WI0400454_DEEMED FILES_20160818

• D~
North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400454
Were any wells abandoned during this injection
1. Permit Information event?
Cemex Construction Materials . Inc.
Permittee
Fonner Cemex Colfax Plant -Incident No. 7196
Facility Name
3415 Sand y Ridge Road . Colfax, Guilford Co., NC
Fllcility Address (include County)
2. Injection Contractor Information
EnviroTrac Ltd.
Injection Contractor I Company Name
Street Address 7343 W. Friendl y Ave. Suite J
Greensboro NC 27410
City State Zip Code
(336 ) 763-6025
Area code -Phone number
3. Well Information
Number of wells used for injection--=2 ____ _
Well IDs MW-12 and MW-13
Were any new wells installed during this injection
event?
D Yes t8l No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells _______ _
Type of Well Installed (Che_ck applicable type):
D Bored · -D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please inclllde a copy of tlie GW-1 form for each
well installed
D Yes t8l No
If yes, please provide the following infonnation:
Number of Monitoring Wells ------
Number oflnjection Wells _______ _
Ple<tw• include u cnpy nf the GW-Jfl for euch well
abandoned.
4 . Injectant Information
Oxyg en gas
lnjectant(s) Type (can use separate additional sheets
if necessary
Concentration 53 to 60 pp m dissolved in water
If the injectant is diluted please i_ndicate the source
dilution fluid.~N....,_._A,,__ __________ _
Total Volume Injected (gal) Continuous passive gas
injection
Volume Injected per well (gal).-"N_,_,A'-'---------
5. Injection History
Injection date(s) Continuous injection started
8/17/16
Injection number(e.g. 3 of5)...:.N..:..:Ac..:.._ _____ _
ls this the last injection at this site?
D Yes t8l No
l DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
SrtflDAR LAID OUT IN THE PERMIT.
~ ~}ig tla
:cTION CONTRACTOR
PRI
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-IER
Rev. 3-1-2016
TABLE 5: SUMMARY OF MONITORING WELL AND GROUNDWATER ELEVATION DATJ!
SAMPLE ID MW-1 MW-2 MW-7 MW-9 MW-12 MW-13 MW-14 MW-15 MW-166
U) Top of Casing 99.60 100.00 101.19 100.57 101.22 101.37 100.38 99.82 101.68 z
0
~ Top of Screen 83.60 85.00 86.19 -104.43 86.22 89.37 85.38 84.82 86.68
w Bottom of ..J 68.60 70.00 71.19 -119.43 71.22 74.37 70.38 69.82 71.68 w Screen
Well depth L 31 30 30 220 30 27 30 30 30
Measure Date
09/01/01
Depth ~ 22.23 NM 21.52 30.36 26.01 19.24 21.83 dry ----
Elevation 77.37 -79.67 70.21 75.21 82.13 78.55 - -
03/02/02
Depth~ 20.74 NM 22.42 30.98 22.31 FP 21.49 21.17 -
Elevation 78.86 -78.77 69.59 78.91 -78.89 78.65 -
02/10/03 Depth'' 19.72 NM 21.35 30.79 21.30 21.40 20.45 19.82 ---Elevation 79.88 -79.84 69.78 79.92 79;97 79.93 80.00 -
03/04/04 Depth " 16.67 NM 17.94 NM 18.19 18.31 NM NM ----Elevation 82.93 -83.25 -83.03 83.06 - --
12/07/07
Depth s 19.50 NM 21.18 NM 21.05 21.15 20.23 19.87 -
Elevation 80.10 -80.01 -80.17 80.22 80.15 79.95 -
06/03/08
Depth ~ 18.84 NM NM NM 20.43 20.51 19.65 19.05 -
Elevation 80.76 -- -
80.79 80.86 80.73 80.77 -
12/30/08
Depth ~ 20.02 NM NM NM 21.68 21.75 20.85 20.32 21.56 --
Elevation 79.58 -- -
79.54 79.62 79.53 79.50 80.12
06/26/09 Depth ' 18.59 NM 20.42 NM 20.22 20.25 19.44 NM NM
Elevation 81.01 -80.77 -81.00 81.12 80.94 - -
01/06/10 Depth ' 18.51 19.30 20.29 NM 20.12 20.15 19.34 18.70 20.15
Elevation 81.09 80.70 80.90 -81.10 81.22 81.04 81.12 81.53
07/08/10 Depth ' 16.84 17.56 18.71 NM 18.44 18.49 17.63 NM 18.25 -Elevation 82.76 82.44 82.48 -82.78 82.88 82.75 -83.43
01/21/11 Depth 17.81 18.33 19.38 NM 19.40 19.48 18.63 NM 19.67
Elevation 81.79 81.67 81.81 -81.82 81.89 81.75 -82.01
06/30/11 Depth ' 17.29 17.99 19.24 NM 18.86 18.95 18.09 NM 18.71
Elevation 82.31 82.01 81.95 -82.36 82.42 82.29 -82.97
11.990018.00
© 2016 EnviroTrac Page 1 of 2 May 2016
TABLE 5: SUMMARY OF MONITORING WELL AND GROUNDWATER ELEVATION DATJ
SAMPLE ID MW-1 MW-2 MW-7 MW-9 MW-12 MW-13
~rn Top of Casing 99.60 100.00 101.19 100.57 101.22 101.37 z
0 --~ Top of Screen 83.60 85 .00 86.19 -104.43 86.22 89.37
w Bottom of .J 68.60 70.00 71.19 -119.43 71.22 74.37 w Screen
Well depth ~ 31 30 30 220 30 27
Measure Date
02/10/12 Depth ' 17.64 18.49 19.33 18.54 19.41 19.46 -
Elevation 81.96 81.51 81.86 82.03 81.81 81.91
11/29/12 Depth ' 18.38 18.90 19.75 NM 19.75 19.93
Elevation 81.22 81 .10 81.44 -81.47 81.44
08/29/13 Depth ' 16.40 16 .97 18.43 NM 18.01 18.06 ---
Elevation 83.20 83 .03 82.76 -83.21 83.31
12/17/13 Depth' 17.15 17.41 19.53 NM 18.73 18.75
Elevation 82.45 82.59 81.66 -82.49 82.62
06/04/14 Depth' 15.68 16.43 17.62 NM 17.28 17.28
Elevation 83.92 83.57 83.57 -83.94 84.09
05/06/15 Depth 16.97 18.33 18.61 27 .10 18.61 18.74
Elevation 82.63 81.67 82.58 73.47 82.61 82.63
10/07/15 Depth 18.06 18.90 19.93 28.38 19.65 19.79
Elevation 81.54 81.10 81.26 72.19 81.57 81.58
04/14/16 Depth 18.16 16.68 18.07 25.93 17.80 17.92 --81.44 Elevation 83.32 83.12 74.64 83.42 83.45
NOTES:
1Elevations resurveyed on 12/14/12 from temporary benchmark (MW-2) assigned an arbitrary elevation of 100 feet
2 Depth of well measured from land surface (feet)
3Depth of water measured from top of casing by Engineering Tectonics (feet)
4Depth of water measured from top of casing by Trigon (feet)
5Depth of water measured from top of casing by Trigon I Kleinfelder (feet)
6 Monitoring well MW-16 installed on December 29, 2008 by Trigon I Kleinfelder
7Depth of water measured from top of casing by Kleinfelder (feet)
FP = Free Product
NM = Not measured
11.990018.00
© 2016 EnviroTrac Page 2 of 2
MW-14 MW-15 MW-166
100.38 99.82 101.68
85.38 84.82 86.68
70.38 69.82 71 .68
30 30 30
18.60 NM 19 .02
81.78 -82.66
19.08 18.50 19.20
81.30 81.32 82.48
17.23 NM 18.06
83.15 -83.62
17.88 NM 18.08 -82.50 -83 .60
16.52 NM 17.75
83 .86 -83 .93
17.74 17.21 18.33
82.64 82.61 83 .35
18.70 18.49 19.28
81.68 81.33 82.40
16.95 17.60 18.07 -83.43 82.22 83 .61
May 2016
Per:nit f'4t:mber
Program Category
Deemed Ground Water
Permit Type
WI0400454
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
sh ri sti . sh restha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Cemex Colfax Plant Incident# 7196
Location Address
7343 W Friendly Ave Ste J
Colfax
Owner
Owner Name
Cemex
Dates/Events
NC
Orig Issue
7/18/2016
App Received
7/13/2016
Reg ulated Activities
Groundwater remediation
Outfall
Waterbody Name
27235
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
7/18/2016
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Denise Corrales
3820 Northdale Blvd
Tampa
County
Guilford
FL
Issue
7/18/2016
Effective
7/18/2016
33624
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent Monday, July 18, 2016 10:50 AM
To: 'Christopher Hay, EI, RSM'
Cc: Knight Sherri; Rogers, Michael
Subject: WI0400454 NOI Former Cemex Colfax Plant
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (INO1) 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-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: jjdep.nc.govjaboutjdivisionsfwater-resources1water-resources-permits/wastewater-branch/ground-water-
rotection/grou nd-wate r-reporti nR--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 Shristi.shresthaVncdenr.g,ov 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 WI0400454. 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 tine.
Thank you for your cooperation.
5hristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shrestha gncdenr.aov
512N, Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Cr

Ema!/ correspondence ta and from this address is subject to the
North Caroline Public Pecords Law and may be disclosed to th!rCJ parties.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Monday, July 18, 2016 10:48 AM
To: Knight, Sherri
Cc: Rogers, Michael
Subject. WI0400454 NCI Former Cemex Colfax PLant
Attachments: site map.pdf; WI0400454 NOI Former Cemex Colfax Plant,pdf
Please find the attached NOI and additional information.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.sh resthaCuncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Arz
&mail correspondence to and from this address is subject to the
North Carolina Public Records Law and msy be disclosed to thfrci parties.

MTro—IF—ac
Environmental Services
July 11,2016
Ms. Shristi Shrestha
NCDEQ - DWR
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notification of Intent to Construct or Operate Injection Wells
Former Cemex Colfax Plant
3415 Sandy Ridge Road
Colfax, North Carolina
Incident No. 7196
Dear Ms. Shrestha:
EnviroTrac is pleased to submit a hard copy of the Notification of Intent to Install or Construct
Injection Wells. The purpose of this corrective action is to improve groundwater concentrations.
Installing a passive oxygen injection device in monitoring wells MW-12 and MW-13 would
increase the degradation rate of petroleum hydrocarbons but still allow the wells to be used as
monitoring points.
Should you have any questions regarding this notification or require additional information,
please contact the undersigned.
Very truly yours,
ENViROTRAC LTD.
Christopher W. Hay, El, RSM
Regional Operations Manager
christopherh(a envirotrac.corn
RECEIVEDINCDECIDWR
JUL I32016
Water Quality Regional
Operations Section
Attachments: Notification of Intent to Install or Construct Injection Wells
7343 West Friendly Avenue, Suite J, Greensboro, North Carolina 274101 Office: [phone] j Fax: [phone]
W W.envirotrac.cern

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 (orm shall be submitted at least 2 weeks prior to in jection.
AQUIFER TEST WELLS f1 5A NCAC 02C .0220 1
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION O5A NCAC 02c .0225 ) or TRACER WELLS O5A NCAC 02c .0229 ):
1) Passive Injection Sv 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 Injection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: June 30, 2016 PERMIT NO. WL0400 lf-Sl/-(to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
B.
c.
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B-F, K, N
___ Aquifer Test Well ....................................... Complete sections B-F, K, N
~X~_.Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
Pilot Tes~ ... ·.· ............................................ Complete sections,..~~\NR
___ Tracer InJect10n Well.. .............................. ·~~i{~~
\ s '2.\)\0
ST A TUS OF WELL OWNER: Business/Organization J\)l . a\
o 0 g,on aua\\\'i ~ · n
WELL OWNER -State name of entity and name of person dele~-n , ~ on behalf of the
business or agency:
Name: ____ C_e_m_ex~C~o_n~str~u~c~ti~·o~n~M~at~e~ri~a~ls~. ~In~c~ .. ~M~s ~. D~en~i~se~C~o=rr~a=le~s ____________ _
Mailing Address: --~3~82_0~N~o=rt=hd=a=le~B~o~ul~e~v=ar~d~. ~Su=i=te~l 0~0~B~---------------
City: Tam pa State: FL Zip Code:~3~36=2~4 ____ County: _____ _
Day Tele No.: (813 ) 269-1035 Cell No.: (813 )486-9191
EMAIL Address: denise.corrales @ cemex.com FaxNo.: ___________ _
UICI In Situ Remed. Notification (Revised 3/2/20 I 5) Page I
D. PROPERTY OWNER (if different than well owner)
Name: ---~O~l=dc~a=st=le~AP~G'-'S"--o~u~th=,~In~c·~· """"Mr~. J~o=hn~An~d=e=rs~o=n'-----------------
Mailing Address: ---------'3'-'4~1=5---=S=an=d y~R=id"'g""'e---=R=o=a=d'--_____________ _
City: ---~C~o=lf:=ax-=-----State: NC_ Zip Code:. __ ~27-'--'2=3=5 ____ County: Guilford
Day Tele No.: (336 )215-3543 Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONTACT-Person who can answer technical questions about the proposed injection project.
Name: ------=Mr"-="'-'C=hr=is=---H=a'-'-'v.'"""'E=n=v'----"i"--'ro'---'T=r=ac=-----------------------------
Mailing Address: ----'-73::...4_,_,3'-W--'--'--'F,,_,r=ie=n=d:.c.lYs...=A:..:.v=e.'--'S=w=·t=e---=J'----------------------
City: Greensboro State: NC Zip Code:_27~4_1~0 ____ County: Guilford
Day Tele No.: (336 ) 763-6025 Cell No.: [phone]
EMAIL Address:christo pherh envirotrac.com Fax No.: ___________ _
F. PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Physical Address: ___ F=-o=r=m=e=r-'C""'e=m=e=x"--C~o=lf:=ax=P=la=n=t_----=In=ci=d=en=t'---'N~o.~7~1=9---=6'--________ _
-------'3=---4-'--'1=5---=S=an=d.,__y--=-Ri=· d=-iz=e'--'R=o=a=d'--___________ County: Guilford
City: Colfax State: NC Zip Code: ---=2'-'--7=23=5'--------
Geographic Coordinates: Latitude**: __ 0
___ " or ____ -=-3=-6 °.101277
Longitude**: __ 0
_' __ "or -79 °.997594
Reference Datum: ________ Accuracy: ________ _
Method of Collection: htt p://itouchmap.com/latlom1 .html
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COO RD INA TES .
G. TREATMENT AREA
Land surface area of contaminant plume: _______ square feet
Land surface area ofinj. well network: square feet(::: 10,000 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
Figure 2 shows the site layout and existing monitoring well locations. Figure 8 shows the extent
of benzene impacted groundwater. The passive oxygen injection system is proposed to be
installed into existing monitoring wells MW-12 and MW-13.
(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/In Situ Remed. Notification (Revised 3/2/2015) Page2
Figure 21 shows the location of the cross sections. Figures 22 and 23 are cross sections of
impacted groundwater. The figures estimate the extent of VOC concentrations which exceed the
NCGS 2L Standard and detection limits.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
Figure 20 shows the potentiometric surface map.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a briefnarrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and
duration of injection over time.
The in jection activities are intended to im prove eroundwater concentrations. Monitorin l! wells MW-12 and
MW-13 will have a passive ox yg en deliver y s ystem installed inside each existing monitorin f!. well. This s ystem
will allow ox yg en to be in jected into the e.roundwater affecting a localized area. The performance of this
s vstem will be monitored during the current semi-annual monitorin g events.
J. INJECT ANTS -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/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 (919-807-
6496).
Injectant: Oxvg en -MSDS attached
Volume of injectant: __ c~o~n~t_in~u~o~u~s_r~el~e~as~e~o~f~o~x~g~e=n~g-a=s~a~t~o=n=e~c~u~b=ic~fi=o~o~t _p~e~r ~d-ay ______ _
Concentration at point of injection: MW-12 and MW-13 will range from 53 to 60 pp m (based on 10
to 15 feet of submergence ). The oxyg en concentrations are estimated based on a saturated ox yg en
content of 41 ppm per atmos phere.
Percent if in a mixture with other injectants: --~N~/~A~-----------------
Injectant: ----------------------------------
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 ___ 2 __ ~Existing MW-12 and MW-13
(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
Table 5: Summary of Monitoring Well and Groundwater Elevation Data is attached.
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Envirotrac will travel to the site and install the delivery system upon receipt of the permit. The oxveen will
be injected continuously and the content of the oxygen cylinder will be monitored monthly. _
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.
Groundwater samples will be collected from MW-12 and MW-13 semi-annually concurrent with the on_oin;
mo11itorine schedule. Groundwater parameters will be measured during; semi-annual sannrline events inciudint;
dissolved nxyeen. oxidation-reduction potential, nH. temperature, and conductivity.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "l hereby certify, under penalty of law, that I ant familiar with the information submitted in
this document and al! attachments thereto and that, based on my inquiry of those individuals immediately
responsible for obtaining said information, I believe that the information is true, accurate and complete. 1 am
aware that there are significant penalties, including the possibility of -fines and imprisonment, for submitting
false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the infection well
ut all related appurtenances in accordance with the l.iA NCA C 02C 0200 Rules,"
Signature of Applicant Print or Type Full Name
PROPERTY OWNER (lithe nrnncrty is not owned by the Oenr applicant):
"As owner of the property on which the infection 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 he
the responsibility of the applicant to ensure that the injection well(s) conform to the Welt Construction
Standards (15,1 NC:IC 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,
�) *-1 `J �t e IAti
Signature* of Prnp wner (i 1I rent from applicant) Print ortype Fun Name
? An access agreement between the applicant and property owner may be submitted in lieu of a signature on this farm
Submit the completed notification package to:
DWR— UIC Program
I b36 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
UICtln Site Remed. Notification (Revised 3R/2015) Page

FIGURES
RAILROAD TRACKS
rn
-x-,r--%-x-x-X-X-x-x-z-x-x--xC-a--x-F--.-x-[- --x
•
MW-4
CAROLINA
STEEL
PROPERTY
EXPLANATION
❑ ABANDON WELL
• TYPE II MONITORING WELL
TYPE III MONITORING WELL
• SUPPLY WELL (ABANDONED)
SYSTEM INFLUENT
SYSTEM EFFLUENT
n STORM DRAIN LOCATION
RECOVERY WELL
I= FORMER UST LOCATION
A - 3,000 GALLON GASOLINE UST
B - 10,000 GALLON NO.2 FUEL OIL UST
C - 10,000 GALLON NO.2 FUEL OIL UST
D - 0,000 GALLON DIESEL FUEL UST
E - 5.000 GALLON DIESEL FUEL UST
F - 1000 GALLON GASOLINE UST
G - 2,000 GALLON GASOLINE UST
rri
11,
30 0 60
MW-6
PROPERTY LINE
Rp,1LROen SPUR
FORMER '
f y REMEDIATION
SYSTEM
MW-11
40.
MW-7
BMW-16
nvliro ra
Environmental Berv[aar
7343 W. FRIENDLY AVENUE, SUITE]
GREENSBORO, NORTH CAROLINA
FIGURE 2
SITE MAP
FORMER CS CONCRETE
3415 SANDY RIDGE ROAD
COLFAX, NORTH CAROLINA
REVISED BY; GGH
DATE: 11/05/15
DRAWN BY: AB APPROVED BY:
DATE:I0/I5/15 CWH
SCALE: AS SHOWN
APPROXIMATE SCALE
PROJECT NO: 11.9900181M

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co
61
as
..ti '
' ,'
SOURCE: USGS 7.5'
TOPOGRAPHIC MAP,
GUILFORD AND KERNERSVILLE
QUADRANGLES
� nviro ra
Environmental Services
soo loco IsoO moo 7343 W. FRIENDLY AVENUE, SUITE
AiArtoivALRHCE' RD
gEHfREW RD
ORNDIRE RD •
1
FIGURE 1
SITE LOCATION MAP
0
0
YQ
CS CONCRETE
3415 SANDY RIDGE ROAD
COLFAX, NORTH CAROLINA
DATE; 10/15/2015
APPROVED BY:
GREENSBORO, NORTH CAROLINA
SCALE iw FEET PHONE: [phone] DRAWN BY: AB
CT PROJECT NO: 11.990018.00
ENVIROTRAC - 7343 W. FRIENDLY AVE-, SUITE J I GREENSBORO, NC 27410 j PH: [phone] I FAX: [phone] € www.envirotrac cam
SCALE: 1" = 2000'
CWH

Y
0
u
9
6
0
u
a
3
J
1.
]
3
i J
EXPLANATION
ABANDON WELL
TYPE 11 MONITORING WELL
TYPE 11I MONITORING WELL
SUPPLY WELL (ABANDONED)
SYSTEM INFLUENT
SYSTEM EFFLUENT
STORM GRAIN LOCATION
RECOVERY WELL
FORMER UST LOCATION
A - 3,000 GALLON GASOLINE UST
{7.3) BENZENE (Ng/L)
BENZENE 1SOCONCENTRATIONLINE
15
0
30
. - —
APPROXIMATE SCALE
MW-15
FORMER
REMEDIATION
SYSTEM
MW-11
0,000
,000
«AW-13
(14,00)
FORMER
CEMEX
MW-16
�viro ra
environmental 8srvlws environmental S rvIDaa
7343 W. FRIENDLY AVENUE, SUITE 1
GREENSBORO, NORTH CAROLINA
FIGURE 8
BENZENE ISOCONCENTRATION MAP
FORMER CS CONCRETE
3415 SANDY RIDGE ROAD
COLFAX, NORTH CAROLINA
REVISED BY: AB
DATE:04/229/16
DRAWN BY: AB
DATE:10/i5/15
APPROVED BY;
CWH
SCALE: AS SHOWN
PROJECT NO: 1L990O18,00

EXPLANATION
❑ ABANDON WELL
• TYPE 11 MONITORING WELL
is ry
TYPE !11 MONITORING WELL
SUPPLY WELL (ABANDONED)
SYSTEM INFLUENT
SYSTEM EFFLUENT
STORM DRAIN LOCATION
RECOVERY WELL
FORMER UST LOCATION
A - 3,000 GALLON GASOLINE UST
1 n21 TOLUENE OgILI
' - TOLUENE 1SOOONCENTRATION LINE
15
0
30
■ ■ �
APPROXIMATE SCALE
F:-
f
4
MW-7
/ i1o'I
MW-15
P�� t
MW—s
1
MW-1
(BQLI/
CD
I, i-.2
MW-14
M�1
(14,000)
FORMER
REMEDAATION
SYSTEM
`�o,000
10.000
600
FORMER
CEMEX
MW-1
vuro ra
Environmental Services
7343 W. FRIENDLY AVENUE, SUITE.)
GREENSBORO, NORTH CAROLINA
FIGURE 9
TOLUENE ISOCONCENTRATION MAP
FORMER CS CONCRETE
3415 SANDY RIDGE ROAD
COLFAX, NORTH CAROUNA
REVISED BY: AB
DATE: D4129/18
DRAWN BY: AB
DATE: 10/15(15
APPROVED BY:
CWH
SCALE: AS SHOWN
PROJECT NO: 11.990018.00

RAILROAD TRACKS
TAW-4
CAROLINA
STEEL
PROPERTY
EXPLANATION
• ABANDON WELL
▪ TYPE II MONITORING WELL
® TYPE ID MONITORING WELL
413, SUPPLY WELL (ABANDONED)
SYSTEM INFLUENT
SYSTEM EFFLUENT
STORM DRAIN LOCATION
RECOVERY WELL
I=1 FORMER UST LOCATION
91.44) GROUNDWATER ELEVATION
WATER TABLE CONTOUR LINE
l� GROUNDWATER FLOW DIRECTION
30 0 60
I F_
MW-
IEJ
•
PROPERTY LINE
RAILROAD SPUR
MW-7
(83,12)
I MW-15 R,W-a
{82.22]
SUILL ZING
-14
FORMER
• REMEDIATION
SYSTEM
MW-11❑
(74.41 RI
81.1)5
•.A,
MW-1
77" (83A.
MV 4
(83.43).
N
MW-13
I83-451
8140
L
F1
row-2.
m3.32, \
83.30
NOTE DEEP WELL MW-9 WAS NOT INGLIJDED IN THE POTENT/METRIC SURFACE.
1
FORMER
CEMEX
N.
MW16
83.60
83.60
nviro ra
Environmental Services
APPROXIMATE SCALE 7343 W. FRIENDLY AVENUE, SUITE 1
GREENSBORO, NORTH CAROLINA
FIGURE 20
POTENTIOMETRIC SURFACE MAP (APRIL 14, 2016)
FORMER CS CONCRETE
3415 SANDY RIDGE ROAD
COLFAX, NORTH CAROLINA
REVISED BY: AB
DATE: 04/15/16
DRAWN BY; AB APPROVED BY:
DATE: 10/15/15 CWH
SCALE: AS SHOWN
PROIECT NO: 11.990618.00

RAILROAD TRACKS
lr ro ecssl i • . J• J• UI7 I b AJU L .e me%11• ILA LIKC Ali- I t]U K tal-a.aw�
LRtJ I•ILt
FENCE
—xa —A—It X X :—X—X—cx—x—x---x---It ,r71,147.-e^ .
iMl�lrlw,,,,, WrrrMw .re,4Hi 11nwMi0+HHrIM11nH4901""""W"."'-'''''--..
INHMr"."'-'''-. --.
y�41LRO?'� SPUR �nur�rrnl+.'+
L MW4
•
MWS
%® 1 E� ..lwr!...,
M49-
W-4 ..,,.,ii..ri .....,,
EXPLANATION
❑ ABANDON WELL
i TYPE II MONITORING WELL
® TYPE ill MONITORING WELL
O SUPPLY WELL (ABANDONED)
I I
CAROLINA
STEEL
PROPERTY
FORMER UST LOCATION
A - 3,000 GALLON GASOLINE UST
B-10,000 GALLON NO.2 FUEL OIL UST
C - 10.000 GALLON NO.2 FUEL OIL UST
D - 6.000 GALLON DIESEL FUEL UST
E - 5,000 GALLON DIESEL FUEL UST
F - 2,000 GALLON GASOLINE UST
G - 2,000 GALLON GASOLINE UST
30 60
AF1'i-30XIMATF '.i:AI F
PROPERTY LINE
MW-13-
BUILDING
MW9
Qi
MW-
MV1�1
y
MW 14
M W-2
A'
A
rifq
MW-13
L
FORMER
CEMEX
MW-16
EflFc
grwironmantal BervMo$s
7343 W. FRIENDLY AVENUE, SUITE 1
GREENSBORO, NORTH CAROLINA
FIGURE 21
CROSS SECTION LOCATION MAP
FORMER C5 CONCRETE
3415 SANDY RIDGE ROAD
COLFAX, NORTH CAROLINA
REVISED BY, DRAWN BY: GGH
DATE: DATE: 06/30/16
APPROVED BY:
CWH
SCALE: AS SHOWN
PROJECT NO. 11.990018.00

A 20 40 60 80 100 120 140 160 180 200 220 240 A'
I
I I I I /I GROUND SURFACE MW-7 MW-9 MW-12 MW-14 I
M\l\'.-1 MW-2
100 r
90
Sandy Slit I -'-
I I
I I ' --n---I I I -
80 J -n, I
I \. MW-14 MW-1 Benzene • 7 .3
\,1
, ADBOL
I \\ Total Xytenes-3.7 MW-2
I 1,2,4-TMB • 0.69 Historical data
' I 1_:,l,5-TMB -0.80 Indicates all
70 MW-7 / ~ MW-12
Benzene-10.8 I, -Benzene-7,170 _,,,,, I/ ta rgeted
Toluene-102
,
Toluene-14,000 / analytes below
Ethylbenzene-78.8 --Ethylbenzene-1,330 --reporting limits
Total Xylenes-488 Total Xylenes-7,620 +--lsopropylbenzene-6.4 lsopropyl ether-859
60 lsopropyl ether.-2.3 Naphthalene-352
Naphthalene-51.3 n-Propylbenzene-132 -
n-Propylbenzene-7.6 Styrene-58.3
: 1,2,4-TMB-139 1,2-Dlchloroethane-59.2
""" 1,3,5-TMB-30.8 1,2,4-TMB-1,110
1,3,5-TMB-282
-105 I--I--._ -
MW-9
I Historical data I Indicates all
-115 targeted -analytes below I reporting llmlls
~ -125
Bedrot
C
~ LEGEND N
1)
ll
l:'. :, '¥ GROUNDWATER ELEVATION IN WELL :2
.L
7i ---APPROXIMATE POTENTIOMETRIC SURFACE
ll
l:'. :, --voes ABOVE REPORTING LIMIT (APRIL 14, 2016)
:2
.L --voes ABOVE 2L STANDARD (APRIL 14, 2016) x
Q)
E
Cl)
~
:, :,
xi
:, :, 20 0 40 FIGURE 22 :,, -~ ~-~-1 I
CROSS SECTION A -A' 1:nv1rolrac l!l HOR IZONTAL SCALE 0
~ FORMER CS CONCRETE
E 20 e:nvltonmtntal StrvlO&& 3415 SANDY RIDGE ROAD :!, 10 0
;,; ~-L~_s COLFAX, NORTH CAROLINA
>
i.i
:::! VERTICAL SCALE SCALE: AS SHOWN
.L 7343 W. FRIENDLY AVENUE, SUITEJ REVISED BY: DRAWN BY: GGH APPROVED BY:
:i GREENSBORO, NORTH CAROLINA DATE: DATE: 06/30/16 CWH
" PROJECT NO: 11.990018.00
~
B 20 40 60 80 100 120 140 160 180 200 220 240 B' -
MWJ 5
I I MW-13 1
I I i I / GROUND SURFACE MW-16 MW-9 ... .-
100 I i
Sandy Silt
90 -
~ I 7
( 7 \ r + 1 I 7 11MW-16
80 ~W-15 --I r---Historical data indicates al
indicates au I targeted
targeted -I I I /
analytes be low
analytes below reporting limits
repo rting lim its ~
70 -.\ \·I MW-13 -----
\ V Benzene-14,500 /
I
Toluene-26,500
"-...
Ethylbenzene-2,130
I Total Xylenes-11,390
60
MTBE-1,590
I~ lsopropyl ether-1,980
Nap hthal ene-636
~~
n--Propylbenzene-207 ·~ Styrene-208
1,2,4-TM B-1,680
-105
1,3.~TMB-414 -
MW-9
HlstO<lcaJ data !
-115
I ln dk;atesal
targeted
an alyles below I reporti ng Umlls
I
Bedrock I ~ -125 .
0
~ LEGEND '-I
'/)
lJ :t::
:::i
~ '¥'. GROUNDWATER ELEVATION IN WELL
.L
'i5 --APPROXIMATE POTENTIOMETRIC SURFACE lJ
:t::
:::i --voes ABOVE REPORTING LIMIT (APRIL 14, 2016) ~
.L --voes ABOVE 2L STANDARD (APRIL 14, 2016) >:
Q)
E
Q)
:)
::, ::,
xi
::, ::, 20 0 40 FIGURE 23 :,-,
~ ~--~ i f 'l'!!!'Ps!!:!'~
CROSS SECTION B -B'
§ u HORIZONTAL SCALE
~ FORMER CS CONCRETE
0 3415 SANDY RIDGE ROAD ~ 10 0 20
> ~---i ; COLFAX, NORTH CAROLINA
>
i.i
:! VERTICAL SCALE SCALE: AS SHOWN
.L 7343 W . FR IENDLY AVENU E, SUITEJ REVISED BY : DRAWN BY : GGH APPROVED BY :
::i GREENSBORO , NORTH CAROLINA DATE : DATE: 06/30/16 CWH
,i:: PROJECT NO: 11.990018.00
:)
TABLE 5 WELL CONSTRUCTION SUMMARY

TABLE 5: SUMMARY OF MONITORING WELL AND GROUNDWATER ELEVATION DATJ
SAMPLE ID MW-1 MW-2 MW-7 MW-9 MW-12 MW-13 MW-14 MW-15 MW-16 6
~ Top of Casing 99.60 100.00 101 .19 100.57 101 .22 101 .37 100.38 99.82 101.68
0
j:: Top of Screen 83 .60 85.00 86.19 -104.43 86 .22 89.37 85.38 84 .82 86.68 < > -w Bottom of ..J 68.60 70.00 71 .19 -119.43 71 .22 74.37 70 .38 69 .82 71.68 w Screen
Well depth < 31 30 30 220 30 27 30 30 30
Measure Date
09/01/01 Depth"' 22 .23 NM 21 .52 30 .36 26 .01 19.24 21 .83 dry -
Elevation 77.37 -79.67 70.21 75 .21 82.13 78 .55 --
03/02/02 Depth"' 20.74 NM 22.42 30 .98 22 .31 FP 21.49 21.17 -
Elevation 78.86 -78.77 69.59 78.91 -78.89 78.65 -
02/10/03 Depth " 19.72 NM 21.35 30.79 21.30 21.40 20.45 19.82 -
Elevation 79.88 -79 .84 69.78 79 .92 79.97 79.93 80.00 -
03/04/04
Depth q 16.67 NM 17 .94 NM 18.19 18.31 NM NM -
Elevation 82 .93 -83.25 -83 .03 83.06 ---
12/07/07 Depth ' 19.50 NM 21 .18 NM 21.05 21.15 20.23 19.87 ----
Elevation 80.10 -80 .01 -80 .17 80 .22 80 .15 79 .95 -
06/03/08 Depth0 18.84 NM NM NM 20.43 20.51 19.65 19.05 -
I-- --Elevation 80.76 ---80 .79 80 .86 80 .73 80 .77 -
12/30/08 Depth" 20.02 NM NM NM 21 .68 21.75 20.85 20 .32 21.56
Elevation 79.58 ---79.54 79.62 79.53 79 .50 80.12
06/26/09 Depth ' 18.59 NM 20.42 NM 20.22 20.25 19.44 NM NM -
Elevation 81 .01 -80.77 -81 .00 81.12 80.94 --
01/06/10 Depth ' 18.51 19.30 20.29 NM 20.12 20.15 19.34 18.70 20.15 ----Elevation 81.09 80.70 80 .90 -81 .10 81.22 81 .04 81.12 81.53
07/08/10 Depth ' 16.84 17.56 18.71 NM 18.44 18.49 17 .63 NM 18.25 --
Elevation 82 .76 82.44 82.48 -82 .78 82.88 82 .75 -83.43
01/21/11 Depth 17 .81 18.33 19.38 NM 19.40 19.48 18.63 NM 19 .67
Elevation 81 .79 81 .67 81 .81 -81 .82 81.89 81 .75 -82 .01
06/30/11 Depth ' 17.29 17.99 19.24 NM 18.86 18.95 18.09 NM 18.71 --
Elevation 82.31 82.01 81.95 -82 .36 82.42 82 .29 -82 .97
11 .990018 .00
© 2016 EnviroTrac Page 1 of 2 May 2016
TABLE 5: SUMMARY OF MONITORING WELL AND GROUNDWATER ELEVATION DATJ!
SAMPLE ID MW-1 MW-2 MW-7 MW-9 MW-12 MW-13
Cl) Top of Casing 99.60 100.00 101.19 100.57 101.22 101.37 z
0
j:: Top of Screen 83.60 85.00 86.19 -104.43 86.22 89.37 <( > w Bottom of .J 68.60 70.00 71.19 -119.43 71.22 74.37 w Screen
Well depth 1 31 30 30 220 30 27
Measure Date
02/10/12 Depth 1 17.64 18.49 19.33 18.54 19.41 19.46
Elevation 81.96 81.51 81.86 82.03 81.81 81.91
11/29/12 Depth 1 18.38 18.90 19.75 NM 19.75 19.93
Elevation 81.22 81.10 81.44 -81.47 81.44
08/29/13 Depth ' 16.40 16.97 18.43 NM 18.01 18.06
Elevation 83.20 83.03 82.76 -83.21 83.31
12/17/13 Depth 1 17.15 17.41 19.53 NM 18.73 18.75
Elevation 82.45 82.59 81.66 -82.49 82.62
06/04/14 Depth 1 15.68 16.43 17.62 NM 17.28 17.28
Elevation 83.92 83.57 83.57 -83.94 84.09
05/06/15 Depth 16.97 18.33 18.61 27.10 18.61 18.74
Elevation 82.63 81.67 82.58 73.47 82.61 82.63
10/07/15 Depth 18.06 18.90 19.93 28.38 19.65 19.79
Elevation 81.54 81.10 81.26 72.19 81.57 81.58
04/14/16 Depth 18.16 16.68 18.07 25.93 17.80 17.92
Elevation 81.44 83.32 83.12 74.64 83.42 83.45
NOTES:
1Elevations resurveyed on 12/14/12 from temporary benchmark (MW-2) assigned an arbitrary elevation of 100 feet
2 Depth of well measured from land surface (feet)
3 Depth of water measured from top of casing by Engineering Tectonics (feet)
4 Depth of water measured from top of casing by Trigon (feet)
5 Depth of water measured from top of casing by Trigon I Kleinfelder (feet)
6 Monitoring well MW-16 installed on December 29, 2008 by Trigon I Kleinfelder
7 Depth of water measured from top of casing by Kleinfelder (feet)
FP = Free Product
NM = Not measured
11.990018.00
© 2016 EnviroTrac Page 2 of 2
MW-14 MW-15 MW-166
100.38 99.82 101.68
85.38 84.82 86.68
70.38 69.82 71.68
30 30 30
18.60 NM 19.02
81.78 -82.66
19.08 18.50 19.20
81.30 81.32 82.48
17.23 NM 18.06
83.15 -83.62
17.88 NM 18.08
82.50 -83.60
16.52 NM 17.75
83.86 -83.93
17.74 17.21 18.33
82.64 82.61 83.35
18.70 18.49 19.28 -81.68 81.33 82.40
16.95 17.60 18.07
83.43 82.22 83.61
May 2016
OXYGEN MSDS
ROBERTS
�f OXYGEN
•
Safety Data Sheet
Roberts Oxygen Company, Inc.
Oxygen Compressed
PRODUCT AND COMPANY IDENTIFICATION
Product Identifier: Oxygen Compressed
Common Name: Oxygen
SDS Number: 20
Revision Date: 10/21/2015
Version: 2,0
CAS Number: 7782-44-7
Chemical Formula: 02
Product Use: Industrial, Medical, Food Applications
Supplier Details:
Emergency•
Phone:
Web:
Roberts Oxygen Company. Inc.
P.O. Box 5507
Rockville, MD 20855
Chemtrec.: 24 hr/day 7 dayslwk [phone]: for spills, leaks, fire, exposure or accidents involving this product
Customer Service: [phone], Mon through Fri from 7:30 am to 5:00 pm ET
www.robertsoxygen.com
J
HAZARDS IDENTIFICATION
Classification of the substance or mixture
GHS Classification in accordance with 29 CFR 1910 (OSHA HCS):
Physical, Oxidizing Gases, 1
Physical, Gases Under Pressure, Compressed Gas
GHS Label elements, including precautionary statements
GHS Signal Word: .DANGER
GHS Hazard Pictograms:
GHS Hazard Statements:
H270 - May cause or intensify fire; oxidizer
H280 - Contains gas under pressure; may explode if heated
GHS Precautionary Statements:
P202 - Do not handle until all safety precautions have been read and understood.
P220 - Keep/Store away from clothing/combustible materials.
P244 - Keep reduction valves free from grease and oil.
P271+P403 - Use only outdoors or in a well -ventilated area.
P370+P376 - In case of fire: Stop leak if safe to do so.
CGA-PG05 - Use a back flow preventive device in the piping.
CGA-PG20 - Use only equipment of compatible materials of construction.
CGA-PG10- Use only with equipment rated for cylinder pressure.
CGA-PG22 - Use only with equipment cleaned for oxygen service.
CGA-PG21 - Open valve slowly.
CGA-PG08 - Close valve after each use and when empty.
CGA-PGO2 - Protect from sunlight when ambient temperature exceeds 52 °C (125 °F).
OSHA-PG01 - DO NOT REMOVE THIS PRODUCT LABEL (or equivalent wording)
CGA-PG27 - Read and follow the Safety Data Sheet (SDS) before use.
SOS Number: 20
Page 1 of 7 Revision Date: 10/21/2015

ROBERTS
OXYGEN
Safety Data Sheet
Roberts Oxygen Company, Inc.
Oxygen Compressed
COMPOSITION/INFORMATION ON INGREDIENTS
Ingredients:
Cas# % Chemical Name
7782-44-7 Oxygen, compressed
Inhalation:
Skin Contact:
Eye Contact:
Ingestion:
FIRST AID MEASURES
Remove victim to uncontaminated area wearing self-contained breathing apparatus (SCBA). Keep victim warm and
rested. Call a doctor. Apply artificial respiration if breathing has stopped.
Adverse effects are not expected from this product
Immediately flush eyes thoroughly with water for at feast 15 minutes. Hold the eyelids open and away from the eyeballs
to ensure that all surfaces are flushed thoroughly. Contact an ophthalmologist immediately. Get immediate medical
attention.
ingestion is not considered a potential route of exposure.
FIRE FIGHTING MEASURES
Flammability: Non -Flammable
Flash Point: N/a
Flash Point Method: Nla
Burning Rate: N/a
Autoignition Temp: N/a
LEL: N/a
Fire Fighting instructions:
Evacuate all personnel from the danger area. Use self-contained breathing apparatus (SCBA) and protective clothing. Immediately cool
containers with water from maximum distance. Stop flow of gas if safe to do so. while continuing cooling water spray. Remove ignition
sources if safe to do so. Remove containers from area of fire if safe to do so. On -site fire brigades must comply with OSHA 29 CFR
1910.156 and applicable standards under 29 CFR 1910 Subpart L—Fire
Standard Protective Clothing and Equipment: SCBA for fire fighters
Use fire control measures appropriate for the surrounding fire. Exposure to fire and heat radiation may cause gas containers to rupture.
Cool endangered containers with water spray jet from a protected position. Prevent water used in emergency cases from entering sewers
and drainage systems. Stop flow of product if safe to do so. Use water spray or fog to knock down fire fumes if possible.
Oxidizing agent; vigorously accelerates combustion.
Contact with flammable materials may cause fire or explosion.
Smoking, flames and electric sparts are potential explosion hazards.
ACCIDENTAL RELEASE MEASURES
Evacuate area.
Remove all sources of ignition. Contact with flammable materials may cause fire or explosion.
Ventilate area or move container to a well -ventilated area. Wear self-contained breathing apparatus (SCBA) when entering area, unless
atmosphere is proven to be safe.
Stop leak if safe to do so.
SDS Number: 20
Page 2 of 7 Revision Date: 10/21/2015

ROBERTS
OXYGEN
Safety Data Sheet
Roberts Oxygen Company, Inc.
Oxygen Compressed
Handling Precautions:
Storage Requirements:
HANDLING AND STORAGE
Wear leather safety gloves and safety shoes when handling cylinders. Protect cylinders from physical
damage; do not drag, roll, slide or drop. While moving cylinder, always keep in place removable valve
cover. Never attempt to lift a cylinder by its cap; the cap is intended solely to protect the valve. When
moving cylinders, even for short distances, use a cart (trolley, hand truck, etc.) designed to transport
cylinders. Never insert an object (e.g., wrench, screwdriver, pry bar) into cap openings; doing so may
damage the valve and cause a leak. Use an adjustable strap wrench to remove over -tight ar rusted
caps. Slowly open the valve. If the valve is hard to open, discontinue use and contact your supplier.
Close the container valve after each use; keep closed even when empty. Never apply flame ar localized
heat directly to any part of the container. High temperatures may damage the container and could cause
the pressure relief device to fail prematurely, venting the container contents.
For additional handling recommendations, consult Compressed Gas Association's Pamphlet P-1
Store in a cool, well -ventilated place. Store and use with adequate ventilation. Store only where
temperature will not exceed 125°F (52'C). Post No Smoking or Open Flame signs in storage and use
areas. There must be no source of ignition. Separate packages to protect against potential fire and/or
explosion damage following appropriate codes and requirements (e.g., NFPA 30, NFPA 55, NFPA 70
and/or NFPA 221) or according to requirements determined by the Authority Having Jurisidfction.
Firmly secure containers upright to keep them from falling or being knocked over. Install valve protection
cap, if provided, firmly in place by hand. Store full and empty containers separately. Use a first -in,
first -out inventory system to prevent storing full containers for long periods_ OTHER PRECAUTIONS
FOR HANDLING, STORAGE, AND USE: When handling product under pressure, use piping and
equipment adequately designed to withstand the pressures to be encountered. Never work on a
pressurized system. Use a backflow preventive device in the piping. Gases can cause rapid suffocation
because of oxygen deficiency; store and use with adequate ventilation. if a leak occurs, close the
container valve and blow down the system in a safe and environmentally correct manner in compliance
with all international, federal/national, state/provincial, and local laws; then repair the leak. Never place a
container where it may become part of an electrical circuit.
For additional storage recommendations, consult Compressed Gas Association's Pamphlet P-1.
SDS Number: 20 Page 3 of 7 Revision Date: 10/21/2015

ROBERTS /
OXYGEN
Safety Data Sheet
Roberts Oxygen Company, Inc.
Oxygen Compressed
8
Engineering Controls:
Personal Protective
Equipment:
EXPOSURE CONTROLS/PERSONAL PROTECTION
Avoid oxygen rich (>23.5%) atmospheres. Systems under presure should be regularly checked for
leakages. Ensure exposure is below occupational exposure limits {where available), Gas detectors
should be used when oxidizing gases may be released. Oxygen detectors should be used when
asphyxiating gases may be released- Provide adequate general and local exhaust ventilation. Consider
work permit system, e.g., for maintenance activities.
Respiratory protection: None necessary
Hand protection: Handle gas containers with working gloves. Gloves must be inspected prior to use.
Eye protection: Wear safety glasses with side shields. Use equipment for eye protection tested and
approved under appropriate government standards such as NIOSH (US) or EN 166 (EU).
Skin and body protection: Wear hand; head, and body protection to help prevent injury from process
associated hazards, e.g., for welding exposure to radiation and sparks wear welder's gloves and
protective goggles. The type of protective equipment must be selected according to the concentration
and amount of the dangerous substance at the specific workplace and the user process and may include
arm protectors, hats, and shoulder protection worn over substantial clothing- Consider wearing
flame -resistant safety clothing and appropriate safety shoes while handling.
Hygiene measures: Handle in accordance with good industrial hygiene and safety practice. Wash hands
before breaks and at the end of workday
Oxygen, compressed (7782-44-7) [100%] : no data available
9
PHYSICAL AND CHEMICAL PROPERTIES
Appearance:
Physical State:
Odor Threshold:
Particle Size:
Spec Gray./Density:
Viscosity:
Sat. Vap. Conc.:
Boiling Point:
Flammability:
Partition Coefficient:
Vapor Pressure:
pH:
Evap. Rate:
Molecular weight:
Decomp Temp:
Colorless gas
Gas
Not applicable
Not/�applicable
.08279 tb/ft'
Not applicable
Not applicable
-118.6°C
Non -Flammable
Not applicable
Not applicable
Not applicable
Not applicable
32 g/mol
650°C
Odor:
Molecular Formula:
Solubility:
Softening Point
Percent Volatile:
Heat Value:
FreezinglMelting Pt.:
Flash Point:
Octanol:
Vapor Density:
VOC:
Bulk Density:
Auto -Ignition Temp:
UFLILFL:
Not applicable
02
Water: 0.0491 rngfl
Not applicable
Not applicable
Not applicable
No data available
No data available
Not applicable
No data available
Not applicable
Not applicable
Not applicable
Not applicable
Gas/vapor is heavier than air- May accumulate in confined spaces, particularly at or below ground level,
SOS Number 20 Page 4 of 7 Revision Date: 10/21/2015

ROBERTS,�
// OXYGEN
i
Safety Data Sheet
Roberts Oxygen Company, Inc.
Oxygen Compressed
10
Stability:
Conditions to Avoid:
Materials to Avoid:
STABILITY AND REACTIVITY
No reactivity
None
Keep equipment free from oil and grease. Consider the potential toxicity hazard due to the presence of
chlorinated or fluorinated polymers in high pressure (.30 bar) oxygen lines in case of combustion. May
react violently with combustible materials. May react violently with reducing agents.
Hazardous Decomposition: None
Hazardous Polymerization: None
TOXICOLOGICAL INFORMATION
Oxygen, compressed (7702-44-7)
Information on toxicological effects
Acute toxicity:
Oral LD50: No data available
Inhalation LC50
Dermal LD50
Other information on acute toxicity
Skin corrosion/irritation: No data available
Serious eye damage/eye irritation: No data available
Respiratory or skin sensitization: No data available
Germ cell mutagenicity: No data available
Carcinogenicity: No component of this product present at levels greater than or equal to 0.1% is identified as probable, possible or
confirmed human carcinogen by [ARC, ACG1H, NTP, or OSHA.
Reproductive toxicity: no data available
Teratogenicity: No data available
Specific target organ toxicity - single exposure (Globally Harmonized System): No data available
Specific target organ toxicity - repeated exposure (Globally Harmonized System): No data available
Aspiration hazard: no data available
Potential health effects. Inhalation: May be harmful if inhaled. May cause respiratory tract irritation. Ingestion: May be harmful if swallowed.
Skin: May be harmful if absorbed through skin. May cause skin and eye irritation.
Signs and Symptoms of Exposure: Nausea, Dizziness, Unconsciousness.
Synergistic effects: No data available
SOS Number: 20 Page 5 of 7 Revision Date: 10/21/2015

ROBERTS/}
{/ OXYGEN
Oxygen Compressed
-ECOLOGICAL INFORMATION
Oxygen, compressed (7782-44-7)
Information on ecological effects
Toxicity: No data available
Persistence and degradability: No data available
Bioaccumulative potential: No data available
Mobility in soil: No data available
PBT and vPvB assessment: No data available
Other adverse effects: No data available
-DISPOSAL CONSIDERATIONS
Waste treatment methods:
Safety Data Sheet
Roberts Oxygen Company, Inc.
May be vented to atmosphere in a well-ventilated place. Do not discharge into any place where its accumulation could be dangerous.
Waste disposal recommendations:
Dispose of contents/container in accordance with local/regional/national/international regulations. Contact supplier for any special
requirements.
-TRANSPORT INFORMATION
UN1072, Oxygen, compressed, 2.2,(5.1)
Avoid transport on vehicles where the load space is not separated from the driver's compartment. Ensure vehicle driver is aware of the potential
hazards of the load and knows what to do in the event of an accident or an emergency. Before transporting cylinders, ensure there is adequate
ventilation. Ensure that cylinders are firmly secured. Ensure cylinder valve is closed and not leaking. Ensure valve outlet cap (where provided) is
correctly fitted. Ensure valve protection device (where provided) is correctly fitted.
-REGULATORY INFORMATION
Component (CAS#) [%] -CODES
Oxygen, compressed (7782-44-7) [n/ao/o] MASS, PA, NJ, TSCA
Listed on the United States TSCA (Toxic Substances Control Act) inventory
SARA Section 311/312 Hazard Classes: Sudden release of pressure hazard, Fire hazard
Regulatory CODE Descriptions
MASS = MA Massachusetts Hazardous Substances List
PA= PA Right-To-Know List of Hazardous Substances
NJ = NJ Right-To-Know List of Hazardous Substances
TSCA = Toxic Substances Control Act
SOS Number: 20 Page 6 of 7 Revision Date: 10/21/2015
ROBERTS
OXYGEN
Safety Data Sheet
Roberts Oxygen Company, Inc.
Oxygen Compressed
16
OTHER INFORMATION
The information contained in this Safety Data Sheet is believed reliable, based on technical information and industry experience. Roberts
Oxygen Company, Inc. provides no warranties or guarantees pertaining to the information provided in connection with the safety
suggestions made. Moreover, it should not be assumed that every acceptable safety procedure, precaution, or device is listed. Abnormal or
unusual circumstances may warrant or suggest further requirements or additional precautions. Roberts Oxygen Company, lnc. requests
Users to thoroughly review this SDS and become aware of the product hazards and safety information. It is the User's responsibility to
determine the conditions for safe use of the product and to confirm the compatibility of any other materials in their use or processes that
come in contact with this product.
User acknowledges that the chemicals listed may be hazardous and must be handled accordingly. User further acknowledges its
understanding that the chemicals listed may be classified by OSHA as hazardous chemicals, and that there are hazards associated with the
possession, transportation and use of the ctzemical(s), containers, and related equipment and that the User must take proper account of
those hazards and deal with them appropriately.
User shall warn all persons who may be exposed to any hazards relating to the chemical(s), containers, and related equipment. User
acknowledges that the Seller has supplied the User with all relevant (Material) Safety Data Sheets (SDS) relating to the Products, and that
additional copies of the SDS are available an request. OSHA regulations require User to develop and implement a written chemical hazard
communications program for its employees regarding all hazardous chemicals.
Further, federal, state and local regulations may exist that are not addressed.
SOS Number: 20 Page 7 of 7 Revision Date: 10/21/2015

FIGURESIFIGURES2-9
F
•
EXPLANATION
TRIBUTARY TO WEST
WATER SUPPLY WELL WITH ID NUMBER
{SEE TABLE 1)
ADJACENT PROPERTY ID NUMBER
(SEE TABLE 2)
0
f 61
,500' Radius 4
Radius
200 0 dO0
APPROXIMATE SCALE
SOURCE; GUILFORD COUNTY AND CITY OF GREENSBORO GIS
Environmental Services
7343 W. FRIENDLY AVENUE, SUITES
GREENSBORO, NORTH CAROLINA
REVISED BY: GGH
DATE:11/05/15
FIGURE 3
RECEPTOR MAP
FORMER CS CONCRETE
3415 SANDY RIDGE ROAD
COLFAX, NORTH CAROLINA
DRAWN BY:AB
DATE: 10/15/15
APPROVED BY:
CWH
SCALE: AS SHOWN
PROJECT NO: 11.990018.00