WI0400458_DEEMED FILES_20161017

Permit Number WI0400458
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
shristi. shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Conoco Store #33027 (RM #6202)
Location Address
637 Martin Luther King Jr Dr
Greensboro
Owner
Owner Name
Philips 66 Company
Dates/Events
NC 27406
Orig Issue
10/17/2016
App Received
10/10/2016
Draft Initiated
Re gulated Activities
Groundwater remediation
Outfall
Waterbody Name
Scheduled
Issuance Public Notice
Central Files: APS SWP
10/17/2016
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Ed Kuhn
420 S Keeler-Pb 1417
Bartlesville
Region
Winston-Salem
County
Guilford
OK 74003
Issue
10/17/2016
Effective
10/17/2016
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent Monday, October 17, 2016 2:20 PM
To: '[e-mail]'; '[e-mail]'
Cc: Rogers, Michael; Knight, Sherri
Subject: WI0400458 NOI Former Conoco Store #33027
Thank you for submitting the Notice of Intent to Construct cr Operate Injection Wells (NOI) 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-is and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe we11s 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
htto:/ /deq.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
rotection/g rou nd-water-re eo rtin e-farms
2) Injection Event Records (1ER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparse 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,shresthaancdenrTov or via regular mail to address
below. When submitting the above forms, you will need to enter the nine -digit alpha -numeric number an the form
(i.e., WOXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number W10400458. 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
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shresth ata? ncdenr.00v
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
'Nothing Compares

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: Monday, October 17, 2016 2:23 PM
To: Knight, Sherri
Cc: Rogers, Michael
Subject: WI0400458 NO! Former Concoco Store #33027
Attachments: WI0400458 NOI.pdf
Please find the attached NOI.
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
sh risti.sh resthaLcvncd a nr. c ov
512N_ Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
"''`"INoth'ng Compares
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.

ATC
ENVIRONMENTAL • GEOTECHHICIIL
RIM nin Sf1F1111FS • MATfBIAIS TESTINA
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices. Qom
I.C. Engineering License No. C-1598
October 5, 2016 NI I � p16
„wow_ �]uriil[y
Ms. Shristi Shrestha
fi84Oiilitipri7i[iC+l.7 S''?r-An
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Former Conoco Store #33027 (RM #6202)
637 Martin Luther King Ir. Drive
Greensboro, Guilford County, North Carolina
Risk Classification: Intermediate 170
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C, (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of Phillips 66 Company. The permit application
covers injection of air at the above referenced site through two proposed air injection wells.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Ashley M. Winkelman, P.G. Gabriel Araos, P.E.
Project Manager Senior Project Manager
cc: Ed Kuhn, Contract Program Manager for Phillips 66 Company
Attachments

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 injection.
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS f15A NCAC 02C .0229 ):
1) Passive Injection Sy 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: October 5 , 20_16_ PERMIT NO. V\/ .I 0'-/-00 '-1-S 8 (to be filled in by DWR)
RECENEOINCDEOIDWR
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
OC110 20\o
(1)
(2)
(3)
(4)
(5)
(6)
Air Injection Well ...................................... Complete sections B-F.z.,K, N
Water Qua\\\y
___ Aquifer Test Well ....................................... Comt!ili\5 0\i'o~
X
___ 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: Business/Organization
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Ed Kuhn -Contract Pro gram Manager for Philli ps 66 Company
Mailing Address: 420 S. Keeler-PB 1417
City: __,B=a=rt=l=es::....:v..:.:il=le,__ _______ State:_ OK_ Zip Code: 74003 County: Washingron
Day Tele No.: 704-676-0502 Cell No.: Not Available
EMAIL Address: Ed.kuhn(a)contractor.p66.com Fax No.: ___ N~o~t=A~v~a=il=ab=l=e ______ _
UICI In Situ Remed. Notification (Revised 3/2/2015) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: Shehzad Ouamar-Grab N Go #7. Inc.
Mailing Address: 637 Martin Luther Kin g Jr. Drive
City: Greensboro State: _NC_ Zip Code:=2_,_74-'-'0~6 ____ County: Guilford
Day Tele No.: 336-215-6655 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available
E. PROJECT CONTACT -Person who can answer technical questions about the proposed injection project.
Name: ----'G=a=b=n=·e=l-=-Ar=ao=s,....---=--A=T'--'C"--"-'As=so""c=ia=t=e~s=o=-fN:.=o=rt=h'--'C=a=r=ol=in=a=,--=P___,_.C='-. ____________ _
Mailing Address: ---=2-'-'72=5'--E=-'-'. M=il=lb=r=o=okc.:.=R=o=ad=·-=S=u=it=e-=1=2-=--1 ________________ _
City: Raleigh State: _NC_Zip Code:27604 County:_W_ak_e ___ _
Day Tele No.: 919-871-0999 Cell No.: 919-816-7915
EMAIL Address: 12abe.araos@ atcassociates.com Fax No.: --~9~1=9--8'-7~1--0~3=3-=-5 ___ _
F. PHYSICAL LOCATION OF WELL SITE
(1)
(2)
Physical Address: 637 Martin Luther King Jr. Drive County:-'G'-u=i=lfi=o~rd~-----
City: Greensboro State: NC Zip Code: ~2~7~40""6'--------
Geographic Coordinates: Latitude**: 36° __ 3' -~3~8" or 0
Longitude**: 79° ___11' __ 5" or 0
Reference Datum: __ _,W_,_G=S=84-'-----·Accuracy: __ --=--1 0=--=m=e=-=te=r'----
Method of Collection: DOO -Acme Mapper 2.1
**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 (;S 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map( s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
UICI In Situ Remed. Notification (Revised 3/2/2015) Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets ifnecessary.
NOTE: Approved iryectants (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).
lnjectant: ---------------------------------
Volume ofinjectant: ____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants:
Injectant: ---------------------------------
Volume ofinjectant: ____________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
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: --=2 ___ P.roposed'---_____ 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
UICI In Situ Remed. Notification (Revised 3/2/2015) Page3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
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.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "1 hereby certify, under penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry ofthose individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all related appurtenances in accordance with the 15, f NCAC 02C 0200 Rules,"
Signature of Applicant
£4 ,r, k..►1✓ 44-/ 1;Troi,-11.--- r.0-,.rf-4
iFs�cef5 4+ Print or Type Full Name
Cars
PROPERTY OWNER (if the Lroperly is not owned bn the permit applicant);
"As owner of the property on which the injection well(s) are to he constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(154 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 ]and shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See Attached Shehzad Quamar — Grab N Go #7_ Inc.
Signature* ofProperty Owner (if different from applicant) Print or Type Full Name
* An access agreement between the applicant and property owner marry be submitted in lieu of a signature on this form.
Submit the completed notification package to:
DWR — L IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
U ICfin Situ Reined. Notification (Revised 3/2/24 15) Pagc 4

WILLIAM BECK
Eastern Region Manager
Remediation Management
PHILLIPS66
420 S. Keeler Avenue, PB-17-1700-01
Bartlesville, OK 74003-6670
Phone [phone]
Email [e-mail]
April 28, 2017
North Carolina Department of Environment and Natural Resources
Division of Water Quality -Aquifer Protection Section
3800 Barrett Drive
Raleigh, NC 27609
RE: Authorization to Sign on Behalf of Phillips 66
Monitoring Well Permit ApplicaUon
To Whom It May Concern:
Remediation Management (RM - a department within the Phillips 66 Health, Safety, and
Environment Department) is authorized to sign documents on behalf of Phillips 66 within its scope of
responsibility and financial authority. These authorities may be delegated for specific transactions
by the person holding that authority with the delegation sent to the RM Manager. Phillips 66
Company also authorizes third-party agents to sign certain documents on its' behalf according to the
same prescribed process. According to our "Document Signature Authorities -Remediation
Managementn (Effective May 1, 2012), a Program Manager is authorized to sign Permit and Licenses
(Well Permits and Similar) on behalf of the Company.
Accordingly, this letter d~legates authority to our Charlotte, North Carolina-based Program Manager,
Ed •<uhn, of GI-ID, Inc. to sign well permit applications on our behalf. This delegation shall be
effective for as long as Mr. Kuhn remains in the position of Program Manager for Phillips 66.
Thank you for assuring that only authorized agents sign documents submitted on our behalf. If you
have any questions, please do not hesitate to contact me at the phone number listed above.
Mil'
William E. Beck
East Region Manager
Phillips 66 Remediation Management
Cc: Steve Belin, RM Manager
I .
ConocriPhillips
November 28, 2011
Mt . Shehzad Quamar
Grab N Go #7, Inc.
4401 United St.
Greensboro, NC 27407
Re: CONSENT TO ASSIGN REQUESr -REMEDIATION AND INDEMNIFICATION AGREEMENT,
dated April 8, 2011, by and between CONOCOPHILLIPS COMPANY and GRAB NGO #7, INC. (the
"Agreement"); with respect to real property located at 637 Martin Luther King St., Greensboro, NC 27406
Dear Mr. Quamar :
On July 14, 2011, the Board of Directors of ConocoPhlllips ("COP") announced that it would pursue the
separation of COP's Refining & Marketing business and COP's Exploration & Production into two
separate stand alone companies via a tax free spin off of the Refining & Marketing business . Phillips 66
("Phillips") will be a global refining and marketing company headquartered ln Houston, Texas .
ConocoPhillips will be a global exploration and production company that will continue to be
headquartered in Houston, Texas. The separation is expected to be completed during the second
calendar quarter of 2012.
Per the terms of the ·subject Agreement, ConocoPhillips Company is requesting your cooperation in
consenting to assign this document. The Agreement along with the Consent to Assign econsent") are
attached for your reference and review.
If you have any questions and/or concerns prior to your execution of the Consent, please either give me a
call at [phone] (office), [phone] (cell), or [phone] {fax), or email me at
cathy.M.Brumwell@conocophllHps .com.
After your review, please indicate Grantor's consent to the assignment by signing and dating the attached
Consents and returning the originals to me by D!;QEMBER fl, 2Q11 and e-mailing or faxing a copy to me.
For your convenience, a self-addressed stamped envelope has been provided for the return of the
executed Consent.
Thank you in advance for your valuable time and assistance in this endeavor. I look forward to hearing
from you soon.
4 ;;1~~
Cathy M. Brumwell
Consultant
Encl.
ConocoPhillips
November 28, 2011
Mr. Shehzad Qualnar
Grab N Go #7, Inc.
4401 United St.
Greensboro, NC 27407
Re: Notice of Assignment and Request for Consent
Dear Mr. Quamar:
On July 14, 2011, the Board of Directors of ConocoPhillips "COP") announced that it would
pursue the separation of COP's Refining & Marketing business and COP's Exploration &
Production into two separate stand alone companies via a tax free spin off of the Refining &
Marketing business. Phillips 66 ("Phillips") will be a global refining and marketing company
headquartered in Houston, Texas. ConocoPhillips will be a global exploration and production
company that will continue to be headquartered in Houston, Texas, The separation is expected
to be completed during the second calendar quarter of 2012.
COP is forming a new company named Phillips 66 Company. COP is assigning our current
agreement with you to Phillips 66 Company, Our agreement is described as follows:
*REMEDIATION AND INDEMNIFICATION AREEMENT ("Agreement"), dated April
8, 2011, by and between CONOCOPHILLII'S CO. (the "Company") and GRAB N GO #7,
INC. cthe "Owner") with respect to real property located at 637 Martin Luther King St.,
Greensboro, NC 27406
As part of our agreement above, we promised to provide you with notice and ask for your
consent if we assigned the agreement to another party. We arc asking for your consent today, by
signing this letter where provided below, and returning it in the enclosed self-addressed and
stamped envelope.
Please do not hesitate to contact me at [phone] if you have any questions or concerns.
Your assistance in this matter is greatly appreciated.
thy M. Brumwel'l
Consultant
1)131168361964.1
Notice of Assignment — GRAB N GO 117, INC.

o1/26/2012 02:30
y
#7058 P.001 /0D1
ConochiIIi ps
CONSENT TO ASSIGNMENT
I consent to assignment of the above referenced agreement to Phillips 0 Company
GRAB NCO #7�yINC.
•
B)k- �`�� bate: / --)11
D$u 62361964.1
Notice of Assignment -- GRAB N GO #7, INC.

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PERMANENT AIR SPRAGE WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
L2
L3
L1 = 0 FT.
L2 = 30 FT.
L3 = 5 FT.
L4 = 35 FT.
PROTECTIVE CASING AND CONCRETE PAC
CASING MATERIAL
CASING DIAMETER
CASING LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
BACKFILL AROUND CASING
MATERIAL
THICKNESS
SEAL
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
DISTANCE ABOVE SCREEN
TOTAL FILTER PACK FOOTAGE
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
WELL
DEPTH TO BOTTOM OF
BOREHOLE
DIAMETER OF BOREHOLE
steel
8 inches
12 inches
2 feet x 2 feet
flush mounted
sch 40 PVC
2 inches
flush threaded
30 feet
cement grout
25 feet
bentonite
3 feet
#2 silica sand
2 feet
7 feet
sch 40 PVC
2 inches
5 feet
0.010 Inches
35 feet
35 feet
6 inches
DRILLING SUBCONTRACTOR:
DRILLER ADDRESS:
DRILLER CERTIFICATION #:
Geologic Exploration, Inc.
176 Commerce Blvd, Statesville, NC 28625
2581
TITLE Well Information
Former Conoco Store #33027 (RM #6202)
637 Martin Luther King, Jr. Drive
Greensboro, Guilford County
North Carolina
;ETC
2725 East Millbrook Road, Suite 121
Raleigh, North Carolina 27604
FILE
PREP. BY
AW
REV. BY
GA
DATE
9/21/2016