WI0300395_DEEMED FILES_20181214

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0300395
Injection Deemed In-situ Groundwater Remf!dlation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Charlotte Wastewater Collection Facility
Location Address
4100 W Tyvola Rd
Charlotte
Owner
Owner Name
Charlotte Water
Dates/Events
Orig Issue
12/10/2018
NC
App Received
11/27/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28208
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
12/14/2018
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 -Municipal
Owner Affiliation
William Deal
5100 Brookshire Blvd
Charlotte
Region
Mooresville
County
Mecklenburg
NC 28216337
Issue
12/10/2018
Effective
12/10/2018
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
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 injection)
AQUIFER TEST WELLS C1 5A NCAC 02c .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION U SA NCAC 02c .0225) or TRACER WELLS (1 5A 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 In jection 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: _____ ~ 20 PERMIT NO. , A./ 2e 3 0 0 3 "1S (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... ~ough F, K, N
___ Aquifer Test Well ....................................... Complete sections B through F, K, N
=X~_Passive Injection System ............................... CofiJVtef,t201ffiB through F, H-N
___ Small-Scale Injection Operation ...................... Comu lece sections B through N
...,, 1.!11 ....
___ Pilot Test. ............................................ ~tig ~Jhrough N
___ Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: Municipal Government
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): Mr. William Deal, P.E.. ~C=h=ar=l=ott=e~W~a=t=er~------------
Mailing Address: --~5~l~0=0~B=r=o=ok=s=hi=·r=e~B~o=ul=ev~ar=d ___________________ _
City: ---~C=h=ar=l=o=tte=----State: _NC_ Zip Code: __ ~2=8=2=1=6 ____ County: Mecklenburg
Day Tele No.: [phone] Cell No.: [phone]
EMAIL Address: wdeal@ ci.charlotte.nc.us Fax No.:
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page I
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: ---------------------------------
Company Name---------------------------------
Mailing Address:---------------------------------
City: _____________ State: __ Zip Code:, _______ County: _____ _
Day Tele No.: ____________ _ Cell No.:
EMAIL Address: _____________ _ Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ----'M=r'-'. Ie..:v_,,,a""'n----"C=o=o,.,p=e1...,·,-=P-=E=·=P-'"rm=· =c_...ip=a"'--1 __________________ _
Company Name: Civil & Environmental Consultants Inc.
Mailing Address: 1900 Center Park Drive · Suite A
City: Charlotte State: _NC_ Zip Code: 28217 County : Mecklenburg
Day Tele No.: (980 ) 237-0373 Cell No.:~(~7=04~)~2=2=6-~8-=-0~74~----------
EMAIL Address: icoo per t. .cecinc.com Fax No.: __ ....,(-=-9=80'"-')=2=-3 7~-~0=-3 7~2~---
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Charlotte Wastewater Collection Facili ty . 4100 West Tyvola Road
City: ---'C=h=ai=·l=.o=tt=e ________ County: Mecklenbure: Zip Code: 28208
(2) Geographic Coordinates: Latitude**: ___ 0 ____ ,, or 35 ° 202369
Longitude**: 0 " or -80 ° 909416
Reference Datum: ________ .Accuracy: ________ _
Method of Collection:_G~oo_0=l~e~E=arth=~------------
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ square feet
Land surface area ofinj. well network: square feet (:S 10,000 ft2 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 Permitted GW Remediation NOi Rev. 3-21-2018 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
In order to reduce MTBE concentrations. CEC will install Advanced Oxvg en Release Compound (ORC
Advanced®) socks in monitorin2: wells MW-8 and MW-12. U pon h vdration, the socks will produce a
controlled-release of oxvgen to increase the rate of aerobic biode gradation. After a period of six months. The
socks will be removed and the wells will be sampled in order to determine the effectiveness of the treatment.
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at htt p://deg.nc.eov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ ground-water-protection/ gr ound-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: Advanced Oxvg en Release Compound (ORC Advanced®)
Volume of injectant: 5 (2' long socks) in MW-8 and 5(2' lon g socks) in MW-8 {based on
approximatel y 10' of eroundwater in each well . based on g:roundwater measurements collected in
A pril of2018}.
Concentration at point of injection: =5~m=/=m=3 ____________________ _
Percent if in a mixture with other injectants: "'N=/~A~------------------
Injectant:
Volume of injectant: _____________________________ _
Concentration at point of injection:
Percent ifin 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)
(2)
Number of injection wells: _____ Proposed~-~2~-~Existing (provide GW-ls)
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
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page3
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 o£casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The ORC Advancedc socks will be placed in the wells and allowed to remain for six months before bein„2
removed.
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 OM result from the injection activity.
MTBE currently exceeds the groundwater quality standards specified in Subchapter 02L. After the OK
Advanced{+ socks are removed from the wells_ groundwater san ding will be conducted to determine the
effectiveness of the socks.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby certify, under penalty of 1 1 am familiar with the information
,submitted in this document and all attachments thereto and that, h Azyiry of those individuals
immediately responsible for obtaining .said information, I believe that the inforMWD2 is true, accurate and
complete. 1 am aware that there are significant penalties, includat ibility offines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, Te as Qna2
d if applicable, abandon the
injection well and all related appurtenances in accordance h th�uCA C 0 C 00 Rules."
Op;Z
�� 1� . ' William Deal. P.E.. Se'n PaftraitcoLManager. Charlotte Water
Signature. of Applicant Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well ❑wner/Applicantl:
"As owner of the property on which the injection wells) 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
(15 9 NCA C 02C . 0200). "
Deemed Permitted GW Rernediation NOI Rev, 3.21-2018
Page 4

"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.
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 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 GW Remediation NOI Rev. 3-21-2018 Page5
DATE: 20_
North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT (NOT) 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 15.4 NCAC ❑2C.0700 {NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS 115A NCAC 02C .02201
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
INSITUREMEDIATION USA NCAC 02C.0229 ar TRACER WELLS (15A NCAC 02C .02291:
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 (1ER) do not need to be
submitted for replacement of each sock used in ORC systems).
2) SmalI-Scale Injection Operations — Injection wells located within a land surface arca not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall he 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 ti,tll scale remcdiation 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 ar groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
81 8d
PERMIT NO. (to be filled in by £WR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(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
STATUS OF WELL OWNER: Municipal Government
WELL OWNER(S) -- State name of Business/Agency, and Name and Title of person delegated authority to
sign an behalf of the business or agency:
Name(s): Mr. William Deal, P.E.. Charlotte Water
Mailing Address: 5100 Brookshire Boulevard
City. Charlotte State: NC_ Zip Code:
28216 County: Mecklenburg
Uay Tele No.: t 704i 357- i 344 Cell No.: (9801 722.0786
EMAIL Address: [e-mail]
Fax No.:
Deemed Permitted GW Remedietion NOI Rev. 3-21-2018 Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: --------------------------------
Company Name --------------------------------
Mailing Address: ______________________________ _
City: __________ _ State: __ Zip C9de:. _______ County:. _____ _
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address:. _____________ _ Fax No.: __________ _
E. PROJECT CONTACT (Typically Environmental Engineering Finn)
Name and Title: __ ___,M=r ..... I'"""va=n~C=oo,,.,p.,,e=r,._,P._.E=,--=P ..... nn=· =c.._ip=a~l _________________ _
CompanyName:Civil & Environmental Consultants, Inc.
Mailing Address: 1900 Center Park Drive · Suite A
City: Charlotte State: _NC_ Zip Code: 28217 County: Mecklenburg
Day Tele No.: [phone] Cell No.:_J(L..!.7.,,_04.,_.)""'2""'26,._-=80"""7'-'4 _________ _
EMAIL Address: icooper@ cecinc.com Fax No.: __ ...1.C9~8"""0'-")2""3'-'-7--"-0""'3.,_.72=-----
F. PHYSICAL LOCATION OF WELL SITE
(I) Facility Name & Address: Charlotte Wastewater Collection Facility. 4100 West Tyvola Road
City: __ _,,C=h=ar=l=otte"""-________ County: Mecklenburn Zip Code: 28208
(2) Geographic Coordinates: Latitude"'*: ___ 0 ____ ,, or 35 ° 202369
Longitude**: 0 __ ,, or -80 ° 909416
Reference Datum: _________ Accuracy: _______ _
Method of Collection:.----'G,,,_0""0""11.""'le"'-E=at..,,th"--------------
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume:. ______ square feet
Land surface area ofinj. well network: square feet (S 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be ~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contatninant 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. 3-21-2018 Page2
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.
In order to reduce MTBE concentrations. CEC will install Advanced Oxygen Release Compound (ORC
Advanced®) socks in monitoring wells MW-8 and MW-12. Upon hydration, the socks will produce a
controlled-release of oxygen to increase the rate of aerobic biodegradation. After a period of six months. The
socks will be removed and the wells will be sampled in order to determine the effectiveness of the treatment.
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-
resourceslwater-resources-peimits/wastewater~branch/l!round-'ivater-protection/irround~water-a pproved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
801-6496).
Injectant: Advanced Oxygen Release Compound (ORC Advanced®)
Volume ofinjectant: 5 (2' long socks) in MW-8 and 5(2' long socks) in MW-8 (based on
approximately 1 O' of groundwater in each well. based on groundwater measurements collected in
A,pril of2018).
Concentration at point of injection: .. s ..... m.._g_,,/=n "--13 ___________________ _
Percent if in a mixture with other injectants:N """"'/A'-"--------------------
Injectant: --------------------------------
Volume ofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in & mixture with other injectants: ___________________ _
lnjectant:
Volumeofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(I) Number of injection wells: _____ .Proposed~-~2'--__ E.xisting (provide GW-ls)
(2) 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
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page3
multiple wells with the same construction details. Wei] 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
L. SCHEDULES -- Briefly describe the schedule for well construction and injection activities.
The ORC Advanced® socks will be placed in the wells and allowed to remain for six months before being
removed.
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.
MTBE currently exceeds the groundwater quality standards specified in Subchapter 02L. After the ORC
Advanced® socks are removed from the wells. groundwater sampling will be conducted to determine the
effectiveness of the socks.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "1 hereby cert fir, under penalty of law, that 1 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, 1 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. 'agree ee to construct, operate. maintain, repair, and if applicable, abandon the
injection weII and all related appurtenances in accordance with the 154 NCAC 02C 0200 Rules."
William Deal. P.E... Senior Project Manager Charlotte Water
Signature of Applicant Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicantl:
"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
{1 SA NCA.0 02C .0200)."
Deemed Permitted GW Remediation NO1 Rev. 3-21-2018
Page 4

"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.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*.4n access agreement between the applicant and property o1vner may be submitted in lieu of a signature on 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 — WC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
slp2784 04,0%0N
Deemed Permitted GIN Remediation NOI Rev. 3-21-2018 Page 5

REFERENCE
1. AERIAL IMAGERY TAKEN FROM GOGGLE EARTH PRO. IMAGE
DATED NOVEMBER 7, 2017
MW-2
(APJ NDONEO)
MW-7
57.54
LEGEND
APPROXIMATE LOCATION OF
GROUNDWATER MONITORING
WELL
66.56 WATER LEVEL ELEVATION
GROUNDWATER p0TENIIOMErRfC
CONTOUR (0CT09ER 2017)
GROUNDWATER FLOW DIRECTION
SCALE IN T-EET
0
6C 12O
Civil & Environmental Consultants, Inc.
5900 CoNor Park Ofko - Sure A - CMrrotte. NC 20217
Ph: 060227.0372 • Far 1220.237.0372
vAvAceclnc.00m
DRAWN BYJKS CI•IECIED RV: DRAFT APPROVED BY. DRAFT FIGURE NO..
DATE: NOVEEMBER 2D17 DWG SCAB: 1 • = BO' PROJECT NO: 171-8E3
CHARLOTTE WATER WASTEWATER COLLECTION FACILITY
4100 WEST TYVOLA ROAD
CHARLOTTE, NORTH CAROLINA
GROUNDWATER POTENTIOMETRIC MAP
2

1.
REFERENCE
7. AERIAL IMAGERY TAKEN FROM GOGGLE EARTH PRO- IMAGE
DATED NOVEMBER 7, 2017
DRAWN BY
Civil & Environmental Consultants, Inc.
1900 Geller Park Drive - Suke A - Charlotte. NC 25217
Ph: 960237.0378 - FAx 9E10.237.0372
www-oacrAc.cor0
JKS CHECKED BY:
DATE; NOVEMBER 2017 DWG SCALE:
64
LEGEND
• APPROXIMATE LOCATION OF
GROUNDWATER MONITORING
WELL
(446) MTBE CONCENTRATION
MTBE CONCENTRATION 100 uq/L
MIKE CONCENTRATION 200 ug/L
MTBE CONCENTITATlON 300 uq/L
MTBE CONCENTRATION 400 u0/L
66.58 WATER LEVEL ELEVATION
GROUNDWATER POTENTIOMEIRMC
CONTOUR (OCTOBER 2017)
- GROUNDWATER FLOW DIRECTION
SCALE IN FEET
0 30 SD
CHARLOTTE WATER WASTEWATER COLLECTION FACIUTY
4100 WEST TYVOLA ROAD
CHARLOTTE, NORTH CAROLINA
DRAFT APPROVED BY:
1' = 30' PROJECT NO:
MTBE SHALLOW PLUME
DRAFT' RGUIIE NO.:
171-B63
3

REFERENCE
1. AERIAL IMAGERY TAKEN FROM GOGGLE EARTH PRO. IMAGE
DATED NOVEMBER 7, 2017
Civil & Environmental Consultants, Inc.
10O41 Carder F i DrNe - Suite A - Charlotte. NC 20217
Ph: 000297A979 • Fair; 000.237.0372
www.amine corn
DRAWN BY: JKS CHECKED BY:
R4
-
LEGEND
. APPROXIMATE LOCATION OF
GROUNDWATER MONITORING
WELL
(4.2) MTBE CONCENTRATION
1,6113E CONCENTRATION 1 ug/L
MTBE CONCENTRATION 2 ug/L
MTBE CONCENTRATION 3 ug/L
MTBE CONCENTRATION 4 ug/L
BS.50 WATER LEVEL ELEVATION
GROUNDWATER POTENT10METRIC
CONTOUR (OCTOBER 2017)
,411r-.- GROUNDWATER FLOW DIRECTION
SCALE IN FEET
0 30 60
CHARLOTTE WATER WASTEWATER COLLECTION FACILITY
4100 WEST TNOLA ROAD
CHARLOTTE, NORTH CAROUNA
MTBE DEEP PLUME
DRAFT APPRp11ED BY; DRAFT .FIGURE No.:
DATE NOVEM$ER 2017 DWG SCALE:
1' = 30' PROJECT NO: 171-963
4

4 REGENESIS SAFETY DATA SHEET
Technology -Based Solurionsfor the Environment
1. Identification
Product identifier
Other means of identification
Recommended use
Recommended restrictions
Oxygen Release Compound Advanced (ORC Advanced®)
None.
Soil 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)
3. Composition/information
Mixtures
Chemical name
Regenesis
1011 Calle 5ambra
San Clemente, CA 92673
949-366-8000
Custom [e-mail]
CltEMTREC''at 1-800-424-9300 (International)
Oxidizing solids
Skin corrosion/irritation
Serious eye damage/eye irritation
Not classified.
Category 2
Category 1
Category 1
Danger
May Intensify Fire; oxidizer. Causes skin irritation. Causes serious eye damage.
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.
Ilan 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.
on ingredients
Caicium hydroxide oxide
Calcium hydroxide
CAS number
a�e
682334-66-3 ?85
1305-62-0 s15
Dipotassium Phosphate
7758-11-4 <5
Monopotassium Phosphate
Composition comments
7778-77-0 <5
All concentrations are in percent by weight unless otherwise indicated.
Oxygen Release Compound Advanced (ORC Advanced')
925597 Version #:01 Revision date; - issue date:02-April-2015
545U5
1/8

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
dust/fume 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 SDS.
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 10 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 (CAS
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
sos us
3/8
Odor 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
physical, chemical and
toxicological characteristics
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.
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
Calcium hydroxide (CAS 1305-62-0)
Acute
Oral
LD50 Rat
Skin corrosion/irritation
Serious eye damage/eye
irritation
Causes skin irritation.
Causes serious eye damage.
Not a respiratory sensitizer.
Test Results
7340 mg/kg
Respiratory or skin sensitization
Respiratory sensitization
Skin sensitization This product is not expected to cause skin sensitization.
Germ cell mutagenicity 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
Persistence and degradability
Bioaccumulative potential
Mobility in soil
Other adverse effects
LC50 Zambezi barbel (Clarias gariepinus) 33.8844 mg/I, 96 hours
Decomposes in the presence of water. The product contains inorganic compounds which are not
biodegradable.
The product does not contain any substances expected to be bioaccumulating.
This substance has very low solubility in water and low mobility in the environment.
None known.
13. Disposal considerations
Disposal instructions
Local disposal regulations
Hazardous waste code
Waste from residues / unused
products
Contaminated packaging
14. Transport information
DOT
UN number
UN proper shipping name
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.
UN1479
Oxidizing solid, n.o.s. (Calcium hydroxide oxide)
Oxygen Release Compound Advanced (ORC Advanced®) SDSUS
5/8 925597 Version#: 01 Revision date: -Issue date: 02-April-2015
Transport hazard class(es)
Class
Subsidiary risk
5 .1
Label(s) 5 .1
Packing group II
Environmental hazards
Marine pollutant No
Special precautions for user Read safety instructions, SOS and emergency procedures before handling.
Special provisions 62, 188 , 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 5L
Special precautions for user Read safety instructions, SOS 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, SOS 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
(SOWA)
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 (CAS 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 Safe 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 (yes/nor
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 (ELINCS) 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 this 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-20t5
SUS US
7 I 8

Disclaimer Regenesis cannot anticipate all conditions under which this information and its product, or the
products of other manufacturers in combination with its product, may be used. It is the user's
responsibility to ensure safe conditions for handling, storage and disposal of the product, and to
assume liability for loss , injury, damage or expense due to improper use . The information in the
sheet was written based on the best knowledge and experience currently available .
Oxygen Release Compound Advanced (ORC Advanced®) sos us
8/8 925597 Version #: 01 Revision date : -Issue date: 02-April-2015
MWID Well Depth
MW-IA 140
MW-4A 114
MW-5 54.50
MW-6 49.50
MW-7 49.50
MW-8 50
MW-9 50
MW-10 50
MW-11 50
MW-12 50
MW-12D 140
Notes:
MW=Monitoring Well
TPC= Top-of-Well Casing
WT= Water Table
bgs= Below ground surface
NM= Not measured
NIA= Not applicable
Table 2
Summary of Water Level Gauging Data
Charlotte Wastewater Collection Facility
CEC Project No. 171-863
October, 2017
Screen Aug. 2017
Interval TOCEiev. Depth to Aug. 2017
Water WT Elev. (ft bgs) (TOC)
75-140 102.63 48.42 54.21
64-114 103.80 37.49 66.31
39-54 105.41 40.45 64 .96
34-49 99.40 37 .97 61.43
34-49 98 .92 40.69 58.23
35-50 102.50 40.82 61.68
35-50 99.49 39.76 59.73
35-50 103.95 37.31 66.64
30-50 NM 42.22 NM
40-50 98.02 NIA NIA
100-140 98.10 NIA NIA
Oct. 2017
Depth to Oct. 2017
Water WT Elev.
(TOC)
49.35 53.28
37.24 66.56
40.65 64.76
NM NM
41.38 57.54
41.20 61.30
40.20 59.29
37.26 66.69
42.85 NM
40.00 58.02
46.38 51.72
1. Well Cpnn,-actor Information:
Robert C assell i4. WAtmii()JilES
Well Contractor Name FROM Tff D11SCRIPTION
4143-A ti. ft.
ft. ft.
NC W.:11 Contractor Cortificatie>n Number 1S. OUTER C ASING' (for lilllht~edwelfs) .OR_LINER (lfappllca,bkj)
Summit Companies FROM L.TO .. ·I D~ I TIOC'-Nl::SS I MAll'RIAL
ft. ft. in.
C-0mpany Name 16. INNER CA$iNGOll. TUBiNG ll!Cnl~amal dnsed,,loo o)
2. Well Construction Penili.t #: FROM TO · · DW\IETE.11.. · TlllCl>'NES$ MATERJAL
List all .:,pplicab!t!we/1 constn,i:tion permits (h. UIC; Cminl){ Store; V,,rfollC<t, etc.) 0 n. 40 ft. 2 in. .040 PVC
3. Well Use (check well use): ft. fL tn:
Water Supply Well: . [7:SCRttN
fRO~I ·TO .DIAMETER SLOT SIZE THICKNESS IL\lERIAL
:}AgriculWml □Municipal/Public 40 ft, 50 . ft. 2 in. ,10 .o~o PVC
Q Oeothamal (Heatin!!/'Coolil\g Supply) □Residential Water: Supply (sing!.:) ft. (t. In.
~ lnd11$al/Commercial t]nesid.:ntial Wata Supply (shared) tii..GR.Otft
_ Irri !!alion FROllf TO '1'11ATERL\L EMPLACEMENT METHOD & AMOUNT
Non-Water Supply Wdl: 0 ft. 36 ft.; pc:,rtlandlbent. tremmi
it Monitoring n ~ecovery 36 ft. 38 ft. ·oentseal pour down borehole
lnjettii!n Well: ft. ft. DAqwfer: Recharge 0Groundwnter Remadiation
1!>. SANOIG~VELl'ACI<; lif •1>11licabl"'i
t)AituiferStorage and Recovery' IJSailnjty Barrier FROM TO lllATERIAL . EMPLACEMENT METHOD
;JAquifer Test Ostorru\\'uter Drainage 38 it. 50 n. #2well sand pour down borehole
□ E."!:perimental Technology □subsidence Control n. n.
Oeo~enual (Closed Loop) OT.racer 2.11. Dtm.i:lNG LOG i irt:b'l'!t additionalsheets. 11'.necessarv'i
7~othennal (Healing/Cooling Return) nolher (ex-pWuunder#21 Rem.arks) FROM TO J1 ~SCRrPTION {color, i.,,r,1.,..._ mil/rock"'"· .,,.in,w. dlc.l
0 n. IL stiff brown and t9n fine to med si sa (PWR)
4. Date Well(ll) Completed: 9-29-17 Well ID# MW-12 ft. 50 ft.
5a. Well Location: ft. ft.
Charlotte Water/City of Charlotte n. ft.
Facility/Owner Name Facility 1Pw (if ~pplicabl.i) ft. ft.
4100 w. Tyvola rd. Charlotte, 28208 ft. ft.
Phy,,ical AddJ:ass, City, ond Zip fL ft.
Mecklenburg :U.-R.EMARKS
eotiniy Pm;,! Identi1foaiiM No. {PIN)
5b. Latitude and longitude in degreeslmbtui:es/seconds !>r decimal degrees:
(i£wcU field. one larJloog is ,;ufficient} 22,CCl't!~
N \V ~/_ ~ 9-io -)""1--~ ~ ,,. I ::-...
6. Is(a.-e) the well(s) ~-Pcnnanent or [J Temporary /'
7. Is this a repair to an msling well: CY es or m)No
Jfthis i:t Q repair.fin out known ,i:elfronstniction information and explain tl,e nafllrt of1h11
r~p;nr muilir#21 reninrlcs set:tinn i:!r ii,i /11eback clfthfsform. ·
8. For Geoprobe/DPT or 00$Cd-l,oop Gt:0~nnal Well$ ha,:ing the saine
constmction, only 1 GW-l is n~~-liidicate TOTAL Nlll.IBER of\.\e.lls
Signature ofC!!ltifi~ Well Cl>nlracf.!lr c7' Date
By sig,ring tlr/$ form. I hereby c,,rtijj• that 1ha well(!;;) was (i,-ere) consrrw>led i11 .:11:cordane4
with JSA NCAO Oz<J .0100 or 15A NCAC 01C .0100 Well Constntcrinn SrMdards ""d that a
copy i,f llal$ /1'COrd /JQS basn provided to the k;ell o .. ni,r.
23. Site diagram 61' additional well details:
You may usa the back of this page to jli-ovi<le a.ddi1ioJ1a! well site details or \I.ell
tonsb'llctiori de~. You may also attach additional pages ifnecessazy.
drilled:___________ SUBMITTAL INSTRUCTIONS
9, Total well depth below lands~~: _S_O.,..· .. '_· _____ ..,_ _____ (ft.) 24a:. For All Wells: Submit this form within 30 days of completion of well
For 11mlttple K¥11s lis.t al.l depth$ //'different (exampie-oS@20D' and 2@1®') con.truction to the following:
10. Static wa~1· level .below t11p nf ~sing: ___________ (ft.) Dhislon of Water Resources, lnfonnatiOJ1 Processing :Unit,
I/water fe,..elisabow,casing,11se ·•·~'" i617 l\>lall Senic'e.Cent~; Ral. NC 27699-1617
8" 11. Boreholedian)eter: ______ (In.) 24b. For Infection Wells: In addition to S<.'llding the forin to the addrass in 24a
·4 2·511 H·s /1. ~~l)V~, aJso S\!~~!_it 0~ CQpy (?fthis form within ;JO da~ of~.· inp!e~~ 9f w!el ,I 12. Well .co--.·...,· .. on. method: · · · ·. · ... I'\ · · · · •-• -•• c911strilctipn to the following:
(i.e. auger. rotary, cable. difecl pmh. ~c.)
FOR.WATER SllPPLY \\.'ELLS ONLY:
Division orWater ~esou~, Undergrow1dlnJectlon Co.J1tml Program,
i .63& Mail Set.-rice Center, Raleigh, NC 27699-1636
13a. Yidd (gpm) ------"---l\fethod oftest:________ 24c. For Water Supply &.In jection Wells: In addition to sen<ling the fomi to
the address{ci) above, also subinit one copy of this fonn within 30 days of
L1::,3::b.:.::Dls=in:fi=ec=ti::on::·.::ty~pe=··:.:= ======~=A=mo=wtt::·::=========-l completion of \Wll ~ction to the ~ounty health department of the cow1ty
""hr:r~ r.nnstmr.tf'.rl
,---·