WI0300389_DEEMED FILES_20181003

D~
North Carolina Department of Environmental Quality -Division of Water Resour-ces
INJECTION EVENT RECORD GER)
Permit Number WI0300389 ~~======----------
1. Pern;tit Information
NCDEQ State Lead Program
Permittee
Lake Lookout 66
Facility Name
5730 Oxford School Road, Mecklenburg County,
Charlotte, NC ---Facility Address (include County)
2. Injection Contractor Information
ATC Associates of North Carolina, P.C
Injection Contractor/ Company N~e
Street Address 7606 Whitehall Executive Center
Drive, S\lite 800 -
Charlotte, NC 28273
City State Zip Code
(704) 529-'3200 _____ _
Area code -Phone number
3. Well Information OCT -8 2018
Number of wells used for injection ,.,
· R . ..ate, 0Ua/ity
eg1onal Operau· Well IDs MW-IR an MW-4 ___ ons Sect· n
Were any new wells installed during this injection
event?
D Yes [8l No
If yes, please provide the following information:
Number of Monitoring Wells ------
Number of Injection Wells -------
Type ofWell Installed (Checkapplicabletype):
D Bored D Drilled □.Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well in.stalled.
Were any wells abandoned duringthis injection
event?
D Yes [gj No
If yes, please provide the following infortnation:
Number ofMonitoringWells ------
Number of Injection Wells -------
Please include a copy of the GW-30 for each well
abandoned.
4 . Injectant Information
Provectus ORS (oxygen-releasing socks)_
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 75~85% calcium peroxide {1 5-25%
inorganic nutrients)
If the injectant is diluted please indicate the source
dilution fluid. -----------
Total Volume Injected (gal)_ total volume = 678.6
• 3 .ID....._
Volume Injected per well (gal) 339.3 in.3
5. Injection History
Jnjectiondate(s) _ _....9=/2=8/=2=0,,_,18.____ _____ _
Injection number (e.g. 3 of S) 1 of unknown
number, may have additional injections
Is this the last injection at this site?
D Yes l8:I No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON TillS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
lNJECTIO WAS PERFORMED WITHIN TIIE
STAND SL OUTINTIIEPERMIT.
~') /0 '/o;IJ
OF INJECTION CONTRACTOR DAT
J.°' /J~Ji>
Submit the original ofthis fonn to the Division of Water Resources within 30 days ofinjection.
Attn: me 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
WI0300389
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shrisli.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Lake lookout 66
Location Address
5730 Oxford School Rd
Claremont
Owner
Owner Name
Ncdeq State -Lead Program
Dates/Events
NC
Orig Issue
9/26/2018
App Received
9/20/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28610
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/27/2018
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Mark Petermann
1646 Mail Service Ctr
Raleigh
Region
Mooresville
County
Catawba
NC
Issue
9/26/2018
Effective
9/26/2018
27699164
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
North Carolina Department of Environmental Quality-Division of Water Resources
NOTIFICATION OF INTENT (Non 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 (1 5A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (ISA NCAC 02C .0225) or TRACER WELLS (ISA NCAC 02C .0229 ):
1) Passive Iniection S 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 area not to exceed I 0,000
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: Se ptember 10 , 2018 __ PERMIT NO. WI De, 00 3'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
__ Tracer Injection Well ................................... Complete sections B ili?Jn0B)J EDfNCOEQ/DWR.
STATUS OF WELL OWNER: Choose an item. SEP 2 0 2018
Water Quality Regional
C. WELL OWNER(S)-State name of Business/Agency, and Name and Title of person dele~allilmtt$ tion
sign on behalf of the business or agency:
Name(s): ---=-N'--"C""'D"-"E"°O"----=S:..,:,ta:eecte"'--L~e""a""'d'----"P...,_r""'o gr=am~ ___________________ _
Mailing Address: ------"-16,,_4..,_,6:::....M=a~il'-'S<-"e,...rv'""i""'ce:::....C=en~t""er'----------------------
City: Raleie:h State: NC
Day Tele No.: 919-707-8260
EMAIL Address: frans.lowman (al atcassociates.com
Deemed Permitted GW Remediation NOI Rev. 8-28-2017
Zip Code:. __ -=-27~6~9~9 ____ County: Wake
Cell No.: Not Available
Fax No.: 919-707-8260
Pagel
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: -------=N'-'-'o=t:..:cA-=..v::..:a:e,il=ab=l=e ____________________ _
Company Name --------------------------------
Mailing Address: ----------"'5_,_73"'-'0"--...>a:O"-'x'""fo""r=-d-==S=ch=o=oa:.:.l--"-R""o=-=a-=-d--------------------
City: Claremont State: NC Zip Code: 28610 Cowty: Catawba
Day Tele No.: Not Available Cell No.: -----"N_,_,o=tce.A~v:..:ca=il=ab=l=e ___ _
EMAIL Address: Not Available Fax No .: ___ N"-'-"'o-"'t A=-=-v=ai=la=b=le"'-----
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: __ __,F'"""r""'an,.,s"-'L""o"-'wm==an=·'--"P'"""r-"-o,._,,je=ct,_,M==an""a""'g""e'O...r _________________ _
Company Name ___ A~T--"'C'--'A~ss'-"o=ci==a""te"'"s-"'o=f -=---N=o=rth=-"C""ar'°-o""l""in"°'a~P'--".C"-'-.---------------
Mailing Address : __ __,_7-"'6-"-06,c___:_Whi:...=·t=eca.:h=al,.__l =E=xe=c=u=ti'-'-v=-e --"'C'-"e~nt=er:c..=D~n,_,_·v=e,,_,S""'u~it=ec...:8~0'""0 ___________ _
City: Charlotte State: NC Zip Code: 28273 Cowty: Mecklenburg
Day Tele No.: ~7~04_-~52=9--3~2~0~0 _____ _ Cell No.: Not Available
EMAIL Address: __ ~fr=an=s=.lo~wm~=an=-=a=tc~a=ss=o~ci=a=te=s-=c=om~ Fax No.: __ .....:7...:::0--=-4--"5=29"--=3=27'--"2,...._ __ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address : Lake Lookout 66 -5730 Oxford School Road
City: ___ C=l=ar=e=m=o=n~t ________ County: Catawba Cowty Zip Code: 28610
(2) Geographic Coordinates: Latitude**: ___ 0 --__
11 or .::.3::..,5.C!..7.!...71=2=1~0 ___ _
Longitude**: 0 __ " or -81.14853 ° ___ _
Reference Datum:. __ ~W~G~S8~4~ __ Accuracy:. __ ~N"----'--"-ot-=-.cA=-=-va=i=la=b=le'--
Method of Collection:,____:G,,,_o""'o"-o..,_le:..=E=arth~-------------
**FOR AIR INJECTION AND AQUIFER TE ST WELL S ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: ______ square feet
Land surface area ofinj. well network: square feet(:: 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be_:::; 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(I) 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 growdwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOi Rev . 8-28-2017 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
pmpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
ATC will install Provectus ORS (oxygen-releasin!! socks) in monitoring wells MW-IR and MW-4 to promote
accelerated petroleum compound biodegradation and reduce compound concentrations to below the North
Carolina Groundwater Quality Standards (2L Standards). The socks come in 3-foot sections and three socks are
anticipated to be installed eacj in wells MW-IR and MW-4 during the installation events. depending on water
volume in the well. The socks will deliver controlled-release oxvgen into the groundwater for four to eight
months. at which point the chemicals in the socks will have depleted.
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 byectants can be found online at htq>://deg.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-injectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Jnjectant: --~P=ro~v~e=c=tus~O~R=S ________________________ _
Volume ofinjectant: __ 6~so~c=k=s--=a=t=l=l3~·=1--=in=.'""'3/=s-=-oc=k=:--=to=ta~l v~o=l=um=e_=--=--67-'--'8=·-=-6~in=·~3 +p=er~in=sta=ll=at=io=n~ev~e=n=t _
Concentration at point of injection: __ _,7--=5--8=5'-"'o/c--=o~c=a=lc=ium=__..,p=e=ro=x=id=e=-------------
Percent if in a mixture with other injectants: ---'-7"""5---'-8=5C-'.o/c-=-o--=c=al=c=ium=-"'p=er=o=x=id=e~<~1=5~-2=5'-'o/c=o~in=o=r=g=an=i=c
nutrients)
lnjectant: --------------------------------
Volume ofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
Injectant: --------------------------------
Volume ofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent ifin a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: _____ Proposed. __ --=2'--__ 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
Deemed Permitted GW Remediation NOI Rev . 8-28-2017 Page3
Depth below land surface of casing, each grout type and depth, screen; and sand pack
Weil contractor name and certification number
I.. SCEEDULES — Briefly describe the schedule for well construction and injection activities.
Approximately two weeks following submittal of this NOL,. ATC will install three socks each in existing wells
MW-I R and MW .4. It is anticipated that changeeouts may occur on a Quarterly basis.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
Approximate semi-annual sampling events in monitoring wells MW-IR and MW-4 will be performed starting
six months after the installation of these socks, During_ each sampling event; ATC will collect a sample from
each well for analysis of volatile organic compounds (VOCs) by EPA Method 6200B. ATC will also measure
dissolved oxygen, conductivity, temperature, pH, and oxygen reduction potential in the well during sampling
events.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "1 hereby certafp, under penalty of Ia , that 1 am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry ofthose individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete 1 am aware that
there are significant penalties, including the possibility of fines and imprisonment for submitting false
information. 1 agree to construct operate, maintain repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the I sit NCAC 02C 0200 Rules."
on behalf of NCDEQ Frans Lowman, on behalf of NCDEO
,Sis»ture of Applicant Printer Type Full Name' Title
PROPERTY OWNER (if the property is not ow, sled by the permit 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 inection 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
(l 5,4 NCAC 02C .0 00j. "
"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 Iand shall be deetned to vest ownership in the land owner, in the
absence of contrary agreement in writing.
NCDEQ UST State Lead Prozram — Scott Rvals
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send this NO! electronically to Stwisti.Shrestha er ncden r._o► AND one hard copy to:
DWR — LAC Program
163 6Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
1)eeme4 Pcrnvtted GW Rcmediatson NOI Rev. 8-28-2017 Page 4

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REFERENCE: USGS 1:100000 MAP, HICKORY, NORTH CAROLINA,
DATE:1995
LATITUDE: 35.77122' NORTH
LONGITUDE:-81,14847° WEST
SAL
° •
r
.11
0 1 000 2 000 3 000
APPROXIMATE SCALE IN FEET
Tra FIGURE 1
SITE LOCATION MAP
LAKE LOOKOUT 66 — NCDENR INCIDENT #27879
5730 OXFORD SCHOOL ROAD
CLAREMONT, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
Maria* North Corals 282V > O FAX i711$] 529-0272
CAA FILE
1254067.dwg
Lf• fiY
8B
AS SHOWN
]:•.1 f•
5.12.15
PROJECT NO.
SLP2787901

Well ID
MW-IR
MW-ID
MW-2
MW-3
MW-4
TABLE4
MONITORING WELL CONSTRUCTION DETAILS
LAKE LOOKOUT 66
5730 Oxford School Road
Claremont, North Carolina 28610
NCDEQ Incident #27879
Date Installed Screen Interval (feet) Well Diameter Total Depth (feet) (inches)
3/17/2011 31.50-51.50 2 51.50
6/28/2007 65-80 2 80
6/28/2007 35-50 2 50
6/28/2007 26.37-41.37 2 41.37
6/28/2007 35.50-50.50 2 50.50
TOC refrenced to an arbitrary on-site benchmark
Top of Casing
Elevation
99.85
100.20
102.03
104.60
100.66
NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Qualit)
WELL CONTRACTOR CERTIFICATION 1$ 2904-A
1. WELL CONTRACTOR;
Q9Jev A. Soeece
Well Contractor (Individual) Name
Carolina Soil Investiaations. LLC
Weil Contractor Company Name
132 Gurnpv Rd.
Street Address
?8660
City or Town State Zip Code
(704 ) 87b-001
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT*
OTHER ASSOCIATED PERMITAr(M applicable]
SITE WELL ID #(+t appiieade} MW-7R
3. WELL USE (Check One Box) Monitoring II MuniapalfPubllc 0
Industrial/Commercial ❑ Agricultural ❑ Recovery CI Injection ❑
lrrigatonU Other p (list use)
DATE DRILLED 12/17/2014
4. WELL LOCATION:
1832 Oakdale Road
($boar Name. Numbers, Communrty, Subdivision, Lot No., PAM& Zip Code)
CITY: Charlotte_ country Mack
TOPOGRAPHIC! LAND SETTING: (check appropriate boxy
❑ Slope p V8 iley Et.Flat 0 Ridge D Other
LATITUDE 35 " VMS OR 34.30091 DO
LONGITUDE so ' DMS CR 80,89580 DD
LatitudeBongitude source: Q0PS :Topographic map
(tocalron of well must ha shown on a USGS Ippo map andatlached to
this form if nor using GPS)
5. FACILITY (Name of the business where the weM is located.)
fins ihlanrl ttlficil
Facility Name
1A:12 nakrialp Roan
Stet Address
Facility I[AF (if applicabte)
_rlhP t
City or Town State Zip Code
Carrion ATC: IRranrinn C:iiIhPrsnnl
Contact Name
7-606 hitehall Fxa Center ❑r S11ifP_ RQO
Mailing Address
Charlotte NC 2t1273
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
s. TOTAL DEPTH:
35
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Top or Casing: n/a
(Use''+" if Above Top of Casing)
FT.
d. TOP OF CASING IS Li FT, Above Land Surface'
"Top of casing terminated atlor below [and surface may require
a variance in accordance with 15A NCAC 2C _0118.
e. YIELD (gpm): n/a METHOD OF TEST n/a
f. DISINFECTION: Type rile Amount n/a_
g. WATER ZONES (depth):
Top GA Bottom n/i Tap Bottom
Top Bottom Top Bottom
Top Slattern Top Bottom.
Thickness/
7, CASING: Depth Diameter Weight Material
Top Bottom Ft.
Top 0 Bottom 20 - - FI._ soh 4.g PVC
Top Bottom Ft.
8. GROUT: Depth Material Method
Top g) Bottom 5 Ft. Portland pour
Top 5 Bottom 18 Ft. Bentonite trernie
Top Bottom Ft.
9, SCREEN: Depth Diameter Slot Size UMoriat
Top 20 Bottom 25 Ft._ 2 in. 010 in. pvc
Top Bottom Ft. in. in.
Top Bottom Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Slze Material
Top 18 Bottom 35 Ft. 10/30 silica sand
Top Bottom Ft.
Top Bottom Ft.
f t . DRILLING LOG
Top Bottom
1
1
1
1
1
1
1
1
1
12: REMARKS:
Formation Description
I DO HEREBY CERTIFY THAT TH15 WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15.A N 'CAC X. WELL CONSTeucrlON STANDARDS, AND THAT A COPY CC THIS
I:£CORa BEEN PRO V D • THE WELL OWNER
12/17/14
SIGNATU -+ s aF Cl RTiF ' ■ WELL Ce NTRACTOR DATE
Corny A_ Sperm
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division or Water Quality - information Processing,
1617 Mail Service Center, Raleigh, NC 27698-161, Phone [phone]
Form GW-1b
Rev. 2149

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 1
North Carolina Department of Environmental Quality – Division of Water Resources

Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.

DATE: September 10 , 2018____ PERMIT NO. (to be filled in by DWR)

A. WELL TYPE TO BE CONSTRUCTED OR OPERATED

(1) Air Injection Well……………………………..…Complete sections B through F, K, N
(2) Aquifer Test Well……………………….………..Complete sections B through F, K, N
(3) X Passive Injection System…………………..……..Complete sections B through F, H-N
(4) Small-Scale Injection Operation………………….Complete sections B through N
(5) Pilot Test………………………………………….Complete sections B through N
(6) Tracer Injection Well………………………….….Complete sections B through N

B. STATUS OF WELL OWNER: Choose an item.

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): NCDEQ – State Lead Program
Mailing Address: 1646 Mail Service Center
City: Raleigh State: _NC___ Zip Code: 27699 County: Wake
Day Tele No.: 919-707-8260 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: 919-707-8260
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 injection.

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 Injection Systems - In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).

2) Small-Scale Injection Operations – Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.

3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells 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.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 2
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Not Available
Company Name
Mailing Address: 5730 Oxford School Road
City: Claremont State: __NC__ Zip Code: 28610 County: Catawba
Day Tele No.: Not Available Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available

E. PROJECT CONTACT (Typically Environmental Engineering Firm)

Name and Title: Frans Lowman, Project Manager
Company Name ATC Associates of North Carolina, P.C.
Mailing Address: 7606 Whitehall Executive Center Drive, Suite 800
City: Charlotte State: __NC__ Zip Code: 28273 County: Mecklenburg
Day Tele No.: 704-529-3200 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: 704-529-3272

F. PHYSICAL LOCATION OF WELL SITE

(1) Facility Name & Address: Lake Lookout 66 - 5730 Oxford School Road
City: Claremont County: Catawba County Zip Code: 28610
(2) Geographic Coordinates: Latitude**: o ′ ″ or 35.77121o
Longitude**: o ′ ″ or -81.14853o
Reference Datum: WGS84 Accuracy: Not Available
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.

G. TREATMENT AREA

Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)

H. INJECTION ZONE MAPS – Attach the following to the notification.

(1) Contaminant plume map(s) with 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 Permitted GW Remediation NOI Rev. 8-28-2017 Page 3
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.
ATC will install Provectus ORS (oxygen-releasing socks) in monitoring wells MW-1R and MW-4 to promote
accelerated petroleum compound biodegradation and reduce compound concentrations to below the North
Carolina Groundwater Quality Standards (2L Standards). The socks come in 3-foot sections and three socks are
anticipated to be installed eacj in wells MW-1R and MW-4 during the installation events, depending on water
volume in the well. The socks will deliver controlled-release oxygen into the groundwater for four to eight
months, at which point the chemicals in the socks will have depleted.

J. APPROVED INJECTANTS – 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/ground-water-protection/ground-water-approved-injectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).

Injectant: Provectus ORS
Volume of injectant: 6 socks at 113.1 in.3/sock; total volume = 678.6 in.3 per installation event
Concentration at point of injection: 75-85% calcium peroxide
Percent if in a mixture with other injectants: 75-85% calcium peroxide (15-25% inorganic
nutrients)

Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:

Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:

K. WELL CONSTRUCTION DATA

(1) Number of injection wells: Proposed 2 Existing (provide GW-1s)
(2) For Proposed wells or Existing wells not having GW-1s, 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)
(c)
Depth below land surface of casing, each grout type and depth, screen, and sand pack
Well contractor name and certification number
L. SCIIEDULES — Briefly describe the schedule for well construction and injection activities.
Approximately two weeks following submittal of this NOI, ATC will install three socks each in existing wells
MW-1 R and MW-4, It is anticipated that changeouts may occur on a quarterly basis.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result from the injection activity.
Approximate semi-annual sampling events in monitoring wells MW-1R and MW-4 will be performed starting
six months after the installation of these socks, During each sampling event, ATC will collect a sample from
each well for analysis of volatile organic compounds (VOCs) by EPA Method 6200B. ATC will also treasure
dissolved oxygen. conductivity, temperature, pH, and oxygen reduction potential in the well during sampling
events.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law, thatl 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 relyid appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
ture of Applicant
, on behalf of NCDEQ Frans Lowman, on behalf of NCDEQ
Print or Type Full Name and Title
PROPERTY OWNER (if the property is not owned by the permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(I5A NCAC 02C . 0 200), "
"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.
NCDEQ UST State Lead Program — Scott Ryals
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send this NOI electronically to Shristi.Shrestha(cr�ncdenr.gov AND one hard copy to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 4

CAD FILE PREP. BY REV. BY SCALE PROJECT NO.
TITLE
DATE
ASSOCIATES OF NORTH CAROLINA, P.C.
REFERENCE: USGS 1:100000 MAP, HICKORY, NORTH CAROLINA.
DATE: 1995
LATITUDE:35.77122° NORTH
LONGITUDE: -81.14847° WEST
SITE
-• I -~ ~ .. --,--r 11 I ~ -,,, -.......-.=..----r • ~--, . I -. -J . , • r; -
-,»"C 1._J -.~ :\ .--
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FIGURE 1
SITE LOCATION MAP
LAKE LOOKOUT 66 -NCDENR INCIDENT #27879
5730 OXFORD SCHOOL ROAD
CLAREMONt NORTH CAROLINA
1254067.dwg BB
i 0
i
1,000 2,000 3,000
i
APPROXIMATE SCALE IN FEET
/4.TC
Charlotte, North CVo1na 28217 [phone] FAX (704) ~2
AS SHOWN 5 .12.15 SLP2787901
ASSOCIATES OF NORTH CAROLINA, P.C.[phone] FAX [phone]PROJECT NO.Charlotte, North Carolina 28217NOTES:DATETITLESCALEREV. BYPREP. BYCAD FILELEGEND
Source: Google
Earth Pro 2013
Type II Monitoring
Well Location
MW-1R
MW-3
MW-4
MW-1D
MW-2
FIRE
DEPARTMENT
LAKE
LOOKOUT
66
OX
F
O
R
D

S
C
H
O
O
L

R
DRIVERBEND RDGRASS
GRASS
GRASS
GRASS
RESIDENCE
RESIDENCE
RESIDENCE
GRASS
FORMER UST
LOCATIONS
UST LOCATION
CANOPY
j~N 0 C.T1 X i:: ~ ('Tl ..,C.Tl (/) 0 ~ zr=-= r ('Tl z "'Tl ('Tl ~ •1 ..... 0 0 J~ / , ( .. / -----~ -----FIGURE 3 SITE MAP LAKE LOOKOUT 66 -NCDENR INCIDENT #27879 5730 OXFORD SCHOOL ROAD CLAREMONT, NORTH CAROLINA 1254067.dwg BB -$-/\TC AS SHOWN 5.12.15 SLP2787901
60.00
63.00
62.00
61.00
59.00
57.00
56.00
55.80
57.48
59.62
CNF
63.50
58.00 ASSOCIATES OF NORTH CAROLINA, P.C.[phone] FAX [phone]PROJECT NO.Charlotte, North Carolina 28217NOTES:DATETITLESCALEREV. BYPREP. BYCAD FILESource: Google
Earth Pro 2013
Type II Monitoring
Well Location
LEGEND
MW-1R
MW-3
MW-4
MW-1D
MW-2
FIRE
DEPARTMENT
LAKE
LOOKOUT
66
OX
F
O
R
D

S
C
H
O
O
L

R
DRIVERBEND RDGRASS
GRASS
GRASS
GRASS
RESIDENCE
RESIDENCE
RESIDENCE
GRASS
FORMER UST
LOCATIONS
UST LOCATION
CANOPY
Groundwater
Elevation Contour
Line
Groundwater
Directional Flow
103
1. Groundwater elevationsmeasured on March 18, 2018.2. Dashed lines indicate areas ofless certainty.3. Deep aquifer well not used incontour.t__ j~N 0 C.T1 X i:: ~ (Tl ..,C.Tl (/) 0 ~ zr=-= r (Tl z "'Tl (Tl ~ •1 ..... 0 0 I I ... , / I I FIGURE 4 ---J ..,, .• / , ( •·--/4 'I --GROUNDWATER ELEVATION CONTOUR MA LAKE LOOKOUT 66 -NCDENR INCIDENT #27879 5730 OXFORD SCHOOL ROAD CLAREMONT, NORTH CAROLINA 1254067.dwg BB ~ -$-/\TC AS SHOWN 4/17 /18 SLP2787901
1,200
20 200
<0.090
DRY
CNF
1,000 ASSOCIATES OF NORTH CAROLINA, P.C.[phone] FAX [phone]PROJECT NO.Charlotte, North Carolina 28217NOTES:DATETITLESCALEREV. BYPREP. BYCAD FILESource: Google
Earth Pro 2013
Type II Monitoring
Well Location
LEGEND
MW-1R
MW-3
MW-4
MW-1D
MW-2
FIRE
DEPARTMENT
LAKE
LOOKOUT
66
OX
F
O
R
D

S
C
H
O
O
L

R
DRIVERBEND RDGRASS GRASS
GRASS
RESIDENCE
RESIDENCE
RESIDENCE
GRASS
FORMER UST
LOCATIONS
UST LOCATION
CANOPY
1. Groundwater samplescollected on March 18, 2018.2. Dashed lines indicate areas ofless certainty.3. MTBE is the only constituentdetected above 2L Standards.MTBE
Isoconcentration
Contour Line
20
j~N 0 C.T1 X i:: ~ ('Tl ..,C.Tl (/) 0 ~ zr=-= r ('Tl z "'Tl ('Tl ~ •1 ..... 0 0 / / / / FIGURE 5 MTBE ISOCONCENTRATION CONTOUR MAP LAKE LOOKOUT 66 NCDENR INCIDENT #27879 5730 OXFORD SCHOOL ROAD CLAREMONT, NORTH CAROLINA 1254067.dwg BB I -$-/\TC AS SHOWN 4/17 /18 SLP2787901
TABLE 4
MONITORING WELL CONSTRUCTION DETAILS
LAKE LOOKOUT 66
5730 Oxford School Road
Claremont, North Carolina 28610
NCDEQ Incident #27879
MW-1R 3/17/2011 31.50-51.50 2 51.50 99.85
MW-1D 6/28/2007 65-80 2 80 100.20
MW-2 6/28/2007 35-50 2 50 102.03
MW-3 6/28/2007 26.37-41.37 2 41.37 104.60
MW-4 6/28/2007 35.50-50.50 2 50.50 100.66
TOC refrenced to an arbitrary on-site benchmark
Top of Casing
ElevationWell ID Date Installed Screen Interval (feet)
Well Diameter
(inches)Total Depth (feet)