WI0400418_DEEMED FILES_20151008

Rogers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael,
Jamie Honeycutt <[e-mail]>
Thursday, October 08, 2015 3:37 PM
Rogers, Michael
Wayne Watterson; Knight, Sherri; Basinger, Corey
RE: NOi -WI0400418 Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
10765 Shumakers Injection Event Signed.pdf
Attached is the completed Injection Event Record for the TF 1075 Shumake rs Grocery site. Call if you have any
questions.
Thank you,
Jamie Honeycutt
From: Rogers, Michael [mailto:[e-mail]]
Sent: Monday, August 31, 2015 5:21 PM
To: Jamie Honeycutt <[e-mail]>
Cc: Wayne Watterson <[e-mail]>; Knight, Sherri <[e-mail]>; Basinger, Corey
<[e-mail]>
Subject: RE: NOi -WI0400418 Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for the Shumaker's Grocery
TF #10765 located at 1601 Lee's Chapel Road, Greensboro, Guilford County, NC 27455. The Central Office of the
WQROS received your complete NOi electronically on August 26, 2015.
Please note the following:
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-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/wg/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., WIOXXXXXX) that has been assigned to the injection activity at this site. This
notification has been given the deemed permit number WI0400418. 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 ply to this email. as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation
1
From: Jamie Honeycutt [mailto:[e-mail] ]
Sent: Wednesday, August 26, 2015 2:35 PM
To: Rogers, Michael
Cc: Wayne Watterson
Subject: NOI -Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10765 Shumakers Grocery located at 1601 Lee's Chapel Road,
Greensboro, (Guilford County). I will also mail a hard copy ofthe NOi to you. We plan to install 0-SOXs at one exiting
monitor well located at the site. Please give me a call on my cell (910 977-7614) if you have any questions.
thanks
Jamie T. Honeycutt
Environmental Professional
~E
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 1 OZ
Fayetteville NC 28306
Ph: 910-323-1091
Fax: [phone]
Mobile: [phone]
jhone [e-mail]
www.smeinc.com
This electronic message is subject to the tenns of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
2
INJECTION EVENT RECORD
North Carolina Department of Environment and Natural Resources — Division of Water Resources
Permit Number Wl0400418
. Permit Information
Pcrmittee
T1; 107s65Shu makers Grocery
Facility Name
1601 Lee's Chapel Rd. Greensboro. NC 27455
Facility Address
Injection Contractor Information
S&MEN Inc.
Injection Contractor / Company Name
Street Address 8646 West Market Street. #105
Greensboro
City
NC 27409
State Zip Code
( 336) 288-7180
Area code — Phone number
Well Information
Number of welts used for injection
Well names M W j
Were any new wells installed during this injection
event?
© Y ®No
If yes, please provide the following information:
Number of Monitoring Wells
Number of injection Wells
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled [] Direct -Push
❑ Hand -Augured ❑ Other (specify}
Please include a copy of the GW-1 form for each
well installed
Were any wells abandoned during this injection
event?
❑Yes ®No
If yes, please provide the following information!
Number of Monitoring Wells
Number of Injection Wells
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
0-SOX• ['Alcium Peroxide, Calcium Hydroxide
Injectant Type (solid)
Concentration 1 40 mgfL at ajec ion point
lfthe injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected i sock (2" x
Volume Injected per well 1 sock in MW-1
Injection History
Injection date(s) 9-17-76l 5
Injection number (e.g. 3 of 5) 1
Is this the last injection at this site? (unknown)
❑ Yes ❑ No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED Wil H IN THE
STANDARDS is4JD OUT IN THE PERMIT.
Oar SL w co(
-�7iQ
SIGNATURE OF INJECTION CONTRACTOR DATE
.G�jrurpx (SkMP Jnr -Agent for Nt_fFNR)
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center. Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-1ER
Rev. 8/5/2013

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400418
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Shumaker's Grocery TF #10765
Location Address
1601 Lee's Chapel Rd
Greensb,oro NC
Owner
Owner Name
Sharon
Dates/Events
Orig Issue
8/31/2015
App Received
8/26/2015
Re g ulated Activities
Groundwater remediation
Outfall
Waterbody Name
27455
Ghiold
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/9/2015
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
Individual
Owner Affiliation
Sharon Ghiold
Geologist
NCDENR -Dwm Ust Section
Raleigh
Issue
8/31/2015
Effective
8/31/2015
NC 27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Ro gers, Michael
From: Ryals, Scott
Sent:
To:
Wednesday, September 02, 2015 4:25 PM
Ghiold, Sharon
Cc:
Subject:
Rogers, Michael; Michael Pfeifer ([e-mail]); [e-mail]
RE: General statement authorizing S&ME to be our agent for O-Sox NOls
Hi Michael,
I am fine with do this. What do you need from me for this to happen?
From: Ghiold, Sharon
Sent: Wednesday, September 02, 2015 1:31 PM
To: Ryals, Scott
Cc: Rogers, Michael; Michael pfeifer ([e-mail]); aq uarles @smeinc.com
Subject: General statement authorizing S&:ME to be our agent for O-Sox NOis
Scott,
Michael Rogers with UIC asked us to provide him with a general authorization for S&ME to act as our agent for the NOls
to install O-Sox at our State-Lead Cleanup sites. I explained that we are testing the product at about 10 sites, and after
evaluating their effectiveness, decide .if we want to continue using them.
Thanks!
Sharon Ghiold, Geologist
NCDENR, Division of Waste Management
Underground Storage Tank Section, Trust Fund Branch
1646 Mail Service Center, Raleigh, NC 27699-1646
Phone and Fax number is 919-707-8166
http ://portal.ncdenr.org/web/wm/
[e-mail]
Email correspondence to and from this address is 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.
1
Rog ers, Michael
From:
Sent:
To:
Cc:
Subject:
Rogers, Michael
Monday, August 31, 2015 5:21 PM
'Jamie Honeycutt'
Wayne Watterson; Knight, Sherri; Basinger, Corey
RE: NOi -WI0400418 Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) for the Shumaker's Grocery
TF #10765 located at 1601 Lee's Chapel Road, Greensboro, Guilford County, NC 27455. The Central Office of the
WQROS received your complete NOi electronically on August 26, 2015.
Please note the following:
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 G~oprobe 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 po•nts in the Comments/Remarks section of form. These forms can be found on
our website at http://po;tal.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 WI0400418. 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
From: Jamie Honeycutt [mailto:[e-mail]]
Sent: Wednesday, August 26, 2015 2:35 PM
To: Rogers, Michael
Cc: Wayne Watterson
Subject: NOI -Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent (NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10765 Shu makers Grocery located at 1601 Lee's Chapel Road,
Greensboro, (Guilford County). I will also mail a hard copy of the NOi to you. We plan to install O-SOXs at one exiting
monitor well located at the site. Please give me a call on my cell {910 977-7614) if you have any questions.
thal'lks
1
Jamie T. Honeycutt
Environmental Professional
:$S&M E
ENGINEERING INTEGRITY.
S&ME , Inc.
409 Chicago Drive, Suite 1 0
Fayetteville NC 28306
Ph : 910-323-1091
Fax: [phone]
Mobile : [phone]
[e-mail]
www.smeinc.co m
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments . Please consider the environment before printing this email.
2
Rogers, Michael
From:
Sent:
To:
Subject:
Attachments:
Please find attached a NOi.
Rogers, Michael
Monday, August 31, 2015 5:17 PM
Knight, Sherri; Basinger, Corey
FW: NOi -WI0400418 Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
NOi TF 10765 Shumakers Grocery In Situ Remediation Notification-2015-8-26.pdf
From: Jamie Honeycutt [mailto:[e-mail]]
Sent: Wednesday, August 26, 2015 2:35 PM
To: Rogers, Michael
Cc: Wayne Watterson
Subject: NOI -Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
Michael,
As discussed earlier, attached is the electronic copy of the Notice of Intent {NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10765 Shu makers Grocery located at 1601 Lee's Chapel Road,
Greensboro, {Guilford County}. I will also mail a hard copy of the NOi to you. We plan to install O-SOXs at one exiting
monitor well located at the site. Please give me a call on my cell (910 977-7614} if you have any questions.
thanks
Jamie T. Honeycutt
Environmental Professional
~~ME
ENGINEERING INTEGRITY.
S&ME , Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306
Ph: 910-323-1091
Fax : [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc .com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments . Please consider the environment before printing this email.
1
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael,
Jamie Honeycutt <J [e-mail]>
Wednesday, August 26, 2015 2:35 PM
Rogers, Michael
Wayne Watterson
NOi -Injection Well Operation-TF 10765 Shumakers Grocery-Guilford Co
NOi TF 10765 Shumakers Grocery In Situ Remediation Notification-2015-8-26.pdf
As discussed earlier, attached is the electronic copy of the Notice of Intent {NOi) to Operate Injection Wells at a
NCDENR, UST Section, State Lead Site identified as TF 10765 Shumakers Grocery located at 1601 Lee's Chapel Road,
Greensboro, (Guilford County). I will also mail a hard copy of the NOi to you. We plan to install O-SOXs at one exiting
monitor well located at the .site. Please give me a call on my cell (910 977-7614) if you have any questions.
thanks
Jamie T. Honeycutt
Environmental Professional
♦S&ME
ENGINEERING INTEGRITY.
S&ME, Inc.
409 Chicago Drive, Suite 107
Fayetteville NC 28306 ~
Ph : 910-323-1091
Fax : [phone]
Mobile : [phone]
[e-mail]
www .smeinc.com
This electronic message is subject to the te rms of use set forth at www.sme inc.com/ernail. If you received this message. in error please advise the
sender by re ply and delete this electronic message and any attachments . Please consider the environment before printing this email.
1
S&ME
August 28, 2015
North Carolina Department of Environment and Natural Rescources
DWR UIC Program
1636 Mail Service Center
Raleigh, NC 27699
Reference: Notification of Intent
To Whom It May Concern:
Please find enclosed Notices of Intent to Constrict or Operate Injection Wells for the following IF sites:
29194-02, 10765-02, 17393, and 7904-02. An electronic copy of each package was sent to Mr. Michael
Rogers, of the NCDENR, on August 26, 2015.
Sincerely,
5&ME, Inc.
&jjJ.
ennifer Powers Crank
Administrator, Environmental Department
S&ME, Inc_
RECE!VEDIOENFIDW
SEA-2205
Water quality Regional
Aerations Section
5& ldPF: A$W' l'$bsk13,90 iliokftbit,'PQA§I6 113 g11504tcailiff9J
061.MirAiWinPr1@tn m

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 15A NCAC 02C .0200. This form shall be submitted at least 2 weeks prior to iniection.
AQUIFER TEST WELLS 0 5A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION {1 5A NCAC 02c .0225) or TRACER WELLS 0 5A NCAC 02c .0229):
1) Passive Injection Systems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale Injection Operations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air lniection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submi«ffeC!ftE:ff!O'tRk!Ow'R mplete.
DATE: Augu st 26 , 2015 PERMIT NO. l.. J!;0'-f OO 41~ (to be filled in by DWR)
-SEP -2'2015
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TE :tY\':Oater Qtit:allty Regional pera ions Section
(1) ___ Air Injection Well ...................................... Complete sections B-F, K, N
(2) ___ Aquifer Test Well ....................................... Complete sections B-F, K, N
(3) X __ Passive Injection System ............................... Complete sections B-F, H-N
(4) ___ 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: State Government
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Sharon Ghiold. NCDENR. DWM. UST Section
Mailing Address: 1637 Mail Service Center
City: Ralei gh State: NC Zip Code: 27699 County:_W'-'-=ak=e~------
Day Tele No.: 919-707-8166 Cell No.: __________ _
EMAIL Address: Sharon.gh iold@ ncdenr.gov FaxNo.: __________ _
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page I
D. PROPERTY OWNER (if different than well owner)
Name: Virenda Sethiya
Mailing Address: 33 Holly Sprin gs Lane
City: Greensboro State: NC Zip Code:=27-'-4-=5=5 ____ County: Guilford
Day Tele No.: 336-601-0404 Cell No.: _________ _
EMAIL Address:______ Fax No.: __________ _
E. PROJECT CONTACT-Person who can answer technical questions about the proposed injection project.
Name: Jamie T. Honeycutt (S&ME . Inc.}
Mailing Address: 409 Chicago Drive. Suite 107
City: Fayetteville State: "'-'N-=-C-Zip Code: 28306 County: Cumberland
Day Tele No.: 910-323-1091 Cell No.: 910-977-7614
EMAIL Address: jhone [e-mail] Fax No.: ________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 1601 Lees Chapel Road
County: Guilford
City: Greensboro
(2) Geographic Coordinates: Latitude**:
Longitude**:
State: NC Zip Code:._2=-7'--'4=5=-5 _____ _
___ 0 ____ "or35_0 .142658
0 __ " or79_0 .770317
Reference Datum: ________ Accuracy: ________ _
Method of Collection:._G=o=o-g-=le~E=art=h~---------
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ .square feet
Land surface area of inj. well network: square feet(::: 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be .:S 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
UICI In Situ Remed. Notification (Revised 3/2/2015) Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -Provide a brief narrative regarding the
purpose, scope , and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
A release of easoline from a former under ground storag e tank system located on the pro pe rty has im pacted
gr oundwater above the 15A NCAC 2L .0202 groundwater quali ty standards. One monitor well {MW-1 ) is
located on the site. A private water su pp ly well is located within 250 feet of the release. The use of O-SOX
(Calcium peroxide or EHC-O chemical ) using MW-1 is planned to enhance the de gr adation of petroleum
contaminant levels in the groundwater to below the 2L Standards.
J. INJECTANTS-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
http://portal.ncdenr.org/weblwq/aps/gwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Hwnan Services . Contact the UIC Program/or more info (919-807-6496).
lnjectant: Calcium Peroxide in solid form . by sock of chemical in monitor well , for oxyg en
Volume of injectant: __ V-'--'ar=ie=s,_. b"'""y.__d=i=ffu=si=o=n-=--. -=-1-'-'. 7--"5--=l=b-=E=H=C=a..-..... O"--=or,_0=·=26=2=5 ..... l=b-'O=x=y=g=e=n-"p=e=-r w-'-'-=-el=l __ _
Concentration at point of injection: ---'1'"""0 __ -4 ___ 0---=m=g/L"'-=--------------
Percent if in a mixture with other injectants: Calcium peroxide <75%. Calcium H vdroxide <25%
Injectant: --------------------------------
Volume of injectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
lnjectant: --------------------------------
Volume ofinjectant: ___________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: ---------'Proposed. __ ---=l~ __ Existing (MW-1)
(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 same construction details. Well
construction details shall include the following:
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
(c) well contractor name and certification number
UIC/Jn Situ Remed. Notification (Revised 3/2/2015) Page3
Well
��
Grout
! ft-1)1st
Screen
t ft-bls)
Casing
(ft-bis)
Well Contractor
Cert#
MW-1
Permanent
, 0-5.5
y _
9.5-19.5
0-9.5
Probe Techrtolag\
4196-8
Well Construction Record is Attached.
L. SCHEDULES - Briefly describe the schedule for well construction and injection activities.
Monitoring well MW-1 was installed in Feb. 2013. Passive oxs en releasinb O-SOX will be placed into the
existing well following receipt of the notification permit number from NCDENR.
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.
The injection of ox\gen is not expected to result in violations of the 2L Standards. The monitor well will be
sampled on a reeular basis and additional O-SOXs installed Lasper NCDENR) This be followed b.post-
remediation sampling without oxen infusion to check for rebound of contaminant levels.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby cent ifir. under penalty of law, that 1 am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiryofthose individuals immediately responsible
for obtaining said information, 1 believe that the information is true, accurate and complete. 1 am aware that
there are significant penalties. including the possibility of fines and imprisonment, jar submitting false
irlfarmation. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the I SA NCAC pc' 0200 Rules."
7 y �i fit, Ik �n'< Six i.]�li}i �.1h'� Jamie T. Hone% cuff i S&ME, Inc.
Signature ofApplkanl � 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 wells) are to be constructed and operated, 1 hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it .shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(l5A 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 agreement with Virenda Sethiva dated August 26. 2015
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 ofa signature on this form.
Submit the completed notification package to:
DWR — UIC Program
1 636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
U]Clln Sffu Remed. Notification (Revised 3/2/2015) Page 4

MYIYT- I
1 ■ ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
John Allen
Well Contractor (Individual) Name
Probe Technology, Inc.
Well Contractor Company Name
P 0 Box 1369
Street Address
Concord, NC 28026
City or Town
( 704 ) 933-5538
Area code Phone number
2. WELL INFORMATION:
State Zip Code
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applirablel MW-1
3. WELL USE (Check One Box) MonitorinXX Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery 0 Injection ❑
Irrigation0 Other ❑ (list use)
DATE DRILLED 2-21-13
4. WELL LOCATION:
1601 i,ee's Chapel Road
(Street Narne, Numbers, Community, Subdhrision, Lot No., Parcel, Zlp Code)
CITY: Greensboro COUNTY Guilford
TOPOGRAPHIC 1 LAND SETTING: (check appropriate box)
0 Slope ❑ Valley )fiat ❑ Ridge ❑ Other
LATITUDE N 36 a 8. 33.50 " DMS OR OD
LONGITUDE W 79. 46. 13.34 - DMS OR DD
Latitude/longitude source: )(MPS []Topographic rnap
(location of well must be shown on a USGS Sopa map andattached to
this /orrn If not using GPS)
5. FACILITY (Name of the business where the well is located.)
Shumaker's Grocery
Facility Name
1601 Lee's Chapel Road
Street Address
Greensboro, NC
Facility ID# (if applicable)
City or Town
NC DENR Attn: Sharon Ghiold
Contact Name
1637 Mail Service Center
State Zip Cade
Mailing Address
Raleigh, NC 27699
City or Town
State Zip Code
( 919 ) 733-1319
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 19.5
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOV
c. WATER LEVEL Below Top of Casing: _
(Use "+" if Above Top of Casing)
FT-
4196-B
d. TOP OF CASING IS 0 FT. Above Land Surface*
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST_
f. DISINFECTION: Type Amount
g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top _ _ - Bottom
Top Bottom
Top _ Bottom
Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 Bottom 9.5 Ft. 2 inch schd.40 PVC
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom 5,5 Ft. portland
Top 5.5 Bottom 8 Ft bentonite
Tap - Bottom FL
9. SCREEN: Depth
Top 9.5 Bottom
Top Bottom
Top Bottom
Method
pour
pour
Diameter Slot Size Material
19.5 Ft. 2 in. 0.010 in PVC
Ft. in. in.
Ft. In. in.
1S. SAND/GRAVEL PACK:
Depth Size Material
Top 8 Bottom 19.5 Ft, #2 silica
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
1
- f
12. REMARKS:
Formation Description
See Geologist notes
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
SIGNATURE OF CERTIFIED WELL CONTRA[:
John Allen
2-26-13
DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Forrn GW-lb
Submit within 30 days of completion to: Division of Water Quality - information Processing, Rev. 2/09
1617 Mall Service Center, Raleigh, NC 27699-161, Phone : [phone]

O:1PROJECTS12614W3O5-14-118LCAD\A4498.dwn FFG4. 8/1912O14 1:41:39 PM.
R UST LOCATIONS
LEGEND
MONITOR WELL LOCATION
(78.94) GROUNDWATER ELEVATION
GROUNDWATER MEASURED JUNE 20, 2014
IMAGE SOURCE: NC ONEMAP, DATED 2010
GRAPHIC SCALE
20 0 10 20 40
(INFEET )
A-4496
SCALE. 1" 40'
RATE AUG. 2014
DRAWN BY BTR
PROJECT NO.
4305-14-118
$S&ME
WNW.SMEINC.COM
NC ENGINEER LICENSE lF-0176
3201 SPRING FOREST RD. RALEIGH, NC 27616
GROUNDWATER ELEVATION MAP
SHUMAKER'S GROCERY TF #10765
1601 LEE'S CHAPEL RD
GREENSBORO, NORTH CAROLINA
FIGURE N0.
4

6
LL
6
m
0
N
L.)
3
PROJECT ND:
o ` 4305-14-118
FO • R UST LOCATIONS'
MW-1
Diisopropyl Ether *87.8
Methyl tent -butyl ether *2,710
LEGEND
MONITOR WELL LOCATION
*INDICATES EXCEEDENCE OF 2L STANDARD
GROUNDWATER SAMPLED JUNE 20, 2014
IMAGE SOURCE: NC ONEMAP, DATED 2010
GRAPHIC SCALE
20 0 10 20 40
( IN FEET )
A-4497
SCALE. 1 " = 40'
DATE' AUG.2014
DRAWN BY: BTR
S&ME
?WM.' n.1FINC.COM
NC ENGINEER LICENSE #F-0176
3201 SPRING FOREST RD, RA—LLEIGH, NC 27618 I
GROUNDWATER CONSTITUENT MAP
SHUMAKER'S GROCERY TF #10765
1601 LEES CHAPEL RD
C,RPPAIRRCIRC) A3f7RT1--1 f.ARCII I1VA
FIGURE NU.
5

e
R UST LOCATIONS �.
I ether- 20 ug1L - \
ether 70 ug/L
PAW-1
LEGEND
s MONITOR WELL LOCATION
ug/L - MICROGRAMS PER LITER
GRAPHIC SCALE
DIISOPROPYL ETHER 2L STANDARD 70 ug/L 20 0 10 20 40
MTBE (METHYL TERT-BUTYL ETHER) 2L STANDARD 20 ug/L
(IN FEET)
IMAGE SOURCE: NC ONEMAP, DATED 2010
A-4498
SCALE: 1 ii = 40'
DATE AUG.2014
DRAWN BY: BTR
PROJECT NO
4305-14-118
S&ME
WWW.SMEINC.COM
NC ENGINEER LICENSEI/F-0176
3201 SPRING FOREST RD, RALEIGH, NC 27616
MTBE & DIPE ISOCONCENTRATION MAP
SHUMAKER'S GROCERY TF #10765
1601 LEES CHAPEL RD
GREENSBORO, NORTH CAROLINA
FIGURE NO.
6
J

ADVENTUS
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Safety Data
MATERIAL SAFETY DATA SHEET:
O-SOXTM Page: I of 6
[. PRODUCT IDENTIFICATION: O-SOXTi,t
PROIHICI' USE:
MANUFACTURER:
Adyentus Americas Inc.
2871 W. Forest Rd.. Suite 2
Freeport. 11.
61032
Sail and water treatment.
EMERGENCY PHONE:
Office Hours: 815-235-35113
After Hours: 815-2 35-i5fl
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid. n.o.ti. (Calcium Peroxide). Class 5.1, PC II, UN 1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
I ngredietits
Calcium Peroxide
Calciimi i-lydre,xiile
3. PHYSICAL. DATA
Chemical Formula
CaO,
CatOli )2
FOR CHEMICAL EMERGENCY
Spill, Leak. Fire Exposure or Accident
Call 1NFOTRAC - 24-Hour Number:
1-8OO 535-5053
Outside of the United States Cali 24-Hour Number:
OO1-352-323.34O8
CAS No. Percentage
1305-79-e) 45%-70%
13O -62-o -- td1 2[;tr e
Appearance White & brown granules
Physical state Solid
Odor threshold None
Bulk Density_ 500-650g/L
Solubility in Water insoluble
pH — I I
Decomposition Temperature Set r accelerating decomposition with nxyeeri release shirting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent. contact midi other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensities fire. This product also contains erys1:tlline silica. Long tern
exposure In hazardous leveiti Of silicas dusts can cause lung disease lsi]icositil. The World Health
Organization had indicated that there is limited evidence that crystalline silica is carcinogenic to hum:uis.
but the N1TP and OSHA have not classified this ingredient as carcinogenic.
Potential Health Meets:
• General irritating to mucous membrane and eyes.

(74)ADVENTUS
Nino,1+qwutr Snrl. S..eluruxrt,:uH1 i•rplvow2rtt'r
Rei;k nanr r 1003r}f Vehlft'S
Safety ;,Data
MATERIAL SAFETY DATA SHEET:
0-SOX'r"' Page: 2 of 6
• I nhul.ttiun, Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
• Lye canto.) May cause irritation to the eyes; Risks of serituts or permanent eye
lesions.
• Skin contact ,,. May cause skin irritation.
• Ingestion irritation of the mouth and throat with nausea and vomiting.
5. FIRST AM MEASURES
• f 0110I iliim IPemc ve affected person to fresh in. Seek nit:div a! attention if effect.,
persist.
• I y4 ct'+ntnct Flush eyes with running water for at ;east 15 minutes with eyelid
held open, Seek specialist advice.
• Skin contact Wash affected skin with soap and mild detergent and large amount; of
water.
• ingestion If the person iti conscious and nut convulsing. Life 2-4 cupfuls ttl'
water to dilute the chemical and seek medical .attention immediutttti
Do not induce vomiting.
6. FIRE FICNT1Nt: MEASURE
Flash Paint
• Not applicable
Flammability
• Not applicable
Ignition 'I'emperattrre
• Noi applicable
Danger o1' Explosion
• Non -explosive
Extinguishing Media
• Water
Fire Hazards
• Oxitli,.e.r. Storage vessels involved in a fire may vent gaff or rupture title to internal pressure.
❑:mip material may decompose exothermically and ignite combustibles. Oxygen release due it►
exothermic: decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents. acids, bases.

ADVENTUS
Prom,:1f SIR N.xtrnwr1P. woi [401010kWit If
krxYh+e'harr+klhi itor
Safety -Data
MATERIAL SAFETY DATA SHEET:
O-SOXI'm Page: 3 of r,
combustible (wood. papers, cloths etc.) Thermal decomposition releases oxygen;sad heat.
Pressure bursts may occur due to gals evolution. Pressurization if confined when heated or
decontposinf;. Containers may burst violently.
Fire Fighting Measures
• Evacuate all nun -essential personnel
• Wear protective clothing and self-contained breathing apparatus.
• Remain upwind of fire to avoid hazardous vapors and decomposition products.
• Use water spray to cool floc- exposed containers.
7. ACCIDENTAL. RE 1.i.ASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers For disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper. nil,.
etc.), 17n not return product to container because of risk of contamination.
S. HANDLING AND STORAGE
Storage
• Oxidizer. Store in a cool. well -ventilated area away from all source ;if ignition and out of direct
sunlight. Store in a dry location away front heat.
• Keep away from incompatible materials. Keep containers tightly closed. Dee not store in
unlabeled or mislaheleti containers.
• Protect lion moisture. Do not store near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Stole separately from organics and reducing materials. Amid cont,tnriruuion that tnay lead ut
cleccutlpnsitittn.
Handling
• Avoid contact with eyes, skin. and clothing, Use with adequate ventilation.
• Do niit swallow, Avoid breathing vapors. mists. or dust. Do not can, drink, or smoke in work
area.
• Prevent contact with combustible or organic materials.
▪ Label containers and keep them tightly closed when not in use.
• Wash thoroughly alter handling.
9. EXPOSURE CONTROLS/PERSONAL PROTECTION

ADVENTUS
rains.; "...II, 1i c! rrrcrir..,+�i� t ,i+rrxasttititrnr r
R0morhat;,ri lel IP iail,i ij c
Safety ,IrData
MATERIAL SAFETY DATA SHEET:
OSOXTM Page: 4 of t�
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, proicess enclosures or other
engineers commis may be needed to maintain airborne levels below recommended exposure Iiniitk,
Amid creating dust or Wrist. Maintain adequate ventilation. Do not use in closed or confined
spaces_ Keep levels below exposure limits, To determine exposure limits_ monitoring should he
performed regularly.
Respiratory Protectitut
• For many condition, no respiratory protection may be needed, however. in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator_
Eye/Face Protection
• Wear chemical safety goggles and a full Face shield while handling this product.
Skin Protection
• Prevent contact with This product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC. neoprene or rubber)
Other Protective Equipment
• Eye -wash statism
• Safety shower
• Impervious clothing
• Ituhher bouts
General Hygiene Considerations
• Wash with soap and water before meal times and at the end of each work %hilt. Good
manufacturing practices require gross amounts of any chemical removed fi4nm skin as $oon ar
practical, especially before eating, or stroking.
lli. STABILITY AND REACTIVITY
Stability
• Stable under normal conditions
Condition to Avoid
• Water
• Acids
• Bases
• Salle of Iraq Melt&
• Reducing agents
• Organic materials
• Flammable suhrttutees
Hazardous Decumptrsitinn Products
• Oxygen vvhich supports combustion
11_ TOXICOLOGICAL INFORMATION

ADVENTUS
1'rrnrr,r 1+ut .drhl a uivnriftvr',rry
Safety Data
MATERIAL. SAFETY DATA SHEET:
a-SOXT' 1
Page: 5 of 6
• I-1D5OOr;il: Min.200[] ntg/kg. rat
• 1..I]50 Dermal: Min. 20OOntg/kg, rat
• I_D50Inhalation: Min. 4580 inn/kg. rat
12. ECOLOGICAL INFORMATION
Eentnxicalrgiea1 Information
• Hazards for the environment is !united due to the product prnpertie.s411. Ill) hioacc:umulation. weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical Properties oxygen is released into the enviE rinn
13. DISPOSAL. CONSIDERATIONS
Waste Treatment
• Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations,
Package Treatment
• The cinpty and clean containers are to be recycled or disposed of in cnnInrinily with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Class: 5.1
• Lahels:5.I (Osidizerl
• Packing Group: II
1S. REGULATORY INFORMATION
• SARA Section Yes
• SARA (3131 Chemicals No
• EPA TSCA hnventtirt Appears
• Canadian WHM]S Classification C,1328
▪ Canadian DSl_ Appears
• EINECS inventory Appears
16. PREPARATION INFORMATION
Prepared By: Kerry ]3nlanos-Shaw
Adventuti Remedi;itinn Technologies
1345 Fewster Drive
Mississauga. Ontario
1.411tr 2A5
Date Prep./Rev:
Print I)ate:
Phtine:
Fax:
1/3/07
1 /3107
905-273-5374
905-273-4367

Sharon Ghiold
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Ghiold:
RE: Site Access Agreement
Shumaker's Grocery (aka Davis Country Store)
1601 Lee's Chapel Road
Greensboro, Guilford County, NC (WSRO)
STF #10765, Facility ID 0-026457
Risk/Rank: High H157D
I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby pennit the Department of Environment and Natural Resources (Department) or its
contractor to enter upon said property for the purpose of conducting an investigation of the
groundwaters under the authority ofG.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 surrounding 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 infonnation 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 Department 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.
Shumaker's Grocery
TF #10765
August 26, 2015
Page 2
I/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.
i Sal h.Iy
Signature
Viet �d
Type/Print Name of Owner or Agent
336 5139a6 336C'est oL -Lr
Phone Number
1 K6 t,1 T C 4 L t C-st hie
Addreth
CF-4423:0-..267t. ?V C. 4.7'i
City/State/Zip Code
_ R6 )..R0 g
Date
s