WI0300331_DEEMED FILES_20200205

D~
North Carolina Department of Environmental Quality -Division of Water Resources
INJECTION EVENT RECORD {IER)
Permit Number WI030033 l
Were any wells abandoned during this injection
1. Permit Information event?
Linda Beam
Pennittee
Comer Store
Facility Name
896 Oakridge Fann Hwv. Mooresville. NC 28115
Iredell County
Facility Address (include County)
2. Injection Contractor Information
Geological Resources. Inc.
Injection Contractor/ Company Name
Street Address 3502 Hayes Road
Monroe. NC 28110
City State Zip Code
[phone]
Area code -Phone number
·3_ Well Information ,-E BO~ 2020
Number of wells used for injection : ';,4. -... :.ia/ili,
" '' ;·.--~~ ""'r.""'-ro:· . -,a.~e-rr..bi
Well IDs AS-1, AS-2 , AS-4 , MW-6 &
MW-IA
Were any new wells installed during this injection
event?
D Yes !gj No
lfyes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells. ______ _
Type of Well Instal1ed (Check applicable type):
D Bored D Drilled D Direct-Push
0 Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
D Yes !gj No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells. ______ _
Please include a copy of tl,e GW-30 for each well
aha11dolled.
4. lnjectant Information
EHC-0
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Solid _..;::.:,=--------
If the injectant is diluted please indicate the source
dilution fluid. ·-----------
Total Volume Injected (gal)_five CS) 3 foot long.
1.5 inch dia. Socks
Volume Injected per well (gal) Solid
5. Injection History
Injection date(s), _ __::0~l w/1~7:..:/2~0 ______ _
Injection number ( e.g. 3 of 5) 7 of 10 { estimated)
Is this the last injection at this site?
D Yes 1'81 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
STAND S LAID OUT INT PERMIT.
/r.23
DATE
Rand Smith
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this fonn to the Division of Water Resources within 30 clays of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number W10300331
1. Permit Information
Linda Beam
Permittee
Corner Store
Facility Name
896 Oakridie Farm Hw',•. Mooresville, NC 28115
Iredell Count y
Facility Address (include County)
2. injection Contractor Information
Geological Resources, Ine.
Inj ection Contractor / Company Name
Street Address 3502 Haves Road
Monroe,
City
(704) 845-401 0
NC
State
28110
Area code — Phone number
3. Well information
Zip Code
JUL 1'7 2019
Ilona% pl unction&
Number of wells used for injection 4
Well IDs AS-1. AS-2, AS-4, MW-6 &
MW-1 A
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 D Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed
Fi
4n
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 GW-30 for each well
abandoned
4. Injectant Information
EHC-O
Ir jectant(s) Type (can use separate additional sheets
if necessary
Concentration Solid
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)_seven (7) 3 foot lom;,
1.5 inch dia. Socks
Volume Injected per well (gal) Solid
5. injection History
Injection date(s) 07/08/19
Injection number (e.g. 3 of 5) 0 of 8 {_estimated){_estimated)Is this the last injection at this site?
❑ Yes ® No
I DC 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 'IIE PERMIT.
SIGNATURE F INJECTION CONTRACTOR D; TE
Randv Smith
PRINT NAME OF PERSON PERFORMING THE INJECTION
qubmit the original of this form to the Division of Water Resotuces within 30 days of injection.
UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIGIER
Rev. 3-1-2016

ir,-·. •. ... ·-··--------------------~
D~ vv~ soo~3r
N_orth Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IE R) .
Permit Number WI0300331
Were any wells abandoned during this injection
1. Permit Information event?
Linda Beam
Permittee
Comer Store
FacilityN~
896 Oalaidge Fann Hwy, Mooresville, NC 28115
Iredell County
Facility Address (include County)
D Yes 181 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 eaeh well
abandoned.
2. Injection Contractor Information ttoll.>a
Ss-(lo 4
JfJ11e;~o ,,,. • Injectantlnformation
EHC-0
---=G=eo=1=o-gi=ca=l-=R=es=o=m=ces=,'-=In=c=·---~--v J;;;,_ , .... n.., . --Ai? ,.,~19¢'
Injection Contractor/ Company Name 6/.ll, " v, a.o 8..
Street Address 3502 Ha;yes Road&M % · 'J.:J
$(1.:).I\IA
NC 28110 Q¾~O,&~
State Zip Code
Monroe,
City
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection _4,_ __ _
Well IDs AS-1, AS-2. A S-4, MW-6 &
MW-lA
Were any new wells installed during this injection
event?
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of]ajection Wells ______ _
Type of Well Installed (Check applicable.type):
0 Bored O Drilled O Direct-Push
0 Hand-Augured O Other (specify) __ _
Pleas.e include a copy of the GW-1 form for each
well installed.
Injectant(s) Type ( can use separate additional sheets
if necessary
Concentration Solid _..;=.=.=--------
If the inj ectant is diluted please indicate the source
dilution fluid. __________ _
Total Volume Injected (gal) seven 0) 3 foot long,
1.5 inch dia. Socks
Volume Injected per well (gal) Solid
S. Injection mstory
Injection date(s). _ _.,,,.0~ll;.::2 ..:.-l.l/~19""-------
Injection number ( e.g. 3 of 5) 5 of 7 (estimated)
Is this the last injection at this site?
D Yes IZI No
I DO HEREBY CERTIFY THAT ALL TIIE
INFORMATION ON TIIlS FORM IS CORRECT TO
TIIE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
s~s;?~P~9/l9
SIGNA~JECTION CONTRACTOR DATE .
Randy Smith
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 mc-IER
Rev. 3-1-2016
]) ~ vv 2-e> 3 CJ O ~ 3 I
North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300331 ,-----------------------=---=.'-'-=,=_-=-_=_=_'-"_-_-_-.:_-_-_-_::-_-_-____________ ____,
1 . Permit Information
Linda Beam
Pennittee
Corner Store
Facility Name
896 Oakridge Farm Hwy. Mooresville. NC 28115
Iredell County
Facility Address (include County)
2. Injection Contractor Information
Geolo gi cal Resources . Inc.
Injection Contractor/ Company Name
Street Address 3502 Hayes Road
Monroe. NC 28110
City State Zip Code
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection 6 -----
Were any wells abandoned during this injection
event?
D Yes 181 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
EHC-O
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Solid -~~--------
If the injectant is diluted please indicate the source
dilution fluid. -----------REC Er~D/NeDEOJl:1WR
Total Volume Injected (gal) eight (8) 3 foot long.
JI t ·31 ·2018
1.5 inch dia. Socks
'
Volume Injected per well (gal) __ s =ol=id=----
~aterauat1if
Well IDs AS-1. AS-2, AS-3 , AS-4. MW-6 & r.-:· ·-~'18Jilifcl'lflnstory
MW-IA
Were any new wells installed during this injection
event?
D Yes 181 No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wel1s -------
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.
Injection date(s)_..;:.0"""7 /""'1"""7/""'l-=-8 ______ _
Injection number (e.g. 3 of 5) 4 of 7 (estimated)
Is this the last injection at this site?
D Yes 181 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 _5!UT Il),~E.PERMIT. ~~ 7/...?///c9
SJGNATUOFJNJECTION CONTRACTOR DATE
Randy Smith
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this fonn 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
Fonn UIC-IER
Rev. 3-1-2016
I
North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300331
1. Permit Information
Linda Beam
Perrnittee
Corner Store
Facility Name
896 Oakridgg FaunH.w) Mooresville. NC 28115
Iredell County -
Facility Address (include County)
2. Injection Contractor Information
Gealoaical Resources. Inc.
Injection Contractor / Company Name
Street Address 3502 Hayes Road_
Monroe. NC
28110
City State Zip Code
[phone] RECEIvEoiNCOEorawte
Area code — Phone number
3. Well Information
DEC 1 2Qti7
Waco► Quality
Number of wells used for inj ection - - 6�i3y oDerations Sec
Well IDs AS-1. AS-2. AS-3. AS- &MW-6 &
MW -1A
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
❑ Hand -Augured ❑ Other (pccify)
Please include a copy of the GW 7 form for each
weII installed
tro
Were any wells abandoned during this injection
event?
El 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.
Iujectant Information
EHC-O
Injectant(s) Type (eau use separate additional sheets
if necessary
Concentration Solid
£f the injectaot is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal) Seven (71 3 feet1vn:;,
1.5 inch dis_ Socks
Volume Injected per well (gal) Solid •
5. Injection. History
Injection date(s) 12/04/17
Injection number (e.g. 3 of 5) 3 of 5 f estimated)
Is this the last 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 1.11I. EIRMIT_
/2/////7
SIGNATURE pt rNJnCTION CONTRACTOR DATE
Randy Smith
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of tbis Exult() the Division of Water Resources within 30 days of injection. Porm UIC-IER
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699.1636, Phone No. 919-807-6464 Rev. 34-20I6

Irv? d 3 n O 33/
North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Pf trmitrNumbelr W10300331
rs� .�i,lrQ u4rE eiio
1, Permit Information J U N 2 8 2 (H 7
Linda Beam
Permittee
Comer Store
Water Quality
fieg FOii 4 Operations Saction
Facility Name
896 Oalcridge Farm Hwy. Mooresville, NC 28115
Iredell County
Facility Address (include County)
2. Injection Contractor Information
Geological Resources, Inc.
Injection Contractor / Company Name
Street Address3502 Hayes Road
Monroe
City
NC
State
28110
Zip Code
(7i14) _845-4010
Area code - Phone number
3. Well Information
Number of wells used for injection 6
Well 1Ds AS-1, AS-2. A.S-3. AS-4, MW-6 &
MW-1A
Were any new wells installed during this injection
event?
0 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
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 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 GW-30 for each well
abandoned.
4. Injectant Information
EHC-O
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Solid
If the injectant is diluted please indicate the source
dilution fluid..
Total Volume Injected (gal) Seven i7J 3 foot long,
1.5 inch dia. Socks
Volume Injected per well (gal) Solid
5. Injection History
Injection date(s) 6/21/17
Injection number (e.g. 3 of 5) 2 of 4 (estimated)
Is this the last injection at this site?
❑ Yes ® No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM I5 CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS t.AID OUT IN TIJL PERMIT.
ea/ 6/2 k/77
SIGNATt1 OF INJECTION CONTRACTOR DATE
Randy Smith
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: U1C Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form LIIC-IER
Rev. 3-1-2016

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0300331
Permit Information
Linda Beam
Permittee
Corner Store
Facility Name
896 Oalsrid2e Farm Hwv. Mooresville. NC 2s 1 i 5
Iredell Count
Facility Address (include County)
2. Injection Contractor Information
_Geological Resources, Inc.
Injection Contractor / Company Name
Street Address 3502 Haves Road
Monroe
City
NC
State
[phone]
Area code — Phone number
3. Well Information
28110
Zip Code
Number of wells used for injection 6
Well IDs AS-1. AS-2. AS-3, AS-4, MW-6 St.
MW-1A
Were any new wells installed during this injection
event?
❑ Yes El 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
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-I form far 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 Welts
Please include a copy of the GW-30 for each well
aha,.doned
4. Injectant Information
MC-O
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration Solid
If the irgectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal) _Eiuht (8) 3 foot long,
1.5 inch dia. Socks
Volume Injected per well (gal) Solid
5. Injection History
Injection dates) 9/14116
Injection number (e.g. 3 of 5) 1 of 4 (estimated)
Is this the last 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 PERFUMED WITHIN THE
STANDARDS LAID OUT IN THE RMIT.
---r-
5IGNATUFWOF INJECTION CONTRACTOR DATE
Randy Smith
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: MC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-TER.
Rev. 3-1-2016

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0300331
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
The Corner Store
Location Address
896 OakridgeFarm Hwy
Mooresville
Owner
Owner Name
Linda
Dates/Events
NC
Orig Issue
9/1/2016
App Received
8/29/2016
Regulated Activities
Groundwater monitoring
Well Construction
Outfall
Waterbody Name
28115
Beam
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/1/2016
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Mooresville
County
Iredell
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Linda Beam
POp Box 304
Mooresville
Issue
9/1/2016
Effective
9/1/2016
NC 28115
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Thursday, September 01, 2016 3:38 PM
To: '[e-mail];'[e-mail]'
Cc: Basinger, Corey; Watson, Edward M; Pitner, Andrew; Rogers, Michael
Subject: FW: WI0300331 NOI The corner store
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NO1) 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-ls and GW-30s if not already submitted (originals go the address printed on 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 points in the Comments/Remarks section of form. These forms
can be found on our website at
httoiiideq.nc.pov/about/divisionsiwater-resourcesiwater-resources-permitsjwastewater-branch; ground-water-
p rotection /ground -water -re porti ng-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 forms directly to me at Shristi.shrestharaincdenr.pov 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., WIOX)XXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number WI0300331. 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
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
sh risti.shrestha, dncdenr.aov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636

i::..·rnail correspo11dence tc and om !his address i:. sub;': cf re
forth Carolina Public Kecords Law and may be disclosed to third parties.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Thursday, September 01, 2016 3:29 PM
To: '[e-mail]';'[e-mail]'
Cc: Basinger, Corey; Pitner, Andrew; Watson, Edward M
Subject: WI0300331 NOI The corner store
Thank you for submitting the Notice of Intent to Construct or Cperate 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 on 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 points in the Comments/Remarks section of form. These forms
can be found on our website at
htt:.'dec..nc.gov/aboutidivisionsjwater-resources)water-resources-permits;wastewater-branch] round-water-
p rotecti o ni ground-water-reporti nt -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 forms directly to me at Shristi.shrestha ncdenr,gov 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 WI0300331. 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
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807--6406 office
sh risti.shresthac: ncdenr... ov
512N. Salisbury Street
1636 Mall Service Center
Raleigh, NC 27699 1636

-=mat: correspondence to and fr:..n this aJdress is subfect to he
\/o,th ._,,arofina P;;.bfic Pecords La•, an'1 may be disclosed 10 third parties.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Thursday, September0l, 2016 3.30 PM
To: Basinger, Corey; Watson, Edward M; Pitner, Andrew
Cc: Rogers, Michael
Subject: WI0300331 NCI The corner Store
Attachments: WI0300331 site map.pdf; WI0300331 NOI,pdf
Please find the attached NOI.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
s hriisti.sh resth aie0 cd e n r. a ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
110
Email correspondence to and from th s address is subject to e
North Carciina public Records aw and may be disclosed to third parties.

August 25, 2016
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Geological Resources, Inc.
Re: Notification of Intent to Operate Injection Wells
The Comer Store
896 Oakridge Farm Highway
Mooresville, Iredell County, North Carolina
NCDENR Incident #15139
GRI Project #3992
UIC Program;
RECEIVED/NCDEQ/DWR
AUG 2 9 2016
Water Quality Regional
Operations Section
Please find enclosed a Notice of Intent (NOi) to Operate Injection Wells for a passive injection system at
The Comer Store located at 896 Oakridge Farm Highway, Mooresville, Iredell County, North Carolina.
See enclosed the NOi and signed access agreement for the property.
If you have any questions or concerns, please do not hesitate to contact me at [phone].
Sincerely,
Geological Resources, Inc.
~d~
Randy A. Smith, P.G.
Project Manager
Enclosures
cc: File
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
North Carolina Department of Environmental Quality -Division of Water Resources
NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This form shall be submitted at least 2 WEEKS prior to iniection.
AQUIFER TEST WELLS USA NCAC 02C .0220 )
These wells are used to inject uncontami nated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (ISA NCAC 02C .0225 ) or TRACER WELLS (ISA NCAC 02C .0229):
1) Passive Injection S y stems -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 p erations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Suhmittals Will Be Returned As Incomplete.
DATE: August , 2016 __
RECE\VEDINCOEQ/OWR
PERMIT NO. ;~ 03 ~1. (to be filled in by DWR)
w l-O UG 2 2016
A. WELL TYPE TO BE CONSTRUCTED OR OPERA~er Quality Regional
Operations Section
(1) --~Air Injection Well ...................................... Complete sections B through F, K, N
(2) --~Aquifer Test Well ....................................... Complete sections B through F, K, N
(3) XXX Passive Injection System ............................... Complete sections B through F, H-N
(4) ___ Small-Scale Injection Operation ...................... Complete sections B through N
(5) ___ .Pilot Test ................................................. Complete sections B through N
(6) ___ Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER(S) -State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): __ ....!L:ein~d,,,,a~B=ea"'m~---------------------------
Mailing Address: __ __,._P..:.. . ..::eOc:... . .::,,B=o=x--=-3=0_,_4 _______________________ _
City: Mooresville State: NC Zip Code:=2=8 l,,___,1=5 ____ County: Iredell
DayTeleNo.: [phone] Cell No.: __________ _
EMAIL Address: LindaBeam@ yahoo.com Fax No.:
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page I
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title:
Company Name ---=R=a=ce"'-=C=it,.,_v_,,E=x=x=o=n"-. I=n=c"--. _____________________ _
Mailing Address: __ ____,,8=9--"6-'O=a=kri=· dccg=e-=F-=a=rm=-=H=wy'--'--J... ____________________ _
City: Mooresville State: NC Zip Code:~28=1~1=5 ____ County:-=Ir"-'e=d=el=l ___ _
Day Tele No.: [phone] Cell No.: __________ _
EMAIL Address:. ____________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ R=an=d=-y<--=Sm=it=h"--, _,,P-=r=o ._.je=ct""'M=an=a g;,.;e=r __________________ _
Company Name ----=G=e=o=lo=g=ic=a=l -=-R=e=so=u=r=ce=s=·~In=c=·---------------------
Mailing Address: -------"3-=5-=0=2-=H=a=y-=e=s =R=o-=a=d _______________________ _
City: Monroe State: __NQ__ Zip Code:~2~8 =1 l~O ___ County:_U~n=i=o=n ___ _
Day Tele No.: [phone] Cell No.: __________ _
EMAIL Address: ras@ geolo ~d calresourcesinc.com Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: DMart
896 Oakridge Farm H \n-
City: Mooresville County: Iredell Zip Code: 28115
(2) Geographic Coordinates: Latitude**: 0 "or 35 °.607716 ----
Longitude**: 0 "or ____]_Q._0 ._._79"""1"-'8'-'4=6 ____ _
Reference Datum: _________ Accuracy: _______ _
Method of Collection: USGS Top o 7.5 min
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ .square feet
Land surface area of inj . well network: square feet (:S 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 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 exi sting
and proposed wells.
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -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. ·
Oxygen release material (EHC-0 ). in the form of socks . will be placed in six existin g wells (MW-IA. MW-6 ,
AS-1, AS-2 , AS-3 and AS-4) at the site usin g the 0-SOX delive ry system to promote biolo gical activity to
remove the remainin g low levels of petroleum constituents from the gr ound water. The socks will be initiall y
checked at three months and semi-annuall y thereafter. Socks will be chan ged out with new socks as needed.
Sock re placement will be based on measured oxyg en levels in the gr ound water durin g semi-annual ground water
sam plin g events. Duration of the pro ject will be dependent upon results from periodic ground water sam plin g
events.
J. APPROVED INJECT ANTS -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 htt p://de g.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-a pproved-in jectants .
All other substances must be reviewed by the DHHS prior to use. Contact the UJC Program for more info (919-
807-6496).
Injectant: __ _,,E""H=C'--0=--------------------------
Volume of injectant: ei ght 3-foot lon g and 1.5-inch diameter socks containin g EHC-0 in six wells
Concentration at point of injection: --~s~o=li=d~-------------------
Percent if in a mixture with other injectants:
Injectant: ----------------------------------
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
Injectant: ----------------------------------
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
K. WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: _____ Proposed six (6) Existing (provide GW-ls)
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
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page3
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
The O-SOX delivery systems will be placed in the in jection wells at end of August 2016. Socks will be
replaced as needed. Sock re placement will be based on dissolved ox yg en levels in the ground water measured
durin g semi-annual ground water sam pling events
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 Subcha pter 02L result from the injection activity.
Ground water samp ling will be conducted approximatel y three months after p lacement of the O-SOX
delivery svstems in the injection wells and semi-annually thereafter.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
thert; are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in acd ordan 'e with the 15A NCAC 02C 0200 Rules. "
~ ,/ . /l'av r..,ft(~vL"' ~ KanAu At5Yll,IJ ds ~cdt<?rL1trda.
Signature~ ~pplicant ~r Print or Type Ful Name and Title &o.,,n,
PROPERTY OWNER (if the prop erty is not owned b y the permit a pplicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership 1n the land owner, in the
absence of contrary agreement in writing.
See attached access a greement
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.
Submit the completed notification package to:
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page4
North Carolina -Department of Enylronment and Natural Resources - Division of Water Quality - Groundwater Secsrus.
1635 Mail Service Center - Raleigh, N.C. 27699-1636 - Phone [phone]
WELL CONSTRUCTION RECORD
WELL CONTRACTOR: GEOLOGIC EXPLORATION. INC,
WELL CONTRACTOR CERTIFICATION #: 2503
STATE WELL. CONSTRUCTION PERMIT Ilk
-- -
1. WELL USE (Cbeoh Appliaagle 8axY Residential !] Municipl D Industrial CI Agricultural ❑ Mlonilorrng
Recovery 0 bleat Pump Water inte&ction ❑ Other [] If Other, List Use'
2. WELL LOCATION! (Show sketch of the lecarion below)
Nearest Team- MOORESVILLE County: 1MEP LL
FHWY a171 8 R0W 150
Mood mama and Mamba% Ciarnfriiimity. a rubdivi6ion sod Lot NC-y — DRILLING LOG
3. OWNER LINDA Br1
Address P.O. COX 11306
(Swot a Kl u9rf No
M0ORESViL1E NC
City or Tam Star Zip Code
4. DATE DRILLED 'tam
5. TOTAL DEPTH 45.o FEET Ft.
6. CUUINGS COLLECTED YES ❑ NO 110
7. DOES WELL REPLACE EXISTING WELL? YES ❑ NO 13
B. STATIC WATER LEVEL Below top of Casing; Fi.
tux. '.- if Above Top cif Ceasing)
9. TOP OF CAS1ING IS 0.0 FT. Above Land Surface
Pigs if coming torsnrnafoxf oche 691ewv hr:d muieaa +tagNir/ml a o nod In acae+-
dancawcl 15A NCAC 2C .d11$
10_ YIELD (gmp) • WA METHOD OF TEST NIA
11 WATER ZONES (depth): N/A
12. CHLORINATION: Type >ruA Amount NIA
13. CASING
Depth 0iamofer
From co To 35.A Ft. 2 INCH
Foam To Ft.
From To Ft.
14. GROUT;
Dull
Frum 0.0 To
From To
15. SCREEN:
Wall Thtcknee
Or Weight/Pt Milreood
SCH 40 PVC
MalAriL l
31.0 Fi. Pommel Bent niie
Pl.
Depin Diamu1F.r
Frurr1 36o To 45o Ft. 2-0 in.
From To Ft_ in.
From To Ft. In.
16. SANDIGRAVVL PACK:
Orvt11
From 321,0 To +1:5.0 Ft.
From To Ft.
6'lot Sire
010
WOW
Sitltrlr
Material
in. PVC
in.
in.
Sire Mria1
20-41 FtNE SILICA SAND
From To
O.A 12.0
iZO 30.0
300 k.0
addrtionel
•
DEPTH
FnOaastigarafi
TM Ye
RET19111TYQAT
TAN 111.TY QM'
Is needed We seen ei rofm
LOCATION SKETCH
(Show de+mbon erid distance from of 1993E two Mute
Roads, or caster m®p reference porrito
17. REIVIAR6(S: . MW.6 6EIVTONITE SEAL FROM 31.0 TO 33.0 FEET.
DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL CONSTRUCTIONS
STANDARDS, AND THAT A COPY OF THIS RECORD HAS SEEN PROVIDED TO THE WELL OWNER.
FOR OFFICE - SE ONLY � �O
Ousel No: - �� WELL �7 e
swarm anginal is 0 iaian 0VWiw 041111b Grrtrdnrt r S.i*n vAltlie aQ dap
Serial No.
tVAN1 REV, 1240
TDTRL P.03

WELL CONSTRUCTION RECORD
North Carolina — Department of Environmental and Natural Resources — Division of Water Quality — Groundwater Section
WELL CONTRACTOR (INDIVIDUAL) NAME (print) MARK GETTYS
WELL CONTRACTOR COMPANY NAME GEOLOGIC EXPLORATION, INC.
STATE WELL CONSTRUCTION PERMI'r f ASSOCIATED WQ PERMITII
(i rapplieable) (if applicable)
CERTIFICATION # 2345
PHONE # [phone]b
I. WELL USE (Check Applicable Box): Residential 0
Monitoring ® Recovery 0 Heat Pump Water Injection 0
2. WELL LOCATION:
Nearest Town: MQOKESVILLE County IREDELL
NC 150/NC 801
Municipal/Public 0 Industrial 0
OtherD If Other, list Use
(Sheet Name, Numbers, Commuairy, Subdivision, Lot No., Zip Code)
3. OWNER: LINDA BEAM
Address P.O. BOK 1606
MOORES V ILLE
(Street or Route No.)
NC 28115
City or Town titote tin Code
i
Area Cade —Phone Number
4. DATE DRILLED 2-11-03
5, TOTAL DEPTH: 55,0 FEET
6. DOES WELL REPLACE EXISTING WELL? YES ❑ NO to
7. STATIC WATER LEVEL Below Top of'Casing. 45.o FT.
{Use "+" if Above Top of Casing)
8. TOP OF CASING IS o.o FT. Above Land Surface'
°Tap of easing tcnoinated atlor below Land surface requires a
variance in accordance with 15A NCAC 2C .0118.
9. YIELD (gprn): NIA METHOD OF TEST NIA
I D. WATER ZONES (depth): N/A
11 _ DISINFECTION: Type NIA Amount
12. CASING:
Depth
From o.o To 40.0
From
From
13. Grout:
To
To
Depth
Wall Thickness
Diameter or Weight/FL
Ft 2 NCH SCEs 40
FL
Ft.
Material
From 0,0 To 36.0 Ft. Portland Bentonite
From To Ft.
14. SCREEN: Depth Diameter Slot Size
From 40.0 To 55.0 Ft. 2.0 in_ .010
From To Ft. in.
15. SAND/GRAVEL PACK:
Depth
From 38.0 To
From
16_ REMARKS:
Material
PVC
Method
Slurry
Material
in PVC
in
Site Material
55.0 FL 20-40 FINE SILICA SAND
To Ft.
DEPTH
From To
0.0 10.0
Agricultural ❑
Topographic/Land setting
0 Ridge ❑ Slope 0 Valley ® Flat
(check appropriate box)
Latitude/longitude of well location
(degrees/minutes/seconds)
Latitude/longitude source: ❑ GPS 0 Topographic map
(check boa)
DRILLING LOG
Formation Description
ORANGE CLAY
10.0 35.0 BROWN SANDY SILT
35.0 45.0 TANBROWN SILT
45.0 55.0 ORANGE/BROWN SILT
LOCATION SKETCH
Show direction and distance in miles from at least
two State Roads or County Roads, 'nettled the road
numbers and common road names.
MW-!A BENTC)NTTE SEAL FROM 36.0 TO 38.0 FAT
l l]Cl HEARBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH.15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER
03
DATE
SIGNATURE OF PERSON CONSTRUCTING TINE WELL
Submit the original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center— Raieigh, NC
2.7609-1636 Phone No. (9!9) 733-3221, within 30 days.
GW-1 REV. 07/200I

r
r
r
-13 81
NONRESIDENTIAL WELL CONSTRUCTION RECORD
Ntii h Carolina Wpm -tomtit ofEnvironment and Natural Resources- Division ol.Wnter Q+I»Ii()
WELL CONTRACTOR CERTIFICATION # Michael Wileac
1. WELL CONTRACTOR:
Mihel Wiz. ear+
Well Canlrectar (Individual) Name
SAEIIACCO Inc
Well Contractor -Company. Name
STREET ADDRESS $one N0RTFIWIt3L,D DR
FP.la:[LL se
_ City or Tawn State
( [phone]
29715
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *fir apprlcahiel asl
STATE WELL PERMITAitappifeable}
DWQ or OTHER PERMIT Plif applicable)
WELL USE (Check Applicatrio Box) Moniloring i Municipal/Public ❑
Iniiustrial/Cornmerclai J Nino/lure' G Recovery L litlection LI
ircigalinrt Other (j (Rst use)
DATE DRILLED
.TIME COMPLETED PM G:
3. WELL LOCATION:
CITY: MCORBSVIL1,E COUNTY IRED T L.
es6 OAIC RIDGE FARM KWY., 28115
iStreet damn. Numban. Community. Saw:6161W. Lot No., Pa reel Zip Code]
TOPOGRAPHIC f LAND SETTING:
Lisiopa LValTey to Flat EIRIdge la Other
lchecrs appropriate box)
LATITUDE
LONGITUDE
May tee ue dcgrri
mtnegl seconds or
ilia decimal Kamm
I.,alitude?Iongi(ude source: .GPS oi'upographic inap
(k c8tkn of well must be shown on a USGS raps mep sera
aiteehed to this forte if not Using GPSf
4. FACILITY. ishenen'o inenueineaa%Almthe %reu alvaugd.
PAO/LETY ID 8(If applicable)
NAME OF FACILITY cxzarfgt_ e'rou
STREET ADDRESS 896 0 .X RTnGI Floral Wt-
MOOE$VILLS
City or Town
NC
Simo
CONTACT PERSON STEVS IRNTxr3sR
28115
Zip Coda
MAILING ADDRESS 7015 ERTNDROWIt Dn.
CONCORD
City or Town
{ 709 )- 755-15E15
Brea cede- Phone number
S. WELL DETAILSt
a. TOTAL DEPTH: 57'
sac
Slade
2a02S
ZIp Code
lt. DOES WELL REPLACE EXISTING WELL? VESO NOti
c. WATER LEVEL Below Tog el Casing: FT.
(Use '4' Ir Above Top of Casing)
AG"I
d. TOP OF CASING IS FT. Above Land Surface'
'Top of rasing terminated ettor below land surface may require
a Valle/ice In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm) METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
From Ta From To
F►orn To From To
From To From To
8. CASING_ Thicknessf
Depth Diameter Welghl Material
From 55' To 4" Ft 2" tiCtre0 PVC
From To ' Ft.
From Tq 55' Ft. -
7_ GROUT: Depth Material
From 5nTos" Ft. PORTLAND
From To FL•
From To FL_____.!^
B. SCREEN; Depth Diameter Slot Size
Melhod
TAiTr4IE
Malaria;
From S7' To 55' FL211 Ill. Ia irl. PVC
From To Ff_ in. in.
From To _ FL In. _ _ in.
9. SAND!GRAVEL PACK_
Depth Size
From 53' To 57' Ft. POURER
From__ To . Ft.
From To R.
Malerlat
SAND
10. DRILLING LOG
From To Formation Description
0 57' ' BROWN SILTY SANDS
11. REMARKS_
i 0O HEREBY COVEY ThI T THIS WELL WAS CONSTRUCTED IN ACCORDANCE W fit
i tE� NCAG 2C. WELL COMM L=CRON STANDARDS. ANO U1AT A COPY OF THIS
RECORD t Rs BEEN PROViUED TO THE WELL OWNER
SIGNATURE OF CE
MXIS(EW. WILSON
1-23-09
Eo WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Tnrormetton lVT9t.,
1617 Mall Service Center— Raleigh, NC 276994817 Phone No. [phone] ext5BB.
Form GW-1b
Rev. 7/05

.13 11
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department al -Environment end Natural Resources -Division of Wrier Quality
WELL CONTRACTOR CERTXFICATION #
f. WELL CONTRACTOR:
Well Contractor (kidlvidual) Name
Well Contractor CompanyName
STREET ADDRESS fors. +c,:,t7 f;€L. df•
Fad- /1/41; Elf 5C-- 947/
Cfy or. Town State 21p Cade
( d0 )_6119 -0353
Ares code- Phone number
2. WELL INFORMATION: �y
SITE WELL !U #(I! applicable) A 5-0--
STATE WELL PERMIT#Or applicable]
DWQ ❑rOTHER PERMIT NCif applicable)
WELL. USE (Check Applicable Box) Manila/tog c Murlclpal!Public 0
Industrial/Commercial fl Agricultural Recovery 0 inaction 0
IrrIgafonf 7 Otters- 0 (Ilet use)
DATE DRILLED__; .a"07
TIME COMPLETED AM ❑ PM ❑
3. WELL LOCATION:
• CITY: I`IL7Lre5tAlle- COUNTY ilebifi
g9% Cr , 4/— 9treel Name lYwnbGa am -Noy, star tar
( Suhdivl N „ Parcel. Zip Code)
TOPOGRAPHC, I LAND SETT1Ne
❑Slope OValley cFfat ❑Ridge 0 Other
(de* npprupriata box)
LATITUDE
LONGITUDE — —
May bola defiers
tnirliltes, seconds or
in a decimal format
Latitude/longitude source: ❑ GPS Topographic map
(location of well must be shown on a elSGS topo map and
attached to this font not using GPS)
4. FACILITY -is ape =me of the business w here thew ell Is loomed
FACILITY to #(if applicable}_
NAME OF FACILITY The CQLrh or S
p'L(-
STREET ADDRESS PO. a +�'ri et✓l
fr14 gr85y; flei. at/
City or Teem State Zlp Code
CONTACT PERSON 'LrM'►15E1" reef) i,1,1'•
MAl NO ADDRESS 70 5 414-60k
Clay or Town State Zip Code
17Q'1 )- 7a - r5`f
Area code- Phone number
6, WELL DETAILS:
a. TOTAL REPTH: �l I /
b. DOES WELL REPLACE EXISTING WELL? YES I3 NO (5
c. WATER LEVEL Below Top of Casing; _FT.
(Use °+° If Above Top of easing)
Pin
d. TOP OP CASING IS 0 FT. Above Land Surface'
lop of casing terminated attur below fend surface may require
. a variance In aacordence with 16A NCAC 2C .0418,
e. YIELD Wpm): METHOD OF TEST
r. DISINFECTION: Type Amount, M • g. WATER ZONES (depth):
From To From i o
From ToFrom To
-
From To From 1 o ..
a. CASING: Thfckneeaf
Depth, „' Diameter Weight Material
Frnm Q - - To 66 Ft.
From To Fl.
- From To FL" - -
7. GROUT: Depth Material
From D To 61 FL pc041
From To R.
From To Ft.
S. SCREEN: Depth Diameter Sint Size Material
From 5-To 5 Ft. t.2,. 1n. / Q In. PVC --
From To Ft. in. In.
From To FL M. En.
a.
Method
SANDIGRAVEL PACK:
Depth Size Ma al
FratTL33 To 57 Ft. .9- ,fw'"{.
From To Ft.
Frail To Ft..
1D. DRILLING LOG
From To Formation Description
11. REMARKS:
IDOi1EREB
15A N¢
ftEgO
THAT MS Wal. WAS CONSTRUCIE0 IN ACCORAANCP Wm{
[INSTRUCTION BTANITARDs. MD7HAT A COPY OFIHIS
P WELL OWNER
SIGNATURE OF CERTIFIED WELL CONTRACTOR
„-09
I]ATE
Z.."4 110
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu: Information Mgt.,
1617 Mali Service Center •- Raleigh, NC 27699.1617 Phone No. (919) 7337R15 ext 568.
Form GWfh
Rev. 7YD5

�3 1
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources -Division of Watcr Quality
WELL CONTRACTOR CERTIFICATION # 025'13
1. WELL SONTRACTOR:
k~ L L (•
Y"-er
Well ConIraictar individual) Name
7CiXPa:-C3
Welt Contractor Companny,�l.Li ii Name
STREET ADDRESS 133fAi1i t c' OR,
Zlp Code
City ar Town Stale
t 1 —?
Ara coder Phone number
2, WELL INFORMATION:
SITE WELL iD #(If applicable)
STATE WELL, PERMIT*, eppllcabls}
• DWG or OTHER PERMIT #(If applicable)
WELL USE (Check Applicabro Box) ManforIng o Municipal/Public L)
Indusl►ial(Contmerctat q Agricultural 0 Recovery ❑ infection L'7
in iatian0 Other n that use) R5 %'i If— S r-
DATE DRILLED
TIME COMPLETEDAM tEr-11/1 D
3. WELL LOCATION:
CITY: jYk•opt eSL3A,,, caUNTY rR
(Street Name. Number. C mm Subchlsion, Lot No., Parcel. VI) Code)
TOPOGRAPI- LAND SETTING:
rJSlope ❑Valley at QRidge 0Other
(check eppropriale bolt)
LATITUDE
LONGITUDE
May Ile in donnas,
Wades. seconds or
in a deasmal format
Latitztddlongitudasauce; OGPS o Topographicmap
(location of smrellmust be shown on a USOS tapo map end
affachedfo [his font ilnot using GPS)
4. FACILITY.u. the ymme of lie buslnesswheal In,e well le located.
FACILITY ID tf(f applicable)
NAME OF FACILITY live_ Czar, SAOne .
STREET ADDRES € W1 Oak , Ac �qrQ� Hi 3V
ma�t�tes:� {1l .
City or Tarn Slate �• Zip Coda
•
CONTACT PERSON - Si e fnl �"
IMLING ADD ss 7 01 ' b r x k
voortz
My or State Zlp Code
7�) ` qs — i 5---"
Area code • Phone number
S.WELL DETAILS: �,r
a. TOTAL DEPTH: 8 f
b. DOES WELL REPLACE EXISTINOIiirEL L7 YES U NO IV
c. WATER LEVEL &low Top of Casing: 4 "i FT.
(Use'+" if AboVe Top of Casing)
-3
d. TOP OF CASING IS 0 - ' FT. Above Land Surface*
"Top of casing terminated at/or brim land surface may require
a variance in accordance w11h 16A NCAC 2C .I1118.
e. YIELD Wpm):
f. DISINFECTION: Type
g. WATER ZONES (depth):
From To
From To
From To
G. CASING:
METHOD OF TEST
Amount
From To
From To
From To
Thickness(
Depth Diameter Walnut,, Material
From C r To Ft, �l"' S }'�
From To Ft.
From To Ft. -
7. GROUT: Depth M-[❑� aaIt�erial y
From 0 To S7 1 FLTn6 1rzofn91
Method
From To FL
From To Ft,
B. SCREEN: Depth Diameter Slot Slze Material
From t] -S.- To .S.-7 FL 1r in. - b i O in.
Frorn To Ft__In, in,
From To Ft_in. _ In.
9: SAND/GRAVEL PACK:
Depth r-^� ire, Material
FrorrTe V f FL e 5/1
From To F.
From To Ft.
10. DRILLING LOG
From To F unittOns iptlon
C1- s7
11. REMARKS:
100 HERESY CER IFY "Hamm WELL wllS CONaTRUCTED 1I l ACCORDANCE WITH
16A NCAC 2C. WELL CONSIRLICiiOH ST RD6, AND THAT A COPY OF THIS
w�...r�.00'TIITi N PROVIDED T1 [Ey .LLOWNER
SIt3NATURRE C I ELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
/617 Mali Service Center-- Raleigh, NC 27899-1617 Phone No. (919) 7337015 ext 5138.
Form GW-lb
Rev, 7105'

i S -(
NON ON_RESIDENTIAL WELL CONSTRUCTION RECORD
North,CaralinaDepartment of Enviconmeet and Nature] Resources -Division of Witter Quality
WELL CONTRACTOR. CERTIFICATION droZgl8
1. WELL CONTRACTOR:
is ►y �. i..sa.Yai t r-
Well Canlrector Individual) Name
Well Contractor Camperry Narne
STREETAnt:TESS 494. 0344T; '
Pc PM( 5 C ac11057
City or 'Rem S e Zlp Cede
S
Area code- Phone number
2. WELL INFORMATION:
SITE Wlri 1.ID di[iI soplloeble]_
STATE WELL PERMITIi(if appllothle).
IPWR er OTHER PERMIT Rt(11 epplIcabte)
WELL USE (Check A;tpiloablo Box) Mwtitorinii d MrtnIcIp2UPub1rc 0
Indosirial/CArremerelel C] Agricultural n Recovery 0 Infection El
Iota/Goo attar n {Gst I►€e] �� kW. S p- 3 _
DATE DRILLED I
TIME COMPLETED AMorig o
3.INELL LCCATLCN: a
CITY: i'Jt�0�l�5Vt(I COUNTY A JAJ`
€09IP o\L i Rom' 0.tn iAWS'
(Street Name, Narnb ra. Gwnmtm; rr,''StddLNelon, Lot No., Pared, lip Code)
TOPO RAP LAND SETTING:
°Slope Walley 0RIdge t7 Other
(cheric eppmpriato box)
LATITUDE 3
LONGITUDE
Latitedeltongilude source: ❑ rGPS ❑Topographic map
(Imat ii of svoR must he shown an a USGS top° map and
attached ro fts form rt net userg GM)
4. FACILITY -limn rams or the rbuxlnass wham the wan is }enamel.
FACILITY ID #(1f epplIcsable)
NAME OF FACLLITY T .t. COWIN
STREET ADDRESS Eitt (3 k �o.Y-li� Hwy
rosy ilk
CRy orTimm Stale 73p Code
CONTACT PERSON f f-��tt'RK1
ILINt3 ADD ESS7 OIc �...rcr}r1 b1rryyqry tit•
City a- Town Stele Zp Code
l710 j. 795— 1 ��
Area code - Phone number
May be in tlegreea,
miautea, salonde or
is a decimal
5. WELL DETAILS:
a. TOTAL DEPTH;
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
C. WATER LEVEE Below Top of Casing: LH. FT_
(Use '+ If Above Top of Casing)
d. TOP -OF CASING IS CO • FT. Above 'Land Surface"
'Top of casing terminated ear below lend surfeee may require
a Wanes In accordance with 15A N'CAC 2C .0116.
e. YIELD (ppmj:
f. DISINFECTION: Typo
METHOD OF TEST
Amount
g. WATER ZONES (depth):
Front_ To
From To
Front To
From To
Frorr, To
Fforn T[�
G. CASING: Thickness/
Depth Diameter Welg}t Material
From C3 To S-t Ft?.'F 5e-At43
From To Ft.
From To Ft.
7. GROUT: Dept) M[atellrfal ll :mhos
CO To S. Ft_T�{L7']ae�ra1�i'
From
From
From
To Ft.
To Ft
8. SCREEN: Depth Diameter 'Slat Size Material
From €7 S- TO? , Ft. X° En, . et f ❑ In. _,
From To Ft. in. 1n.
From To Ft. in. In.
8. SAND/GRAVEL PACK;
Depth Sire M tarlal
From fro s� FL F7� � 5 3
From To Ft.
From To R.
W. DRILLING LOG
From To
—S7
11. REMARKS:
F .� larr Des flan
Jet
ao Hammycirn'nrcriATTIila way. WAS come -MU Tlo IN ACCORDANCE Wr1H
16AHOAG2C, WELL CONSTRUDTION UTA • • • DS, AND 'MAT A COPY or THIS
N PROVOEO Tr`, eE VL OWNER.
SIGNATURE CE IF sn ELF. CONTRACTOR DATE
1 al LL IF,;•p
PRINTED N E OF PERSON CONSTRUCTING THE WELL
Submit the Original to the Division of Water quality wrlthin 30 days. Attn: Information Mgt.,
16'17.MaII Service Centers Raleigh, NC 27899-1G 17 Phone No. [phone] ext L68.
Form GVV-lb
Rev. 7105

ADVENTUS
REMEDIATION TECHNOLOGIES
Safety Data
MATERIAL SAFETY DATA SHEET:
EHC-O 111
Page: 1 of 5
1. PRODUCT IDENTIFICATION:
PRODUCT USE:
MANUFACTURER:
Adventus Remediation Technologies Inc.
1345 Fewster Drive
Mississauga, Ontario
L4W 2A5
LHC-OTM
Soil and water treatment.
EMERGENCY PHONE:
Office Hours: 905-273-5374
After Hours: 416-457-9491
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide). Class 5.1, PG II, UN1479
WHIMS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Calcium Hydroxide
Sodium, Calcium Aluminosilicate,
Hydrated
3. PHYSICAL DATA
Chemical Formula
CaO
Ca(OH)2
Ca2(Na,K)2AIRSi28O72 24H20
CAS No. Percentage
1305-79-9 45%-70%
1305-62-0 10%-20%
12172-10-3 20%-30%
Appearance White
Physical state Solid
Odor threshold None
Bulk Density 500-650g/L
Solubility in Water Insoluble
pH -11
Appearance White
Decomposition Temperature_ Self -accelerating decomposition with oxygen release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product also contains crystalline silica. Long tern
exposure to hazardous levels of silica dusts can cause lung disease (silicosis). The World Health
Organization had indicated that there is limited evidence that crystalline silica is carcinogenic to humans,
but the NTP and OSHA have not classified this ingredient as carcinogenic.

ADVENTUS
REMEDIATION TECHNOLOGIES
Safety Data
dii
MATERIAL SAFETY DATA SHEET: EHCOTM Page: 2 of 5
Potential Health Effects:
• General In-itating to mucous membrane and eyes.
• Inhalation Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
• Eye contact May cause irritation to the eyes; Risks of serious or permanent eye
lesions.
• Skin contact May cause skin irritation.
• Ingestion Irritation of the mouth and throat with nausea and vomiting.
5. FIRST AID MEASURES
• Inhalation Remove affected person to fresh air. Seek medical attention if effects
persist.
• Eye contact Flush eyes with running water for at least 15 minutes with eyelids
held open. Seek specialist advice.
• Skin contact Wash affected skin with soap and mild detergent and large amounts of
water.
• Ingestion If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Point
• Not applicable
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• Water

ADVENTUS
REMEDlATION TECHNOLOGIES
Safety' Data
nuii
MATERIAL SAFETY DATA SHEET: EHC-OTM Page: 3 of 5
Fire Hazards
• Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution. Pressurization if confined when heated or
decomposing. Containers may burst violently.
Fire Fighting Measures
▪ Evacuate all non -essential personnel
■ Wear protective clothing and self-contained breathing apparatus.
■ Remain upwind of fire to avoid hazardous vapors and decomposition products.
■ Use water spray to cool fire- exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper, oils,
etc.). Do not return product to container because of risk of contamination.
8. HANDLING AND STORAGE
Storage
• Oxidizer. Store in a cool, well -ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
• Keep away from incompatible materials. Keep containers tightly closed_ Do not store in
unlabeled or rnislabelcd containers.
• Protect from moisture. Do not gore near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Store separately from organics and reducing materials. Avoid contamination that may lead to
decomposition.
Handling
• Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
• Do not swallow. Avoid breathing vapors, mists, or dust. Do not eat, drink, or stroke in work
area.
• Prevent contact with combustible or organic materials.
• Label containers and keep them tightly closed when not in use.
• Wash thoroughly after handling.

ADVENTUS
REMEDIATION TECHNOLOGIES
Safety Data
MATERIAL SAFETY DATA SHEET: EHC-0"1 Page: 4 of 5
9, EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits_
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no respiratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
• Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
■ Prevent contact with this product, Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC, neoprene or rubber)
Other Protective Equipment
• Eye -wash station
• Safety shower
• Impervious clothing
• Rubber boots
General Hygiene Considerations
• Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
■ Stable under normal conditions
Condition to Avoid
▪ Water
• Acids
• Bases
• Saks of heavy metals
• Reducing agents
• Organic materials
• Flammable substances

ADVENTUS
REMED1AT[ON TECHNOLOGIES
MATERIAL SAFETY DATA SHEET: EHC-OTM
Page: 5 of 5
Hazardous Decomposition Products
■ Oxygen which supports combustion
11. TOXICOLOGICAL INFORMATION
■ LD5O Oral: Min.2000 mg/kg, rat
• LDSO Dermal: Min, 2O00mg/kg, rat
• LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological Information
■ Hazards for the environment is limited due to the product properties of no bioaccumulation, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste Treatment
■ Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations.
Package Treatment
• The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
* Proper Shipping Name: EHC-O
• Hazard Class: 51
• Labels: 5.1 (Oxidizer)
• Packing Group: Ll
15. REGULATORY INFORMATION
• SARA Section Yes
• SARA (313) Chemicals No
• EPA TSCA Inventory Appears
• Canadian WHMIS Classification C, D2B
• Canadian DSL Appears
• EINECS Inventory Appears
16. PREPARATION INFORMATION
Prepared By: Geoff Bell
Adventus Rerediation Technologies Inc.
1345 Pewster Drive
Mississauga, Ontario
L4W 2A5
Date Prep./Rev:
Print Date:
Phone:
Fax:
2/24/06
2/24/06
905-273-5374
905-273-4367

RIGHT :OF ENTRYAND ACCE SS AGREEMENT
.• THIS_ RIGHT_ OF ENTRY -AND ACCESS AGREEMENT :(this ~Agreement") is entered
into as of.this 1"6 -day of-February, -20 t6. 'by and-between :Linda Beam, {'\RP"}, and Race Cit¥
Exxon, Ing .• f'Landowner").
WHEREAS, RP is the party identified by the North Car:olina Department of Environment
Quality ("NCDEQ") :for the cleanup .of environmerntal contam1natlon at-the site commonly known
· as. The Corner Store located at -~96 Oa krj dg e Farm Hwy, Mooresville N orth Carolina and havin g
facility LO. number9~017677 (the "Site"); . ··
WHEREAS, l~andowner .is the owner of the property jooated at -896 Oakridge Hyyy for
which access is required for the purposes of conducting -environmental assessment and
remediation as directed by -NCDEQ, collectively the "Property";
WHEREAS, RP and its consultant .Geological Resources, Inc. ("GRI") desire to gain
:access to the Property for the purposes of conducting environmental assessment .and
remediation as directed by NCDEQ; and
WHEREAS, pursuant to the terms and conditions set forth in this Agreement,
Landowner :is willing to allow RP and GRI, their agents, employees, and contractors-.access to
fhe Property for the -purpose of :performing such work.
NOW, THEREFORE, in -accordance with the mutual covenants, terms .and conditions
.. set forth ,herein, the rece\pt and sufficiency of which are hereby acknowledg.ed by both .parties,
the parties-hereby agree as follows: ·
1. Recitals. The recitals set out above .are true and. correct and are 'in.c~rporated
,herein by reference.
2. Right -.of .Entrv. RP and GRI, their agents, -employees and contractors shaH
.have a license to access ·the Property for the purpose .of performing environmentar· assessment
and remediation. including, but -not limited to, the installation of monitoring and recoveiy wells,
taking soil and ground water sam.ples, .soll excavation, the installation and operation of a
remediation ·system or equipment, and the taking of other actions required for the proper
assessment and remediation of contamination at the Properly as -directed by NCDEQ {the
llCorreclive Action,;) •
. 3. Term. The right of entry .granted herein is effective immediately upon execution
of this Agreement and. subject to earlier terminatron as hereinafter provided. ·shall be In effect
until tha Corrective Action has .been completed, .and NCDEQ has Issued a No Further Action
letter, or until terminated pursuant to the terms hereof, whichever occurs sooner. Landowner
shall have the right ·to terminate this Agreement at any time, upon giving thirty (30) days
.advance written notice to RP .and GRI .
.4. .Site Restoration. :Upon termination -of this Agreement and after ·completing the
Corrective Action, RP promptly shall restore the :Property to the condition ,existing Immediately
,prior t~ RP =or GRrs first entry on the Property under this Agreement.
I •
5. Per.formance -of Work. .AU work done on the Property pursuant to this Agreement shall
be done in a professional manner, in accordance with the professional · standards of
environmental consulting firms tn the area, and in compliance with applicable environmenta.I
laws and NCDEQ requirements.
6. Indemnification. RP and GRI, their employ~s. agents, and contractors shall
enter the Property at their own risk. accepting the Property "as is" without limitati.on. RP agrees
to defend, indemnify, and hoid harmless Landowner and its respective officers, directors,
employees, agents, and contractors, from and against any and all losses, claims, .damages,
tines, expenses. and all other costs (including without limitjltion reasonable attorneys· fees)
arising ;out of any loss of life, personal .injury or property Joss or damage whatsoever which
results from any actions of RP •Or GRI hereunder, the presence of RP or Gm or their ag.ents,
employees, or contractors on any part of the Property, or from the presence of any monitoring
well or :remediation equipment installed hereunder, except to the extent such loss, injury or
dama.ge is solely caused .by the negligence or willful misconduct of Landowner. Any dangerous
.conditions created by RP or GRI or their employeeS;, agents. and contractors or :arising as a
result of their activities cm the Property shall not be deemed to .constitute any negligence or
misconduct on the part of Landowner or its respective o.fflcers, directors, emp!C,>yees, agents
ar:id contf8ctors. Landowner's .liability for currently exi$tlng environmental contamlnation, if any.
is not hereby assumed by RP,. :i:ts :employees, agents or contractors, and RP shall .have no duty
to indemnify Landowner from and a·gainst such liability. · ·
RP and ·GRI shall ensure that Landowner is added as an additional ,insured to GRrs
liability Insurance.
7. Materlalme n's Liens. If any mechanic's lien, materialmen's lien, contractor's
·lien or other order for the payment of money shall 'be . filed against the Property by .reason or
arising out of any Jabor or material .furnished or alleged to have been furnished to or for RP or
GRI •Or under any .contract relating thereto in connection herewith, then within thirty (30) days
after the filing of .any .such lien., RP shall cause the same to be canceled and discharged of
record 'by bond or otherwise, at RPs sole expense. RP shall defend, at its sole cost and
expense, any· action, ·suit or proceeding which may be brought thereon or for the .enforcement
of such lien or order. RP shall pay .any damagas and discharge any judgment entered thereon
and shall defend, :indemntfy and save harmless Landowner from and .against :any ·Claim or
damage J:esutting therefrom. ·The intent of this Paragraph ,is to protect ,Landowner and the
Property from .any Uen rights which may attach to the Property .as a result of any hon-payment
or alleged non-payment on the part of RP· or :GRI in connection with •thls Agreement.
8. Assi gnment. RP shall not assign this Agreement nor make any use of the
Property other than as specified in this Agreement without the prior written consent of
Landowner.
9. .survival. The provisions ·of Paragraph Nos. 4, 5, 6, and 7 :hereof shall survive
the .expiration or termination ofthis Agreement.
10. Counterpart.~~ This .Agreement may be executed in multiple counter.parts, each
of which shall be deemed •an original, all of which constitute one and the same instrument.
11. S pecial Conditions. None .
. 2
1 -
\
IN WITNESS WHEREOF, the undersigned, by authority duly given, have executed this
Agreement, as of the day and year First above written.
Race City Ex,
¢y:
Name
Title:-{.
4Landowner)
Address: 896 Oakridge Farm Road
Mooresville, NC 28115
Linda Bea (RP)
By:
Name: t 11 /Via- Cr�
Title:
Address: P.Q. Box 304
Mooresville, N G 28115
GEOLOGICAL. RESOURCES, INC.
a North Carolina Corporation
By:
3
Name:
Vii "Me
Title: r .f (HS .�i .. �'�G ti►�
Address: 3502 Hayes Road
Monroe, NC 28110

s
LEGEND
• TYPE 11 MONITORING FW1L
61 TYPE 111 MONITORING WELL
▪ AIR SPARGING WELL
• VAPOR EX7RAC770N NYELL
AIR SPARGE PIPING
•••- VAPOR EXTRACTION PIPING
E
[o)
- - — SUBJECT PROPERTY
BOUNDARY LINE
- - — ADJACENT PROPERTY
BOUNDARY LINE
UTILITY/ELECTRIC POLE
— E — OVERHEAD ELECTRIC LINE
UNDERGROUND STORAGE
TANK BASIN
FUEL DISPENSER
Note:
1. This Site Mop is based on data from the
!cede., County G15 of NC as well as ❑ Site
Pion dated May 1, 2009 that was prepared
by the previous consultant. the remedial
system layout on this mop is based on an
As -built Crowing dated May 1, 2009 that was
included in the previous consultant's October
2009 Remediation Monitoring Report (Initial
Report)!
2 This mop has been modified based an
observations mode by ON Field Personnel.
iv V1-M'f(
?q,, Air65 &roL(x►d
owl cipiiraiTePt
(addr) 5-fithc,
I edr n IM ! (64 di&)
•
UST
Basin
Ccre1�
.10
E�
ESE„t—EEE--E—
MW-5A
I" ALL MW-5
Q
AS--1
EE - -
E~E—E`E EE
E
MW-2 ate! =ads
e
8 Svt -5
SIB 6•••'��"°s
0'
Fuel
Canopy
AS-3
MI
,d „ddddddddddd,A5-4
The Comer
Store
Con venience
Shop
0 10 20
40
(IN FEET)
linch =20ft
• Ahi41A
MWI 1Q
SW-2
0
Milt 4A
co MW-4
MW-T
1aiELLd
Garage
S ysterrl knt.
Residence
Ai re C 13 L, t cr1X4 cr ; I L tv / • J �7
REMEDIAL SYSTEM LA Your MAP
The Corner STore
Incident No. 15139/22752
OR/ Project No. 3992
896 0okridge Farm Highway
Mooresville, IredeJl County.
NC
Geological Resources, Inc.
Date:
06/08/16
Drawn by
ECH
Figure: 4

LEGEND
• TYPE 11 MONITORING WELL
TiPE 11! MONITORING WELL
o❑ WATER SUPPLY HELL
ABANDONED WATER SUPPLY
HELL
----SU6LECTPROPERTY
BOUNDARY LINE
-
--ADJACENTPROPERTY
BOUNDARY LINE
077LITVELECTRIC POLE
— E — E — OVERHEAD ELECTRIC LINE
UNDERGROUND STORAGE
TANK BA.SIN
FUEL DISPENSER
— — 57 — — WATER TABLE SURFACE
CONTOUR
(56.52) GROUND WATER ELEVA T70N
(FT)
NOT MEASURED
(NJ
►
1
UST
8051,7
-_-__-_-�
MW-SA
1 " WELL
(h4v.) (N4+I
FARM HIG3yW.4Y�
Mid'-5
❑ ❑
E�mW=2�E�g�E�
NM)
0 0
(59.
Fuel / /
Canopy
/
/ 1
The C Ier
Sto
Convenience
Shop
1
1
1
1
1
1
/
VF1-•_.
Mr�'r 0MW-M
(N 0 ❑ (5652)
Garage
i MW=7�
i 1 " HfLL System
(Sf 5SJ L J
,,
{
M oJA
(56.62)
r
1
Ml-10
(56 ►6)
►
I
►
Residence
N
G2
0 15 3O
60
(IN FEET)
1lnch=.30ft
WATER TABLE SURFACE MAP (05/18/16)
The Corner Stare
Incident No. 15139/22782
GPI Project No. 3992
896 Oakridge Farm Highway
Mooresv/T1e, Iredell County,
NC
06/06/16 r Drawn 6y
Geological Resources, Inc.
Date:
ECH
Figure.
5

oti
y�
►�
-."'•
�:11 scr +-
N.TFE e i /
TS F Jo Contvelhairoir nf t i-
r
2,0
7
I
Cross. .ecrn-t_
Corn eA 5-10 re-
e 96 Oct_Ari`cy6 Fafr 7
f'2 ores utl fe dPIG