WI0400391_DEEMED FILES_20150608

)_ \ ~
~Ro gers, Michael
From: JeffGerlock ·<jeff.gerlock@gmaiLcon,>
Monday, June 08, 2015 1 :54 PM
Rogers, Michael
Sent:
To:
Cc: Heery, Jim; Jim Heery
Subject: Re: WI0400391 NOi -RE: Request for Approval of Small-Scale Injection Operation -Fiber
Dynamics, High Point, NC
Attachments: Fiber-injection report-2015.pdf
Mike, we performed the remediation injection activities at the site from May 18 to 20, 2015. attached is a brief
report including the well construction / abandonment records. please let me know if you have any questions or
if you need additional information. thanks!
Note -please respond to this email to let me know that you received it and the report.
On Tue, Apr 14, 2015 at 2:07 PM, Rogers, Michael <michael.ro ir ers (a),ncdenr.2.ov> wrote:
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) at the Fiber Dynamics
Facility. This facility is located at 200 South West Point Ave., High Point, Guilford County, NC 27261. We received your
complete NOi on April 13, 2015. Please remember to submit the following regarding this injection activity:
1) Well Construction Records {GW-1} and Abandonment Records (GW-30) when completed. Please provide
copies of the GW-ls and GW-30s if not already submitted (originals go the address printed on the
form). NOTE: Direct push or Geoprobe wells are considered wells and require construction (GW-l)·and
abandonment forms (GW-30). If well construction/abandonment information is the same for the wells, only one
form needs to be completed-just indicate total number of injection points in the Comments/Remarks section of
form. These forms can be found on our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.rogers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit numberWI0400391. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re p ly to this email. as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
1
Michael Rogers, P.G. (NC & FL)
Hydrogeologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Monday, April 13, 2015 1:16 PM
To: Rogers, Michael
Cc: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
here is a summary table to help show you the information. let me know if you need anything else.
On Mon, Apr 13, 2015 at 11:49 AM, Jeff Gerlock <ieff.2.erlock(@g mail.com> wrote:
Good morning Mike; hope you had a nice weekend. just wanted to check in with you on your email request for
info on the proposed injection at Fiber Dynamics in High Point. the information requested in your email on
April 1st is included in our application (page 3).
Geoprobe borings will be drilled to auger refusal/ top of rock expected at 11 to 21 feet and then HRC will
be injected through the rods from the bottom of each boring to the water surface. intervals are shown in the
application. we will use the recommended 6 lbs per foot of HRC at each borehole. there is no water added to
the HRC. a schematic of the geoprobe locations/ areas and depths is shown on the cross section attached to the
application. we may also inject 3-D ME into the bottom 10 foot of well DW-1 at a rate of2.4 gallons per foot
2
or 24 gal / 200 lbs total of material at a 10 % dilution rate therefore we will mix the 3D ME with 240 gallons of
water. MSDS forms for the two chemicals are attached. let me know if you need me to prepare a table, figure,
or provide other information for t11e_proposed work at the site.
On Wed, Apr 1, 2015 at 3:15 PM, Rogers, Michael <michael.ro gers @ncdenr.gov> wrote:
Would you please provide a total estimated average on the total amount of injectant plus chase water you are going to
inject at each proposed Geoprobe (in gallons}, and at DW-1.
Additionally, would you proved a schematic of proposed Geoprobe with total depth. We realize this is proposed and
actual depth will vary a little at each point.
Thanks
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Monday, March 30, 2015 12:56 PM
To: Rogers, Michael
Cc: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
I understand -we were not planning to do the work for about a month or so. just wanted to make sure you have
all the paperwork and answers you need to process.
On Mon. Mar 30. 2015 at 12:54 PM, Rogers, Michael <michael.ro uers(w,ncdenr.gov> wrote:
NO, not yet. We need to review and process, enter project into our system, and forward a copy to the regional office for
their review. That's why we require a 2-week notice before injection activities.
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Monday, March 30, 2015 10:14 AM
To: Slusser, Thomas; Rogers, Mike; Rogers, Michael
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
3
sounds good. so is everything complete and all look fine to order the materials and proceed with our pilot test?
On Mon, Mar 30, 2015 at 10:08 AM, Slusser, Thomas <thomas.slusser/a),ncdem.izov> wrote:
Greetings Jeff,
Thanks for the submittal. Mike Rogers, copied on this email, will be your project contact for this one.
Take care,
-Thomas Slusser, L.G.
Underground Injection Control Program Manager
thomas.slusser@ncdenr.g ov I ph# 919-807-6412 I fax# [phone]
Mailing Address: NCDENR Division of Water Resources I 1636 Mail Service Center I Raleigh, NC 27699-1636.
Physical Address: Room 640M, Archdale Building, 512 N. Salisbury St., Raleigh, NC 27604.
Internet Address: http://portal.ncdenr.org/web/wq/ap s/gw 9 ro
E-mail correspondence tn and from this address may be subject tn the lvnrth Carolina Public Records Law and may be disclosed tn third parties unless the content is
exempt by statute or other regulation.
From: Jeff Gerlock [mailto:i [e-mail]]
Sent: Friday, March 27, 2015 5:42 PM
To: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
Good afternoon Thomas. hope you are having a good Friday. attached is our revised NOI for injection at the
site. please review and call if you have any questions and/or if you need any clarification or other
infonnation. thanks.
4
Note -please respond to let me know that you received this email and the attachments.
On Thu, Mar 12, 2015 at 1:56 PM, Slusser, Thomas <thomas.slussert@ ncdenr.gov> wrote:
Thanks Jeff for the update. Let me know if you have any questions for me as you move forward with this.
Take care,
-Thomas Slusser, LG.
Underground Injection Control Program Manager
[e-mail] I ph# 919-807-6412 I fax# [phone]
Mailing Address: NCDENR Division of Water Resources I 1636 Mail Service Center I Raleigh, NC 27699-1636.
Physical Address: Room 640M, Archdale Building, 512 N. Salisbury St., Raleigh, NC 27604.
Internet Address: http:llp ortal.ncdenr.orglweblwqla pslgwpro
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties unless the content is
exempt by statute or other regulation.
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Thursday, March 12, 2015 11:16 AM
To: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
sorry I forgot to get back with you on this matter. I have recently revised our remediation plan and injection
strategy after further discussions with my supplier. I will make the change you suggested and our changes and
resubmit the plan this week. thanks for your follow up!
On Tue, Mar 3, 2015 at 12:52 PM, Slusser, Thomas <thomas.slusser _ ncdenr.12ov> wrote:
Greetings Jeff,
I have not yet received the revised NOI for this project. Have you submitted it yet?
5
Thanks,
-Thomas Slusser, L.G.
Underground Injection Control Program Manager
thomas.slusser@ncdenr.g ov I ph# 919-807-6412 I fa x# 91 9-80 7-6496
Mailing Address: NCDENR Divisio n of Water Resources I 1636 Mail Service Center I Raleigh, NC 27699-1636.
Physical Address: Room 640M, Archdale Building, 512 N . Salisbury St., Raleigh, NC 27604 .
Internet Address: http://portal.ncdenr.org/web/wq/aps/gwpro
E-mail correspof7def7ce to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to thi,•d parties unless the content is
exempt by statute or other regulation.
From: Slusser, Thomas
Sent: Tuesday, February 17, 2015 1:40 PM
To: Jeff Gerlock
Subject: RE: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
Greetings Jeff,
I looked at the submittal and everything looks good, but I did not see a table or diagram of well construction information
as asked for in Part K(2). Otherwise, everything is fine.
Thank you,
~ Thomas Slusser, L.G.
Underground Injection Control Program Manager
NC Division of Water Resources
ph# 919-807-6412
http: //porta I. ncdenr .org/web/wq/a ps/gwpro
1636 Mail Service Center
Raleigh, NC 27699-1636
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be
disclosed to third parties.
6
From: Jeff Gerlock [[e-mail]]
Sent: Monday, February 16, 2015 5:10 PM
To: Slusser, Thomas
Subject: Request for Approval of Small-Scale Injection Operation -Fioer Dyhamics, High Point, NC
Thomas, per our conversation this morning attached is our application/ NOI for the project. please review and
let me know if we need to modify or include additional information. thanks for your help.
Note -please respond to let me know that you received it.
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, NC 27263
336-431-5454 office phone and fax
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridgegeo.com
Jeff Gerlock
Blue Ridge Geological Services
7
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridgegeo.com
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridge geo.com
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridgegeo.com
8
... , .:,··,.~·· ..
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridge geo.com
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336~431-5454 office phone and fax
www.blueridgegeo.com
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridge geo.com
9
June 8, 2015
Mr. Michael Rogers
NCDENR
Division of Water Resources-Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Subject: Injection Well Construction/ Abandonment Information
Fiber Dynamics, Inc.
200 South West Point Avenue
High Point, Guilford County, North Carolina
NCDENR Permit #WI0400391
NCDENR Site ID#NON CD 0002854
Dear Mr. Rogers:
As authorized, Blue Ridge Geological Services, Inc. (Blue Ridge) and its subcontracted driller performed
remediation activities at the subject site in 2015. On May 18 and 19, 2015 we drilled 19 borings around
monitoring wells MW-3, MW-4, MW-5, MW-6, and MW-7 using a Geoprobe and then injected
remediation media into the borings through the hollow drill rods. A map showing the boring/ injection
point locations is attached . A total of 1,380 gallons of Hydrogen Release Compound (HRC) was injected
into the borings / injection points; a table summarizing the information on each injection point is attached.
No water was mixed with the HRC. The temporary wells / injection points were abandoned immediately
following injection activities; the top of each boring was filled with bentonite pellets/chips to seal the
injection point. Copies of the well construction/ abandonment records are attached. On May 20, 2015
we injected media into deep well DW-1 using a tremie pipe. Approximately 180 gallons of water mixed
with 20 gallons of 3-D MicroEmulsion (3-DME) was injected/ gravity fed into well DW-1.
Please contact the undersigned if you have any questions and / or if you need any additional information.
Sincerely,
/' ;,,,
( 1 .. 11 -?✓ /l . I / '--.. .-J~,1-£.,1 L~'x. ·· ./ t!·~L,L-"' .. _,L_ ff(i~) ·-··
Jeffrey L. Gerlock, L.G.
NC Licensed Geologist # 1141
Attachments-Figure, summary table of injection points, construction/ abandonment records
cc: Mr. Jim Heery, Fiber Dynamics
Ms. Sharon Cihak, GCDPH
306 Eden Terrace, Suite C, Archdale, NC 27263 * Phone/Fax: [phone]
,Gate
Sludge
Rollofl Area
(tinder canopy)
0.7
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Asphalt
Parking Lot
I W 3-:
w s.4
Q I
Itvs-Q 0 •MW-5
V s.3
NE Corner of
Building - Basement MW-6
eend:
• Groundwater Monitoring Well
D.7 Tetrachloroethene (PCE) in Groundwater (micrograms per liter) in 2014
Groundwater Flow Direction
IW3-4 0 Temporary Injection Well / Point - May 2015
REF.: Surge} 6} Triad Land Surveying Dated Jul) 2009 amended Nov 2012,
N
N
ND-
Iwo-1 .MW-4
`01W4-2
DW- 1
IW6-3
iW6-4
IW6-2
i
0.7
Gravel
Parking Lot
N
1W3-] \
IW3-. 0. DW-2 \' N N.
nv3.20 • MV} -3
I143-4 D I
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IW3-3 / WP 0
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r
MW-2
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/
N
I
11
MW-9
•
MW-10
•
c—I Residence
1
Ennis Street
Scale: 1 inch = 50 feet
Site Plan
Fiber Dynamics
200 South West Point Avenue
High Point,North Carolina
June 2015
Figure 1
a

Table 1
Fiber Dynamics, High Point -Injection Information
TD/ Bottom Top of Vertical HRC Mixing
Injection of Boring/ Well Injection Injection zone Injected Water
Area Well ID# Date (feet bgs) (feet bgs) (feet) (lbs) (gallons)
Well MW-3 IW3-1 5/18/2015 21 2 19 90 0
IW3-2 5/18/2015 21 2 19 90 0
IW3-3 5/18/2015 21 2 19 90 0
IW3-4 5/18/2015 21 2 19 90 0
IW3-5 5/18/2015 21 2 19 90 0
Well MW-4 IW4-1 5/18/2015 18 2 16 75 0
IW4-2 5/18/2015 17 2 15 75 0
Well MW-5 IW5-1 5/19/2015 10 2 8 60 0
IW5-2 5/19/2015 11 2 9 90 0
IW5-3 5/19/2015 9 2 7 60 0
IW5-4 5/19/2015 9.5 2 7.5 30 0
IW5-5 5/19/2015 9 2 7 60 0
Well MW-6 IW6-1 5/19/2015 13 2 11 75 0
IW6-2 5/19/2015 13 2 11 75 0
IW6-3 5/19/2015 14 2 12 75 0
IW6-4 5/19/2015 14 2 12 75 0
Well MW-7 IW7-1 5/19/2015 25 14 11 60 0
IW7-2 5/19/2015 25 14 11 60 0
IW7-3 5/19/2015 25 14 11 60 0
TOTALS 1380 0
3-D ME Mixing
(gallons) Water
Well (gallons)
I DW-1 I I 5/20/2015 I 55 I 50 I 5 20 180
TD -Total Depth
BGS -below ground surface
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
John Allen
Well Contractor Name ( or well owner personally abandoning well on his/her property)
4196
NC Well Contractor Certification Number
Terra Sonic Intl
Company Name
2. Well Construction Permit#: WI0400391 ------------------List all applicable well permits (i.e. County, State, Variance, Injection, etc.) if/cnown
3. Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
Dlrri !!ation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge 0Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
5-18-2015 4. Date well(s) abandoned: ________ _
Sa. Well location:
Fiber Dynamics, Inc.
Facility/Ovmer Name Facility JD# (if applicable)
200 South West Point Ave, High Point 27261
Physical Address, City, and Zip
Guilford 0172345
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.9465 ------------N -80.0159
CONSTRUCTION DETAILS OF WELUS} BEING ABANDONED
w
Allach well constn,ction record(s) if available For multiple injection or non-water supp(v
wells ONLY with the same co11s/ruc/ionlaba11do11menl, you can submit one form.
6a. Well ID#: IW3-1 to 3-5
6b. Total well depth: _2_1 ______ (ft.)
6c. Borehole diameter: _2_.5 ______ {.in.)
6d. Water level below ground surface: _3 ________ (ft.)
6e. Outer casing length (if known): _________ (ft.)
6f. Inner casing/tubing length (if known): _______ {ft.)
6g. Screen length (if known): ___________ {ft.)
I For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: _5 _______ _
For multiple injection or non-waler supply wells ONLY with the same
construction/abandonment, you can submit one form.
7b. Approximate volume of water remaining in well(s): O (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: _______________ _
7d. Amount of disinfectant used: ______________ _
7e. Sealing materials used (check all that apply):
D Neat Cement Grout
D Sand Cement Grout
D Concrete Grout
D Specialty Grout
D Bentonite Slurry
0 Bentonite Chips or Pellets
D Dry Clay
D Drill Cuttings
D Gravel
D Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
half bag
7g. Provide a brief description of the abandonment procedure:
Drilled borehole to refusal/rock using Geoprobe
Injected HRC through drill rods from bot of borehole
to about 2 feet bgs. Removed rods and poured
and packed bentonite from O to 2 ft
Digitally signed by Mike Tynan
8. Ce rAlillTk" T DN: cn=Mike Tynan, o, ou, IV I e y n a n email;;;;::[e-mail],
c=US
Date: 2015.06.02 20:17:57 -04'00'
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
IOa. For AH Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of\Vater Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
Forni GW-30 North Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 2013
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
John Allen
WeU Contractor Name ( or well owner personally abaiid~nmg well on his/her property)
4196
NC Well Contractor Certification Number
Terra Sonic Intl
Company Name
2. Well Construction Permit#: WI04 00 391 -----------------List all applicable well permits (i.e. County, State, Variance, Injection, etc.) if/mown
3. Well use (check well use):
Water Supply Well:
□Agricultural □MunicipaVPublic
□Geothennal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irri g ation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge 0Groundwater Remediation
□Aquifer Storage and Recovery □ Salinity Barrier
□Aquifer Test OStonnwater Drainage
□Experimental Technology □Subsidence Control
□Geothennal (Closed Loop) □Tracer
□Geothennal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned: 5-18 -2015
Sa. Well location:
Fiber Dynamics, Inc.
Facility/Owner Name Facility ID# (if applicable)
200 South West Point Ave, High Point 27261
Physical Address, City, and Zip
Guilford 0172345
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field , one lat/long is sufficient)
35.9465 N -80.0161 -----------
CONSTRUCTION DETAILS OF WELL<S} BEING ABANDONED
w
Atrach well construction record{s) if available. For multiple injection or non-waler supply
wells ONLY with the some construction/abandomnem , you can submit one form .
6 a. Well ID#: IW4-1 to 4-2
6b. Total well depth: 17 to 18 (ft.)
6c. Borehole diameter: _2_. 5 _____ (in .)
6d. Water level below ground surface: _3 _______ (ft.)
6e. Outer casing length (if known): _________ (ft.)
6f. Inner casing/tubing length (if known): ______ (ft.)
6g. Screen length (if known): ___________ (ft.)
I For Internal Use ONLY:
WELLABANDONMENTDETAU.S
7a. Number of wells being abandoned: _2 _______ _
For multiple injection or non-waler . supply . wells · ONLY with the ·same
constn,ctionlahandonment , you can submit one form.
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: _______________ _
7d. Amount of disinfectant used: ______________ _
7e. Sealing materials used (check all that apply):
D Neat Cement Grout
□ Sand Cement Grout
D Concrete Grout
D Specialty Grout
D Bentonite Slurry
lt'.l Bentonite Chips or Pellets
D Dry Clay
□ Drill Cuttings
□ Gravel
□ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
half bag
7g. Provide a brief description of the abandonment procedure:
Drilled borehole to refusal/rock using Geoprobe
Injected HRC through drill rods from bot of borehole
to about 2 feet bgs. Removed rods and poured
and packed bentonite from O to 2 ft
8. Ce · DN: cn=Mike Tynan, o, ou,
. R T Digitally signed by Mike Tynan Ml e y n a n., ~m•il=mat@terrasonicinter~tl~nal.com, c=US
Date: 2015 ,06,02 20:19:05 -0400
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner,
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details_ You may al so attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following :
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
IOb. For In jection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of\Vater Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & [njection Wells: In addition to sending the form to
the address(es) above , also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
Form GW-30 North Carolin a Department of Enviro nment and Natural Reso urces -Division of Water Resources Revised Au gust 2013
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
John Allen
Well Contractor Name (or well owner personally abandoning well on his/her property)
4196
NC Well Contractor Certification Number
Terra Sonic Intl
Company Name
2. Well Construction Permit#: WI0400391 ------------------
List all applicable well permits (i.e. County, State, Variance, Injection, etc.) if known
3. Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
Dlrri!rntion
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge 0Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
5-19-2015 4. Date well(s) abandoned: _________ _
Sa. Well location:
Fiber Dynamics, Inc.
Facility/Owner Name Facility ID# (if applicable)
200 South West Point Ave, High Point 27261
Physical Address, City, and Zip
Guilford 0172345
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N -80.0163 ------------35.9465
CONSTRUCTION DETAILS OF WELL{S) BEING ABANDONED
w
Attach well construction recordM if available. For multiple injection or non-waler supply
we/is ONLY with the same co11stn1ctia1v'obando11ment, you can submit one }Orm.
6a. Well ID#: IW5-1 to 5-5
6b. Total well depth: 9 to 11 (ft.)
6c. Borehole diameter:_2_-5 ______ (in.)
6d. Water level below ground surface: _3 ________ (ft.)
6e. Outer casing length (if known): _________ (ft.)
6f. Inner casing/tubing length (if known): _______ (ft.)
6g. Screen length (if known): ___________ (ft.)
I For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: _5 _______ _
For multiple injection or non-water suppZv wells ONLY with tlfe same
construclionlabandonment. you can submit onefom,.
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: ________________ _
7d. Amount of disinfectant used: ______________ _
7e. Sealing materials used (check all that apply):
D Neat Cement Grout
□ Sand Cement Grout
D Concrete Grout
D Specialty Grout
D Bentonite Slurry
Ill Bentonite Chips or Pellets
D Dry Clay
D Drill Cuttings
□ Gravel
D Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
half bag
7g. Provide a brief description of the abandonment procedure:
Drilled borehole to refusal/rock using Geoprobe
Injected HRC through drill rods from bot of borehole
to about 2 feet bgs. Removed rods and poured
and packed bentonite from Oto 2 ft
. er IC • DN: cn=Mike Tynan, o, OU, 8 C Nlltk T DigitallysignedbyMikeTynan e y n a n email=[e-mail], c=US
Date: 2015.06.02 20:20:42 -04'00'
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby cerfifj, that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided lo the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
S llBMITIAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For In jec tion Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of\Vater Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
Form GW-30 North Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 2013
WELL ABANDONMENT RECORD
This fomt can be used for single or multiple wells
1. Well Contractor Information:
John Allen
Well Contractor Name (9r well owner personally. ~b~doning well on liis/her property).
4196
NC Well Contractor Certification Number
Terra Sonic Intl
Company Name
2. Well Construction Permit #:_W_I_0_4_0_0_3_9_1 ________ _
List all applicable well permits (i.e. County, State, Variance, lnjeClion, etc.) if known
3. Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply(shared)
□Irri e ation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge 0Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
5-19-2015 4. Date well(s) abandoned: ________ _
Sa. Well location:
Fiber Dynamics, Inc.
Facility/Owner Name Facility ID# (if applicable)
200 South West Point Ave, High Point 27261
Physical Address, City, and Zip
Guilford 0172345
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.9464 N -80.0162
-----------
CONSTRUCTION DETAILS OF WELL{S} BEING ABANDONED
w
Aflac/, well conslruclion record{s) if available. For multiple injection or non-water supply
wells ONLY with the same construcho11/obando11me11t, you can submil one form.
6a. Well ID#: IW6-1 to 6-4
6b. Total well depth: 13 to 14 (ft.)
6c. Borehole diameter: _2_.5 _____ (in.)
6d. Water level below ground surface: _3 _______ (ft)
6e. Outer casing length (if known): _________ (,ft.)
6f. Inner casing/tubing length (if known): _______ (ft.)
6g. Screen length (if known): ___________ (ft.)
I For Internal Use ONLY:
WE LL ABANDONME NT DETAIL.
7a. Number of wells being abandoned: _4 ______ _
For ' multiple ·· injeClion or .non-water supply wells ONLY with the same
construction/abandonment, you can submit one foi-in :·
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FORWATERSUPPLYWELLSONLY:
7c. Type of disinfectant used: _______________ _
7d. Amount of disinfectant used: _____________ _
7e. Sealing materials used (check all that apply):
□ Neat Cement Grout
□ Sand Cement Grout
□ Concrete Grout
□ Specialty Grout
□ Bentonite Slurry
0 Bentonite Chips or Pellets
D Dry Clay
□ Drill Cuttings
□ Gravel
□ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
half bag
7g. Provide a brief description of the abandonment procedure:
Drilled borehole to refusal/rock using Geoprobe
Injected HRC through drill rods from bot of borehole
to about 2 feet bgs. Removed rods and poured
and packed bentonite from O to 2 ft
Digitally signed by Mike Tynan
8. Ciffifl1ilr, T ON: cn~Mike Tynan, o, ou, IV I I\. e Y n a n ;:tmat@terrasoniante,nationat.com,
· Date: 2015.06.02 20:21 :10 -04'00'
Signature of Certified .Well Contractor or Well Owner Date
By signing this form, I hereby certify that the well(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary .
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit.this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 !\fail Service Center, Raleigh, NC 27699-1617
lOb. For Injection Wells: In addition to sending the form to the address in JOa
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supplv & Injectjon Wells: In addition to sending the form to
the address(es) above , also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
Form GW-30 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
I. Well Contractor Information:
John Allen
Well Contractor Name (or well owner personally abandoning well on bis/her property)
4196
NC Well Contractor Certification Number
Terra Sonic Intl
Company Name
2. Well Construction Permit#: WI0400391 ------------------Lis I all applicahle well perm ifs (i.e. County, State, Variance, Injection, etc.) if known
3. Well use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□ Industrial/Commercial □Residential Water Supply (shared)
□ Irri uation
Non-Water Supply Well:
□Monitoring □Recovery
Injection Well:
□Aquifer Recharge ~Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothermal (Closed Loop) □Tracer
□Geothermal (Heating/Cooling Return) □Other (explain under 7g)
4. Date well(s) abandoned: 5-19-2015
Sa. Well location:
Fiber Dynamics, Inc.
Facility/Owner Name Facility ID# (if applicable)
200 South West Point Ave, High Point 27261
Physical Address, City, and Zip
Guilford 0172345
County Parcel Identification No. (PIN)
Sb. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.9464 N -80.0158 ------------
CONSTRUCTION DETAILS OF WELL{S} BEING ABANDONED
w
Aflac/, v.•e/1 construction record(s) if available. For multiple 11yec1ion or non-wafer supp(v
wells ONLY with the same construction/abandonment, you can suhmil one form.
6a. Well ID#: IW7-1 to 7-3
6b. Total well depth: _2_5 ______ (ft.)
6c. Borehole diameter: _2_.5 ______ (in.)
6d. Water level below ground surface: _1_4 _______ (ft.)
6e. Outer casing length (if known}: _________ (ft.)
6f. Inner casing/tubing length (if known): ______ (ft.}
6g. Screen length (if known): ___________ (ft.)
I For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: _3 ______ ~_
For multiple injection or non-water supp~v wells ONLY with the same
consLnictiow'ahandonmenl, you can submit one form.
7b. Approximate volume of water remaining in well(s): 0 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used: ________________ _
7d. Amount of disinfectant used: ______________ _
7e. Sealing materials used (check all that apply):
□ Neat Cement Grout ~ Bentonite Chips or Pellets
□ Sand Cement Grout □ Dry Clay
□ Concrete Grout □ Drill Cuttings
□ Specialty Grout □ Gravel
□ Bentonite Slurry □ Other ( explain under 7 g)
7f. For each material selected above, provide amount of materials used:
one bag
7g. Provide a brief description of the abandonment procedure:
Drilled borehole to refusal/rock using Geoprobe
Injected HRC through drill rods from bot of borehole
to about 14 feet bgs. Removed rods and poured
and packed bentonite from Oto 14 ft
• e DN: cn=Mike Tynan, o, ou, 8 t{·• . Digitally signed by Mike Tynan M1 ~ Ty n a n email=[e-mail], c=US
Date: 2015.06.02 20:21 :37 -04'00'
Signature of Certified Well Contractor or Well Owner Date
By signing this form, I hereby certify that the welf(s) was (were) abandoned in
accordance with 15A NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
10a. For All Wrlls: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Injection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Supply & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
where abandoned.
FormGW-30 North Carolina Department of Environment and Natural Resources -Division of Water Resources Revised August 20 I 3
Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400391
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Fiber Dynamics
(
Location Address
200 S W Point Ave
High Point
Owner
Owner Name
Fiber Dynamics Inc
Dates/Events
NC
Orig Issue
4/14/2015
App Received
3/27/2015
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27263
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
4/14/2015
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Guilford
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Jeffrey L. Gerlock
GL
306 Eden Ter
Archdale
Issue
4/14/2015
Effective
4/14/2015
NC 27263
Expiration
Requested /Received Events
Additional information requested
Additional information received
Streamlndex Number Current Class
4/1/15
4/13/15
Subbasin
Ro gers, Michael
From: Rogers, Michael
Sent: Tuesday, April 14, 2015 2:07 PM
To:
Cc:
'Jeff Gerlock'; '[e-mail]'
Basinger, Corey; Knight, Sherri
Subject: WI0400391 NOi -RE: Request for Approval of Small-Scale Injection Operation -Fiber
Dynamics, High Point, NC
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi} at the Fiber Dynamics
Facility. This facility is located at 200 South West Point Ave., High Point, Guilford County, NC 27261. We received your
complete NOi on April 13, 2015. Please remember to submit the following regarding this injection activity:
1} Well Construction R~cords (GW-1) and Abandonment Records (GW-30) when completed. Please provide copies of
the GW-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct push
or Geoprobe wells are considered wells and require construction (GW-1} and abandonment forms (GW-30). If well
construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.ro gers @ncdenr.gov. send by fax to my attention at 919-
807-6406, or via regular mail to address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WI0XXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400391. This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re p ly to this email, as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL}
Hydrogeologist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http:ljportal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Monday, April 13, 2015 1:16 PM
To: Rogers, Michael ·
Cc: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
1
here is a summary table to help show you the information. let me know if you need anything else.
On Mon, Apr 13, 2015 at 11:49 AM, Jeff Gerlock <[e-mail]> wrote:
Good morning Mike; hope you had a nice weekend. just wanted to check in with you on your email request for
info on the proposed injection at Fiber Dynamics in High Point. the information requested in your email on
April 1st is included in our application (page 3).
Geoprobe borings will be drilled to auger refusal / top of rock expected at 11 to 21 feet ·and then HRC will
be injected through the rods from the bottom of each boring to the water surface. intervals are shown in the
application. we will use the recommended 6 lbs per foot of HRC at each borehole. there is no water added to
the HRC. a schematic of the geoprobe locations / areas and depths is shown on the cross section attached to the
application. we may also inject 3-D ME into the bottom 10 foot of well DW-1 at a rate of2.4 gallons per foot
or 24 gal / 200 lbs total of material at a 10 % dilution rate therefore we will mix the 3D ME with 240 gallons of
water. MSDS forms for the two chemicals are attached. let me know if you need me to prepare a table, figure,
or provide other information for the proposed work at the site.
On Wed, Apr 1, 2015 at 3:15 PM, Rogers, Michael <michael.rogers@ncdenr.2:ov> wrote:
Would you please provide a total estimated average on the total amount of injectant plus chase water you are going to
inject at each proposed Geoprobe (in gallons), and at DW-1.
Additionally, would you proved a schematic of proposed Geoprobe with total depth. We realize this is proposed and
actual depth will vary a little at each point.
Thanks
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Monday, March 30, 2015 12:56 PM
To: Rogers, Michael
Cc: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
I understand -we were not planning to do the work for about a month or so. just wanted to make sure you have
all the paperwork and answers you need to process.
On Mon, Mar 30, 2015 at 12:54 PM, Rogers, Michael <michael.ro 2.ers c ,ncdenr.iw v> wrote:
NO, not yet. We need to review and process, enter project into our system, and forward a copy to the regional office for
their review. That's why we require a 2-week notice before injection activities.
2
Ro gers , Michael
From: Rogers, Michael
Sent:
To:
Tuesday, April 14, 2015 2:05 PM
Basinger, Corey; Knight, Sherri
Subject:
Attachments:
FW: WI0400391 NOi -Fiber Dynamics
20150414133417149.pdf
Please find attached a NOi for the above project.
-----Original Message-----
From: Michael Rogers [mailto:michael.rogers @ncdenr.gov)
Sent: Tuesday, April 14, 2015 1:34 PM
To: Rogers, Michael
Subject:
This E-mail was sent from "RNPAC7DD0" (Aficio 2075).
Scan Date: 04.14.2015 13:34:17 (-0400)
Queries to: robin.markham@ncdenr .go v
1
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Jeff Gerlock <[e-mail]>
Monday, April 13, 2015 1: 16 PM
Rogers, Michael
Slusser, Thomas
Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
Fiber-Injection lnfo.pdf
here is a summary table to help show you the information. letme know if you need anything else.
On Mon, Apr 13, 2015 at 11 :49 AM, Jeff Gerlock <jeff.gerlock@ gmail.com> wrote:
Good morning Mike; hope you had a nice weekend. just wanted to check in with you on your email request for
info on the proposed injection at Fiber Dynamics in High Point. the information requested in your email on
April 1st is included in our application (page 3).
Geoprobe borings will be drilled to auger refusal/ top of rock expected at 11 to 21 feet and thenHRC will
be injected through the rods from the bottom of each boring to the water surface. intervals are shown in the
application. we will use the recommended 6 lbs per foot of HRC at each borehole. there is no water added to
the HRC. a schematic of the geoprobe locations / areas and depths is shown on the cross section attached to the
application. we may also inject 3-D ME into the bottom 10 foot of well DW-1 at a rate of2.4 gallons per foot
or 24 gal/ 200 lbs total of material at a 10 % dilution rate therefore we will mix the 3D ME with 240 gallons of
water. MSDS forms for the two chemicals are attached. let me know if you need me to prepare a table, figure,
or provide other information for the proposed work at the site.
On Wed, Apr 1, 2015 at 3:15 PM, Rogers, Michael <michael.ro e:ers(@ncdenr.rzo v> wrote:
Would you please provide a total estimated average on the total amount of injectant plus chase water you are going to
inject at each proposed Geoprobe (in gallons), and at DW-1.
Additionally, would you proved a schematic of proposed Geoprobe with total depth. We realize this is proposed and
actual depth will vary a little at each point.
Thanks
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Monday, March 30, 2015 12:56 PM
To: Rogers, Michael
Cc: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
1
I understand -we were not planning to do the work for about a month or so. just wanted to make sure you have
all the paperwork and answers you need to process.
On Mon, Mar 30, 2015 at 12:54 PM, Rogers, Michael <michael.ro gers @ncdenr.gov> wrote:
NO, not yet. We need to review and process, enter project into our system, and forward a copy to the regional office for
their review. That's why we require a 2-week notice before injection activities.
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Monday, March 30, 2015 10:14 AM
To: Slusser, Thomas; Rogers, Mike; Rogers, Michaer
Subject: Re: Request for Approval of Small~Scale Injection Operation -Fiber Dynamics, High Point, NC
sounds good. so is everything complete and all look fine to order the materials and proceed with our pilot test?
On Mon, Mar 30, 2015 at 10:08 AM, Slusser, Thomas <thomas.slusser@.ncdenr.gov> wrote:
Greetings Jeff,
Thanks for the submittal. Mike Rogers, copied on this email, will be your project contact for this one.
Take care,
-Thomas Slusser, L.G.
Underground Injection Control Program Manager
[e-mail] I ph# 919-807-6412 I fax# [phone]
Mailing Address: NCDENR Division of Water Resources I 1636 Mail Se:i;vice Center I Raleigh, NC 27699-1636.
Physical Address: Room 640M, Archdale Building, 512 N. Salisbury St., Raleigh, NC 27604.
Internet Address: http://portal.ncdenr.org/web/wq/aps/gwpro .
2
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties udess Me content is
exempt by statute or other regulation.
From: Jeff Gerlock [mailto:[e-mail]]
Sent: Friday, March 27, 2015 5:42 PM
To: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
Good afternoon Thomas. hope you are having a good Friday. attached is our revised NOi for injection at the
site. please review and call if you have any questions and/or if you need any clarification or other
information. thanks.
Note -please respond to let me know that you received this email and the attachments.
On Thu, Mar 12, 2015 at 1:56 PM, Slusser, Thomas <thomas.slusser@p cdenr.1:mv> wrote:
Thanks Jeff for the update. Let me know if you have any questions for me as you move forward with this.
Take care,
-Thomas Slusser, L.G.
Underground Injection Control Program Manager
[e-mail] I ph# 919-807-6412 I fax# [phone]
Mailing Address: NCDENR Division of Water Resources I 1636 Mail Service Center I Raleigh, NC 27699-1636.
Physical Address: Room 640M, Archdale Building, 512 N. Salisbury St., Raleigh, NC 27604.
Internet Address: http://portal.ncdenr.org/web/wq/aps/gwpro
E-mal1 correspondence to and from this address may be subject to the North Carolina Public Records Law and may be discloser/ to third parties unless the content is
exempt by statute or other regulation.
3
From: Jeff Gerlock [mailto:jeff [e-mail]]
Sent: Thursday, March 12, 2015 11:16 AM
To: Slusser, Thomas
Subject: Re: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
sorry I forgot to get back with you on this matter. I have recently revised our remediation plan and injection
strategy after further discussions with my supplier. I will make the change you suggested and our changes and
resubmit the plan this week. thanks for your follow up!
On Tue, Mar 3, 2015 at 12:52 PM, Slusser, Thomas <thomas.slusser(a),ncdenr.2ov> wrote:
Greetings Jeff,
I have not yet received the revised NOI for this project. Have you submitted it yet?
Thanks,
-Thomas Slusser, L.G.
Underground Injection Control Program Manager
thomas.slusser®ncdenr.gov I ph# 919-807-6412 I fax# [phone]
Mailing Address: NCDENR Division of Water Resources I 1636 Mail Service Center I Raleigh, NC 27699-1636.
Physical Address: Room 640M, Archdale Building, 512 N. Salisbury St., Raleigh, NC 27604.
Internet Address: http://portal.ncdenr.org/web/wq/aps/gwpro
E-mail correspondence to and from this address may be subject to the North Carolina Public Records Law and may be disclosed to third parties unless the content is
exempt by statute or other regulation
From: Slusser, Thomas
Sent: Tuesday, February 17, 20151:40 PM
To: Jeff Gerlock
Subject: RE: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
4
Greetings Jeff,
I looked at the submittal and everything looks good, but I did not see a table or diagram of well construction information
as asked for in Part K(2). Otherwise, everything is fine.
Thank you,
~ Thomas Slusser, LG.
Underground Injection Control Program Manager
NC Division of Water Resources
ph# 919-807-6412
http://portal.ncdenr.org/web/wg/aps/gwpro
1636 Mail Service Center
Raleigh, NC 27699-1636
E-mail correspondence to and from this address may be subject to the North carolina Public Records Law and may be
disclosed to third parties.
From: Jeff Gerlock [[e-mail]]
Sent: Monday, February 16, 2015 5:10 PM
To: Slusser, Thomas
Subject: Request for Approval of Small-Scale Injection Operation -Fiber Dynamics, High Point, NC
Thomas, per our conversation this morning attached is our application/ NOi for the project. please review and
let me know if we need to modify or include additional information. thanks for your help.
Note -please respond to let me know that you received it.
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, NC 27263
336-431-5454 office phone and fax
Jeff Gerlock
5
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridge geo.com
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridge geo.com
Jeff Gerlock
Blue Ridge Geological Services
306 Eden Terrace, Suite C
Archdale, North Carolina 27263
336-431-5454 office phone and fax
www.blueridge geo.com
6
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT 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 ISA 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 (1 5A NCAC 02C .0225) or TRACER WELLS <ISA NCAC 02C .0229):
1) Passive Injection S y stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale In jection 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.
Print Clearly or Type Information. Rlegible Submittals Will Be Returned As Incomplete.
DATE: March 25 , 2015_ PERMIT NO. 1 _j r O y oo ) q / (to be filled in by DWR)
~ ~
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) ___ Air Injection Well. ..................................... Complete sections B-F, K, N
(2) --~Aquifer Test Well ....................................... Complete sections B-F, K, N
(3) --~Passive Injection System ............................... Complete sections B-F, H-N
(4) X __ Small-Scale Injection Operation ...................... Complete sections B-N
(5) ___ Pilot Test ................................................. Complete sections B-N
(6) ___ Tracer Injection Well ................................... Complete sections B-N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: ---=F~ib~e=r=D__.y:rumu=· ==·c=s~. =In=c~. -~C~Je=ff~G~e=rl=o=ck~of~B==lu=e~Ri=·=d=ge~a=u=th~to~si.._.gn~o=n~b=eh=a=l~fo=f~F~i=b=er~) __ _
Mailing Address: 200 South WestPoint Avenue
City: High Point State: _NC_ Zip Code: 27261 County: Guilford
Day Tele No.: 336-886-7111 Cell No.: 336-382-6849 Jeff
EMAIL Address: [e-mail] Fax No.: _______ _
VIC/In Situ Remed. Notification (Revised 11/19/2013) Page 1
March 25, 2015
Mr. Thomas Slusser
NCDENR
Division of Water Resources — UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Subject:
Revised Notice of Intent for injection
Fiber Dynamics, Inc.
200 South West Point Avenue
High Point, Guilford County, North Carolina
NCDENR Site ID#NON CD 0002854
Dear Mr. Slusser:
On behalf of Fiber Dynamics, Inc., Blue Ridge Geological Services, Inc. (Blue Ridge) is planning to
perform additional environmental activities at the subject site in 2015. Attached are a Notice of Intent
(NOD application form and the required attachments for performing injection activities at the site. Per
our discussion we plan to drill boreholes and inject material through hollow drill rods of a Geoprobe and
then abandon the boreholes. We do not plan to install any injection wells at this time, We may also inject
media into existing well DW-1.
Please contact the undersigned if you have any questions and / or if you need any additional information.
We appreciate your review of this information.
Sincerely,
Jeffrey L. Gerlock, L.G.
NC Licensed Geologist #1141
Registered Environmental Consultant #149
Attachments —NOI Form, Figures, DW-1 construction record
cc: Mr. Jim Heery, Fiber Dynamics
306 Eden Terrace, Suite C, Archdale, NC 27263 * Phone/Fax: [phone]

D. PROPERTY OWNER (if different than well owner)
Name: ---~s=am~e =a~s =ab=o~v~e _______________________ _
Mailing Address:--------------------------------
City: ____________ State: __ Zip Code: _______ County: _____ _
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: __________ _
E. PROJECT CONTACT -P_erson who can answer technical questions about the proposed injection project.
Name: ___ .,c.Je=f=f -=G=e=rl=o=ck=,..:B=l=u=-e =Ri=·d=-g:,.;::e:....;G=eo=lo=e=i=ca=l-=S=e-=--rv'-"i=ce=s"--, =In=c"-. ______________ _
Mailing Address: 306 Eden Terrace Suite C
City: Archdale State: _NC_ Zip Code:~2=7=2=6~3 ___ County: Randolph
Day Tele No.: 336-431-5454 Cell No.: __ ~3~3~6~-3~8=2-~6~84~9~---
EMAIL Address:[e-mail] Fax No.: ---=-3~36~-4~3~1~-5~4=5~4 ___ _
F. PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Physical Address: ---"2=0=0'-"S=o=u=th=-..W"-'e=s:.:..t -=-P=om=· :=..t _,,_,Ac_,_v,=en=u=e,_____ ______________ _
_______________________ County: ___ G~m=lfi=o=rd~--
City: High Point State: NC Zip Code: ~2~72=6~1 _____ _
Geographic Coordinates: Latitude**: N __ ~3~5° 56_' 47_" or
Longitude**: W __ ~8~0° __QQ' 47 _,, or
0
0
Reference Datum: MW-4 p lume ctr Accuracy: _______ _
Method of Collection: Google Earth and GPS
**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:~1=3.=6~00~ ___ square feet
Land surface area ofinj . well network: 3 000 square feet (:5 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 25 (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.
UIC/ln Situ Remed. Notification (Revised 11/19/2013) Page2
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES — Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity.
We plan to drill sail borings to the top of rock (expected at 11 to 21 feet bgs) near wells MW-3, MW-5. MW-
6. and MW-7 and then inject media (HRC) into the groundwater through the hollow rods of the Geoprobe rise
(no wells will be installed). As shown on the attached figure. we nlan to inject at approximately 17 locations.
The media will be injected from the bottom of boring to the groundwater surface (about 11 to 14 feet vertically
in each borehole). Injection intervals at well areas are as follows: MW-3 (4 to 21),_MW-5 (3 to 14), M W-6 t4
to 181, MW-7 (14 to 25). The purpose of the work is to attempt to degrade the contaminants (primarily PCE)
in the shallow groundwater to below the 2L action levels to attempt to get site closure. We also plan to inject
HRC and/or 3-D Microemulsion (3DME) into well DW-1 to attempt to remediate the PCE in the rock.
J. U' JECTANTS — Provide a MSDS and the following for each injectant_ Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
hur.:, portal.ncdenr.orgfwebrwglaysigwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
Injectant: 3-D Microemulsion
Volume of injectant: 24 gal per pointplus water
Concentration at point of injection: DW-1 -122 ug L
Percent if in a mixture with other injectants: 1O% dilution rate - injectant linjectant plus water)
Injectant: HRC
Volume of injectant: 61bs / ft of injection at each borehole/injection point
Concentration at point of injection: 7.1 to 61.2 ualL (as shown an figures)
Percent if in a mixture with other injectants:
lnjectant:
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: 18 points Proposed U Existing • -
(2) 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 sarne construction details. Well
construction details shall include the following:
(a)
(b)
(c)
well type as permanent, direct -push, or subsurface distribution system (infiltration gallery)
depth below land surface of grout, screen, and casing intervals
well contractor name and certification number
U!C11n Situ Rcrneel, Notification (Revise411111912013) Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Plan to inject over a two dal period startinc in mid to late April 2015
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.
We plan to collect groundwater from on -site and off -she downgradient wells following the injection aetivin.
We will analyze the samples for VOCS by. Method 8260. We will provide a summary report to the NCDENR.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "1 hereby certify, 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 passibility 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 1.5A NCAC 02C 0200 Rules."
Jeffrey L. Gerlock (agent for Fiber[
leant Print or Type Full Name
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 1 hereby consent
to allow the applicant to construct each injection well as outlined in this application and agree that it shall be
the responsibility of the applicant to enure that the injection we11(s) conform to the Well Construction
Standards (1 SA 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,
Signature* of Property Owner (if different from applicant) Print or Type Full Name
• An access agreement between the applicant and property owner may be submitted in lieu of a signature on this form.
Submit one copy of the completed notification package to:
DWR — U1C Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
U1C1an Situ Remed. Notification (Revised 1 I/ 9/2013) Page 4

G
Gate
w- I /
*tiff/
Sludge
RolloflArea
Legend:
• ' Monitoring Well
513.9 Tetrachloroethene (PCE) in Groundwater (micrograms per liter) on 1/14/2014 (NS- Not Sampled)
N '°'4 Gravel / /
` 4.Parking Lot I ': 1 /
f kPr C
ea Asphalt / 4I
Parking Lot �,v,� I q;°
�r NI
47.12 Fulmer sludge Id
Rolloff
Nib Ccnncr of
Budding - Basrnient
W-5
06
30.
0.7
p N / MW-1a
MW-4
nw-.a,' ''
w•1 • S `1
12'-* 1 ~ �42.5 I — N ` \
•
oA
L
•
I1
10
1M [, MW-2
<I /ND
NS
>� I
I /
co /
/
• / b
/ /9
�n� f
•
Groundwater Flow Direction
0 Proposed Injection Point
REF.: Survey by Triad Land Surveying Dared July 2009 amended Nov 2012.
MW-7
7,I *
F
M W-9
•
-1
Residence
0
M W-8
NS*
1
Ennis Street
Scale: 1 inch = 50 feet
1-
-Si c It I-.II�t i
Prop used Inj eciion Areas
Fiber Dynamics
200 South West Point Avenue
Iligh Point,North Carolina
March 2U75 Figure 1

00
595 —
190
585
180
575
570
165
160
¢55 —
150
S45
140
535
130
125
120
515
110
505
100
A (NORTHWEST)
MW-1
MW-1
AR
MONITOR WELL &
SCREEN INTERVAL
651 75.6 PCE ITOTAL VOC (ug!L) CONCENTRATION IN GROUNDWATER
ND NOT DETECTED
AR AUGER REFUSAL
BT BORING TERMINATED
r DEPTH TO WATER (FT BGS) IN JAN 2014
FILL/ RESIDUUM
►
►
►
►
HIGHLY WEATHERED ROCK
►
ND\
FRACTURED ROCK
1
10
PCE ISOCONCENTRATION IN GROUNDWATER
PROPOSED INJECTION POINTS
(verllcel blue hogs)
DW-1
AR
HIGHLY WEA7
BT
▪ '. • 1a
ND "
ED HOCK
_- 1421132.5 ti/f� s'
!
MW-6 DW-2
1.58
AR
MW-2
A' (SOUTHEAST)
90:
Property
Line
ATER TABLE
Flu.! RESIDUUM 1
r
19.1
r
1
r
1
AR
HIGHLY WEATHERED ROCK
Fractures �l
UNFRACTURED BEDROCK
20
BT
NOTES:
1) MONITORING WELLS SAMPLED IN AUG 2012{MW1, MW6) S JAN 2014(MW2, MW5, MW7, DWI, DW2).
2) SEE SITE PLAN FOR CROSS SECTION LOCATIONS. Q APPROXIMATE SCALE 40
3} ELEVATIONS ARE REFERENCED TO NATIONAL GEODETIC VERTICAL DATUUM (NGVD). 3b1 FEET
FRACTURED ROCK
!
1 !
• •
19!24.,9f'
✓ '� r
• UNFRACTURRO BEDROCK
1
■
...ram
MW-7
I
1
1
1
I
I
■
1
ND
89E
89r_
8s;
86C
85:
85C
84i
84C
835,
83t
82".
82C
81:
81(
80:
80(
Cross Sec A - Prop I nj ection Areas
Fiber Dynamics
200 South West Point Avenue
High Point, North Carolina
Mar 2015
Figure 2

Fiber Dynamics, High Point -Proposed Injection Information
Approx HRC Mixing
DTW DT Rock Injection Interval Vertical interval No borings/ (lbs) Water
Area {feet bgs) {feet bgs) (feet bgs) length (ft) injection points Total footage @Glbs/ft (gallons)
Well MW-5 3 14 3 to 14 11 5 55 330 0
Well MW-6 3.5 18 3.5 to 18 14.5 4 58 348 0
Well MW-3 3.5 21 3.5 to 21 17.5 5 87.5 525 0
Property line 14 25 14 to 25 11 3 33 198 0
near MW7
TOTALS 17 233.5 1401 0
3-D ME Mixing
(gallons) Water
Well 2.4 gal/ft (gallons)
I DW-1 I I I 45 to 55 I 10 I inject in well I 10 24 240
1 ■ ON ESIDE_ TIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources - Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2580
4. WELL CONTRACTOR:
JASON MANTAK
Well Cmtracter (lrrdiuidual) Name
GEOLOGIC EXPLORATION, INC.
Wei[ Contractor Company Name
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC
28625
City or Town State Zip Cade
( T04 }. 872-7686
Area code- Phone rxvr6er
Z WELL INFORMATION:
SITE WELL ID #(lr applicable) DW-1
STATE WELL PERMIT$(irappticabte)
DWQ or OTHER PERMIT #(i► applicable)
WELL USE (Check Applicable Box) Monitoring ] Municipal/Public 0
lndusleallCmmerciaf p Agricultural 0 Recovery o Injection D
Irrigation❑ Other 0 (list use)
DATE DRILLED 02fa8110- 02/09/14
TIME COMPLETED AM ❑ PM Q
3 WELL LOCATION:
CITY: HIGH POINT
200 S WEST POINT AVENUE 27250
COUNTY GUILFORD
(Street Name, Number, Community, Subdivision, Lot No., Panel, 2 p Code)
TOPOGRAPHIC LAND SETTING:
❑Slope ❑Valley LJFiat ❑Ridge ❑ Other
(check appropnate box)
LATITUDE
LONGITUDE
Latitude/longitude source: oGPS ❑Topographic map
(location of well must be shown on a USGS tapo :nap and
attached to this form Inca using GAS)
4. FACILITY- to the name e1 the business where we well is located.
FACILITY ID #(if applicable)
NAME OF FACILITY FIBER DYNAMICS, INC
May be in degas,
minutes, seconds or
in a decimal format
STREET ADDRESS 200 S WEST POINT AVENUE
HIGH POINT NC 27260
City c r Town State
CONTACT PERSON FIBER DYNAMICS, INC
Zip Code
MAILING ADDRESS 200 S WEST POINT AVENUE
HIGH POINT NC
27260
City or Tom State
Area code - Phone number
5. WELL DETAILS:
a. TOTAL DEPTH: 55.0 FEET
Zip Code
b. DOES WELL REPLACE EXISTING WELL? YES © NO KI
c. WATER LEVEL Below Tap of Casing: 5.0 FT,
(Use'+" if Above Top of Casing)
d. TOP OF CASING IS 0,0 FT. Above Land Surface'
'Top of casing terminated allot mow land surface may require
a valance in accordance with 15A NGAC 2C .0118.
a YIELD (gpm): NIA METHOD OF TEST NIA
f. DISINFECTION: Type NIA Amount NIA
g. WATER ZONES (depth):
From To From To
From To From To
From To From To
6. CASING:
Depth or
From 0.0 To 50.0 Ft, 4"I'n
From 0.0 To 20.0 Ft. B 1M INCH
From To Ft.
7. GROUT: Depth Materiel
From 9.0 To 41.0 Ft Portland benlcnite
Frrxn 0.0 7o 20.0 Ft. Portland begrime/
From To FL
Thickness/
PMVaterial
.198 ascwwaEu
8. SCREEN: Depth
From 50-0
To 55.0
Diameter
Ft.2.0 in.
From To Ft. in.
Fram To Ft. in.
9. SAND/GRAVEL PACK:
Depth
From 49.0 To 55.0 Ft. 20-40 FINE SILICA SAND
Frorn To Ft.
From To FL
Method
SLURRY
SLURRY
Slot Size Material
,010 in• PVC
in.
10. DRILLING LOG
From To
0.0 1.0
1.0
10.0
48.0
50.0
10.0
46.0
50.0
55_0
Size Material
Formation Description
CONCRETE/GRAVEL
GRAY/GREEN CLAY
TAN WEAThiERED ROCK
GRAY FRACTURED ROCK
GRAY ROCK
14. REMARKS:
BENTONITE SEAL FROI4 41.0 TO 49,0 FT
I DP HEREBY
15A NCAC
RECORD F+
RTIFY THAT TM$S WELL WAS r' • STRUCTED IN ACCORDANCE WITH
EU-CONSTRU •N S. AND THAT ACOPY OF THIS
EN tr. OWNER
021o9/1'0
SIGNAT
E OF CERTIFIED WELL CONTRACTOR
J • ON MP.NTAK
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center,- Raleigh, NC 27699-1517 Phone No. [phone] ext 568.
Form GW-1 b
Rev. 7105

3-D Microemulsion (3DMeYrm
MATERIALS SAFETY DATA SHEET
Last Revised: March 26, 2007
Section 1-- Material Identification
Supplier:
.:).
REGENESIS
1011 Calle Sombra
San Clemente, CA 92673
Phone: [phone]
Fag: 949366.8090
E-mail: [e-mail]
• Glycerides, di-, mono [2-[2-[2-(2-hydroxy-1 -oxopropoxy)-1-oxopropoxyl]-1-
oxo propoxy] propanoates]
Chemical Name(s): • Propanoic acid, 2-[2-[2-(2-hydroxy-l-oxopropoxy)-1-oxopropoxy]-1-
oxopropoxy]-1,2,3-propanetriyl ester
• Glycerol
Chemical Family: Organic Chemical
Trade Name: 3-D Microemulsion (3DMe)TM
Synonyms: HRC AdvancedTM HRC-PED (Hydrogen Release Compound — Partitioning
Electron Donor)
Product Use: Used to remediate contaminated groundwater (environmental applications)
Section 2 — Chemical Identification
CAS# Chemical
823190-10-9
61790-12-3 or
112-80-1
201167-72-8
HRC-PED
Fatty Acids (neutralized)
Glycerol Tripolylactate
56-81-5 Glycerol

Regenesis-3-D Microemulsion MSDS
Melting Point:
Boiling Point:
Flash Point:
Density:
Solubility:
Appearance:
Odor:
Vapor Pressure:
Extinguishing Media:
Section 3 -Physical Data
Not Available (NA)
Not determined (ND)
> 200 °F using the Closed Cup method
0.9 -1.1 glee
Slightly soluble in acetone. Insoluble in water.
Amber semi-solid.
Not detectable
None
Section 4 -Fire and Explosion Hazard Data
Use water spray, carbon dioxide, dry chemical powder or appropriate foam
to extinguish fires.
Water May be used to keep exposed containers cool.
For large quantities involved in a fire, one should wear full protective clothing and a NIOSH approved
self contained breathing apparatus with full face piece operated in the pressure demand or positive
pressure mode as for a situation where lack of oxygen and excess heat are present.
Acute Effects:
RTECS#
Irritation Data:
Section 5 -Toxicological Information
May be harmful by inhalation, ingestion, or skin absorption. May cause
irritation. To the best of our knowledge, the chemical, physical, and
toxicological properties of the 3-D Microemulsion have not been
investigated. Listed below are the toxicological information for glycerol,
lactic acid and fatty acid.
MA8050000
Glycerol
SKN-RBT 500 MG/24H MLD
EYE-RBT 126 MG MLD
EYE-RBT 500 MG/24H MLD
85JCAE-,207,1986
BIOFX* 9-4/1970
85JCAE-,207,1986
Regenesis -3-D Microemulsion MSDS
Toxicity Data:
Target Organ Data:
Section 5-Toxicological Information (cont)
ORL-MUS LD50:4090 MG/KG
SCU-RBT LD50:100 MG/KG
ORL-RAT LD50:12,600 MG/KG
IHL-RAT LC50: >570 MG/M3/1H
IPR-RAT LD50: 4,420 MG/KG
IVN-RAT LD50:5,566 MG/KG
IPR-MUS LD50: 8,700 MG/KG
SCU-MUS LD50:91 MG/KG
IVN-MUS LD50:4,250 MG/KG
ORL-RBT LD50: 27 MG/KG
SKN-RBT LD50: > 10 MG/KG
IVN-RBT LD50: 53 MG/KG
ORL-GPG LD50: 7,750 MG/KG
FRZKAP (6),56,1977
NIIRDN 6,215,1982
FEPRA 7 4,142,1945
BIOFX* 9-4/1970
RCOCB8 56,125,1987
ARZNAD 26,1581,1976
ARZNAD 26,1579,1978
NIIRDN 6,215,1982
JAPMA8 39,583,1950
DMDJAP 31,276,1959
BIOFX* 9-4/1970
NIIRDN 6,215,1982
JIHTAB 23,259,1941
Behavioral (headache), gastrointestinal · (nausea or vomiting), Paternal
effects (spermatogenesis, testes, epididymis, sperm duct), effects of fertility
(male fertility index, post-implantation mortality).
Only selected registry of toxic effects of chemical substances (RTECS) data is presented here. See
actual entry in RTECS for complete information on lactic acid and glycerol.
Fatty Acids
Acute oral (rat) LD50 value for fatty acids is 10000 mg/kg. Aspiration of liquid may cause
pneumonitis. Repeated dermal contact may cause skin sensitization.
Section 6 -Health Hazard Data
One should anticipate the potential for eye irritation and skin irritation with large scale exposure or in
sensitive individuals. Product is not considered to be combustible. However, after prolonged contact
with highly porous materials in the presence of excess heat, this product may spontaneously com bust.
Handling: Avoid continued contact with skin. Avoid contact with eyes.
In any case of any exposure which elicits a response, a physician should be consulted immediately.
First Aid Procedures
Inhalation:
Ingestion:
Remove to fresh air. If not breathing give artificial respiration. In case of
labored breathing give oxygen. Call a physician.
No effects expected. Do not give anything to an unconscious person. Call a
Regenesis -3-D Microemulsion MSDS
Skin Contact:
Eye Contact:
Conditions to A void:
Hazardous
Polymerization:
Further Information:
physician immediately. DO NOT induce vomiting.
Section 6 -Health Hazard Data ( cont)
Flush with plenty of water. Contaminated clothing may be washed or dry
· cleaned normally.
Wash eyes with plenty of water for at least 15 minutes lifting both upper
and lower lids. Call a physician.
Section 7 -Reactivity Data
Strong oxidizing agents, bases and acids
Will not occur.
Hydrolyses in water to form lactic acid, glycerol and fatty acids.
Hazardous Decomposition Thermal decomposition or combustion may produce carbon monoxide
Products: and/or carbon dioxide.
After Spillage or
Leakage:
Disposal:
Section 8 -Spill, Leak or Accident Procedures
Neutralization is not required. The material is very slippery. Spills should
be covered with an inert absorbent and then be placed in a container. Wash
area thoroughly with water. Repeat these steps if slipperiness remains.
Laws and regulations for disposal vary widely by locality. Observe all
applicable regulations and laws. This material may be disposed of in solid
waste. Material is readily degradable and hydrolyses in several hours.
No requirement for a reportable quantity (CERCLA) of a spill is known.
Section 9 -Special Protection or Handling
Should be stored in plastic lined steel, plastic, glass, aluminum, stainless steel, or reinforced fiberglass
containers.
Protective Gloves:
Eyes:
Ventilation:
Storage:
Vinyl or Rubber
Splash Goggles or Full Face Shield. Area should have approved means of
washing eyes.
General exhaust.
Store in cool, dry, ventilated area. Protect from incompatible materials.
Regenesis -3-D Microemulsion MSDS
Section 10 -Other Information
This material will degrade in the environment by hydrolysis to lactic acid, glycerol and fatty acids.
Materials containing reactive chemicals should be used only by personnel with appropriate chemical
training.
The information contained in this document is the best available to the supplier as of the time of
writing. Some possible hazards have been determined by analogy to similar classes of material. No
separate tests have been performed on the toxicity of this material. The items in this document are
subject to change and clarification as more information becomes available.
Last Revised:
Supplier:
~
Hydrogen Release Compound (HRC®)
MATERIAL SAFETY DATA SHEET (MSDS)
March 23, 2012
Section 1 -Material Identification
REGENESIS
1011 Calle Sombra
San Clemente, CA 92673
Phone: [phone]
Fax:
E-mail:
Chemical Name:
Chemical Family:
Trade Name:
Product Use:
CAS#
201167-72-8
56-81-5
50-21-5
Melting Point:
Boiling Point:
Flash Point:
Density:
949.366.8090
info @regenesis.com
Propanoic acid, 2-[2-[2-(2-hydroxy-1-oxopropoxy)-1-
oxopropoxy ]-1-oxopropoxy]-1,2,3-propanetriyl ester
Organic Chemical
Hydrogen Release Compound® (HRC®)
Glycerol tripolylactate and Glycerol
Used to remediate contaminated soil and groundwater
( environmental applications)
Section 2 -Chemical Identification
Chemical
Glycerol Tripolylactate
Glycerol
Lactic Acid
Section 3 -Physical Data
Not Available (NA)
Not Determined (ND)
ND
1.3 glee
Regenesis -HRC MSDS
Solubility:
Appearance:
Odor:
Vapor Pressure:
Section 3 -Physical Data ( cont)
Acetone and DMSO
Viscous amber gel/liquid
Not detectable
None
Section 4 -Fire and Explosion Hazard Data
Extinguishing Media: Use Water Spray, Carbon Dioxide, Dry Chemical Powder or
Appropriate Foam.
Water may be used to keep exposed containers cool.
For large quantities involved in a fire, one should wear full protective clothing and a
NIOSH approved self contained breathing apparatus with full face piece operated in the
pressure demand or positive pressure mode as for a situation where lack of oxygen and
excess heat are present.
Acute Effects:
RTECS#:
Irritation data:
J:\Operations\MSDS\HRC MSDS
Section 5 -Toxicological Information
May be harmful by inhalation, ingestion, or skin absorption.
May cause irritation. To the best of our knowledge, the
chemical, physical, and toxicological properties of the glycerol
tripolylactate have not been investigated. Listed below are the
toxicological information for glycerol and lactic acid.
MA8050000
Glycerol
SKN-RBT 500 MG/24H MLD
85JCAE-,207,1986
EYE-RBT 126 MG MLD
EYE-RBT 500 MG/24H MLD
SKN-RBT 5MG/24H SEV
EYE-RBT 750 UG SEV
Page2
BIOFX* 9-4/1970
85JCAE-,207,1986
85JCAE -,656,86
AJOP AA 29,1363,46
Regenesis -HRC MSDS
Section 5-Toxicological Information (cont)
Toxicity data:
Target Organ data:
RTECS#:
ORL-MUS LD50:4090 MG/KG
FRZKAP (6),56,1977
SCU-RBT LD50:100 MG/KG
ORL-RAT LD50:12600 MG/KG
IHL-
RA TLC50:>570MG/M3/1HBIO
FX*9-4/1970 IPR-RAT LD50:
4420MG/KG
IVN-RAT LD50: 5566 MG/KG
IPR-MUS LD50: 8700 MG/KG
SCU-MUS LD50: 91 MG/KG
IVN-MUS LD50: 4250 MG/KG
ORL-RBT LD50: 27 GM/KG
SKN-RBT LD50:> l0GM/KG
IVN-RBT LD50: 53 GM/KG
ORL-GPG LD50: 7750 MG/KG
ORL-RAT LD50:3543 MG/KG
SKN-RBT LD50:>2 GM/KG
ORL-MUS LD50: 4875 MG/KG
ORL-GPG LD50: 1810 MG/KG
ORL-QAL LD50: >2250
MG/KG
NIIRDN 6,215,1982
FEPRA 7 4,142,1945
RCOCB8 56,125,1987
ARZNAD 26,1581,1976
ARZNAD 26,1579,1978
NIIRDN 6,215,1982
JAPMA8 39,583,1950
DMDJAP 31,276,1959
BIOFX* 9-4/1970
NIIRDN 6,215,1982
FMCHA2-,C252,91
FMCHA2-,C252,91
FAONAU 40,144,67
JIHT AB 23,259,41
FMCHA2-,C252,91
JIHTAB 23,259,1941
Behavioral (headache), gastrointestinal (nausea or vomiting),
Paternal effects (spermatogenesis, testes, epididymis, sperm
duct), effects of fertility (male fertility index, post-
implantation mortality).
OD2800000
Lactic acid
Only selected registry of toxic effects of chemical substances (RTECS) data is presented
here. See actual entry in RTECS for complete information on lactic acid and glycerol.
J:\Operations\MSDS\HRC MSDS Page3
Regenesis -HRC MSDS
Section 6 -Health Hazard Data
Handling: Avoid continued contact with skin. Avoid contact with eyes.
In any case of any exposure which elicits a response, a physician should be consulted
immediately.
First Aid Procedures
Inhalation:
Ingestion:
Skin Contact:
Eye contact:
Conditions to Avoid:
Hazardous
Polymerization:
Further Information:
After Spillage or
Leakage:
Disposal:
Remove to fresh air. If not breathing give artificial
respiration. In case of labored breathing give oxygen. Call a
physician.
No effects expected. Do not give anything to an unconscious
person. Call a physician immediately.
Flush with plenty of water. Contaminated clothing may be
washed or dry cleaned normally.
Wash eyes with plenty of water for at least 15 minutes lifting
both upper and lower lids. Call a physician.
Section 7 -Reactivity Data
Strong oxidizing agents, bases and acids
None known
Hydrolyses in water to form Lactic Acid and Glycerol.
Section 8 -Spill, Leak or Accident Procedures
Neutralization is not required. This material may be burned
in a chemical incinerator equipped with an afterburner and
scrubber.
Laws and regulations for disposal vary widely by locality.
Observe all applicable regulations and laws. This material,
may be disposed of in solid waste. Material is readily
degradable and hydrolyses in several hours.
No requirement for a reportable quantity (CERCLA) of a spill is known.
J:\Operations\MSDS\HRC MSDS Page4
Regenesis -HRC MSDS
Section 9 -Special Protection or Handling
Should be stored in plastic lined, steel, plastic, glass, aluminum, stainless steel, or
reinforced fiberglass containers.
Protective Gloves:
Eyes:
Ventilation:
Storage:
Vinyl or Rubber
Splash Goggles or Full Face Shield
Area should have approved means of washing eyes.
General exhaust.
Store in cool, dry, ventilated area. Protect from incompatible
materials.
Section 10 -Other Information
This material will degrade in the environment by hydrolysis to lactic acid and glycerol.
Materials containing reactive chemicals should be used only by personnel with
appropriate chemical training.
The information contained in this document is the best available to the supplier as of the
time of writing. Some possible hazards have been determined by analogy to similar
classes of material. No separate tests have been performed on the toxicity of this material.
The items in this document are subject to change and clarification as more information
becomes available.
J:\Operations\MSDS\HRC MSDS Page 5