WI0300338_DEEMED FILES_20161103

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0300338
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Kangaroo Express 2853 North Center Street
Location Address
2853 N Center St
Hickory
Owner
Owner Name
Circle K Stores Inc
Dates/Events
NC
Orig Issue
11/3/2016
App Received
10/28/2016
Re g ulated Activities
Groundwater remediation
Outfall
Waterbody Name
28601
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
11/3/2016
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Afflliatlon
Major/Minor
Minor
Facility Contact Affiliation
Brent Puzak
PO Box 8019
Cary
Owner Type
Non-Government
Owner Affiliation
Brent Puzak
305 Gregson Dr
Cary
Region
Mooresville
County
Mecklenburg
NC
NC
27511
27511
Issue
11/3/2016
Effective
11/3/2016
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Thursday, November 03, 2016 10:17 AM
To: 'Christine Schaefer'
Cc: Watson, Edward M; Rogers, Michael; Pitner, Andrew
Subject: WI0300338 RE: NOI Kangaroo Express 2853 North Center Street
Sorry I didn't see the site map which was together with the well construction records.
The Notice of Intent to Construct or Operate Injection Wells (NOI) for the above referenced site has been given the
deemed permit number WI0300338.
Please remember to submit the following regarding this injection activity:
1) Injection Event Records (IER). All injections, including air and passive systems require an IER. The 1ER can be
modified for aft sparge welts (e.g., air ffow'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at Shristi.shresthaancdenr.eov 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 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
shristi.shrestha a�].ncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
tic
`' isfat# g Com ire
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Christine Schaefer[mailto:[e-mail]]

To: Shrestha, Shristi R <[e-mail]>
Cc: Watson, Edward M <edward.watson@ncdenr,gov>; Rogers, Michael ‹[e-mail]; Pitner,
Andrew <[e-mail]>
Subject: RE: NOI Kangaroo Express 2853 North Center Street
The last page of the pdf is a site map showing the existing and proposed sparge wells. Please let we know if it didn't
come through. The information provided in section A indicates section His not required for an air injection well, which
is what our NO1 relates to. Hopefully the site map will suffice.
Christine Schaefer I PROJECT MANAGER ATC Group Services LLC
[phone]
7606 Whitehai[ Executive Center Drive, Suite 800 1 Charlotte, NC 28273
[phone] fax 1 christine.schaefer©atcassociates.com I www.atcgroupservices.com
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From: Shrestha, Shristi R[mailto:[e-mail]}
Sent: Thursday, November 03, 2016 9:25 AM
To: Christine Schaefer<[e-mail]>
Cc: Watson, Edward M <edward.watsont, ncdenr.gov>; Rogers, Michael <michael.rogersryrncdenr.gov>; Planer.
Andrew <[e-mail]>
Subject: NOI Kangaroo Express 2853 North Center Street
Good morning,
While going through the NO1 for Kangaroo express 1 did not find any injection zone map as required in the section H of
the application form. 1 would need the map for the application to be complete and to process it. Please submit it by
email or in the address betow to me directly,
For future all the NOI applications can be submitted directly to me.
Best regards,
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
shristi.shrestha@,ncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
i n9 Compare_

North Caroiina Public Pecords Law and may be disclosed to third partie,s.
Shrestha, Shristi R
From: Shrestha, 5hristi R
Sent: Thursday, November 03, 2016 10:20 AM
To: Basinger, Corey, Watson, Edward M; Pitner, Andrew
Cc: Rogers, Michael
Subject: W10300338
lam sending the NOI for records even though it came from the regional office.
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 . s hre stharw n cd enr. q ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
—'Nothing Compares
Errlai, corre pondence to and from this address i, subject to the
North Carolina Public Records Law and may be disclosed to third parties.

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 (15A NCAC 02C .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225} or TRACER WELLS (15A NCAC 02c .0229):
1) Passive In jection S v stems -In-well delivery systems to diffuse ipjectants 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. Illegible Submittals Will Be Returned As Incomplete.
DATE: ~Ju=lv------=--"18~--·· 2016 PERMIT NO. ~ (to be filled in by DWR)
w:I.-0 3b o 33S
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
(1)
(2)
(3)
(4)
(5)
(6)
=x ___ Air Injection Well ...................................... Complete sections B through F, K, N
___ Aquifer Test Well. ...................................... Complete sections B through F, K, N
___ Passive Injection System ............................... Complete sections B through F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B through N
___ Pilot Test ................................................. Complete sections B through N
___ Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: 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): Circle K Stores. Inc./Brent Puzak. Director. North American Environmental Shared Services
Mailing Address: -----=-P-=O'"-'B=-o=x-=--=-80"-"1""9 ________________________ _
City: Carv State: NC Zip Code:-=27-'-'5"'"'1"""1 ____ County:-'W'"'--=ak=e'-----
Day Tele No.: 919-774-6700 CellNo.: ___________ _
EMAIL Address: b puzak@l circlek.com Fax No.: 919-774-4242 ------------
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page 1
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: ---------------------------------
Company Name ____ N~a~ti~o_na~I_R_e~t~ai_l _P_ro~p~e~rt~ie~s~L~P ___________________ _
Mailing Address: ___ 4~50~S_O~r~a_n~ge~A_· ~v~e._S~u~it~e~9~0~0 __________________ _
City: Orlando State: ___f1_ Zip Code:~3-=2~8~0 ~1 ____ County: Orange
Day Tele No.: 407-650-1269 Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: 321-206-2143
E. PROJECT CONT ACT (Typically Environmental Engineering Firm)
Name and Title: --~M~ik=e~S=h=a~w~-~S~e=n=io=r~P~r=o..,g=ra=m~M=a=n=a=g=er~----------------
Company Name ---~A=T~C~A=s=so=c=·ia=t=es~of~N~o=rt=h ....,C=a=r=ol=in=a=·~P~.C~. _______________ _
Mailing Address: --~7~6-=0=6....,Wh~=ite=h=a=ll~E=x=e=c=u=ti"'"v-=-e~C=e=n=te=r-=D""'r_,_iv'-'e=. -=S=u=it-=-e -=8-"-0-=-0 ___________ _
City: Charlotte State: NC Zip Code: 28273 County: Mecklenburg
Day Tele No.: 704-529-3200 Cell No.: __________ _
EMAIL Address: mike.shaw@.atcassociates.com Fax No.: ___ 7'--'0'--'4....,-5=2=9....,-3=2'-'-7=2 ___ _
F. PHYSICAL LOCATION OF WELL SITE
(I) Facility Name & Address: Kangaroo Express , 2853 North Center Street
City: __ ....,H""""'ic=k=o.._rv.__ ________ County: Catawba Zip Code: _28_6_0_1 __ _
(2) Geographic Coordinates: Latitude**: ___ 0 --__ " 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 of inj. well network: square feet (.:S. 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be .:s_ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Pennitted GW Remediation NOi Rev. 3-1-2016 Page 2
I.
J.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets ifnecessary.
NOTE: Only irljectants 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 q.nc.!w v/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-a pp roved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
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: ____________________ _
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: ___ 4 ___ Proposed ___ l~5 __ Existing (provide GW-1 s)
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.
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 .
N. SIGNATURE OF APPLICANT AND PROPERTY OWN ER
APPLICANT: "/ hereby certify, under penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
/~;, ~I . ~--<-~ .
l~--J'.'.~-d c. .,._~(.. -. c~:.: z.
. as aeent for Circle K Stores . Inc . Christine E. Schaefer. Project Manager
Signature of Applicant Print or Type Full Name and Title
PROPERTY OWNER <if the property is not owned by the permit appl.ican():
"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 we/1(.r) conform to the Well Conslniction Standards
(.I SA NC AC 02C. fJ 2lJOJ . "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
~ .. ~ .. l::f ~~Wdlff•«ot from ,ppH~nt) P,OU "Typ, foll N,m, Jl!l!! -no,
* An access agreement beMeen the applicant and property olt'ner may be submilfed in lieu qf a signature on this form.
NATIONAL lt£TAJL PROPERTIES LP. q
•O.....finllld~ • • "'
By: NHN GP CO!Jt., a Oall'ftre~ion, '"
er. -~amet ~;a.;=
Submit the completed notification package to:
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOi Rev . 3-1-2016 Page 4
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DATE
PRINTED NAME FPERSON -CONSTRUOTINO THE WELL
Submit the original to the eivisidn of Water Quality within:at) days. Attn: Inforrhation Mgt..
1611 Mail Service Center - Raleigh, NC 1760-16i7 Phone Nei (91)) 73-1016 ext801.
Form QW-ib
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t(-)1.114n* ca Lawb a
28601
(StreeNiarile04infori,;Cornmurily,- SubdsiArtEirilsIlia.AinaktittO0d4),
76POGRAPP.110.-66AlkiNa
croloto.laveirerl inr. a
0000017441.* oc*
35.76938
itifiberikit el. 33 41
.I.gitittided4itudourtiOr 116Pg tfecOVilblc4:60
MRO `,07 •f1411011x,60-tinIMM14506-**4
ii
11-587460f 0466:19/24p
4tPiC1141PA
0,Aduryierkeig#10ithr8y PANT" 4 395
141;4E.0'0000'amass
STREET AND141.-0 2a s3 N. TER ST
DIC.XORY NC
.P.14590:Tr'
eit0E-Rebtetat
F1AW
iviktiadrANIRE,46 4020 OLD PIKEVILLE RD .
28601
ZitIck04"
CHARLOTTE 28601
t7Q4 ,, 972-418/
esiva.4006.4..p4ownointxt.!
.mat DETAIL;
TOTAG,MPTIli 60
b.. liplif*LL.004******-00 *37 OKI
�.leigER RO*700.0 FT.
06 1'0000 6404 , tr:7-Abaiii3.14rid tiurritcok
*44$.100110404#10. no100/144"40100)410Y4fitiulre
166giatift4eirith fisA i4dAt:2c
• O.L.Y-101afilpili1;••M WNW CIF Tgti
k .M[10E06064* Maui*.
10.0331.1400440
Frazi tir Fr 'oni 16
rermarpu__
gi:00100:' '11**.
ql*riiiit IOW :Motoriol:
F65-t se 1-s-irr-ft. 2" SRC 40 PVC
:194111..
7;440* .4*. 1.414: Mnibacr
:FAO 54 .746.4 _„„eitPortIona •
tri• wale
- • -
OM* PP# .0.0410.K. *174fp. 611406)
Vidim Pvc
:r*
WAWA. RAM
Mileg
60 "a! 56 pt-.,A2 sand
*tlida**1
o
t a 60
.RFP.614411W
Fliititeatitik,0610561i1
TAN AND $SD MICHA SI LT
1: 051MeigglYtAkr*VOT
6L(cotiga 7C.: WELL
11
TA-.WA8,00451-Rtere0IN
Siii0400a55.:4006\TAtiaPY °F This
TFiR IkatitiWNER, "
n-1-11
4.0gRAcTqn 4kTE
heal toils=
•PRO1TVI'1.8.M.E.0FLPOR$Q4CfPrOgR114474017/4146-1-
thn'Ohtinico �f Woo 4inaiity within 31* days. AO: intoriont1OnAl41Li,
141100 UW4 Phone No, okipiraet47.044408,.
Farm OW- 1 b
Aay. 7/115

RESMENTIAL Wax CoV$1103061 gt ORD
NOM rOarelfrid Ditered4ritnr EnVitiOnaOliOn4Nalukel-ROoMp:1)1141gre,e1Water
WELL CONTIACTORVERMICA.11014* 3351
4t010$40FORI-
Michael Wilson
WeIcanter (41.00114NAIR/!•
SAEDACCO inc
WellCbrnredn'rcrzinpartiNaMik
STREET ADDRESS.•• 9068 northfield di
ft ,mill
2 9 707
.04-1474.0 MAW
y- [phone]
A0od9-. InenoNliMe
2. WE ul INFORMATION:
VrrE-WECLip-.0:4ppilpotiby
'ZIp...garie •
StATEL_ WEIL OdiNii*6applicebto)
bleirCi or PTWERPERMPTAIrOPPAble) as 4
WELL Me PtditKAPPlicAlig VOW motacipaWRiblireu
IRdOnototryilscOcIL Agnculkinl AIFFIXT)`:P .4.1,040W
,C1001111ilit Lige9L-
.0.00,0Ftiit4,4- 11-2-11
TVAE.0,0010Tria 9; o ,Ailitvg Fit 4
3. WELL LiXAtietii
City hickory MAT ea tawb a
2853 N.CEPTER ST,
286G1
(Strait Nigme, tiumbors, bocanumtty; lait•tio6 PlinleUtP Cod
LAN6 Sim r
inSietd:CIVdiay. ElfTet1dge00W
PkokoordPPideb0)::
•Of A•IDE- 35 759 3 8
LoNtlit/DV 91.33041
Latirt#MIlightideVUtife• MOPS OTO00,100440
OaCOMPt) ail/00*P* $ileferdh kOMOPOON400
thiirom trilo 11:30,001#
4. PACIUTX•410airikifiNi4041aailwrig-e410101110414K
PACILiTY-11:40 **arm, WINTRY # 3958
4/00•5r:FAcicii•Y, PitngY P84 In:NOP
ETREV Ai5OKEE.S• 2853 N. CENTER Su.
.P.:!/*-4004tlitt
HICKORY NC
26601
Clkorrogra On.te•
CiaN TAM' pERE-0N ,MIKE SHAN
MAII-U4•10b722-§S 4020 OLD PINEVILLE RD.
CHARLOTTE NC 28601
7,474YirP slaft 4,0*,
( 704 11-972-4081
Area bode • Phone-rturnizer
d: WELL DETAILS:
6. TOTAL DEPTH: 60 •
b. Does WELL REPLACE EXISTING WELL?. YES.b NOEi
c. WATER LEVEL.Bei TO ni 940:1• FT.
(Vse "+ it Above Top of OWN)
di 1`.43P OF- WINGS FT; 'Above tend Suriate7_
'Top of Ai,5ing• tennineledieVo0elowlond:444ce fray require
a van arta in accentiricarithr ISA OttAG-2c..01 it.
O. POW METHOD Of Tow
DissimdrioNay0
fet3tEktONgig--(OPH 4);
PO* -7-4
Witte To. Frenr_4 To
'004:171:1;1:-: fftalit To_____
A3eptd EI100160' Wigb MMeriat
fire58 To, 0 Ft 2" SHC 40 PVC
r
44gitirr I:1*# Material
Refer 54•YO211
___,Ft, per t land
:Fro_ 41*
4. #.4100* „DA06 lt*TOr 40*if8. M
OA* so Tos8,2J 10 ivc
Method
trimmie
--Fr601. Ft..
Frn Tri- fr.
sosumpwEt. pAcog,
thaISItt Elie" ).tererlid
:Frail 60 'yb 56 h .02 sand
rffplop 0-•
PtFil ' r.11•
041411400?
Fron Th.Formarloirttekrjfilion
0 60 TAN man asp lc c_mp, slur
11,,REmAsk4
fr-Plittr-jr1"00retreTHAT1H AM:A_ WAS coNsTEUCTF_13 RACCORbANCZ' WITH
Otcrtir.AC 2C, Ontil aRrIKTh STAIsitiARDS. AND:MAT ACOPY0F11115
REctiROHAS ES POovioEu 1 THE WELL OWN.eL
etGNATImE
ELL OONTRACTqlF,t. DATe
Micheal wilson
PRINTED NAME OF PERSON CONST131f0TINATI-tE WELL
Submit_ the original to the Division of Wgiter Quality within 30 clays. Attn:. Information Mgt.,
'1617 Mail Service Center- Raleigh, NC nal-1017 Phone No. (9ft) 7334016 Oxt sfia.
Form 6W-1 b
Rev. y115

ENT WELL r011., [TM N 'UMW') NoNREgiji " IA • -- • • -0 •
iodireolgtic000152iWitqf glivOhlkialiggi401:44010WW6A0M400*.3147
WgEritorfrititpitiltailliMpi-110** 3351
tt,t5rill4-0.01111. ***I
Michael Wilson
W1In:(h)d+)INarne
S7EDACCO Inn
WOO g_0101101W-01/0.009:1440K
riREETADCWStf.9088 northf ield dr .
ft. will BC
20707
fr [phone]
,A0414100-
:t *ELL ottilwAtikiiii.
'UTKiriiti004-9p#40
t1-kliMrnfOioppfita t;fe)
00161,9eQpieRmp.mmlaffporcodio
5
WiL t4r100610011041160*Vo4taftit, fikomtke160411
10000701!'d.. A094.01.171§eFfr4/5190104-
Vthern ilk4.904
loofttc. 11-2-11
.111.0-6.041/irti) 3 °.
3. WELL airmlOtti,
:errif;1.3 hickoz-,
2853 N.CENTER ST. 20601
fsteetiiimieknumbeisiCommussikiliiiMikipi I.cf•No;-, 4Farook2iretaiil
TINVORAPkIIVICANEYSWITII4i*
SItsp4iitikaliic 1:31o004t3:
:wilp4001:000.00
LAtivot: As . 930
hAri3.40:615kAM•
:4040044400.
btiktTlik5t. 81,33041
LtIti11/0/400.41A416:10:0 KGPs Affatiti"lild*Fi
I-001/AW*Ygtf.#,V.W00.6-•40"610;
affklikillbaft fiiitfaitikGFV,
OP iittkiiiinic01040.***444,,400;1014,14.
- FACIL.t1a:/#0*.gablik PANTRY 0 3.9.5B
1.4is*00'40 PANTRY .ErrRO REPRESS
'.8Tft'Etr Athitg.S 2 esa 1./ . (=TER ST.
HICKORY NC 28601
tvoriown,
d0i4f4er 0817:466041KE
V40.;
SHAM
Waltakhribilettifi 4030 OLD IP TEE VILLE RD .
CHARLOTTE
41P,OPPO:
NC 28601
Piti;s0;TOW SW,
704 1- 972-4001.
Aito:00e4 Nilteumber_
5 WEU. BELMLS:
a. TODAL IZIEFft 60 t
b. oga 101.4C I10444. 06tOtiiiteittiU0 *ea NOP
wATERWYWROlefrekcikotcaOct
4.tse Ma -wrap Cagfiig)
.0; itifiitiOk; /.4.41— *OA- ' .0..
i - 'Iii10145:410161illii•
maticaCIFIT
NCIA;d7-201041i• —
l'IKAIIItt-
---:t..01040.•
ToppI i2•514terr0)4ted;i0ier
ktf ArtstractligOtilisi-milijo
:',Ainalitk
iii •*0001, 0404
0411A. • . Tki--
Wiiiii ,. tii
.
.fikt00.1*
fetgiI ;
731•;4---
n moo go'
_91 W V** Mptutior
2 SHC 40 ..LOVC
TfiK • • -
to:MO& 1*i-A
..E0604 :4:r4474. '
fi:IY))1TVE.
6. 0000 gt!,!**.' 004 *O.
Pvc
Wfdk fiNq
Vri$10;r4Clgit,
ORIPIONOVak- PAW
!1:+01#1 ttilk
60 ,T6 56 6%.,„#2
•
,tqa 11.Q -OF
0#4144*
iVtettgtcr
triMetie
GO
it,RWARKS.
send
TAN AND RED MICHA_ _SILT
TAVZ5tifilre0044801regtitARVIMAYM801M"Will
iREOORD4 *WORD. iliVAINLOtOWNWR. " "
•
11-2-11
ST
tjWIIA.QTOR DATE
rdohesi
RI b NAME:4JF pppi-R14cil$G,THE WELL
Li.brrilt.th# oFiglitai•-tw th� E.)ivis kin -of Wator 010611ty Withkri.*Oly0..ALtortifitiOnti*-,
I•611.Mall5erviCe,00.0t0r.-•Ritle1g*.NO..2/499401/ 0.11000;fW($1.9).034,040•All.c.t$00k
Form
rienf4 7/b

0'4
t WELL.
41.4000.00;
Michael Wilson
NeArRrstot • -
iNt
gEL cripikRu no' sigeoRD
Nofth ax�JD4iefltarffilafthilidit-641SNidrAlIMAItOdf•Diviigi90,0WijWitjaiitY
WILL CONTRACT: tilt ERVIEIcATION* 3351
Qtrthr#10074044.0104T#:
SABMICCO Inc
WOI.00Ita0.0t 0001{M1Y Mama_
ay HIEET ADDRESS'. 9CB northf ld dr
ftt1U. 29707
Ow of TOM SMM ZuNCtictt?
(700 507-41373
keRd0de- 147tfutuiiiSer,
+NELL IRPCiailaATION:
SITg WELL fp *froppli;:6010.1
sTATE WEii PERNO*8-eirp8tabfki)
OWQ orQT44ElifillitalTIEfpfikable) ae 6
WELL us Excbeit'AilillObleffek) lytorioxihd fi4ii*OVIniblibl3
Milyd,triaScrienrciRrTf kg JrdLJ-.ReplYerY 1:1190cflorli)
ttirtEitiPM gt4P0 (110t
,Dpiorw rigiuvo 10 -26-11
'r*•00061.PLOW,, 11: 3 0
&WELL...LOCATION:
111-v: hickory
2053 N.CRS-THR ST.
PM0
.aititilre: cat a wba
2060/
[straetiiime,MumbimiCommunity, IldiVORNI; LOIN° Oamoi•EprOode).
TOPOGF1000/1.,A146SETT11&:'
aS10013 effS MOO
10,10:010.111040140 POW
LATtewke. 35.7693a
LON6111i13t' 81.33041
- Mak' Wit,d9m,
I.
Lalltii,040igki4ealiVtar 1613PS OTOpitgiVitifi;niari.
114"0171)4$Pek9S7 009fiPtgWS:1•574VileaViket
iitfabliiid tit* .ftiidisesiir0 Wig)
*.,17.ggirt-rtuilitfei*arihaidlicnokrittife'01410.003W
FAditspiltioufloWeitukr.pwrIty 3958
OkitiF FA,d11..rrY Pablay_MEg 2XEVE5S
•STRELET ADDREaS 2053 N. CENTER ST.
HICKORY NC
28601
PEVRI.9".AP 1134.t
COMA& PEOON MIKE sHAvi
klAtt.INOAIDDRE8S 4020 ow PINEvILLE R.
CHARLOTTE 20601
};11Catii.
city orTokep, Zip paste
Area code = Pi** number
a: WELL DETAILS
TOTAL. DEPTH:. 60'
b. Dogs iival RekiwE ixe-rituj WELL? YES Li NO tO
c. WATER LEVEL BOMAT*0 0E04 ET,
0.ho*+"if Abdigito0:0 botti.0)
d; TOP op CASSOW Ft.'Ab044 iedSiffface
*MO tit I t'MTUrted atlor tOptv leridaiii410/P3)/LnIquIre
4,440/01cei IZANdA023,0118-.
YlEMAtIPITI11 ,men-rop CFI/4T
f.f3111110EtrnOWlyklAio�iit
*4PSOC/t10 (4110);
• Frmti
Fr�th re
6. 'cis.tfiy*
T" PameOr
,Frofy
•
Florb
From
F tons .Tp .
WOW-- ktplork#
Sric 40 PVC
0.4 4111-0i Mod
FA*4.54 01* gt.portland tr
M_
OS* nth 04,14* 0.19* 104f0
Fieol, €0 vvc
rh* T6
fit* —111.
8ANgirqRAVEL PAM:
Tej5th AtiorrIM
60 'fa 56 sand
'Olorn___Yo_.
T9 4
-10-00000
Etiernitifigi timootin -
60 I Atip RED HIGH. SILT
ninn••••••••....
11. REMARKS;
1.0OHEitgoi.:001#4.111,47HaWka.WACOOTRIVNI1,1H ArApkOlitir.6Wrffi
145 tici9?P:-WP4P01,161/10OPPO6TrANDARMA.N44W ipppy'aF,TAs
ofecio plurvro0D70 THE voriownec
EIRIATURE at co fo-RApToR
10-26-11
DATE
rzti, camel wiison
.PRINTED•NAME OF PERSON'ootigRuipT*GiTHEwELL
SUbrnit the oridirtatto ti4rOlVision of Water Quality WitIgn 30 clayt. Atinrinfornnation Kat,
1817 Mail Service Center - Raleigh, NO 27699-1817 Phone N* (91.9):74340164ixt 568.
Form GW-lb
Rev, 7105

RESIDE/01qt Wgi ,L CCfAtikilieriON
1401± 04040104 Mfdifiti$I00004016i1 P.14004s4:40tiviitif MliziktQUAT
14/311A(OrritACTORaittirldittiON* 3351
0,04....004407:04s.
Michael Wilson
C*1101.4F00.40.14101)*Fe.44.
SAEHACCO Inc
Z1NritcoectifttsipOsii,
ar REM ADDRE,Sti 900B tort hfield dr.
ft .!Tall
QC 29707
jettle004: 44001:' 2404.640
[phone]
Atea.4/00"--FfiblikellSOW
triastitisAllok:
Srrg;.vitti7.10**Ofiroblis,)
STAtLERMppIkab
Oftiogyi.i-ERPgatilillliF001000.1.4ri 7
lam us glom KA,015110111013-WE Morileld 11/4MirlIdliionbiteett
indoojuigispipej040: '4.4014P
ikshotoko
bps:b .10-26-11
TMPTD
2:-30 44171.• *RV
:ak .411/15t,
ertvr:., hickory •daility catawba
2853 N.CENTIM ST.
28601
1$0eatNaavii-Nsanberla trOMMAIly; SU0(16,00003,00*;•ftaar6621p160:40
TOPOGRAIWOI,LANEXSE17110f.'
C15004. ORRIOIZI Offer
(otzkagKookte PFX9
Likt-#46t 35_76938
Ltihe3r111M. 81.33041
Ltilifti,d4/toiteideWONO tatiO#000.,. mgri
floPig1k0 tif3104010*POYfe-CRi WP00101#06.:i60:iglit
7.41licheri Witt treesziO Mt 1464:
FAQIYb
44%01076 146444444011400060044100:1400-;
ziNecint*PANTRY # 3958
eilkii*Wi410*}'ANTRY .PETRO -IMPRESS
,FREO.AtIOMOI 2853 N, COMER ST,
HICKORY NC
28601
9110$10n1: SlaPf
d014t-4=1-004$0#41MI]CE S;1AW
MAILITidilitiblkEga 4020 OL10 PINEVILLE P.13.
CHARLOTTE NC
.51,Pf
70
a 2.), 972-4081
:.101k004.,
28601
Olase,
Neil: *Ale:,
V. WELL DETAILS;
TOTAI- DEPTH: 60'
b. D005 Wkil Ot011411 1(1):C1 110.11
e., WATER WM-0*W TWatr4.014474
iibentote0 dii614)
d.
_T4:46004:1140 gtAviiirtaii0
IPP210astinOtrilt00401. 4000(10:41*4041,, mtngto
NOAceaciblio
4). NIVI-Ptitit0 m ETHOD,0 F TEST
O. wilioriattobl* -11-1;nio kink
Rod
1"1&71i:
ieth
T',45r. om
64140v TIOSIMO
PoF ,804016t Ntets:
1V06 56 Tn, 0 ;FL 2" SHC 40 PVC
1*-411:60
.Ftportland trirnia _
0 Ogg* *Ps* Sat* *to*
vtteif * ::Ft;
slANDW4V14. poxr
1-.344k ute.' UAW
Ipigik 60 56 pf.,#2 sand
ROO
"4-6,,t#50/144*
Patilit61100116101tail
,t0 69 Tan ZNO RED MICHA_SILT
-tt.REPARK14.
fot40.000.0111:tentitomt.A9 L-..4;9003g-rp;1.0.0okorfi*_61,1m
11"73"1.1,1,611tegt==R" -
••
nicheal wilson
POINT414E-01:00,940NgRIAPTiko-44E WELL.
10-26-11
44.01TRAgrOft
Siiittilt-thear0400110)ivrirpf *ter Cioality yikth in 30 Otrys. Atim.injormatioilMapv
1617 1144a soy* roNflor No i/49*-{017 Phponito. PIO 134-7.00.9xi 006,
Form OW -lb
R0'1470)5

NON RESIAKIVTIAX-, Vi-rtEt•CON$IAjt14115tiT
NOtilgitiOESS usitaftvir taMitfilit9-0404 fteS01.00:94)0.1006fWQiLiy
Wait, CONTRACTOR-a-RVISICA11014 it 3351
Michael Wilson
Welt Cqrdrolor (CricsOlyal)Nlyne
SAEWACCO nc
Wp11.0britra010.1.6Infilltly KIM*.
STREET. ArYDRESS.: 9006 uvrthf it'd dr. .
sc
29707
Gfty at Town Milk airrikr,
[phone]
.000:0061.! --ROOS:900u
••2. WELL INFORMATIOR: •
•SITE:WEEL*40:840r4qa):
STATE-WEIL FIE RMI TiOaplitioatodij
DINO ot.o.T.tiarKpRwryKif loiropRo..-as
WELL.usi(Chei4:40114.*r.kRi.%), MentwnW latraMPimari
imus..frieu0.47raa.c..*-0. 404cuIurat l;1.,0.1VP.APX.0.110.4tonLlgt
lktIgatimei Vhr erlaiustails).
_DoloRmo_igial 10-27-31
TiME. C.WAIPLAItn, 9:3° 40-151
3, '6101,1„LriCATIOM
bITY. bickory
eotifity: catawba
2853 N CENTER ST.
(Slreel. Arne. umbers, ComnitAily, ulcie.1144
'TOPOORAFillalLANEi.SEITINa,
[MIN* tiVaittay. its134.6e,c1
V5a4kgkoLatl.03410 OP4
LATOODE: 35 . 7653 0
Lbiltbrilli5E. 01.33041
28601
. „
416,*.-404,
luifislics7i4imiitiot
LatittideAdi*itildOsourda OAPS
OadariOihkOt.a0400 Oria0
-iiMiaisidii):itiletao ;hi& ailoiry01:1,
PAch,Er6 rAiiis.11:0411: kaki&
FACiLITYVV i466ablnyPA!?TRY # 3958
tikkgbirAtitill RANTRy arra° jakas,..sQ
milgEt•jitiiiitg;st, 2853 N . CENTER ST
HICKORY NC
28601
Town ziff G90.
ceotrAcr PE -REM 'MI KR MAW
MAI LiNd ADDRESS 4020 OLD pi biEviLLs RD.
CRAY:LOME NC 28601
•PV,SirrOWA- State
L p 4 ..j.• 972-4001
Area code. Ftarili number
6. WELL DETAILS:
a. TOTAL DEPTH: 60
b. DOES *ELL REPLACE EXI&IING WEU,.? YES CI
NO X.1
q. WATER. 4E114 BO* 1-00.0 000.,1* FT.
ithe 'el Matte IrOp •00t44000)
TbPdfdikEiiiprik WAN* Land Sittaite
0••60,61:601110.40040r-bef$41.1110:11:44*-60.-rgcNi-m
a Wiwi -Okla .atMlike MIT l'6A NO.402cAirae,
YiEtttfelatil:' mEniPtVOY TEST
biettkiFtefilolik-rtrie
(1! .VOTElk.*(00-01014;
MM. .'"6
• From, KW T
Itin, 1751
:c4.4040:: 11)050?:
-.POP 010g101* 1%/10)40041
Frkin Se 0 FL 2" SBC 4 0 PVC
From_ Ft
1
040* OP* Mt arjal Matnaff
404 Portland trim:ride
%SI Ft
.60_144; • ft
OS* ptb.1**07' -,t9r* VOli•41k
fii&;60 rolaFf o
wonwoo,ovek-P-ACK:'
`-.Doth
60 7,5 5 6 Ft .42 sand
Prom_To
-to Ft
*•004111.00C
.Rarit _ flcr@toh
0 60 IAN _LINO ;RED HICKA- S 117
REMARKS:-
iltekEre ORI:il*rfFik.117i1S'ATij. V:1%0 Cpt4STRUCIPEF,NAW.4444144ce wm:1
1sPi NOAC -1.941;,9P,NUTOK`itt:iN arANimps, 41f:i 51-15-1kq:Py OF TIE
RECORD NE pRo13Ep :Ks THE 0,00..OWNER:
S OW -LIRE -OF
ELL 00 NITFiACTCR
10-27-11
DATE
m.che3J wil&on
PRiNTECi NAME OF PER$Ohl ONSTRUcTINO. tHE WELL
Submit the origiin4 to the Dtvitien Of Viliatir Quality VANIA 30,4ye. Atit4 inforWiition
1617 Mail Sewice Center — Raleigh, NC Z169001 Phone*. Oliin 733.7016 eat 688.
Farm Ovy-117
,Rev. 7/05

AIWATREgth' TALIL• • - - - - - - _ wrilteciNpriturrtaii net)
NoturroviumoroltwowoorilooglattakeitikosourgoafottanftorAgety
liVIU,CorintApniamEirrine:Wriox-# 3351
1:*1•00004106*:
Michael Wilson
WO 0°0704 01009104.1fr.tei
SAEDACCO Inc
Wour.talltii0E0MiralWiffift.
WREETADORE..5.%,cks a northfield dr.
ft _mill sc 29707
CftTi
040:- ZrEkc-40
pl. [phone]
i?*01:1103W,
liaLL INEtiftitatritiki
r;41$,EkE., iti:#0:41306.00
•-stet:Writffigkiwitikii4ptcat-60
tilik0"011:EFL:FEWITAWOORSOO)
5
InvuultErglitooponoototoymatlysjrtti Tbi
incoto04*101,0f( kWt*
RO:gdfdVi1I 441.1r.C3 i104.401
- -rtijo00-4461, 11-1-11
913° - AM 1BY 41 u.
trrt:' hickory :aln'T cat awbst
2851 N.CENTER ST. 28601
(-PASOLN60NIAMbiNI6,:03MMunith-.8011ahaakiotINO;.Paelti34
fltROORAPHIOMAI46.55rttNal
fisiatsi tivali0y; COSI tlii0i5:11-'00t,
-(0.0.00005041101.44/ -
0K/NoV: ,35.76938
Logetrait. 81-33041
1.4104404144163dA00- VMS trE010#400::*#
(42°100 La6rOPOOtOOV1010VOIWORgt0i*O#104:
:14604-Lediahialdfnikecidliii*:00.-
-4.,40:10417-14tiii****04164.41440#4010.***
FAtalty:ittikWakkPANTRY I 3958
14,040K.F44)04 PANTRY PETR, EXPRESS
,..StAgertittii4e06 2853 N. CENTER ST.
:iitaArcijokims.
-iiii4:0-040110
HicEORY NC
20601
P,Trotr
tOitAdt PERiptit,i'ml ICE
SHAW
14344;51e.
tolAlCiN6AtORE66 4020 MD PTNEVTLLE fag.
CHARLOTTE NC 28601
,q1iysitIottire 63040.! ;WNW
i 704 ). 972- 4081
kE6-6.13dal. fhp*ntfintter
WELL
4. VITAE- DEFIVIi GO
b. Dorat*u., R014,0E40410.4G YOTI NQ
c, WATPILAVELE4OPT*4. Pot
age+* Moverop
f T.
itigtit &WOO #1''Abrori‘i tkiirt;stO
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4.4137,11PWIP TER
*.#00010.1iito;
Ian .
xtotto rA00000r, AWOL JO@NOW
Vfrifi* se 1,;:, 0 1L2ff SHC 40 PVC
-
71140;1.47rj Et „
1F41 tz go rt land
•
lirgo_fft___.;
05* Eh :1890. ** liY0110
1,60
, )ft••,_
4.; ittflaffaMAVEL PAM'
`DelEali
SE 1;142.2_,. alma
Nlea.f014'
trimmie
lcORK411464-00
tAtrii "Vo--
, 0
60
PtiftWattoialekription
TAN AND ESD MICA SILT
tV.Ilidltria:MULWAIRV..0.4tiA0390- tIA&W.
Cotarrin0014 OTATIDARCK/SirMilAraccipprilla
Ticl3eal wilRcm
pRitifOLN*OF PEFWOR.00NstRUPT144:74-4E Wtti,
, -
Submit trio otioinatto•titOVIVIMon*Viajer Algt.4.infoonatkin mo4
1417 ManseivickCifoter-RagikiAAq#6$0441.7 Pihom! 006-.(01.9)134406.ext-508,
ECM GW.-1b
Meu, 7/05

NavRisitikivnek • • " • • WEILL COatiSTituCrukcitEautu
1461111KNIENM'i4iiiti000E1WAVIINI.600:1N8NNal ge.40:8069‘DIPIARATWRkefOgiiitY
W_ELLitONTRAPVitetitritleATION # 3 351
1, WELL ODNTRAqUiR:
Nichatl 54i icon
Weli OontiagOr. (1r1009*Npiw
sABOACCO Inc
Weitgeobactorooropo".400..
STREETAD9REss. .9088 northfield dr.
. mil 1 sC
297 67
yairWfl St6(9,
[phone]
A0.10 604-:!flOnfiti.tthbr
2; WELL
Zia.C.000
$11-5461-0-0-opoi;:a*
Sta-rg:mieiOlEktiatiivivOco*
DWa#0.1THEIRMERMittIreppVdebloy8p 1.0
WU USEIGhetICANIFOVEVatfMatlittifttlMRGO
rcerO.64'10(tr0
ikrbtatidrilD -911EVI31141
coxtrijfirja- 10 -2 7-11
tig*.60,010L-016,6 11; 3 0 *itiEr 0141;I
MLLjOCATOI
titik:: hickory
:cduarke cat awba
2 8 3 E CEN718R ST . 286 01
(Strestnirnee Numbers, Communiiy,-Satalifam: LoCbla; FCanstkOpCbcki
'-roP00401.4idnikiiti SETTINO:
Slap0-1iValfey: 13'RA% tlRidOln2 Cid*:
APeckFArit.013,1160100.4i
biTintitt:,3576938
LeekdiTtkit BI 3 3 04i
LatittAirenIckiideAtitatOer ta:GPS n .1kbiolifo
MOO* brivolkIMO:frthOtitzcO ALWA.00.*-ffiliarriff.id
46a-ea tivitialirit iMatritti6.:01V _
tr ?mum. eromiggii$641#041klifitgri-0.041#it
FAclur(litovo (600110-140-PANTRY # 395 0
NAM FApiurt PANTRY . PETRO .EXPRESS
.:0744/Aech-
.435*.04.*Oiftion
tTIR Ekr AbiziketlYs
HICKORY
2853 N. CMNTSR T.
286 01
tlity-or l'o,yn •
cpkrAdT pOtsorkrmi KS
MAitINCIADOR Eta 402 0 OLD PINSV1L1.E P.11
SP*,
SEM
Zia-9000
es/Ix/An-cm 2a601
§kiate 2-1P_Nre
(, 704 972-40t
Area cpde- PlideppOrober.
a, WELL DETAILS!
a. TOTAL DEPril: 6 a
b. DOES WELL REPLACE SXISTiriCi WELL? YES o NO ra
c. WATER LEVEt. Re#0-T011.0( cOtrvil:
Fr,
e•+" if' Abbvel'oli of Catl)
0 TOP OF dAsoals AbooitariOIColace'
irrrgonysiptiVatOatod'atief bleed tilnittliikleInaY rOUIre
igitleElnr441 NaKd-2.0
0. YIALNikiFok isq RPM OF TEST
t INE1.iONiTt* AnUnt
a *(640.004 0101*
Rah Fisitk_zro,,
6.
*bin
Frlp_to
410.1 hiWfi.
Perlib Pfencittfr WOO _.1v1StiEr
Airn 5R 140 Ft 2 " SHC 4 0 PVC
Fronl -14)...L
From -PS
!OW* 6/1460
9)pprtland rirnie
,Ftl;
Mgt*, OiF0).4T. IS**
111305s__.-f7.2 PVC
11#
frOgi-aTit- -
-.e
REMMINSI.
sand
• TAN NM EU ALCHA SILT
-10011EIBERYGEMBEtittHAT-1)41B WEI:1 WAS:cONNTRLICTEDift AcCOROP44Weefill
IRAtiPAC120.051,i_C,ONS/RVOTI2NSEANPARESkAlictrewki;:OlvfOrrilk3
fRE&B;10 s sh pabitogo ff.a WEfi. ElWN011.
slow, IRE OP
mioheal wilson
tat gt0t,ITRACroli
10-27-11
PATE
PRII4TED NAME PERBON.CONSTRUCTINQ:THE WELL.
Submit the original to the Division of.Water quality' within SO days. mai; Info rma Con Mgt.,
1617 M1I Servke Center - Raleigh, KO 2713$9-11117 Phone tde, (919) -733-7015 oxt 864-
Faro GW-4b
Rev. Ms

NKFJNTMJ viguLcoveriiVOT likeOka-
Nottitikainiiitiratevaior eottoi*ft000vMitrs01Irxsv*,dV'w.aikeQooty
WELL,COrritAprOitantWATION4 33E1
-.04-070#1:
Michael Wilson
Well gontr,OM On**.10)14MPIA
SAEDACCO Inc
weii
•Cdalllirgifq00.0013106
STA*1MOIMEW9088 ncrthfield dr.
se
Ailf,30,000t:
[phone]
29707
.-4=c.440
WO** ktif/Or
WELL Itiramthltwif
41TEWEt4IPAI:appii644):
• 6tAltWati: ilEkilti*Ottstabfii).
OVICksitgri-NIUTRMITNRI,P0qable) as 11
WF.1.1.1.1Sgreliliel(APPlicgMfib-4149011044i111 WhAtiltWebblOtt
1000106**0•0 :41r fc.1.9.** b.-:fgeffircY,044#.5*:
-Merl:log
11--11
404.0_00-
Wauxt6TIOre.
am hickory
2853 IA .CENTER ST.
iStreticNo me,1NurnberN community,: SubdnigeorrAdt-Ne4 PfirtecApc..A.
'T.010.001AVOIC1-1ARiiiiETTINik
06100.:ItlVar0
043)0?
LAT1.1 „35.76938
8/.33041
LAW" *IR
:ftitiaty cat awba
- . . • . .....,.
28601
tIV111171
Litifild01610tilde§,WW:- riCiPS
Adiselol *Mb? MP 401#4000 difjgWAVOiiinilt#
;:litiikbrisci fiihmitikt OFV:
AL:WM* rig* fikiiketi1044440
Ado rw 4106-eg iv ANT RY 3958
0'4*AP-0'100:Oil PANTRY . PETRQ EXPRSSE
STRg_erAtior/FXS 2853 N. CHNT83. ST.
Bier.ORY NC
28601
lit9PATILt 010
ppl.trAdit pglipfellTHE SHAW
paaiiiNtAbottrtt 4020 OLD PENT51r11.148 8Dt.
*Goo-
IMAP.LOTTE Ile 28601
.4414- -?:0906-
972-4081
PM(
WELL teriat
•a. TOTAL:DEM:if 60
b. Dogs kgpLikos to(isrpso WELL? yes Ntim
c.ifilATERLEVR14.400000:0:a4ingr • FT.
hstivii1160:410610))
TOP-0,64:64104 _ n:Ab6iie traid.totiteeir:
vtivIttaftle.01111Welgior-WPONVAIAPOOlretit#F
kfc' IELPIIIPMI VET1400:0,r. TEAM
t • tilSilifEttioip.
*040* 4.0:10i):
, • • - 170i: • : • •
Piark_(70
40A400v
ADM EVIOn44 Aiteifiti
At* 5a 'r-rk 0 :Et; 573c 40 PVC
To=t#-:
'k4:01106: :Etwitv .*001 M!*hpd
0054 oport land -
tripatict
-ft0.0—ttv
Otiv:eor 04`tko *to&
tft..tr•!vc •-•
•
-; SAMPSON, PAM
Elifeiti! 56 _,-FVf2 sand
riT.1 -
1004044.1*
tiy; acitteatioh:Vegatklkitt
19
• tli_REMASICO:
TAN AND RBD MIN. SILT
RE& arrirellAT 411)04 6:44-Tritiavuo WzgOLIAtmw rrEt
0 ci,virki1-;40NOW MN 5046,ttbS,Atictrwea A iteMY CF1110
AEG Ativtpeo gm* fivetuowrIER.
fq6', 101P:
(INTIrfATIQPI :
11-3-11
p.krE.
micheal wile=
160.14M4/ pe.4*.tploc.. N.47filtpTiNorn-i.ONELL
Sil61111t the origitiatto the Pig 1010# 01.-WigtOr Olatilatwithfit 3044yaj,,..Aing oifigOa Hon 14§t„
181Y Mffl1 tervka QintAr -14100fitli.140 009-100 FhnutNo (91$)$3O$ex*66
FOrrn GW-lb
Rev, 71Q5

:Et 11
1, WELL CONTRACTOR:
Corey A. Sfaeece
Nov RESIDENTIAL WELL cOvsrRUeT!UN RECORD
North C aroiina Ekpiirintent of Etn ironment and Natural Resources- DDi%ision or Vr alur Quafit'.
N ELL, CONTRACTOR CER-riFi('ATION # 2904-A
Weil Contractor (individual) Name
CaC9lin oil Inveatioations= LLC
Well Contractor Company Name
13g QurRev Rd.
Street Address
Qiin N.C. 28660
City or Town State Zip Cade
(704 , 876-001 0
Area code Phone number
2_ WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMrT'it(d applicable)
SITE WELL ID fit arpicablel AS - 12
3. WELL USE (Check One Box) Monitoring Kt Municipal/Public iJ
Industrial/Commercial = Agricultural Recovery;-; Injection,
irrigalian_, Other z (list use)
DATE DRILLED 4/30/2013
4. WELL LOCATION:
2853 North Center Street
[Street Name. Numbers Communay, SuNtiv.sion. tot NO Parcel Zip Code
CITY. Hickory couNrY Catawba
TOPOGRAPHIC r LAND SETTING' teck appropriate lmx)
Scope Valley VFlat :"Ridge Lather
LATITUDE 35 = 46 • ^ OMS OR UD
LONGITUDE $T 19 ' 499000 '• DMS OR 7x.xxxxxxxxx 00
Latitudelicngitude source: QGPS ,'?Topographic map
NoCatron of well must be shown or a USGS repo map endattechad to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
_ The P,antru
Facility Name Facility ID#It (If applicable
28h 3 North Center S.treef
Street Address
Hickory NC
City or Town
S:ardno ATC
!Christina ntirllli&l
Contact Name
4070 Old Pinevilte Road
State Zip Code
Mailing Address
Charlotte NC _282 t7
City or Town State Zip Code
Area rode Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: .55
b- DOES WELL REPLACE EXISTING WELL? YES u NC ./
c. WATER LEVEL Below Top of Casing. n/a FT.
(Use •* If Above Top of Casing)
d. TOP OF CASING iS Q. _ _ FT Above Land Sul -lace'
'Top of casing terminated aVor below land surface may require
a varranm in accordance with 15A NCAC 2C .0116.
e. YIELD (gpm)• rl/ I METHOD OF TEST nla
f. OIS1NFECTION: Type rt/a Amount 11/2
g. WATER ZONES (depth)
Top nla Bottom nia Top Bottom
Top Bottom Top Bottom
Top Bottom - - Top— -- Bottom
Trl icicrtessi
7. CASING- Depth Diameter Weight Material
Top Bottom Ft. __ Y
Top 0 Bottom 30- 53Ft.,,2• sch 40 ovc
Top Bottom FL
8 GROUT. Deptt, Material
Top Bottom 5 Ft. Portland
Top_5 Bottom 51 Ft. f +pritvflite
Top Bottom Ft -- -
Method
_paljr
trernia
9. SCREEN: Depth Diameter Siot Size Material
To 53 Bottom 55 Ft. 2 in. 010 in. DVC
Top Bottom Ft. in. in.
Too Bottom Ft In. in.
10. SAND/GRAVEL PACK:
Depth Size
Top 51 Bottom 55 Ft 10/30
Top
Top
Bottom Ft.
Bottom Ft
11 DRILLING LOG
lop Bottom
. 1
1
1
• _ 1
12. REMARKS:
Malaria!
Silica Sand
Formation Descriplidn
r fAt r!ERE8Y CERT.-!' HAT THIS YJELL WAS CONSTRUCTED i`f ACCOR0aNC`c wit•+
sbAN 21^ 'Art l• rt'4,ISYiiuOSIO"+STANDARDS .nNGTHAT ACOPY OFTWS
RECORD 5 BEEN PRO OWNER
5/2/13_
SIGNATURE, F CERTI'ED WELL CONTRACTOR DATE
Corey A. Speece
PRINTED NAME OF PERSON CONSTRUCT1NGTHE WELL
Submit within 30 days of compie ion to: Division of Water Quality • Information Processing,
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-lb
Rev- 2/09

NON RESIDENTIAL '% ELL CONSTRUCTION RECORD
North Carolina Department of Environment 4nd Netural Resources- Dn iston of Water Quality
WELL CONTRACTOR CERTIFICATION # 2904-A
1, WELL CONTRACTOR:
+rev A. Speece
Well Contractor (lndividuaf] Name
Car4lirla Soil Investigations, LLC
Well Contractor Company Name
132 Gurney Ad.
Street Address
QIin
City or Town
L704 J 876-0010
Area code Phone number
2. WELL INFORMATION:
WELL. CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMITX(rr appiicebte) _
SITE WELL. iD #(it applicable)_ AS - 13
3. WELL USE (Check One Box) Monitoring Nf MunlcipallPublic
fndustriaL+Commercial ^ Agricultural Recovery _ Infection
irrigation, Other ' (list use)
DATE DRILLED 4/30/2013
4. WELL LOCATION:
2853 North Center Street
NC 28660
State Zip Code
(Street Name, Numoers. Community, Subdivision Lot No . Peroer, Zip Code)
C+TY- Hickory COUNTY Catawba
TOPOGRAPHIC 1 LAND SETTING(check appropnete box)
L., Slope : Valley VFlat .2-Ridge _ Other
LATITUDE 35 es ' to 9000 " DMS OR DO
LONGITUDE 6t ' +o • 501000 DMS OR 7x.xxxjaCXxxx DO
Latituaeliongitude source. 3PS !topographic map
(+ocarian of well must he shown on a USGS topo map andatfached to
this form if not usrng GPS)
5. FACILITY (Name of the business where the welt is located )
Thtt Pantry
Facility Name
2eA_5n North Center Street
Street Address
Hicknry
Facility 1D# (it applicable)
NC
City or Town State Zip Code
Ctrrinn ATC:
Coistact Name
4tpo Old PinwVIIIA Rnarl
Mailing Andress
Chndotte
City or Town
(Christine ❑iinili��
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 55
NC 21 217
State Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES CI NOV,
c. WATER LEVEL Below Top of Casing; n/a FT.
(Use '4 if Above Top of Casing)
d. TOP OF CASING IS ..�_ _ _ FT. Above Land Surface'
"Top or casing terminated allot below land sumacs may require
a variance in accordance with 15A NGAC 2C .011$.
e. YIELD (gpm): r1/A METHOD OF TEST nla
f. DISINFECTION: Type rl/a Amount (l/a
g. WATER ZONES (depth).
Top- n/a _ Bottorn n/a Top Bottom
Top Bottom Top Bottom
Top _ Bottom Top Bottom
Thickness)
7. CASING: Depth Diameter Weight Materiel
Top Bottom Ft.
Top Q Bottom 30- 5 3 Ft_ 2 sYh 4.0 pvc
Top Bottom FL
S GROUT Depth Material Method
TopO_ Bottom 5 Ft Portland pour
Top 5 Bottom 51 Ft Bentonite trernt
Top Bottom Ft. _
9. SCREEN: Depth Diameter Slot Size Material
. fop 55 Bottom 55 Ft. �_in. _i1 Q in. pvc
= Tap Bottom Ft. in. in.
Top Bottom Ft. in. in.
: 'f0. SAND/GRAVEL PACK:
Depth Size Material
Top 51 Bottom 55 Ft. 10/30 silica sand
Top Bottom Ft
Top Bottom Ft.
: 11. DRILLING LOG
' Top Bottom Formation Description
/
• 12. REMARKS-
. GO Hi RCBV 'EPTiE^, -NOT `Fr;S VVS: , WAS LONSTRI`C7'E}'r l ACCr'RORNCE 'MTh
N - .:. dC AFL, Z.,.NSTRU"'i ':. ST ANL ARt:0 AND :HAT A COPS` OF'NS
• RFC'IR- S BLS'. PR MAX T' 'Ft.:vE�4 '31f-rfE.R
5/2/1
SIGNATUOF CE FLED WELL CONTRACTOR DATE
Coley A. Speece
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27699-161. Phone : (919) B07-6300
Form GW-1b
Rev. 2/09

NON RESIDENTIAL WELL. CONSTRUCTION RECORD
North Carotins Department or Envirnnincot and (tiattrral Rccoones- Di% isiun at' Water Qualiq
WELL CONTRACTOR CERTIFICATION tf 2944-A
1. WELL CONTRACTOR:
Corey A, Soeece
Well Contractor (individual) Name
Carolina Soil inyestiaations. LLC
Well Contractor Company Name
132 Gurney Rd.
Street Address
Olin N C. 28660
City ar Town State Zip Cnde
(704 ) 876-001 D
Area code Phone number
2. WELL INFORMATION;
WELL CONSTRUCTION PERMITS
OTHER ASSOCIATED PERMIT#{6 appGrable)
SITE WELL ID Stir applicable) AS -14
3. WELL USE (Check One Box) Monitoring dMunicrpat/Pubtic
industria11Commerdal Agricultural Recovery L ; Injection
Irrlgatiorc Other (fist use)
DATE DRILLED 5/2/2013
4. WELL LOCATION:
2853 North Center Street
(Street Herne, Numbers. Community Subdivision, Lot No . Perct:l, Zlp Coder
CITY: Hickory couNTY Catawba
TOPOGRAPHIC / LAND SETTING: (check epprnpriate box)
.=•Siope "Vatley "Flat ,_ Ridge -,other_
LATITUDE 35 e6 ' tt, " ❑MS OR DD
LONGITUDE e1 19 • 51• " DMS OR 7x.xxxxxxxxx DD
Latitude/longitude source: 23PS DCopographic map
(location of well must be shown on a LlSGS boa map ant attached to
this roam if not trs+ng GPS)
5, FACILITY (Name of the business where the well is located.)
The Pantry
Facility Narne
7A51 Nnrth (AntAr Strapt
Street Address
Hit`.knry_
Fealty ID# (it appEicabie)
NC
City or Town State Zip Code
Cardna ATC (Christine Di►nlls's1
Contact Name
4f)20 Old Pine►►illt? Road
Mailing Address
Charintta NC 28717
City or Town State Zip Code
1 1 _
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 55
b. DOES WELL REPLACE EXISTING WELL? YES r i afi
c. WATER LEVEL Berow Top of Casing: Fifa FT.
(Use `+ if Above Top of Casing)
d. TOP OF CASING 1S 0 FT Above Land Surface'
'Top of casing terminated aVor below land surface may require
a variance in accordance with 15A )JCAC 2C .4118.
e. YIELD (gpm): nla METHOD OF TEST n/a
f. DISINFECTION: Type alit Amount _ilia
g. WATER ZONES (depth):
Top n/a Bottom n/a. Top Bottom
Top•_,___ .�. _ Bottom Top Bottom
Top Bottom Top - _ Bottom
1. CASING: Depth Diameter
Top Bottom Ft.
Top 0 Bottom 34 5 3 R 2 .
Top Bottom Ft
Thickness/
Weight Mstertal
. �L0 _gyp
8_ GROUT: Depth Material
Top_ 0 Bottom 5 FL a rtland
Top 5 Bottom 51 Ft. Bentonl(e
Top Bottom Ft
Method
_pour
Ir$mie
9. SCREEN: Depth Diameter Slot Size Material
Top 5.3 Bottom 55 Ft.2in. 0110 in. pv0
Top Bottom Ft in. in. _
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Material
Top 51 Bottom 55 Ft. 10/30 Silica sand
Top Bottom Ft.
Top Bottom Ft.
1 i_ DRILLING LOG
Top Bottom
1
1
f
1
12. REMARKS:
Formation Description
t GO RE.ElYZERT.F-YTrr--. sNEll_W sC'+t•L,rRucrEbINAc;.oRnANCE.vrrr:
3A N: y:. 2C weu_ t.•As-mi C rnC?I 61ANOARiDE. AND THAT A COPY 4F THIS
FIE PSPfd of lfl ;+ J 7C Ti lE W EL. rs NNER
SIGNATURF CERTI WELL`GONTRA TOR DATE
5/2/13
Corey A. 5peene _
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water quality - information Processing,
1617 Mail Service Center, Raleigh, NG 27699-161, Phone : [phone]
Form GW-lb
Rev. 2/09

NON RESIDENTIAL WELL caNsrRt. CTRON RECORD
North C:ueline. Department orr.n4irunrent end NatumI Resotnax:.- Di4i•ian orWat.:r Quality
WELL CONTR ACTOR CERTIFICATION # 290,E-A
1. WELL CONTRACTOR:
Corey A. Soeece
Well Contractor (lnclhAdual) Name
Carolina Soil inves#jaations. LLC
Well Contractor Company Nance
132 Gurney Rd.
Street Address
Olin N.C. 28660
City or Town State Zip Cod%
704 ) 876-0010
Area Code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT*
OTHER ASSOCIATED PERMIT#(ir applicahre/
SITE WELL ID eta applicable) AS -15
S. WELL USE (Check One Box) Monitoring ,fir Municipal/Public L
IndustriaUCommercial :r Agricultural 7 Recovery Injection
Irrigation ". Other 7 ilist use)
DATE DRILLED 5/1/2013
4. WELL LOCATION:
2853 North Center Street
(Street Name, Numbers, Community, Sued -mien, Lot ND. Parcel. Zip Code
CITY: Hickory COUNTY Catawba
TOPOGRAPHIC / LAND SETTING: (check appropriate boo)
Slope DValley 'Flat ?Ridge r?Other
LATITUDE 35 " _','t. a ")MS OR DD
LONGITUDE 81 is sn.sixn - MIS OR 7x.XXX)000 kx DE/
Latitude/longitude source: PPS jfopographuu map
(location of well must be shown on a USGS ropo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the wet/ is located.)
T$p Pj ntry
Facility Name
9851 North Caritpr Str4At
Street Address
Hinkinru
FacIfily ID (if applicable)
NC
City or Town State Zip Code
Cardnn ATC
Contact Name
4020 tpirl Pincsvitle FlnAfi
[Christina Duuni tiS1
Mailing Address
r:barintta NC 78217
City or Town State Zip Code
i 1
Area code Phone number
S. WELL DETAILS:
a. TOTAL DEPTH: 55
b. DOES WELL REPLACE EXISTING WELL? YES r". NC -41
c. WATER LEVEL Below Top of Casing' nLa t
(Use "+• if Above Top of Casing)
d. TOP OF CASING IS .0 FT. Above Land Surface'
'Top of casing terminated attar below land surface may require
variance in accordanre with 15A NCAC 2C .0118.
e. YIELD (gpm). n!a METHOD OF TEST rite
f DISINFECTION: Type f1Ea Amount _pia
g. WATER ZONES tdepth),
Top f11a Bottom nla Top ^ Bottom
Top Bottom_ Top Bottom
Top Bottom Top Bottom
7. CASING: Depth
Top Bottom
Top_f) _____ Bottom
Top Bottom ..
Ft.
Thickness/
Diameter Weight Material
30- 5 3Ft. 2 soh 40 pvq
Ft.
8. GROUT Depth Ma tenet
Top f _ 8oUore 5 _ Ft pactiana. _..
Top 5 Botiem 51 Ft. Ben -tonne
Top Bottom rt.
9. SCREEN: Depth Diameter
Top 53 Bottom 55 Ft jn. 010 in. INs
Top., _ Bottom Fi. in. in.
Top Bottom Ft. in. in. -_
Method
.Dour
tremie
10. SAND/GRAVEL PACK:
Depth Size
Top 51 - Bottom 55 Ft. 10/30
Top, _ Bottom F'.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
1
1'
1
12. REMARK$:
Slot Size Material
Materiat
silica sand
Formation Description
HEREev firYTIFY • -riAT TIPS !1'Ft ,, ems ODNSMUCTED IN AC+::CRIZONCE W.TV!
1544CCUNSTr;1rm1NSTANZA 41 .ANL+THATACOF-YOF,Nis
tiE opriJii+s ea -r: . rF': /Ei! 0W+1F1e
5/2/13
SIGNATUREF CERTI D WELL CONTRACT -Oh DATE
Corey A. Sgeece
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Mail Service Center, Raleigh, NC 27$99-161, Phone : [phone]
Form COW -lb
Rev. 2/0

WELL CONSTR UCTIO! RECORD
This kink t+IF bCtotal rear riftglt srmutt ipfr WO' •
1. Wi'Il' omtlittn.rlllfornIAAtllin:
Stefan Smith
WrIEC 1 uelotN4f1w
3576A
NC Well Coafiteter Catlike! k ii ffinehor
SA817AC00 Inc
Carew r#lhrily
1 ►1+d1(`viestrocrOtti Nrrn 11:
IiM4 j{grplfr 46irfitipa'i Qktfa: Coma. Shirr, Vttrierz
iWO *Cb.[C!r@diCw i.44j1
Woo. guppiylwin
CEtfcuitnnit:
iMeotltatmui iHeatilgiConti ng' Sppply)
InilinfrIalKosonwrziol
farad, t:4 err-
Pot Trial-40 tree ON E.Y
trtopt 'rl% nl t,0rir)�r
40 ttiA 55 fl. weathered rook
19, OH7RHS.A-5iE+fl EN? irehrkcatedYrclfiq.pItlIfiEit'1E[aaorkiRkE
moor .
Ta
Pt. M 111 • Ifig lireti'1
WA11- tfAr,
0 tl. 50 ft.
2 -rn 40
PVC
t61}NA*
1'I10
NCI o [e 1n8. r ir[ i r ) .i1TuoAm.
UNto►ii41porobik_
t7Ret,klo tio1 WiuerSup+ply ¢singlel
G1Arsidential Wald[ Supply (sl:ot'odj
Nurt arat►rSupply Welt:•
Q oiplie`` lgg 011.4coyrrt
(nTit4eni df:_
C1Aliiitfsr RoQpo
064kitri i' 1pi a dild RoLW4pria
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Miro /1mLtd 604.1.40 )
L7iloothemial4Hr..fill y'EoiliiirgReturs
�ti�d?isiifiixlei'�iiledialta►i .
p?tMn46$4
tAubiltlCack.Cbmrii
❑Trrapr-.
1Goih icesAiiihusildt.#3tit2li19ik3j
NW*WOW 0antiptt:tte ;•; 3 June 20lirmafl,A51S
Rowa.rco iixpree
2853 North Center:Street..Hickory, NO. 28601.
1 FEglleigt11: %,litiil.�(JF
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35.4528 -jir 81.1942
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7; With ai;ejirlr-tis a>ricelaid.4vok. 0101''4r; i<.
`j!•xrriper rafrharr80484 iyttffitirwrtYSAbb refon1'pithertskfr hire t•rkrourare te. +r
me &rats/er 2Y: hr+iei•ic. hares iir wt As bait drake jemrt.
8. A'efeber OFR108lplm iilttfd: 4
Ff,r rryl{ipre tkJtorlpei rlefoi¢rOr rllfg + wilt UA'L - u'h1i fAe ma+tsailsowtiur, ;w i' ran
nOwffitoreAtin::
7:'�4ieli detriG. rra819: 00$u 8i 55
eui:iR Iftiff oltsilr+t: intiik•.;£hal(9'etPki301110)
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42 (!. 55 fit 'PPiR
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111
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You :0041Et} Eis> 1t' of l i - pagifiv pre*: ual:it; site dEifStli or w tt
cootrofelloo tldlii>ir; Yoe. 14aniioeb.vdslildoiusl-ppget.ifites esanr�.
$iF�[tRl`S'PA.LIf9y�`�' fS+Gi?;:
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41140DPO: go !OA*? test/
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WELL COB YFRUCl'ION RECORD: .
71or.10tc!isi: . . -..- :;• _
-
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1;.-Sr44410*bialr'013;100;
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NC .vhdi CaalaelOgroalleSjal !oak,.
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2 853 „North. iCanter. strciet., Hickory, NC,. 28601_ . .
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irilt -ft
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titilktiliaiiiii4.6W;i1166.11***6-0
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41tytii:/kyOrkgifit.ii0ippioe; k4-'. ' 100fikeliwil0 014,4101011i NtlifiSVAralir
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(ICAO MILlittOf

WILL CosmwerroN RECORD
1760 hinrtcup L+e Revd far slag k of wtuliipk 1rd [
1. Wok Gila# tier Fi1'rr01a.Iidii:
Stefan Smith
1576A
NC.Wall chi+nsrsclnt`'CmillbtctlanTiau r
131►NDACCQ Ina
CeiliipariC>~'MOHO
44100001i +aileli kitiil.t&a. cawity,,21.0*, Varktrxli:,j.
3. *Ad 1I If0tl!Q14Nilt r V.
Willer $►lrniI W h
C>algtictiilltai: 47 1 1 1*
tideolftdrimat6Itailiterooilhg.$010 titsidioriatFAt5ldi'S1 i (ai11g1ej
Milli deontOavia1 Mosidoolial WiReSslppl?.1Oa' j[
nhribitton
L?cA8llld tai ttoi 681_ou
14iu S.I1a► 0:
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q st r,cc`CcIlstrl
Gamer..
RICItertritsrlilit rkliitRif Renuirkt1
4 D1tik 'kpitspmem 2 June 201-
WW11.gflti*
Kangaroo Expraea
A318
TFlW:?tkjr.
2853 North .Centar,.street HickoryR • NCr 2136.43.. .
0SA
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{if'We3 ASK ens TiI WAS nit 1s.e rllic ttt}
35.4619 81.1942
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l741j51 f rp -, I1iai'ktrrtax
-o ft 148 ft,
Weathered rock
35.`gtt-yr cAfifNQtCl#uttts-8s.rterpdOR.1.IMItOrgill 84rhkl:
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cat+4tiifr�Lap. edf►f :Yeu: +a{y. 1561Weh'fgiticgsgip iliimp,Isuiy'.
Ictoigio odovr, 48 - reir • MI 1:41111I; .$01401'tllin 3$:I[k¢3R 1f' _ . l .'iai rit'wcil
i�ili Z7fdlf ar�vlfittIPA ithT ii rreiti 2 ithdleian.
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WELD COTS IMUON-gem%
This kiy.1 ca ixbc uia 1 rot 041k4f. hmkipll: ri'eirir
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Stefan.Smith
35'iSA
AAKDACcv inc
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dire ii Wpnvpi gi% ;
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Kangaroo Y3rprelfs
>iipetup
2853. North Center Street,-iriokory, NC, .28E01.
USA
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PAN3958065

Shrestha, Shristi R
From: Rogers, Michael
Sent: Friday, October 28, 2016 10:37 AM
To: Shrestha, Shristi R
Subject: FW: Pantry 3958, 2853 N Center St, Hickory: Incident No. 36700
Attachments: Air Injection_Permit_Pantry 3958_20160718.pdf
Per our discussion.
From: Watson, Edward M
Sent: Friday, October 28, 2016 8:51 AM
To: Rogers, Michael [e-mail]>
Cc: Pitner, Andrew <[e-mail]>
Subject: FW; Pantry 3958, 2853 N Center St, Hickory; Incident No. 36700
Mike,
I found this information while reviewing recently received GW-1 records. The consultant had installed air sparge wells
at this site prior to the 2012 rule change that required the submission of an NOl for this type of work. However, there
have been several air sparge wells installed after the rule went into effect.
I contacted the consultant to get a copy of the NOI that had been competed for tine recently installed wefts to find
that no NOI had been requested by the consultant. The consultant has recently forwarded to me the NOI along with
GW-1 records of the total air sparge system that has been installed at the site. Some of the air sparge wells that were
installed in 2011 and do not fall under the rule change.
I am forwarding this information to you for a determination of how you wish to proceed with an NOI not being
submitted prior to injection well installation after the rule change.
The driller that performed the work has recently been given an NOV for the installation of step -out monitoring wells
without a permit. Unfortunately, the drillers are getting caught up in the consultants' lack of following required
procedures.
Best Regards,
Edward Watson
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources
North Carolina Department of Environmental Quality
704 235 2198 Office
704 235 6040 Fax
edward.watson( .incdenr.gov
610 E. Center Ave.
Suite 301
Mooresville, NC 28115
--Not f onsrrar e':

Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: Christine Schaefer[mailto:christine.schaeferatcassociates.comj
Sent: Thursday, October 27, 2016 9:45 AM
To: Watson, Edward M ‹edward.watsontr'ncdenr.gov>
Cc: Steven Aldis <steven.aldisi atcassociates.com>
Subject: FW: Pantry 3958, 2853 N Center St, Hickory; Incident No. 36700
Ed,
Please find attached an embarrassingly late air sparge well installation NOI. It took nearly 3 months to get the
property owner signature. The NO1 indicates the new wells are "proposed" but let us know if this should be revised
since they're already installed.
Thank you and my sincere apologies,
Christine
Christine Schaefer 1 PROJECT MANAGER l ATC Group Services LLC
[phone]
7606 Whitehall Executive Center Drive, Suite 800 1 Charlotte, NC 28273
[phone] fax 1 chriatint,sC,. taefernotossoclateS.Mm 1 www.atcarouDservices.com
T: IE arca' ?- T.3y'
a; a r)ct the 2ed ,.c use, d
y,pu :-Lot `r,ceivad : $r`.ai; s _
ti _ ..a•� yf� Ii _. .-
.
From: Christine Schaefer
Sent: Monday, July 18, 2016 9:40 AM
To: edward.watson[ncdenr.lrov
Subject: Pantry 3958, 2853 N Center St, Hickory; incident No. 36700
Hi Ed,
Dave Hunter said you called Friday regarding permits for the most recent well installations conducted at the
referenced site. We recently installed 4 additional air sparge wells as part of remedial system enhancement activities.
I completed the NOI form today and sent to Circle K for signature by the property owner and will forward to you upon
my receipt.
apologize this notice was not sent previously. The regular manager for this project has been on a long-term site
survey for same time and I'm trying to help him with his projects while he's out.
know in the past you and I have talked about status of injection well forms but I'm assuming this will be required
once the permit has been issued for the new wells. Please let me know if there is anything else I can provide at this
time.
Thank you,
Christine
Christine Schaefer j PROJECT MANAGER II ATC Group Services LLC
[phone]

**Effective May 31st, 2016, my [e-mail] email address will no longer be in use,
Please update my e-mail address if you've not done so already.**
7606 Whitehall Executive Center Drive, Suite 800 I Charlotte, NC 28273
[phone] fax I christine.schaefer @atcassociates.com I www.atcgrou pservices.com
T:,is en-:zll and its attar.:r,r,ients r,ay contain confdentia ana:,,r p, ivi!eged :nformat:cn for the so'e use cf the interded recipie 1t(s). If )'O;J
a;e ,,ct th2 L ,tenced ieci-:iiern:, arf i.Jse, d!sr1 'i:ut1,,n or copying •,f tr e info, maticn contair.eo in this erra'l arci its attach1,.en::s :s strictly
p1 o:;::c:t2c. :' you have r>::ceived this erra:1 in e: rnr, pi ease .. or.ify tfie sen:::er oy e~iying to chis 'nessage a:1d irn, ,ed'ately de'ete and
destroy any ::opis,; G-f this cr:12H ar.d any a~tac~n1ents. TLe v~ev\ls op )ns e:x ressea are· the auth::·rls ~.-and rnay not =fleet ;:he
v:~wE-•''T opin;o;:s .A.TC.
Shrestha, Shristi R
From:
Sent:
To:
Cc:
Subject:
Rogers, Michael
Friday, October 28, 2016 10:39 AM
Shrestha, Shristi R
Watson, Edward M
RE: Pantry 3958, 2853 N Center St, Hickory; Incident No. 36700
And in the acknowledgement email tell them these NOls come to the Central Office.
From: Rogers, Michael
Sent: Friday, October 28, 2016 10:37 AM
To: Shrestha, Shristi R <[e-mail]>
Subject: FW: Pantry 3958, 2853 N Center St, Hickory; Incident No. 36700
Per our discussion.
From: Watso·n, Edward M
Sent: Friday, October 28, 2016 8:51 AM
To: Rogers, Michael <michael.rogers @ncdenr.gov>
Cc: Pitner, Andrew <andrew.p itner @ncdenr.gov>
Subject: FW: Pantry 3958, 2853 N Center St, Hickory; Incident No. 36700
Mike,
I found this information while reviewing recently received GW-1 records. The consultant had installed air sparge wells
at this site prior to the 2012 rule change that required the submission of an NOi for this type of work. However, there
have been several air sparge wells installed after the rule went into effect.
I contacted the consultant to get a copy of the NOi that had been completed for the recently installed wells to find
that no NOi had been requested by the consultant. The consultant has recently forwarded to me the NOi along with
GW-1 records of the total air sparge system that has been installed at the site. Some of the air sparge wells that were
installed in 2011 and do not fall under the rule change.
I am forwarding this information to you for a determination of how you wish to proceed with an NOi not being
submitted prior to injection well installation after the rule change.
The driller that performed the work has recently been given an NOV for the installation of step-out monitoring wells
without a permit. Unfortunately, the drillers are getting caught up in the consultants' lack of following required
procedures.
Best Regards,
Edward Watson
Hydrogeologist
Water Quality Regional Operations Section
Division of Water Resources
North Carolina Department of Environmental Quality
704 235 2198 Office
704 235 6040 Fax
edward.watson @ncdenr.gov
610 E. Center Ave.
Suite 301
Mooresville, NC 28115
ND
Email correspondence to and from this address is subject to the
North Carolina Public Records Low and may be disclosed to third parties,
From: Christine Schaefer[mailto:christineschaeferfoatcassociates.comj
Sent: Thursday, October 27, 2016 9:45 AM
To: Watson, Edward M <[e-mail]>
Cc: Steven Aldis<[e-mail]>
Subject FW: Pantry 3958, 2853 N Center St, Hickory; Incident No, 36700
E d,
Please find attached an embarrassingly late air sparge well installation NOt. It took nearly 3 months to get the
property owner signature. The NO1 indicates the new wells are "proposed" but let us know if this should be revised
since they're already installed.
Thank you and my sincere apologies,
Christine
Christine Schaefer 1 PROJECT MANAGER I ATC Group Services LLC
[phone]
7606 Whitehall Executive Center Drive, Suite 800 I Charlotte, NC 28273
[phone] fax j [e-mail] I www,atcgroupservices.com
I. _R' ".• _.rrt: tre_•1 . .•I._... . t ._ _!:!_ " r-' �� .'4-`_2�.�r..r ; G'•^=.G• ;�.:f ,:d
I. _ed =G;" �r . sny �5' _�. _ �i. J:' 1 5'�- of . _ f� 1:3Cr� n ti.: ��:. sL- ,e er.13 2.rlH `v':i� iZ3 �._'�3- _ "t-rid
_ •v ::r1 _ _._-1'E''i f,r15 Eft c Er. ,}['_ n'ecsE .ec'yiny -i3Esa:.ye -n'} 1etete arr,d
&len. c., __ _ r? r 3 2':1•,• E.C;=.21 eT.t. 7, re:' ids r: ._ E!.r,.r=5s era c.le E-C:IC''Z ,_7ti1'. 2 i:l_• It,. •_feet � cT
From: Christine Schaefer
Sent: Monday, July 18, 2016 9:40 AM
To: edwa rd.watson ncdenr. ov
Subject: Pantry 3958, 2853 N Center St, Hickory; Incident No. 36700
Hi Ed,
Dave Hunter said you called Friday regarding permits for the most recent well installations conducted at the
referenced site. We recently installed 4. additional air sparge welts as part of remedial system enhancement activities.
I completed the NOI form today and sent to Circle K for signature by the property owner and will forward to you upon
my receipt.
I apologize this notice was not sent previously. The regular manager for this project has been an a long-term site
survey for some time and I'm trying to help him with his projects while he's out.
I know in the past you and I have talked about status of injection well forms but I'm assuming this will be required
once the permit has been issued for the new wells. Please let me know if there is anything else 1 can provide at this

Thank you,
Christine
Christine Schaefer I PROJECT MANAGER I ATC Group Services LLC
+ 1 704 529 3200
**Effective May 31st, 2016, my [e-mail] email address will no lon ger be in use.
Please update my e-mail address if you've not done so already.**
7606 Whitehall Executive Center Drive, Suite 800 I Charlotte, NC 28273
+ 1 704 529 3272 fax I [e-mail] I www.atcqrou pservices.com
This err ail ;;wd its ::ittac.h.rents .,·,a; ccmain wnf.dentia! and/or privileged inforn:at'on for Lhe sole use of ti-,e intended re{:o:e.1c(s). If y;1.1
are riot the intended recip:ent, an; :;se, dlstribu,:on or co;ring of the ·nfc-mation contained i:. thi_, ema'i and its atu,ii;hments ;s strictl"
p~ohib:~ed. If you have received this er:.a:: errn;-, f,iease notify ,he sender by repiyi 19 to this r.,essage and im,ned'.ateiy elete a,·;ct
des~roy an1' cc pies ;Jf this erir:, a•1d any ttachrr:E,nts. The vie•Ais .:,p -.-,ressed are the a:1thor'::: (1wr . ma·1 ~ e,.,:;r_t the
ews or opin'ons of ATC.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Thursday, November 03, 2016 9:25 AM
To: '[e-mail]'
Cc: Watson, Edward M; Rogers, Michael; Pitner, Andrew
Subject: NOI Kangaroo Express 2853 North Center Street
Good morning,
While going through the NOI for Kangaroo express I did not find any injection zone map as required in the section H of
the application form. I would need the map for the application to be complete and to process it. Please submit it by
email or in the address below to me directly_
For future all the NOI applications can be submitted directly to me.
Best regards,
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
shristi.shrestha(ncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
41111Z
'''Ni thing Compares
Email correspondence to and from this address is sribject to the
North Carolina Pubic Records Law and may be disclosed to third parties.