:. EN PRavlo£O TO THE
GTE IN ACCORDANCE T TTH
TWIT A COPY OF THIS
A RE OFIED WELL CONTRAeb�R
�W
1A.a�
t >. IC)
IIJ�
PRINTED NRMi OF PERSON CONSTRUCTING INE WELL
Submit within 30 days of completion to: Division of Water Quality • Information Processing,
1917 Mefl Service Center, Raleigh, NC 27899-161, Phone : (91e) 8074300
Form GW-lb
Rev. 2#Q9

Al Quarles
From: Ghiold, Sharon <[e-mail]>
Sent: Thursday, February 4, 2016 8:05 AM
To: Rogers, Michael
Cc: Al Quarles; Ryals, Scott; Petermann, Mark; Jackson, Vance
Subject: RE: General statement authorizing S&ME to be our agent for 0-Sox NCIs
Michael,
S&ME has authorization from NCDEQ/UAWM/UST Section to act as our agent in submitting and executing groundwater
remediation permits and notifications.
Thank you for your help,
Sharon Ghiold
Hydrogeologist
Division of Waste Management, Underground Storage Tank Section
Department of Environmental Quality
(919 707-8166 office
[e-mail]
217 West Jones Street
1646 Mail Service Center
Raleigh, NC 27699-1646
-2 Nothing Compares►,
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Rogers, Michael
Sent: Tuesday, February 02, 2016 3:46 PM
To: Ghiold, Sharon <[e-mail]>; Al Quarles <AQuarles@smeinc,com>
Subject: RE: General statement authorizing S&ME to be our agent for 0-Sox NOIs
Send me a letter or email indicating that S&ME is authorized to actas your iDWMy agent in submittal and execution of
groundwater remediation permits/notifications. Thanks.
From: Ghiold, Sharon
Sent: Tuesday, February 02, 2016 3:26 PM
To: Al Quarles <AQuar=[e-mail]>; Rogers, Michael ‹[e-mail]>
Subject: RE: General statement authorizing S&ME to be our agent for 0-Sox NOIs
1