WI0400450_DEEMED FILES_20160524

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400450
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Williams Grocery Incident #15063
Location Address
2425 US Hwy 21
Hamptonville NC
Owner
Owner Name
27020
North Carolina Department of Environmental Quality
Dates/Ever.ts
Orig Issue
5/23/2016
App Received
5/20/2016
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS .swP
5/24/2016
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
Facility Contact Affiliation
Owner Type
Government -State
Owner Affiliation
Herb Berger
1637 Mail Service Geter
Raleigh
Yadkin
Issue
5/23/2016
Effective
5/23/2016
NC 27699163
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Tuesday, May 24, 2016 9:47 AM
To: Knight, Sherri
Cc: Rogers, Michael
Subject: WI0400450 NOI DEQ/ Williams Grocery Incident tt 15063
Attachments: WI0400450 Williams Grocery NOI,pdf
Good morning,
Flease find the attached NOI.
Thank you,
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Anima! Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
s h risti. shresthauncd en r. r;ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
�'N�ztl�irty Ccmpares
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Tuesday, May 24, 2016 9:50 AM
To: '[e-mail]'
Cc: Rogers, Michael; Knight, Sherri
Subject: WI0400450 NOI RE: Williams Grocery, Incident 15063 - NOI to Construct or Operate
Injection Wells
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NCI) for the above referenced
site.
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-1s 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
httr:,' •dea.nc.Rovi about;'divisionswater-resources'water-resources-cermits:'wastewater-branch; nround-water-
nrotection; Around -water -reporting -forms
2) Injection Event Records (1ER). 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 meat Shristi.shresthagncdenr.eov 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 W10400450. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in reply to this email, as it will already have the assigned deemed permit
number in the subject line.
Thank you for your cooperation.
Shristi
Shristi R. Shrestha
I-lydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-8406 office
shristi.shrestha(Dncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
�`Nnthing Cornpares . -.
.-+. •+:1 ...,...-...r+.. �. r1.+.. n.+ �.+ -.._,4 i....., fl,in .+.►.Jr...,,. IT" n

North Carolina Public Records Law and may be disclosed to third parties.
From: Rogers, Michael
Sent: Friday, May 20, 2016 9:14 AM
To: Shrestha, Shristi R <[e-mail]>
Subject: FW: Williams Grocery, Incident 15063 -NOi to Construct or Operate Injection Wells
From: David Loftis [mailto:DLoftis @smeinc.com]
Sent: Thursday, May 19, 2016 10:51 AM
To: Rogers, Michael <michael.rogers @ncdenr.gov>
Subject: Williams Grocery, Incident 15063 -NOi to Construct or Operate Injection Wells
Good morning Michael,
Please find the attached Notice of Intent to Construct an air sparge well at the referenced site for the purposes of
conducting a pilot test for groundwater remediation.
Please contact me with any questions.
Best regards,
David R. Loftis, P.E.
Senior Engineer
S&ME
S&ME, Inc.
44 Buck Shoals Road, Unit C-3
Arden, NC 28704 . •''';l.!!
Ph: 828-687-9080 (office)
828-483-3012 (direct office)
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
LDc -41 t\i1 0,4 co tit -co
S&ME
May 19,2016
North Caroline Department of Environmental Quality
DWQ — Aquifer Protection Service
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Attention: Mr. Michael Rogers
Reference; Notice of Intent to Construct or Operate Injection Wells
Air Injection Well
Williams Grocery, UST Incident # 15063
2425 US Highway 21, Hamptonville, Yadkin County, NC
S&ME Project No. 4305-14-2398
Dear Mr. Rogers;
S&ME, Inc. (S&ME), is currently assisting the North Carolina Department of Environmental Quality
(NCDEQ) with assessment and remediation activities of State -Lead Cleanup sites. S&ME, on behalf of the
NCDEQ, submits the attached Notice of Intent to Construct and/or Operate Injection Wells to the NCDEQ,
Division of Water Quality, Aquifer Protection Section. The risk classification of the referenced UST Incident
is High based on the groundwater quality and the proximity of nearby water supply wells.
S&ME plans to install one air sparge test well (AS-1) to maximum depth of 50 feet below land surface for
the purposes of performing limited testing to determine the effects that air sparging may have on the
dissolved groundwater contaminant concentrations. The well will be constructed with approximately five
feet of slotted screen and sufficient riser casing to bring the well to approximately ground surface.
If you have any questions concerning this Notice of Intent, feel free to contact us at 828-687-9080.
Sincerely,
S&ME, Inc.
t ti
Darren
Staff Professional
0/4024Q44--
David Loftis, P.E.
Senior Engineer
Attachments:
Notice of Intent to Construct or Operate Injection Wells
Figure 1: Topographic Map
Figure 2: Benzene Concentration Contour Map (October 3, 2015)
S&ME, inc 19751 Southern Pine Boulevard I Charlotte, NC 28273 J p 704.523.4726 I f 704.525.3953 I wwwsmeinc.com

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 fo rm shall be submitted at least 2 weeks prior to ini ection.
AQUIFER TEST WELLS C1 5A NCAC 02c .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to detennine a quifer hydraulic characteristics.
IN SITU REMEDIATION O5A NCAC 02c .0225 ) or TRACER WELLS O5A NCAC 02C .0229):
1) Pas sive In jection S vstems -In-well delivery systems to diffuse injectants into the subsurface. Ex amples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale In jection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests . An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an are a that does not ex ceed 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 In jection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: May 18 2016 PERMIT NO. w.10 't 00£1-SO (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
(1)
(2)
(3 )
(4)
(5)
(6)
~X'--__ Air Injection Well ...................................... Complete sections B-F, K, N
___ Aquifer Test Well ....................................... Complete sections B-F, K , N
___ Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
___ Pilot Test. ................................................ Complete sections B-N
___ Tracer Injection Well ................................... Complete sections B-N
B. STATUS OF WELL OWNER: Federal Government
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: North Carolina Department of Environmental O ualit (attention: Mr. Herb Berner. L.G .)
Mailing Address: --~1~6~4""'-6~M~ai=n~S~e=r~vi=c~e~C~e=n=te=r ____________________ _
City: Ralei !!h State : NC Zip Code: 27699-1646 County : Wake
Day Tele No.: 919-707-8170 Cell No.: __________ _
EMAIL Address: herber.berger@ ncdenr.Qov Fax No.: ________ _
UIC/In Si tu Remed. Noti fication (Revised 11 /19/2013 ) Page I
..
D. PROPERTY OWNER (if different than well owner)
Name: Derek Shore
Mailing Address: 2424 US HWY 21
City: Ham ptonville State: NC
Day Tele No.: 701::546-3200
Zip Code: 27020 County: Yadkin
Cell No.: _______ _
EMAIL Address: -----'d=s=ho=r~e-t .... l=o=c=al=fi=rs=t--=-ba=nk=.c=o=m~--Fax No.: __ _,_7-=-04-'--=-54-'-'6'--'-3=-=2=-=0-=-5 ___ _
E. PROJECT CONT ACT -Person who can answer technical questions about the proposed injection project.
Name: David Loftis
Mailing Address: -----'4---'-4-=Bc..;u=c=k-=S=h=o=al=s -=-R=o=a=d '--'S=u=it=e--'C=------=-3------------------
City: Arden State: E_ Zip Code:_2_87_0_4_. ___ County: Buncombe
Day Tele No.: 828-483-3012 Cell No.: __ ~82~8~-3~3~7~-1~9~2-=-3 ___ _
EMAIL Address: dloftis/@ smeinc.com Fax No.: ___ 8~2~8--6~8_,_7~-8~0~0-=-3 ___ _
F. PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Physical Address: --~2=---4=2-=-5~U~S~H~W~Y~2-=-1 __________________ _
________________________ County:~Y~a=dk=in~---
City: Ham ptonville State: NC Zip Code: ~2~70=2=0~------
Geographic Coordinates: Latitude**: 36 __ 0 5 __ ' 52.11 N ___ " or 0 • ___ _
Longitude**: -80 __ 0 45_' 36.96 W __ " or __ 0 ____ _
Reference Datum: Former USTs Accuracy: ________ _
Method of Collection:~G=---o~oc...ag=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 05: 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be.::: 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
UIC/Jn Situ Remed. Notification (Revised I 1/19/2013) Page2
I.
J.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity .
INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved ir!iectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/web/wq/aps/gwpro. 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 (9 I 9-807-6496).
lnjectant: ----------------------------------
Volume ofinjectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants:
Injectant: ----------------------------------
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
lnjectant:
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
K. WELL CONSTRUCTION DAT A
(I) Number of injection wells: _____ Proposed ______ 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 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
Grout Screen Casing
Well ID Type Driller#
(ft-bis) (ft-bis) (ft-bis)
AS-I Permanent 2" Sch 40 PVC 0 -42 45 -50 0 -50 TBD
UlC!Jn Situ Remed. Notification (Revised 11/19/2013) Page 3
L. SCHEDULES — Briefly describe the schedule kir well construction and injection activities.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plan to be used to detennine
if violations of groundwater quality standards spec'slied in Suhclt.iptcr 021, result from the injection activity,
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, harder penalty a f law. that 1 aur,fuuriliar with the itrfveynaticm submitted in Ibis
document undo!! attachments thereto old that, bused on trey inquiry ofihose individuais immediately responsible
for obtaining said information. 1 believe that the inf rmatirrrr is true. accurate and complete. I am aware that
there are significant penalties, i►rrhrdhrg the passibility of fines and iinprisomnent. ,fear submitting ,false
information. I agree to construct. operate. rrrafulain, repair. and f applicable, abandon the injection will and
al4 E'1ated'o purf trees in accordance with the 15 -1 A 1i ' () 09 00 Rules."
J'
�A,Vi0 ice- LoVS
Signature of Applicant Print or Type Full tame
PROPERTY OWNER fir the property is not owned by the permit applicant):
As owner (One property r►rt which the injection n ellls) are to he constructed and operated I hereby consent to
allow the applicant in cnnslrucl each infection well as outlined in this application and agree thai it shall he the
rexponsibility rf'thc applicant to entree that the injection we(s) conform to the Wd1 Consh•uction Standards
"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 Shaul be deemed to vest ownership in the land owner. in the
absence 9t, contrary agreement in witin4g.
,-ho v.
Signature* of property Owner (if different from applicant) Print or Type Full Name
• An access agreement between the applicant and per l+at,v owner may he submitted in lieu of a signature an this form.
Submit one copy of tite completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh. NC 27699-1636
Tetephoiie: [phone]
tiiCitn Step Reined. Notification {1tevktw1 I I; I9;2013)
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SOURCE BROOKS CROSSROADS, NC
USGS TOPOGRAPHIC
MAP. 7.5-MINUTE SERIES,
DATED 2013
{vrvnv.usga.govj
SCALE 1" = 600'
GRAPHIC SCALE
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TOPOGRAPHIC MAP
WILLIAMS GROCERY
2425 V S HIGHWAY 21
HAMPTO WILLE, YADKIN COUNTY, NORTH CAROLINA
INCIDENT No 151%3
FIGURE nU

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SHELL
STATION 3•
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Refarenp7: "SITE LAYOUT MAP, FORMER WV LLIAMS GROCERY". Dy TerraqueM Ernironmerrtal CansuEaEI ,
Figure 3. dated 8RS712, and 2C10 aerial pAamQrapI COt 41ad from wrvw,naanemap cam
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•
LEGEND
t- MONITORING WELL LOCATION
- WATER SUPPLY WELL LOCATION
I23,40j • BENZENE CONCENTRATION IN ugIL
(Km) - NOT MEASURED
i — — - BENZENE ISOCONCENTRATION CONTOUR
a ug+L- 2LSTANDARD
5,00E uglL - GROSS CONTAMINANT LEVEL
EQlL - MICROGRAMS PER LfT£R
pp - FREE PRODUCT
g
GRAPI-IIC SCALE
ILO
» c
5rALE, 1-. ,LQ
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AS SHOWN
PROJECT HO.
4305-14-239A
£ AL-
OCT.2015
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BENZENE CONCENTRATION
CONTOUR MAP (OCTOBER 3, 2015)
W LLIAMS GROCERY
2425 U.S. kIGHWAY 21
HAMPTXNVILLE, YADKIN COUNTY, NORTH CAROLINA
INCIDENT Na• 15063
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