WI0300379_DEEMED FILES_20180622

North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD <IE R}
Permit Number WI0300379
Were any wells abandoned during this injection
1. Permit Information event?
□ Yes XNo
Mr. Ram Singh Dass, Ramji , Inc.
Permittee If yes, please provide the following information:
Handy Mart Number of Monitoring Wells _____ _
Facility Name
3166 NC mvY 16 South. Maiden, Catawba County. NC
Facility Address (include County)
2. Injection Contractor Information
Geologi cal Resources, Inc.
Injection Contractor/ Company Name
Street Address 3502 Hayes Road
Momoe NC
City State
(704)-845-4010
Area code-Phone number
3. Well Information
28110
Zip Code
RE'CE'IVEDINCOEQJD R
JUN 1 2·-2018
R Water Ouallty
Number of wells used for injection ~• Ope,atfons
Well IDs MW-1. MW-2. MW-3 andTW-1
Were any new wells installed d:uzing this injection
event?
0 Yes X No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells ______ _
Type of Well Installed (Check applicable type):
0 Bored O Drilled O Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
Number of Injection Wells ______ _
Please include a copy of die GW-30 for each well
abandoned.
4. lnjectant Information
Oxygen releasing compound Advanced (QRC
Advanced) socks
Injectant(s) Type (can use separate additional sheets
ifnecessary
Concentration __ _JS...,o""'li.,,·d:.__ _____ _
If the injectant is diluted please indicate the source
dilution fluid. _ __;..N=A.,,__ ________ _
Total Volume Injected (gal) 13 I-foot long, 1.5-
inch diameter socks containing ORC advanced. MW ft 1
through MW-3 have 3 socks each and TW-1 has 4 socks
Volume Injected per well (gal)---=S=o=lia=.d ___ _
5. Injection mstory
Injection date(s).__,,0=5/'-"0.!.l.7/-=-17....__ _____ _
Injection number ( e.g. 3 of 5) 1 of 2 ( estimated) -Is this the last injection at this site?
0 Yes X No
I DO HEREBY CERTIFY TIIAT ALL TIIB
INFORMATION ON TIIIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
,~,,,,.,,.., .,.,,. r= Glz.uh6 ~ ~ SIDNATUOFlNJECTION CONTRA~ DATE
Cn ~v N , i}\. r,\;.w.~GtfJ-~ ~~
PRINTN,1.ME OF PERSON P ORMING TIIE INJECTION
Submit the origmal of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program. 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
Permit Number
Program Category
Deemed Ground Water
Permit Type
Wl0300379
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Ramji, Dba Handy Mart
Location Address
3166 NC Hwy 16 S
Maiden
Owner
Owner Name
Ram Singh
Dates/Events
NC
Orig Issue
4/27/2018
App Received
4/16/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28650
Dass
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
4/27/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Ram Singh Dass
Major/Minor
Minor
Region
Mooresville
County
Cabarrus
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Deepka Kharb
Owner
Issue
4/27/2018
Effective
4/27/2018
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Geological Resources, Inc.
April 12, 2018
DWR -illC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Re: Notification of Intent to Operate Injection Wells
Handy Mart
3166 NC Hwy 16 South
Maiden, Catawba County, North Carolina
NCDEQ Incident #36860
GRI Project #3622
UIC Program;
. \t:CE\VEDINCDEQ/D'f-t. ~
APR ! 6 2018
·Nater Quality Reg!on:-\
lr:'Pf~tinn~ ~E>rt•(V'
Please find enclosed a Notice of Intent (Non to Operate Injection Wells for a passive injection system at
Handy Mart Site located at 3166 NC Hwy 16 South, Maiden, Catawba County, North Carolina. See
enclosed the NOL
If you have any questions or concerns, please do not hesitate to contact me at [phone].
Sincerely,
Geological Resources, Inc.
t~/U ~ev O\_-
Corey N. Buchanan, P .G.
Project Manager
Enclosures
cc: File
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Wlntervllle, 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 (NOTE: This form must be received at least 14 DAYS prior to in jection)
AQUIFER TEST WELLS 0 5A NCAC 02C .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (1 5A NCAC 02C .0225) or TRACER WELLS (1 5A NCAC 02C .0229):
1) Passive In jection Sy stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) Small-Scale Injection Operations -Injection wells located within a land surface ar ea 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: March 29, 2018_ PERMIT NO. vv l O::>Oo 3-t l 'f (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
(1)
(2)
(3)
(4)
(5)
(6)
___ .Air Injection Well ...................................... Complete sections B through F, K, N
___ Aquifer Test Well ....................................... Complete sections B through F, K, N
X __ 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
\N \")
T In . . w II ,;:f"E ~QI ~r. le t O 1· B thr h N ___ racer ~echon e ...................... ,\J ..... 01 sec ions oug
STATUS OF WELL OWNER: Choose an item.
APR 16 201S
C.
Water Quality Reg)on:-,\
. I ~tinn~ RPC;\l('f' . WELL OWNER(S) -State name of Busmess/ Agency, an a.me and Title of person delegated authonty to
sign on behalf of the business or agency:
Name(s): Mr. Ram Singh Dass. Ram ji , Inc.
Mailing Address: =26=5~0~S=o~c=o~R=o~a~d~----------------------
City: ---~M~a=g=l!~ie_V~a=ll=e .... v ____ State: _NC_ Zip Code: 28751-8803 County: Hayw ood
Day Tele No.: {828 ) 244-6369 Cell No.: __________ _
EMAIL Address: __ --=-N-=A-=---------Fax No.: __ _._(=82~8 .... )~92=6~-~96~8~4 _____ _
Deemed Permitted GW Remediation NOI Rev. 3-21-2018 P age 1
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: ---=Sa=m=e ___________________________ _
Company Name ---------------------------------
Mailing Address:---------------------------------
City: ____________ _ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ____________ _ Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONT ACT (Typically Environmental Engineering Firm)
Name and Title: ___ C=or=e'--'"y~N~-~B~u=c=h=a=n=an=----------------------
Company Name ___ .:,,G~e=o...,lo~gt.:.:·c=a""-1-"'-R""e""so:,c;u,e,r""c""'esc<,.,..=In~c"--'.---------------------
Mailing Address: -----=-3-=-50=2=-=H=a"'-ye=s'-'R=o=a=d,__ _____________________ _
City: -----=M=o=nr=o=e'--------State: _NC_ Zip Code:=2""-81"-'l,_,,O ____ County:....:U=n=i=on=-----
Day Tele No.: [phone] Cell No.: __________ _
EMAIL Address: cnb @.geolo cicalresourcesinc.com Fax No.: ___________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: --=-H=an=d v.,___._,_M=art::.,:__-=3c.:.1=66"'----'---'N,_,,C'-'H=WY-'--'--''--"--'16"'-=So=u=th=-------------
City: ---'M=a=id=e=n~ ________ County: Catawba Zip Code:--=2=8-=--65=0=----
(2) Geographic Coordinates: Latitude**: ___ 0 ____ " or __ 3"'-'5"-0 .6256057
Longitude**: 0 "or _ ___,,8=1°.1482837
Reference Datum: ________ Accuracy: ________ _
Method of Collection: USGS To po 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~ 10,000 ft 2 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 growidwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOI Rev . 3-21-2018 Page 2
I. 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.
Regensis Oxyg en release com pounds (ORC), in the form of socks , will be placed in four existin g wells (MW-1
through MW-3 and TW-1) at the site to promote biolo gi cal activi ty to remove the remainin g low levels of
petroleum constituents from the ground water. The socks will be initiall v checked one month followin g
installation and semi-annually thereafter. Socks will be changed out with new socks as needed. Sock
replacement will be based on visual and/or measured oxyg en levels in the ground water during semi-annual
ground water sampling events. Duration of the pro ject will be de pendent u pon results from periodic gro und
water samplin 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 http ://deq .nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ !.'!round-water-protection/ ground-water-a pp roved-in j ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: Regensis ORC Filter socks-a mixture of calcium h ydroxide oxide and calcium h ydroxide
Volume ofinjectant: Thirteen 3-foot long and 1.5-inch diameter socks containing ORC in four wells
Concentration at point of injection: Solid
Percent if in a mixture with other injectants: -----"N_,_,A'---"---------------------
Injectant: ----------------------------------
Volume of injectant: _____________________________ _
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) Number of injection wells: _____ Proposed Four (4) Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-1 s, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
( c) Well contractor name and certification number
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page 3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The ORC socks will be faced in the injection wells during the month of Atml 2418. Socks will be changed out
with new socks as needed. Sock replacement will be conducted semi-annually following the April site 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 Suhchapter On result from the injection activity.
Ground water sampling will be conducted approximately one months after placement of the ORC socks in the
injection wells and semi-annually thereafter.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well 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 there are significant penalties, including the possibility of fines and imprisonment
for submitting false information. I agree to construct, operate, maintain, repair, and afapplicable, abandon the
injection well and all related appurtenances in accordance with the 1 a.•i,�tiCAC 02C 02 ''? Rules. "
IQ, au ct4
Signature of Appamt ! Print or Type Full Name and Title
Property Owner Of the property is not owned by the Well Owner/Applicant}:
"As owner of the property on which the injection well(s) are to be constructed and operated. 1 hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(I5.4 NCAC 02C .02O0). "
"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
al s c e of contrary agreement in writing. {` }
Signature* of Property Owner Of 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 an this _form
Please send 1 (one) hard color copy of his NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted OW Remediation NOI Rev. 3-21-2018 Page 4

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4: w*LL. Co�ITRAC• R:
R. J. Wyatt
NON Ri SIDENT.1A-L WELT:coNsTRVCflaN Icortri
North Caraiina Departntifrai of Envfrcmmarzt and Water Quality
WELL CQNpACTOR.3022
b•
Well Contractor (Ind MOO) {•larrie
.Geoscle(tce arid, Tecl-iriology, •P:A.
Weil Contractor Corr>panyitFariia '
aTRE'El•ADDRESS - DOSO Northpoint Drive, Suite A
Winston-Salertl, NC 27106. 3363
CV or Torten State Zip Code
3.36 896 -1300
Aura code. Phononumb.er
2. WELL INFORMATION:
WELL la oitrsppiieat,:e) MW1
STATE WELL PERMIT#(i!'appllmabfe}
DWI or 071-1ER PERMIT #¢If appi?cable]
WELL UBEE (CFTeakApollo able 6a?q Monitoring X Municipal/Public
Industrl&ICommsrclal _ Agricultural_ Recovery 1n}gctlan
lrrigatlon► Other 0 (list use)
DATE DRILLED 12/3/13
TIME COMPLETED NIA'
•
3. WELL. LOCATION:
car. Maiden, NC cowry Catawba
Handy Mart, 3166 NC Hwy 16 S.
(Stook Name. Numdens, Community, Suftdrvisiarr, Lot No.. Peroel, Zip Code)
TOPOGRAPHIC 1 LAND SETTING:
;51Elope fVallay Flat (Ridge 0 Other
(check appropriate box)
LATITUDE 35.6256468° N
LONGITUDE 81.1484795° DIY
AM PM_
May ba is degrcas,
sviriures, aeconda m
bt x decimal format
Latitudefidngitude samc: ' 1 PI'S Topographic map
aocelien of wall must be shown on a USeS fopo Map cad
afidched fa Mkfund ffnot using GPS) See back of form
4. FACILITY-1s the narso of Rio huslriess whore the tuetl re Iccerad.
FACILITY ID # (1f epplict=.ttla) 0-004981
' NAME' OF FACILITY Handy Mart Convenience
STREET ADDRESS 3166 NC Hwy 16 South
Maiden NC 28650
City or Town State Zip Code
CONTACT PERSON Mr. Roam S. floss
MAILING ADDRESS 2650 SOcO Road
Magpie Valley, NC 28751
City orTampa • State Zip COde
(•• 828 .1- 244-6369
Area code - Phono cur bcr
5. WELL DETAILS:
a. 'FATAL DEPTH 35 feet
b. DOES WELL REPLACE EXISTING WELL? YES I+rD
c. WATER LEVEL Salim Top of Casing: 29.1 FT.
(use"+° 1f Above Top of casing) 1 2/6/ 1 3
rime, 25 To_ 35 _FL 2
From To Ft. In. in,
From _To Ft. )n. in. 9. SAND/GRAVEL PACK;
Depth Size Mete:iBr
From_ 15 To 35 Ft No, 2 Filter Sand
•Front_ To Ft
From To Fr.
ID. cRILLENG LOG
From To Formation ❑esarriptknn
d. TOP O CASING 4S 0 FT. Above Land Surrace"
{To0 'Of basrrrtl te,,rr,ipated ei/or befoW,land 31iefaoe tray requlrr
a variance In 4ccortfanoet wit 15A NCAC 2C-.01113,
e: )*LP (gP?3t); i1I/A h+iETFHOD OF T1 6T N/A
CiSiNFECTION: Typo Amount N/A
9. WATER ZONES (depTh):
From To rri
Frown Th To
Front To :FIF:rrLoornmirker
Too
S. CASING: Thlvknsss/
Qaptl+ jAi,.L.'I hAnkn.eal
From 0 _ To 7S..Ft. 2 Sch. 40 ._ PVC _
Frnh'4 To Ft. -
F!pal Ta - Ft.
7. GROUT: Depth Material Method
From_ 0.0 To. 12 _Ft._ N. Cement _ Slurry
Frdm re _ Ft.
From To F.
O. SCREEN: ❑epIti Olamater Slat5ize
0.10 in.
Material
PVC
0 15 ft. ^ Fill (Clayey silt) in former
• kerosene UST excavation _
15,0 20 ft. - Silty clay, red (Munsell 2.5YR 4/6)
20.0' 25 ft. S. clay, yellowish red (5YR 4/6)
25,0 35 ft. - Saprolite, dark yellowish brown-
- (10YR 4/6) weathered to s. clay
35 ft. Bottom boring.
4 is REMARKS:
Bentonite 12 to 15 feet. Monitoring.r,vefl MW1
UST incident No. 36860
I OO HEREBY CEa1IFFf THAT THIS WEL WAS CONeRLICTED IN ACCORDANCE WrrH
leA1NCAC 2G, WELL C0NSTRUCT4ON STANDARo9; AND THAT COPY OFT 1s
RECORsDifk3 EENPROVIDED WELL owNEF4
1 2/06/1 3
SIGNi4uJi4 dPCERTFFI 7WELL CONTRACTOR CATE
R. J. Wyatt and M. Alex McGilvary
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original tt, the Division of Water Duality within 30 clays. Attn: Fnlam:c alran Mot_.

04/05/2006 23: 44 9104202731.
RANSIER
PAGE 83
WELL CONSTRUCTION RECORD
This fate eon be luCdfar aingla or rmili pia walla
1, Wall Caitlraefor late rmatlont
Bryan Vest
Wehtl Cc esmeterlheo
3590
NC Weil Ce>gtrmtArCrrULmil art lwniror
Ransier Environmental Drilling, Inc.
Co Poppy Hame
Z. W011 Conetninitan Permlith
Clot allfipple (Air wriipenuihrt1+cC!waa;y.Str'W, Garfearry rrr)
S. Well Um (check well nee):
W /kW Sapp
E1Agrtoultural
JOeolhonnal (I•lealingittwllug Supply)
CIh dtiattiel1C:nmmoroial
0) lion
OMursiaipel�+lbhc
ORe3ldentlal Water 8trpldy(singla)
C31tasidentiel Water Supply (hered)
Non -Writer Supply Weil:
ldiv#1mSte DA=overl
ft eat W
C]AgaiferReohetgn
El Aquifer $forage and Rae eery
OATIAr Teat
Cllixpari menial 7 echaology
ntarolltenmul (ClOood p)
1 enthe:noel Ieatin. nail Rattan
DOrnum' water RariadIatipa
DCulirrity Buller
oStor wader 1]rniaago
17Subslrronne Cntlt+ul
17Proear
001her ex 'yin underfill Rernarlpl'
Far lmeflniUR ONLY:
mae+riurrryos
ft
11L
35,.U\Tf KCAli1Nti06r1r44- .d1,rtldoyy1il4lliir■I hoMO
rants nos MAMMAS.
MOM
0 n.
Y[3
fR
DSAMItfra
In.
�It 1 •13:a9lEy c nU11.T} L ...ldlsell ono]
� It ft. 2 ieofQF�m in cow ii d MA WA*
1J
lit
}!. dCRE N
n f1. 35 t.
In,
alAlr • 0
.01
'I1llt,fjCi t81
ea i40
na,r311)41,
ri.
ft
In.
r o
fa T Atka$ ila4
lG 41a 1 Mleat cement
n,
a.
fR If:
?#J'.I.ACENIgsrr hlftrilLafiAst[oirrr
trmmle
Mq'rettnt 1,A[t'1aOWN PMM TH01r
fnOQIum quartz pour
XtJl_RR,1 . r (Rtteeh nitikrpat sheen y[n+roaarr?
nol+l Tl1 11Ci{'&t J'lONScoiof air nroi walgrwi< enln �r11, rig
rrillbrowi silty day
0 n. 35 11.
1orrfl4 Mir-2+3
4. bale Wake) Complain di Wurl
dn. Well X.oeai{nat
Handy Mart
Fsallhyeawaorlie on
3166 NC Hwy 16, Maiden
1htWilty11 (ii'appiknblu)
CBerl Address City. end Zip
atawba
Comity Parcel IOnutl IioAlon No. (PIN}
54. hide red 11.04iglfinl to tltgreeeintIntttorite Eonda 0r decimal &gro e
(tF�tett Gold. ono UMI na •t %detain)
35 38.59 81 11.E
..It {are) rlrewela(y)! IiiPerntratent or °Temporary
7. Is Ihh a repair to an existing welt DYei or EINo
Sf this rr emalr, jllgelr brewer wsil wnsnrtr#C+t bera Winn mid aaplarn rho nom of me
mporrsoar t2fraunerka.taarhpt.oronthe bark gfA tetra►
2
0. Number anvil! unaelenehult
For ms+seeplegJarfrarrortw+rrreldrarrpply weeltONLY W►de the lane cev+rrrteakn you ran
s IMMI Car fonttc 35
4. Total me11 depth below Ind rvurfaot: t��]
Forratlrlpk walla last air dr(ir t d'd jInte r (mane,- M20' and:?7+1A7)
26
10.131411e water level below top a1ltluisgi
frwneerkwelI,r*Ow tilalftes 10,0 "+
11. Bo rebate dlalmetelr (tn.)
auger
12. won oaaotrue Ilan m,ztirgel;
Om. opt, tasty, as % an3ot peak, Oa)
(R.]
fl.
ft.
ff.
ft
fl.
ft
teL
or.
l�
21. IIll1NAlK
FOR WATER SUPPLY W SI IS ONLY!
3 3a. Yield Wort) Method of tote
13b. rllthiteallvn types Attuning;
22, Cetraffeanem
10/17/14
Stgnatu of wed ol1 Conlrsulor Dtte
9y 11040114Pio. i Mtei9 6016 dHrt din aiel!(aj tared• (wr.raj anr1ener►ed in mennrrrrice
NAA ISA NC'A 42C , OIII& or 104 NC4C 03:'.0$oQ 19'®tl Canm+wrfun sinndardr card rim: a
coo reihb ward r,eet hrctrpeavt Irdin ewe mr71 owner.
23. glt.diagram oriddttkn>;1 vela dut u i
You nary ua0 fife Wok of this }'ago to provide: additional well eila detain nr wofl
non olruation detain. You muy also attach addtieml pages if navesaary,
14a. For All 11/e1 : Nututtlt Oda form within 30 Uaya of completion of wall
oonslruetien to the following:
U1vlalair ef'Watariitre1troca, %uCCrtuutlan FrucerringUntl,
1617 Mall flarwlco Captor Raleigh, NC 27699,16J1
24b. For inleclf op Weak OMNI In atiditiou ire sending titG reran ur tlto midterm ilk
2464two, nlaa aulanat a nary of this Comt within :10 soya of aernpll.Ina of watt
nnrhatrttotior] W tlfo fi I!Otvingt
Plvlelan of"Water Awanr v , Underground L Jeellen Cvntrek Program
1636 Mali Scrs'lca Celtter. Raleigh, NC 27699•1636
24e. For 'W.xter i3upplkdtIndeedart Waller
Also submit ono ropy of licit form within 30 days of amyl alma of
wall conatrvatiar+ to the aaonty heeltil dverhr ee11 of the Dountywhore
aanetntetod.
Corn OW-t
Non}ICuntlmDepart lnaala}Y.rettvmoat and 74alma gesorraee- r}Ivlilvnb£Wwer RarleadA 24I3

WELL CONSTRUCTION RECORD
This farm can he used Dar single or multiple wells
1. Well Contractor Information:
Bryan Vest
Well Contractor Name
3580
NC Well Contractor Certification Number
Ransier Environmental Drilling, Inc.
Company Name
2. Well Construction Pertnit#:
List all applicable well permits (i.e. Cowily. State, Variance.
3. Well Use (check well use):
etc,)
Water Supply Well:
JAgricultural OMunicipalIPublic
❑Geothermal (lieatingiUooling Supply) ❑Residential Water Supply (single)
Ilndustria ?Commercial °Residential Water Supply(shared)
❑ Irrigation
Nora -Water Supply Well:
IRIMonitoring
❑Recovery
Injection Weil:
o Aquifer Recharge
0Aquifer Storage and Recovery
❑Aquifer Test
❑ Experimental Technology
❑ Geothermal (Closed Loop)
OGeothermal (Heating/Cooling Return)
9/9/15
4. Date Well(s) Completed:
Sa. Well Location:
Handy Mart
Facility/Owner Name
3166 Hwy 16 Maiden
o Groundwater Reenediation
°Salinity Barrier
❑Stormwater Drainage
❑Subsidence Control
❑ Tracer
❑O her (explain under142l Remarks)
TW-1
Well IDii
Facility IO# Iifapplicahle)
Crcal Address, City, and Zip
atawba
County
Parcel Identification No. (PIN)
5b. Latitude and Longitude in degrees/minutes/seconds or decimal degrees
;If well field, one istltong is sufficient)
3538.16 N 8110.01
6. Ie (arc) the weU(s): L4Permanent or ❑Temporary
7. Is this a repair to an existing welt ❑Yes or IgNo
Ifthis is a repair. Jill out know] wail construction information end explain the nature of the
repair under #21 remarks section or an the hack of thalami.
1
8. Number of wells constructed:
For ew/:ipte injection or non-watersuppty welds ONLY with the same cansrruthoa, you can
submit one. Ann. 75
9. Total well depth below land surface: (ft.)
For multiple wells list all depths rfdifferent (example- 3®200'and 2 a[�100)
45
10. Static water level below top of casing: (ft.)
II -water level is above easing.. use •'+„
it Borehole diameter: 4 (In,)
auger + air rotary
12. Well construction method:
(ie. auger, 40 Cary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _ _ Method of test:
13b. Disinfection type: A mou nt:
For Internal use ONLY:
14. WATER ZONES
FROM
TO
RESUMPTION
ft.
tt
ft,
15, OUTI RCASING (tor multi -cased we8sl Oft LINER Iu applicable)
FROM
O ft.
TO
40
1L
DMMETER
5 in.
THICKNESS1
MATERIAL
sch 40 PVC
16. INNER CASING OR TUBING i •eotbermal dosed-1oa
FROM TO DIAMETER THICKNESS
sch 40
O R.
70 ft.
2
lo.
MATERIAL
fL
in.
17. SCREEN
FROM
70
TO DIAMETER
75 ft. 2 la.
SLOT SIZE
.010
THICKN SS MATERIAL
sch 40
ft: fa
18. GROUT
FROM
O it.
TO
40 ft.
MATERIAL
neat cement
EMPLACEMENT M ETHOD & AMOUNT
tremmie
O ft.
66 ft.
neat cement
tremmie
fI. IL
19. SAND/GRAVEL PACK elf appliieab1es
FROM
TO MATERIAL
MPI,ACRM ENT METHOD
68 11.
75 fL
medium quartz
pour
ft.
10. DRILLING LOG IM ieh additionalsheets if necessary:
TO D►seLNrer[IJh(corer,hardness, soil/rock ripr. grain sue. ere)
75 it. redibrown clayey silt
FROM
0 ft.
n.
rt.
ft.
rt.
rt.
rt.
ft.
ft
tr.
ft
2L REMARKS
13 Certification:
9/16/15
Signature of Certified Well Contractor Date
By signing this form. 1 hereby eery that the walks) was (were) constructed in accordance
with 154 TA 02C .01 t?O or 154 NC4C 02C .02040 Well Construction Standards and that o
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
24a. For All Walls: Submit this farm within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Weak ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground lisjeetion Control Program
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
Also submit one copy of this farm within 30 days ofcompletion of
well construction to the county heaith department of the countywhere
constructed,
Form GW-t
North Carotins Department of Environment an
d Natural Resources —Division of Water Revised A 20t3

REGENESIS SAFETY DATA SHEET
Technology -Based Sokutions ( or rtie Ervir3lu net!
1. Identification
Product identifier
Other means of identification
Recommended use
Recommended restrictions
Oxygen Release Compound Advanced (ORC Advanced®)
None.
Sail and Groundwater Remediation.
None known.
Manufacturerllmporter(Supplier/Distributor information
Company Name
Address
Telephone
E-mail
Emergency phone number
2. Hazard(s) identification
Physical hazards
Health hazards
OSHA defined hazards
Label elements
Signal word
Hazard statement
Precautionary statement
Prevention
Response
Storage
Disposal
Hazard(s) not otherwise
classified (HNOC)
Regenesis
1011 Calle Sombra
San Clemente, CA 92673
949-366-8000
[e-mail]
CNEMTREC' at 1-800-424-9300 (International)
Oxidizing solids
Skin corrosion/irritation
Serious eye damage/eye irritation
Not classified.
6
i
V
Danger
May intensify fire; oxidizer. Causes skin irritation. Causes serious eye damage.
Category 2
Category 1
Category 1
Keep away from heat. Keep/Store away from clothing and other combustible materials. Take any
precaution to avoid mixing with combustibles. Wash thoroughly after handling. Wear protective
gloves/eye protection/face protection.
if on skin: Wash with plenty of water. If in eyes: Rinse cautiously with water for several minutes.
Remove contact lenses, if present and easy to do. Continue rinsing. Immediately call a poison
center/doctor. If skin irritation occurs: Get medical advice/attention. Take off contaminated
clothing and wash before reuse. In case of fire: Use appropriate media to extinguish.
Store away from incompatible materials.
Dispose of contents/container in accordance with local/regional/national/international regulations.
None known.
3. Composition/information on ingredients
Mixtures
Chemical name
Calcium hydroxide oxide
CAS number
682334-66-3 ?85
Calcium hydroxide
1305-62-0 s15
Dipotasslum Phosphate
7758-11-4 <5
Monopotassium Phosphate
7778-77-0 <5
Composition comments
All concentrations are in percent by weight unless otherwise indicated.
Oxygen Release Compound Advanced (ORC Advanced')
925597 Version It: 01 Revision date: - Issue date: 02-April-2015
SDS U5
118

4. First-aid measures
Inhalation
Skin contact
Eye contact
Ingestion
Most important
symptoms/effects, acute and
delayed
Indication of immediate
medical attention and special
treatment needed
General Information
5. Fire-fighting measures
Suitable extinguishing media
Unsuitable extinguishing
media
Specific hazards arising from
the chemical
Special protective equipment
and precautions for firefighters
Fire fighting
equipment/instructions
Specific methods
General fire hazards
Move to fresh air. Call a physician if symptoms develop or persist.
IF ON CLOTHING: rinse immediately contaminated clothing and skin with plenty of water before
removing clothes. Rinse skin with water/shower. If skin irritation occurs: Get medical
advice/attention. Wash contaminated clothing before reuse.
Do not rub eyes. Immediately flush eyes with plenty of water for at least 15 minutes. Remove
contact lenses, if present and easy to do. Continue rinsing. Get medical attention immediately.
Never give anything by mouth to a victim who is unconscious or is having convulsions. Rinse
mouth. Do not induce vomiting . If vomiting occurs, keep head low so that stomach content doesn't
get into the lungs. Get medical attention if symptoms occur.
Severe eye irritation. Symptoms may include stinging, tearing, ,redness, swelling, and blurred
vision. Permanent eye damage including blindness could result. Dusts may irritate the respiratory
tract, skin and eyes. Skin irritation . May cause redness and pain .
Provide general supportive measures and treat symptomatically. Keep victim under observation.
Symptoms may be delayed.
Take off all contaminated clothing immediately. Contact with combustible material may cause fire .
Ensure that medical personnel are aware of the material(s) involved, and take precautions to
protect themselves. Wash contaminated clothing before reuse.
Water spray, fog (flooding amounts). Foam. Dry chemical powder. Carbon dioxide (CO2).
None known.
Greatly increases the burning rate of combustible materials. Containers may explode when
heated. During fire, gases hazardous to health may be formed. Combustion products may include:
metal oxides.
Self-contained breathing apparatus and full protective clothing must be worn in case of fire.
In case of fire and/or explosion do not breathe fumes. Move containers from fire area if you can do
so without risk. Use water spray to cool unopened containers.
Cool containers exposed to flames with water until well after the fire is out.
May intensify fire; oxidizer. Contact with combustible material may cause fire.
6. Accidental release measures
Personal precautions,
protective equipment and
emergency procedures
Methods and materials for
containment and cleaning up
Environmental precautions
Keep unnecessary personnel away. Keep people away from and upwind of spill/leak. Keep away
from clothing and other combustible materials. Wear appropriate protective equipment and
clothing during clean-up. Use a NIOSH/MSHA approved respirator if there is a risk of exposure to
dusUfume at levels exceeding the exposure limits. Do not touch damaged containers or spilled
material unless wearing appropriate protective clothing. Ensure adequate ventilation. Local
authorities should be advised if significant spillages cannot be contained. For personal protection,
see section 8 of the SOS.
Eliminate all ignition sources (no smoking, flares, sparks, or flames in immediate area). Collect
dust using a vacuum cleaner equipped with HEPA filter. Keep combustibles (wood, paper, oil, etc.)
away from spilled material. Ventilate the contaminated area . Stop the flow of material, if this is
without risk. Absorb in vermiculite, dry sand or earth and place into containers.
Large Spills: Sweep up or vacuum up spillage and collect in suitable container for disposal. Shovel
the material into waste container. Minimize dust generation and accumulation. Avoid the
generation of dusts during clean-up. Following product recovery, flush area with water.
Small Spills: Wipe up with absorbent material (e.g. cloth, fleece). Clean surface thoroughly to
remove residual contamination.
Never return spills to original containers for re-use. Place all material into loosely covered plastic
containers for later disposal. For waste disposal, see section 13 of the SDS. Wear appropriate
protective equipment and clothing during clean-up.
Avoid discharge into drains, water courses or onto the ground.
Oxygen Release Compound Advanced (ORC Advanced®) SDSUS
2/8 925597 Version#: 01 Revision date: -Issue date: 02-April-2015
7. Handling and storage
Precautions for safe handling
Conditions for safe storage,
including any incompatibilities
Minimize dust generation and accumulation. Routine housekeeping should be instituted to ensure
that dusts do not accumulate on surfaces. Keep away from heat. Provide appropriate exhaust
ventilation at places where dust is formed. Keep away from clothing and other combustible
materials. Take any precaution to avoid mixing with combustibles. Avoid contact with water and
moisture. Do not get this material in contact with eyes. Avoid contact with eyes, skin, and clothing.
Avoid prolonged exposure. Wear appropriate personal protective equipment. Observe good
industrial hygiene practices.
Keep away from heat. Store in a cool, dry place out of direct sunlight. Store in original tightly
closed container. Store in a well-ventilated place. Do not store near combustible materials. Store
away from incompatible materials (see Section 1 O of the SDS).
8. Exposure controls/personal protection
Occupational exposure limits
US. OSHA Table Z-1 Limits for Air Contaminants (29 CFR 1910.1000)
Components
Calcium hydroxide (GAS
1305-62-0)
Type
PEL
Value
5 mg/m3
15 mg/m3
Form
Respirable fraction.
Total dust.
US. ACGIH Threshold Limit Values
Components Type Value
Calcium hydroxide (GAS TWA 5 mg/m3
1305-62-0)
US. NIOSH: Pocket Guide to Chemical Hazards
Components
Calcium hydroxide (GAS
1305-62-0)
Biological limit values
Appropriate engineering
controls
Type Value
TWA 5 mg/m3
No biological exposure limits noted for the ingredient(s).
Good general ventilation (typically 10 air changes per hour) should be used. Ventilation rates
should be matched to conditions. If applicable, use process enclosures, local exhaust ventilation,
or other engineering controls to maintain airborne levels below recommended exposure limits. If
exposure limits have not been established, maintain airborne levels to an acceptable level. If
engineering measures are not sufficient to maintain concentrations of dust particulates below the
Occupational Exposure Limit (OEL), suitable respiratory protection must be worn. If material is
ground, cut, or used in any operation which may generate dusts, use appropriate local exhaust
ventilation to keep exposures below the recommended exposure limits. Eye wash facilities and
emergency shower must be available when handling this product.
Individual protection measures, such as personal protective equipment
Eye/face protection Use dust-tight, unvented chemical safety goggles when there is potential for eye contact.
Skin protection
Hand protection
Other
Respiratory protection
Thermal hazards
General hygiene
considerations
Wear appropriate chemical resistant gloves. Frequent change is advisable. Recommended gloves
include rubber, neoprene, nitrile or viton.
Wear appropriate chemical resistant clothing.
If engineering controls do not maintain airborne concentrations below recommended exposure
limits (where applicable) or to an acceptable level (in countries where exposure limits have not
been established), an approved respirator must be worn. Recommended use: Wear respirator with
dust filter.
Wear appropriate thermal protective clothing, when necessary.
Keep from contact with clothing and other combustible materials. Remove and wash contaminated
clothing promptly. Always observe good personal hygiene measures, such as washing after
handling the material and before eating, drinking, and/or smoking. Routinely wash work clothing
and protective equipment to remove contaminants.
9. Physical and chemical properties
Appearance
Physical state
Form
Color
Solid.
Powder.
White to pale yellow.
Oxygen Release Compound Advanced (ORC Advanced®)
925597 Version #: 01 Revision date: -Issue date: 02-April-2015
SDSUS
3/8
O.dor Odorless.
Odor threshold Not available.
pH 12.5 (3% suspension/water)
Melting point/freezing point Not available.
Initial boiling point and boiling Not available.
range
Flash point Not available.
Evaporation rate Not available.
Flammability (solid, gas) Oxidizer.
Upper/lower flammability or explosive limits
Flammability limit -lower Not available.
(%)
Flammability limit -upper Not available.
(%)
Explosive limit -lower(%) Not available.
Explosive limit -upper(%) Not available.
Vapor pressure Not available.
Vapor density Not available.
Relative density Not available.
Solubility(ies)
Solubility (water) Slightly soluble
Partition coefficient Not available.
(n-octanol/water)
Auto-Ignition temperature Not available.
Decomposition temperature 527 °F (275 °C)
Viscosity Not available.
Other information
Bulk density 0.5 -0.9 g/ml
Explosive limit Non-explosive.
10. Stability and reactivity
Reactivity
Chemical stability
Possibility of hazardous
reactions
Greatly increases the burning rate of combustible materials.
Decomposes on heating. Product may be unstable at temperatures above: 275°C/527°F.
Reacts slowly with water.
Conditions to avoid Heat. Moisture. Avoid temperatures exceeding the decomposition temperature. Contact with
incompatible materials.
Incompatible materials
Hazardous decomposition
products
Acids. Bases. Salts of heavy metals. Reducing agents. Combustible material.
Oxygen. Hydrogen peroxide (H2O2). Steam . Heat.
11. Toxicological information
Information on likely routes of exposure
Inhalation Dust may irritate respiratory system. Prolonged inhalation may be harmful.
Skin contact
Eye contact
Ingestion
Causes skin irritation.
Causes serious eye damage.
Ingestion may cause irritation and malaise.
Symptoms related to the
phys ical, chemical and
toxicological characteristics
Severe eye irritation. Symptoms may include stinging, tearing , redness, swelling, and blurred
v ision. Permanent eye damage including blindness could result. Dusts may irritate the respiratory
tract , skin and eyes . Skin irritation . May cause redness and pain .
Information on toxicological effects
Acute toxicity
Oxygen Release Compound Advanced (ORC Advanced®)
925597 Version#: 01 Revision date : -Issue date: 02-April-2015
sos us
4/8
Components Species Test Results
Calcium hydroxide (CAS 1305-62-0)
Acute
Oral
LD50 Rat 7340 mg/kg
Skin corrosion/irritation
Serious eye damage/eye
irritation
Respiratory or skin sensitization
Respiratory sensitization
Skin sensitization
Germ cell mutagenicity
Causes skin irritation.
Causes serious eye damage.
Not a respiratory sensitizer.
This product is not expected to cause skin sensitization.
No data available to indicate product or any components present at greater than 0.1 % are
mutagenic or genotoxic.
Carcinogenicity This product is not considered to be a carcinogen by IARC, ACGIH, NTP, or OSHA.
OSHA Specifically Regulated Substances (29 CFR 1910.1001-1050)
Not listed.
Reproductive toxicity
Specific target organ toxicity -
single exposure
Specific target organ toxicity -
repeated exposure
Aspiration hazard
Chronic effects
This product is not expected to cause reproductive or developmental effects.
Not classified.
Not classified.
Due to the physical form of the product it is not expected to be an aspiration hazard.
Prolonged inhalation may be harmful.
12. Ecological information
Ecotoxicity The product is not classified as environmentally hazardous. However, this does not exclude the
possibility that large or frequent spills can have a harmful or damaging effect on the environment.
Components Species Test Results
Calcium hydroxide (CAS 1305-62-0)
Aquatic
Fish LC50 Zambezi barbel (Clarias gariepinus) 33.8844 mg/I, 96 hours
Persistence and degradability Decomposes in the presence of water. The product contains inorganic compounds which are not
biodegradable.
Bioaccumulative potential The product does not contain any substances expected to be bioaccumulating.
Mobility in soil This substance has very low solubility in water and low mobility in the environment.
Other adverse effects None known.
13. Disposal considerations
Disposal instructions
Local disposal regulations
Hazardous waste code
Waste from residues / unused
products
Contaminated packaging
14. Transport information
DOT
Collect and reclaim or dispose in sealed containers at licensed waste disposal site. Dispose of
contents/container in accordance with local/regional/national/international regulations.
Dispose in accordance with all applicable regulations.
The waste code should be assigned in discussion between the user, the producer and the waste
disposal company.
Dispose of in accordance with local regulations. Empty containers or liners may retain some
product residues. This material and its container must be disposed of in a safe manner (see:
Disposal instructions).
Empty containers should be taken to an approved waste handling site for recycling or disposal.
Since emptied containers may retain product residue, follow label warnings even after container is
emptied.
UN number UN1479
UN proper shipping name Oxidizing solid, n.o.s. (Calcium hydroxide oxide)
Oxygen Release Compound Advanced (ORC Advanced®)
925597 Version#: 01 Revision date: -Issue date: 02-April-2015
sos us
5/8
Transport hazard class(es)
Class 5 .1
Subsidiary risk
Label(s) 5 .1
Packing group II
Environmental hazards
Marine pollutant No
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
Special provisions 62, 1B8, IP2, IP4, T3, TP33
Packaging exceptions 152
Packaging non bulk 212
Packaging bulk 240
IATA
UN number UN1479
UN proper shipping name Oxidizing solid, n.o.s. (Calcium hydroxide oxide)
Transport hazard class(es)
Class 5.1
Subsidiary risk
Packing group II
Environmental hazards No
ERG Code SL
Special precautions for user Read safety instructions, SDS and emergency procedures before handling .
IMDG
UN number
UN proper shipping name
Transport hazard class(es)
Class
Subsidiary risk
Packing group
Environmental hazards
Marine pollutant
Ems
UN1479
OXIDIZING SOLID, N.O.S. (Calcium hydroxide oxide)
5.1
II
No
F-A, S-Q
Special precautions for user Read safety instructions , SDS and emergency procedures before handling.
Transport in bulk according to Not applicable.
Annex II of MARPOL 73/78 and
the IBC Code
15. Regulatory information
US federal regulations This product is a "Hazardous Chemical'' as defined by the OSHA Hazard Communication
Standard, 29 CFR 1910.1200.
All components are on the U.S . EPA TSCA Inventory List.
TSCA Section 12(b) Export Notification (40 CFR 707, Subpt. D)
Not regulated.
OSHA Specifically Regulated Substances (29 CFR 1910.1001-1050)
Not listed.
CERCLA Hazardous Substance List (40 CFR 302.4)
Not listed.
Superfund Amendments and Reauthorization Act of 1986 (SARA)
Hazard categories Immediate Hazard -Yes
Delayed Hazard -No
Fire Hazard -Yes
Pressure Hazard -No
Reactivity Hazard -Yes
SARA 302 Extremely hazardous substance
Not listed.
SARA 311/312 Hazardous Yes
chemical
Oxygen Release Compound Advanced (ORC Advanced®)
925597 Version#: 01 Revision date: -Issue date: 02-April-2015
SDS US
6/8
SARA 313 (TRI reporting)
Not regulated.
Other federal regulations
Clean Air Act (CAA) Section 112 Hazardous Air Pollutants (HAPs) List
Not regulated.
Clean Air Act (CAA) Section 112(r) Accidental Release Prevention (40 CFR 68.130)
Not regulated.
Safe Drinking Water Act Not regulated.
(SDWA)
US state regulations
US. Massachusetts RTK - Substance List
Calcium hydroxide (CAS 1305-62-0)
US. New Jersey Worker and Community Right -to -Know Act
Calcium hydroxide (CAS 1305-62-0)
Calcium hydroxide oxide (GAS 682334-66-3)
US. Pennsylvania Worker and Community Right -to -Know Law
Calcium hydroxide (CAS 1305-62-0)
US. Rhode Island RTK
Not regulated.
US. California Proposition 65
California Sate Drinking Water and Toxic Enforcement Act of 1986 (Proposition 65): This material is not known to contain
any chemicals currently listed as carcinogens or reproductive toxins.
International Inventories
Country(s) or region Inventory name On inventory (yestno)"
Australia Australian Inventory of Chemical Substances (AICS) Yes
Canada Domestic Substances List (DSL) Yes
Canada Non -Domestic Substances List (NDSL) No
China Inventory of Existing Chemical Substances in China (IECSC) Yes
Europe European Inventory of Existing Commercial Chemical Yes
Substances (EINECS)
Europe European List of Notified Chemical Substances (EL1NCS) No
Japan Inventory of Existing and New Chemical Substances (ENCS) Yes
Korea Existing Chemicals List (ECL) Yes
New Zealand New Zealand Inventory Yes
Philippines Philippine Inventory of Chemicals and Chemical Substances Yes
(PICCS)
United States & Puerto Rico Toxic Substances Control Act (TSCA) Inventory Yes
*A "Yes" indicates thls product complies with the Inventory requirements administered by the governing country(s)
A "No" indicates that one or more components of the product are not listed or exempt from listing on the inventory administered by the governing
country(s).
16. Other information, including date of preparation or last revision
Issue date
Revision date
Version #
Further information
HMIS® ratings
NFPA ratings
02-April-2015
01
HMIS® is a registered trade and service mark of the American Coatings Association (ACA).
Health: 3
Flammability: 0
Physical hazard: 2
Oxygen Release Compound Advanced (ORC Advanced®)
925597 Version #: 01 Revision date. - issue date: 02-April-2015
SDS US
718