WI0300414_DEEMED FILES_20190619

Permit Number WI0300414
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Pennitted Flow
Facility
Facility Name
Tom SAwyer's Arlington Park
Location Address
1205 Martin Luther King Jr Dr
Greensboro
Owner
Owner Name
Ncdeq State -Lead Program
Dates/Events
NC
Orig Issue
6/19/2019
App Received
6/12/2019
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27406
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
6/19/2019
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
Sharon Ghiold
1637 Mail Service Ctr
Raleigh
Region
Mooresville
County
Mecklenburg
NC 27699
Issue
6/19/2019
Effective
6/19/2019
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
DATE: June 10 , 20_19
A.
B.
C.
North Carolina Department of Environmental Quality —Division of Water Resoxigel s z019
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELkfterQualltf
fip tastes o�
The following are "permitted by rule" and do not require an individual permit when constructed in Zcordance
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 (ISA 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 sail 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.
W.L 300`H 9-
PERMIT NO. a (to be filled in by DWR)
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) X Air Injection Well Complete sections B through F, K, N
(2) Aquifer Test Well .Complete sections B through F, K, N
(3) Passive Injection System Complete sections S 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 on behalf of the business or agency;
Name(s): NCDEQ — State Lead Pro Aram
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27699 County: Wake
Day Tele No.: 9 1 9-7 07-8 I 66
Cell No.: Not Available
EMAIL Address: sharon.eltioldrCencdenr.gov
Deemed Permitted GW Remcdiatian NO1 Rev. 8-28-2017
Fax No.: Not Available
Page 1

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: __ __,Z=a=f:=a=ir~C=h=o~u=d=h-'---rv~-----------------
Company Name _______________________ _
Mailing Address: --~1~2~0~5_ML __ K~J=r~. D_ri~v_e ___________________ _
City: Greensboro State:~ Zip Code:-=2-'--74-'----'0"----'6'-___ County: Guilford
Day Tele No.: 336-420-2878 Cell No.: Not Available
EMAIL Address:-"'N--'-'o=tc.a.A""'v"-'a=il=a=b=le'-----------Fax.No.: Not Available
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ E_r_i_n ~G~r_e _en_e~._P_ro....,j_ec_t_M_an_a~g~e_r __________________ _
Company Name ---"---'A,..,,Tc..=C"---'A"--=ss=o=c=ia=te=s"----o=f,__,N'---'-=ort'--"h""---"C=ar=o=l=in=a,,_. -"---P-'--'.C=.'----------------
Mailing Address: __ __,7--=6=0"""'6_W'-'-=h=it=eh=al=l,__,E=x=e=c=u=ti"-v-"---e ~C'"""e=nt=ec=..r -=D'"""r-"---iv~ec.,.., -=S-=u=ite~8..:.0 ..c...0 ___________ _
City: Charlotte State: _NC_Zip Code:~28=2~7=3 ____ County: Mecklenburg
Day Tele No.: 704-529-3200 Cell No.: __________ _
EMAIL Address: ___ e=r=in=· .... e:r=--e~e=ne=®-=a=tc..._g~s.=c~om~---Fax No.: --~70~4~-5~2~9~-3~2~72~---
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Tom Sawyer's Arlington Park
1205 Martin Luther King Jr. Drive
City: --~G=r=e=en=s=b..:.or=o'-_______ County: Guilford Zip Code: ---=2-'--74-'--0=6'--
(2) Geographic Coordinates: Latitude**: ___ 0 __ __" or 36.056096 °. _____ _
Longitude**: a "or -79.784213 ° ------
Reference Datum:. ________ .Accuracy: _______ _
Method of Collection:_G~o-"---o=--□=l~e -=E=a=rt=h--'-----------­
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COO RD INA TES.
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.
(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 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.
NIA
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 hll p://deq.nc.Q.ov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more irifo (919-
807-6496).
Injectant: --~N~/~A~----------------------------
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 ___ l ___ Existing (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
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
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
The air-s parf!.e enhanced MMPE event is schedule for Jul v 1-5 .2019.
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.
A com prehensive gr oundwater sam plin g event is schedule for August 1. 2019.
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 3
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto andthat, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. "
t~t ~ On behalf ofNCDEO Erin E. Greene. on behalf ofNCDEO
Signature of Applicant Print or Type Full Name and Title
PROPERTY OWNER (i f the pro pe rty is not owned b y the permit a pp licant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(.15A NCAC 02C .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached access a greement
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Please send this NOi electronically to Shristi.Shrestha @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 Page4
CONCRETE SURFACE
LOCKABLE PVC CAP —�
8—INCH DIA. BOREHOLE
6—INCH DIA. STEEL OUTER CASING
GROUT
2—INCH DIA. SCHEDULE 40 PVC PIPE —
4
i
0
40
IMO
BENTONITE SEAL u Pt
4—INCH DIA. BOREHOLE
SAND PACK —'
2—INCH DIA. SCHEDULE 40 PVC SCREEN
(0,010 INCH SLOTS)
CAP
INSTALLATION DATE 7/12/02
COVER ASSEMBLY WITH
REMOVABLE STEEL COVER
DEPTH TO
BASE OF
OUTER CASING
32 FT.
DEPTH TO
BASE OF
GROUT
33 FT.
SCREENED
INTERVAL
38 — 48 FT
DEPTH TO
TOP OF
SAND
36 FT,
TOTAL DEPTH
OF WELL
48 FT.
TOTAL DEPTH
OF BOREHOLE
48 FT.
AENGINEERING AND ENVIRONMENTAL SERVICES, INC.
GREENSBORO. NORTH CAROLINA
LAW
GROUNDWATER MONITORING WELL
INSTALLATION RECORD
TWA SAWYER'S ARLINGTON PARK
GREENSBORO, NORTH CAROLINA
NOTE: ALL PVC JOINTS ARE FLUSH THREADED.
JOB NO.
30440-1--0651 FIGURE MW-5

Mrs. Sharon Ghiold
DWM UST Section
1646 Mail Service Ctr
Raleigh, NC 27699-1646
Dear Mrs. Ghiold:
RE: Site Access Agreement
Tom Sawyer's Arlington Park
1205 Martin Luther King Jr. Drive
Greensboro, Guilford County, NC (WSRO)
STF # 24155, Facility ID 0-013194
Risk/Rank: Intermediate, 1110D
I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby permit the Department of Environmental Quality (Department) or its contractor to enter
upon said property for the purpose of conducting an investigation of the grow1dwaters under the
authority of G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the sun-ounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.
6. The activities to be carried out by the Department or its contractor are for the primary benefit of
the Depatiment and of the State of North Carolina. Any benefits accruing to the owner are
incidental. The Department or its contractor is not and shall not be construed to be an agent,
employee, or contractor of the land owner.
Tom Sawyer's Arlington Park, Incident # 24155
February 7, 2018
Page 2
1/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
1
Signati
41 Ul?,/,12/64./
Type/Print Name of Owner or Agent
Phone Number
r?e• t-//» R
Address
City/State/Zip Code
4
Date
Email

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NOTES:
1. GROUNDWATER SAMPLES FOR WELLS MW-2, MW-3,
MW-4, AND MW-5 COLLECTED ON JULY 2 AND 3,
2015.
2. GROUNDWATER SAMPLES FOR WELLS MW-1 AND
RW-1 COLLECTED ON APRIL 29. 2019.
3. BOLD VALUES EXCEEDED THE 2L STANDARD; BOLD
AND ITALICIZED VALUES EXCEEDED THE GCL.
4. CONTOURS REPRESENT INFERRED BENZENE PLUME
IN THE OVERBURDEN AQUIFER.
5. NS = NOT SAMPLED
TITLE FIGURE 6
BENZENE ISOCONCENTRATION MAP
TOM SAWYER'S ARLINGTON PARK - NCH() INCIDENT NO. 24155
1205 MARTIN LUTHER KING JR DRIVE
GREENSBORO, NORTH CAROLINA
ATC
Charlotte, North Carolina 28273
[phone] FAX [phone]
CAD FILE
TYPE CODE
PREP. BY
AD
REV. BY
EG
SCALE
AS SHOWN
DATE
5.13.19
PROJECT NO.
SLP24155D5