WI0400465_DEEMED FILES_20170410

WELL CONSTRUCTION RECORD (GW-1)
~-Well Colllrac1Dr lllfonaatln:
Thomas Whitehead R RECEIVED/NCDEQ/DW
Well Coubac1vr Name
2907-A APR l O 2017
NC Well CoDlnlcklrCcrtificaaon Numbar
S&ME, Inc. Water Quality
Re giaaal Ope,etio S
ColllpllllyNamc us ecf1on
Wl0400465 2. Wei Comanaetioll Permit#:
. I.I.ft all applil:abk wdJ COIISITW/IDn pmnlb jt.t. ll1a C-U,,. Slale, Yartan«, tie.)
3. Wei UR (cllecl: wel •te):
Water Supply Well:
JAgricultmal 0Muo.icipal/Pllblic
:]Geothennal {Heating;/Cooling Supply} QRementiaI Water Supply (single)
jlnduBlrial/Commeroial DR.cllidc:ntial Wa1cr Supply (shami)
,lrrio.tion
No11-Water SUp9Jy Well:
tlMoniloriJJ& n Recovery
Injection Well:
tJAquim Reclwge l!)Oroundwa1cr Remediation
t:)Aqllifrr Stootge and Recovery a~lyBmrier
:)Aquifer Teat Ostor:mwater Drainage
:JExperimental Technology Qsubsideoce Control
:JGeothennal (Closed Loop) □Tracc:r
"10eotbenna1 (HcatirullCoolirut Rctmn) MOther (explain DDdcr #21 Ranarlcs)
4. Dt,te WeD(1) Completed: 1118117 Well ID# SPG-2
Sa. Wei LocatloD.:
Huff's C-Store
Facility/Owner Name Facility ID# (ifappllc.ablc)
2668 NC Hwy 49 North, Burtlngton
PbyeicalAdrnl,s,City, ...iz.
Alamance
Couniy Pan:el Identmcalion N,;,. (PIN)
Sb. LatHnde md lon&itude la clegreelllmlalltalHC1111ds or decimal d :
(If well mid, one lltlloag is ndlicient)
36.154 79.337 _________ N ___________ W
6. ll(are) tile well(1)1:]Pemument or Or-pol'IIJ'y
7. II llllla repair to a oiltill&well: DYn or E}Ne
(/Iha i611 rq,air,Jill-~ wdl t:DNfnlt:don ~""• uplain /Ire 111111n '1.f/Jw
npair IIIIIW#2I nJII01'b ffi:llall orM th bttdtj'tltJsfim,t.
Print Form
r For Internal Use Only:
14. WATER.ZONES
ll'llOM TO DISC.RJ1'11ON
II:. ft.
ft. ft.
15. OIJTER CASING Im Dlllld-cued wellll OR LINER IV ...
FROM r TO r DIAMETlll TDJCKNBSS I MATKRL\L
ft. ft. la.
l~INNERCASJNGOJlltlBING r-..,....,.ll:hHIMaoDl
ROM TO DIAME'r1:lt TBICICNBSS MA'J1!lllAL
0.5 ft. 39.6 ft. 2 Ill. sch40 PVC
ft. ft. Ill.
17.SCREEN
IJtOM TO DIAMn'Bll SLOT SIZE TIIICICl'il!SS MATIIIIIAL
39.6ft. 44.6 ft, 2 hi. .010 sch40 PVC
ft. ft. hi.
18.GROtlT
JIIOM TO M.t.'l'ERLU, llMl'LII.CEMENTME'l1IOD ,I: AMOIJNT
2 · ft. 36 ft. Cement Pour
36 ft. 38 ft. Bentonite Pour
ft. ft.
19. SAND/GRAVEL PACK M
JKOM TO MAnJll'.AL IIMKACEIIOINTMlmlOI>
36 ft. 44.8 ft, #2Sand Pour
ft. ft.
28. DJULLING LOG {dad! addltloul lllleetiJ If JU!UH""''
ntOM TO Ol!SCIUP'nO,"I , ....... --IC!ll-k•~--•• ''"" tit.I
0 ft. 5 ft. Orange Clayey Silt
5 ft. 30 ft, Tan Sandy Slit
30 ft. 44.8 ft. Ora ng e Slit
ft. ft.
rt. ft.
ft-ft.
ft. ft.
Jl.REMABXS
22. Cerdfication:
3 ~;. ··-tz-f,'k:-;,·· 2/1/17
Sipltun, of Certified WeUCommctor Date
By .signt,,g-tlda fon,t. I hBeby cm/fy dtat rite wdl(s) 11'/U ~ COllll1'IICted bl a~
wtdl IJA NCAC02C .OI90or ISA. NCAC02C .0200 W11U Colutn«:llan Slaltdaruand dtata
cop)' oflltis ""'°"',_,_,prow/ltd 10 tlw _,, __
23. S1111 dlqram or addidoul well detdr.
8. For Geoprobe/l)Pr or CJoRCJ.Loop Geodaermal Wells llaving the &!IDlC Yoa may wie tbe back of this 1J88e to ptOv:ide additi<mal well Bite details or "11.
COll8lrUCtion, OClly 1 GW -1 is needed. Indicate TOTAL NUMBER of wells COllllruc:tioo details. You DIIIY aleo &Ullch additioml P8FI if aecessary.
drilled: SUBMITTAL INSTllUCTIONS
!>. Total well mpth below land t11rface: _4_4•_8 ________ .(ft.) 2.: For AD Welf: Submit 1h.is fi>rm within 30 days of completion of well
For ffltlittple ~lb li4l all dllptlis ii di/ferettJ (f111f1111Pk• J@100 'amJ 1@100') construction to the following:
N/A JO. Stade watu level below tup of ca1in1: _________ (ft.)
ffwaur leffl i.J <tbovi! Cd.Mg, ;,,:i ''+ •
11. Borellole dlan;ieter. _1_2 ____ (Ill.)
. A 12. Wdcoutracdonmedlod: _u_ger ___________ _
(ie. ..... rolaly, eablc, dm,ctpush. di:.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) ______ M etllod oftest: ______ _
Divldoll of Water lleloarc:e1, 111.fonaatioa Procealng Unit,
1617 MaD Sen.Ice Center, Rald&h, NC 27699-1fil7
24b. f PC IBiegtipp wen,: Jn addition to IIClldiog 1bc funn to tlle address in 24a
above, abo submit me oopy of dlis fuim wi1hiD 30 days of oampletioo of wdl
OOll8tnll:tion 111> the fililowing;
Dividn af'Water Rem■rce■, U■cle...,-oud IJljecdon Conlrol Prognm,
1636 Mall ScrvJce Center, Riilllab, NC 276'!J.l'36
24c. For water Sgp1y A 1piegigpg wen,: 1n addition m &ending die ~ to
die addre&s(es) above, also submit ODe copy of .this :limn within 30 days of
Ll::3::b-:_:Disill::"=:fi.:::eeoo::·:n:_:typ~e:.:: :::::====:::::=-..'.:A:'.:mo~llB::t::· ===========~ completion of well c:onslnlclion to the county health depaIUnent of the county ~ construclcd.
FomaGW-1 Norrh Carolina Department ofEnvimmntmal Qmli!y -Division of w..,.. Ra,oun:es Revised 2-22-2016
WELL CONSTRUCTION RECORD (GW-1}
1. Well Ccnltraetor lafornatio■:
Thomas Whitehead
Well Contmctor Name
2907-A
NC Wcl!Contmctor c~ Number
S&ME, Inc.
Company Name
2. Well Collltnlcdo■ Permit#: WI0400465
J.bt all appllcabk well construcilonpmnll8 {t.rt. U1C, County, Slau, Yartance, IIC.)
3. Well Uae (elleck well ■se):
Wmr Supply Well:
j Agricultural □Municipal/Public
t)Gexi1hermal (Heirtin@'Cooling Supply) □Residential Water Supply (single)
j fndustrial/COIDIDlln:ial □Residemial Water Supply (shared)
,.hri garion
No•-Water Supply Well:
".lMOD.itoring □Recovery
lnjeetlon Well:
'.]Aquifer Recharge l3Groundwate:r Remediation
□Aquifer Storage and Recovery □Salinity Barner
BAqtrifrr Tmt □storm.water Drainage
Experimental Technology □subsidence Control
□Geothermal (Closed Loop) □T= n~ (Heeliog/Cool iog Return} n O!her (exp lain undet #21 Remarks)
4. Date Well(1) Completed: 1/25/17 Well ID# SPG-3
Sa. Well Locadon:
Huff's C-Store
Facility/Owner Name Facility ID# (if applicable)
2668 NC Hwy 49 North, Burlington
Physical Addn,l!S, City, and Zip
Alamance
County Parcel rdcnlification No. (PIN)
5h. Lafltu.de ud hi minatAIIIHCODdl or decimal longit■de dqreet/
(If well field, one lat/long is sofficim)
dep'ees :
36.154 79.337 __________ N ____________ W
6. Js(are) the weD(1)8Pel'llllblent or □Temporary
7.&thlurepairtoane:dsthagwell: □Yea or l!]No
Qthb i& a rq,air,jlU Ollf hro>m mil C<lll8lr'IIClio iqformalian and up/lJin ~ "'1.ture ofthl!
,epa/1' under #21 ,v,na,ks m:ttaa Ill" OIi 1M baclc r,f this fonn.
I For Internal Use Only:
[ Print Form
14, WATERU>NU
IIROM TO DFSCRIPTJON
ft. ft.
ft. ft.
15. OUTER CASING If air muJikasetl welbl OR LINER Of imnllc llhle
FROM I TO \ DIAMETER. THICKNESS MATERIAL
ft. ft. Jn.
16. INNER CASING OR TUBING /o..,.bcn,qd " --l
l'llOM TO DIAMETER THICKNESS MATERIAL
0 ft. 39.9 ft. 2 hi. sch40 PVC
ft. :ft. m.
17.SCREEN
ntOM TO DIAMETER SLOTSIZE TBJCKNESS MATDUAL
39.9ft. 44.9 ft. 2 lo.. .010 sch40 PVC
ft. ft. in.
111.GROUT
FROM TO MA.TI.IIJAL at:Pl.A.CiMKNTMln'EIOD & AMO Q,T
2 ft. 36.2 ft. Cement Pour
36.2 ft. 38 ft. Bentonite Pour
ft. ft.
1', SAND/GRAVEL PACK llf '"""'""""')
IROM TO MATEII.TAL ll\lPLACEMENTMBl'BOD
38 ft. 45.1 ft. #2Sand Pour
ft. ft.
ll. DRILLING LOG {attadt .adltloul llaeets lf_...,l
n.OM TO Di:llCKirnON (color ~ llllYnck i---onbl Ib, . .,,.1
0 ft. 5 ft. Orange Clayey Silt
5 ft. 28 ft. Ora noe Silt
28 ft. 45 ft. Ora nge Clayey Silt
ft. ft.
ft. ft.
ft. ft.
ft. ft.
?I.REMARKS
22. Cerdfieation:
~l "wD:,fdv-a J. · 2/1/17
Sigm,tum of Certified Well Contractm Date
By signing thl8 form. I hutby cuttJy lhal the wdl(s) was (wen) co1l3lnlcud in accorr/anai
with 1 LI NCI.C IJ2C .0100 or J.J,t NCA.C 02C .0200 Well Constn<cdon Standards Olld dtat a
copy Qf tht$ naml has l,co, pn;vided la ilw wdl OWIIU.
.23. Site dlagrui or additional well details:
8. For Geoprohc/DPI' or Closed-Loop Geothermal Wells having Che smne You may use the back of 1his page to provide addiliooal well site details or well
eoas1l'lll:tion only 1 GW •l is needed. fndicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessmy.
drilled· SUBMITTAL INSTRQCTWNS
9. Toul well depth below land 111rfaee: ......,
45,...·...,.1
=-:-:c:-,-...,.,,-=-=,c:-,----<ft.) 241. Fpr All Ws,111: Submit !his funn within 30 days of completion of well
For multiple Mils 11st all dq,llu if diffm,rl (~,,,pie-1@200 'and 2@100') construction to the following:
NIA 10. Static water level below top of aimg: __________ (ft,)
(fwatt!rl-114 abow cosing, uu "+"
11. Borebole diameter: _1_2 ____ (in.)
12. Wei eoutnttion melllod: Auger
(i.e.111Fr,rowy, cable,din,c:tpush. etc.---:c)-------------
FOR WATER SUPPLY WELLS ONLY:
DhWon of Water Reaoarcer, lnformadu. Proeeablg Unit,
1617 Mail Scnice Center, Raleigh, NC 27699-1617
24b. For lnieqion WeJII: In addition to sending 1he form to the address in 24a
above, also submit one copy of this funn within 30 days of completion of well
consb:uc:tion to the following:
DiviJkm of Water RelOurcet, U■dercrollDd JajeetioD CGntrol Program,
1636 Mal Service Cellter, Rale1gb, NC 27699-1636
1311. Yidd (gpln} ______ Method of test:_______ 24e. For Waur Supply & lnjfflion Wells: ID addition to sending !he funn m
the address(es) above, also submit one copy of this funn witbln 30 days of
L1=3.:b.:.:D=ililll='=feetio='=n:..::'.ty~pe=:======.....:.Am=o=11:.•t::_: ========:J completion of well construction to 1he county health department of the county whmc constructed.
FormGW-1 NOJ1h Carotm. Dcpulmcut ofEJMJOnmenllll Quality· Division of Water Resoun:es ~ 2.-22-2016
WELL CONSTRUCTION RECORD {GW-1)
I. Well Colltradlllr Id,nudllll:
Thomas Whitehead ·---' Woll Coabaclw Naa
2907-A
NC Well Commctor Cettification Nlllllba
S&ME, Inc.
Company Name
WI0400465 2. Wei C1>11Stnledon Pmnlt #:
List fl]J appll,:abk wdl ~~ (u UJ(; Caa,ty, Stare, Yll11tma, etc.)
3. Wdl Ole (eheckwel ue):
Water Supply Well:
□Agricultural 0Mllllicipal/Public
□Geotbermal (Heatiaa,'Cooling Supply) IJaesidenlial waier Supply (single)
JI JndwJtrial/Comm.mcial □Resideutial. Water Supply (shared)
,Jrri o tioll.
Noll-Water Supply Well:
,MOllitoring n Reeovery
Iajedion Well:
JAquifa-Recharge l!JGrourulwau:r Remediation
Aqwfer Storage and Recovery IJSalinity Blllrier
:]Aquifer Test □Stormwa1er Dlainage
j&pcrim.ental Technology □ Subsidence Control
t]Geotbenna1 (Closed Loot>) □Tracer n Geotbermal. (l-l eatin &ICooliDg ReUDn) M Other (explain under #21 Rcmmb)
4. Daa Wcll(s) Completed: 1126117 Well IP# SPG-4
Sa. WeD Loa11cm:
Huff's C-Store
Facilily/Owner Name Facility JD# (if applicable)
2668 NC Hwy 49 North, Burlington
Physical AdclMs, City, and~
Alamance
County Pan:$! klenliflcation No. (PIN)
5b. Latitude ud lo . la UCOIICeouds or decimal : ngjtudedep-eel/ndll
(if well &Id, one 1at11mQi is sufficient)
38,154 79.337 __________ N ____________ W
6. h(an) tile weB(1)1!1)P-mt or []Temporuy
7. h tllila repair to 1111 ailtinawdl: □Yes or [:]No
Q'dd11 f.J a rrpair.fill out""'-'WltU~ ilrfon,,a#fl>ltllld aplain 1M natllre afdte
1'epalr vndu #2/ MIIOl'ls section ar"" dv had of rlli6fon,,.
I For Interoal Use Only:
[_. Print Form
14. WATER ZONES
PROM TO DESC1UP1'ION
ft. ft.
ft. ft.
15. OIJ'l'ER CASING ,.,,, mnlll-cMlll WIii,) OR LINER (If ·-"--~·
FROM TO DIAMETBR THICKNESS I MATDIIAL
ft. ft. In.
16. INNER CASING OR TUBING ••-thnmld-1
PROM TO DIUIETD 11DCKNl:SS MATl!JUAL
0.9 ft. 39.9 ft. 2 bl. sch40 PVC
II. ft. IL
17.SCR&EN -TO DIAMETll'.R SLOTSIU TIIICJINl!SS MATKBIM,
39.9ft. 44.9 ft. 2 In. .010 sch40 PVC
ft. ft. ID.
18.GROVT
1'1IOM TO MATIIIJAL EMl'LACEMffiT MBTIIOD 6 AMOIJNT
2 ft. 36 ft. Cement Pour
36 ft. 38 ft, Bentonite Pour
ft. ft.
19. SAND/GRAVEL PACK /if •~....,.••II)
DOM TO MATIJUAL IIMl'LACICMJINTMnl!OD
36 ft. 45.1 ft. #2.Sand Pour
ft. ft.
10. DRILLING LOG !amd1 addllloul lllltets If 111!0ef.uim
llltOM TO DE!ICRJPllON' (ctill:w .... .,._.... ~rvlll',----. Ila. dt.1
0 ft. 7 ft. Red Clayey Slit
7 ft. 25 ft. Red Sand y Silt
25 ft. 45.1 ft. Ora ng e Cla yey Silt
ft. ll,
ft. ft.
ft. ft.
ft. ft.
21.REMARKS
22. Ccrtlfteatioa:
::rIY?;:;&;2 . "i,.;.i])Jtd£4 .J ~ 2/1/17
Sig,ratun, ofCeitlfied Well CO!lln!l:lor Dale
By .r/pllv tlris Jam,. l hereby artoo, tltal ~ well(&) ,_ (were) constnll:ttd in °"""'°""
wtdt 1:U NCA.C 02C .0J(J0 or JSA. NC4C 02C .0200 Well Covlr!don Sltuulanh tllld tliat a
cr,py af//tiz T«IOl'd l..u bttltpnwiud ID tlle Mil owner.
.23. Slee cllagraJII Clr addidoaal •ell detalll:
8. For Geoprobe/DPT or CJellld-Loop Ga,ClleJDal wen, baving Che same You lllay use: ~ back of this page to provide additional well ai1e dCJlails or well
C0118Uuctiao, only I GW-1 isnealed. Indicate TOTAL NUMBER of wells ~ delails. You may alao ldlachaddilioual page9 ifneceasary.
drilled: SUBMIUAL INSTRUCTIONS
9. To1al well deptli. below hind suface: _◄_5 •_1 _________ ,(ft.) l4a. For AR Wei ■: Subtnit this furm within 30 days of completion of well
For mu/dpl, ells list all deptlu If d/jfUMt (aample-J@JOO' 1111d 2@10D') COD8lrlletion IIO the fullowing:
NIA 10. Static waf.eJ' level below top of callng: __________ (ft.)
v-1.ve1 is ahem casing, -• + •
11. Borellole diameter: _1_2 ____ {la.)
12. Wei conmuaioa mcdiod: Auger (ic. lu,et,rotary, cable, dlrect)llllh,ele._) ____________ _
FOR WATER SUPPLY WELLS ONLY:
Divilioa of Water Rnource1, Jaronnadoll Proanlng IJnlt.
Ui17 Mall Senlce Cater, RaJtJp, NC 27699-1617
24b. For Iqig:tiop wens: In addition to ,ending the furm to !be address in 24a
above, also submit onc copy of thia fulm within 30 dayB of completion of well
CClll81l'aCCion 1o the following:
DiYillan efWatu .e-rca, Uadffarouad IDjecdoD COlltrol Proanm,
1636 Mllll 8en1ee Cam, RaleJp, NC 27'99-1636
1311. Yield (gpm) ______ Metllod of test:_______ 14c. Fpr Wffi Supply & Iptecdop WeJ11: ID addition ID !ellding the fiJon to
the add!m,(cs) above, also 1Ubmit one copy of this 1mm. within 30 days of
1 _l:.:.3.:.b·:..:D:.:hhd=:.:i!edon=::..:::typ~e::..:======.......:.Alllo=:.:u=•t:.t ========:.J compleuon of well CODBtrUCtion to the county health d.cpartmcut of the cmmty -where CODStnlcted.
Fonnow.1 Nolth Carolina 1.Jep111tmc11t ofEnmoami:nlal Q\lal!ty • Division of Water Resources Revised 2-22-2016
WELL CONSTRUCTION RECORDJGW--1)
1. Well Carrtrac*aritrformetfanl
Thomas Whitehead
Well Contractor Name
290P A
NC Well Contactor Certification Number
S8tiulE,inc.
jai y Nude
2. Well Coutruct1ou Permit #: WI04004655
Lire all apparable+xiirwrsarucdc'rpermits (Le. WAG Caws, Stair, Parham eel
3. Wd1 Use (ditch will ere):
Water Supply Well:
Agricultural © MwucipsNPublic
Geothermal (Heating/Cooling Supply) ©Raaidmtial Water Supply Omsk)
Industrial/Commercial ORcsideatial Water Supply (shared)
hri stem
Nee -Water Supply Well:
Mceimri'og
Injee
Aquifer Recharge
Aquifer Storage rind Recovery
Aquifer Test
Experimental Toehno10 y
Geothermal (Closed Loop)
Geothermal; I i
'Cool
Return)
©RCS'
Omaadwatrr Remedios -km
El Salinity Berries
© Starmwater Bonnege
©Sabaidenca Control
Tracer
e Other (c.-.p lain midis 421 R.eEtadcx)
4. Date well(:) Completed:
il24111
Sa. Wen Ludlam:
Huffs C-Store
Facility/Owner Name
2668 NC Hwy 49 North, Burlington
:Wen IDSSPG fi
Facility 1D# (ifapplicebte)
Ilyskat Adams, CityZip
Alarm ic°
County Panel lddouNo. (PIN)
SIN Latitude end longitude In degreeslrakiatesraecoei or decimal degrees:
(if well field, one Wong in wrFficieat)
36.154 79.337
6. Islam) tie wdi(s)aPermeeeat or [Temporary
7. Is this a repair to an existing well: QYcs or Q No
{fdds is a repair, Jill awe Moral r consrriezio„ iafornwtiee aril opiate the Flan yr of the
repair under M21 meatier seaiwt or an the back rf this farm,
S. For GcoprubellPT or Closed -Lapp Geothermal Wells having the same
caastmuian, catty 1 OW-1 is needed. bulieute- TOTAL NUMBER dwells
drilled:
9. Tottriwell depth below lend sedum 45.2(TO
For multiple mill list all depths ifdli rene r xantpie- 3@2O6' 0ed2@t66')
t0. Static water level below top of cueing: N/A (}t.)
q'xater iced is above castng, use ••+'•
11. Ilarrhok diameter: 12 4.1
Auger
12. wen emnstructiost method:
(Le Eger, :vary, cable, direct pull]. etc.)
rFOR WATER SLY WELLS ONLY:
13a. Yir1d (Spm) Method of teat:
I3h. DIdefectioa type: Assault:
LM Form
Far Internal Use Only:
14. WATER Tht41.9
mat
70
e>tttLR1 t11t 1
ft.
if
f
13.eurekCAS1NG(form&It-c.. d wrioL9RLINERif )
]egm;t TO VL41,l ER TRICSMETS MATERIAL
2.
It l..
26 WWI CASING OR TUBING (east6.rm! Clan d-harp)
MOM
TO
MCKEE=
TE IERNESE
MA1R1L4L
1 IL
40 t
2
soh 40
PVC
ft
ft.
-
lu.
17. SCREEN
RltOM
TO
DIAMETER
E.t7rs122
TRIMMER
MATERIAL
40 '•
45 t
2
.010
'soh 40
PVC
t
ft.
Ia.
IL 4 R011T
FROM
TO MATERIAL j EMPLACEMENT MR1'9t)D& ASIG N1
2 R'
36 R• Cement
Pour
36 It.
38 'It
Bentonite
Pour
ft.
t
19. $tRNIrt211AYLLPAC1CIMIp¢itraik
tmomsiD
llfAT"flLLtL
EMPfACetMRNT'IMRt'>1nD
36 ft-
45.2 t
#2 Sand
Pout
8
R
12, nR1U.131GLOG
(i
eddlll■et.l!ba dsf.eeewsrlt
sxQse
Tv
nr.5rr•rine (fount,.Artrn.,.Nurrrt trim ormbi .trr.ALI
0 R.
17 e.
Orange Sandy Sift
11 IL
45 ft.
Yeilow Sandy Silt
ft.
ft.
ft.
ft.
ft.
fr.
It.
R.
ft.
r.
t21. REMARKS
21. CerNSc.tloa:
211117
Signato:4 ofCessiiad Well Cadracror Date
$r stid+g PM 1harrbY eerie Mat the +.rf1(s) wtrs (nrrr) rnnstr4aed fir arawdatree
Halo 114 NCACO2C.6fo0 cr ISA NC4C 02C , 0200 Will Coartr crion Standards and dart a
copy of this record Pear been provided m to rrrl owner.
23. Site diagram or additional wen detifiet
You may use the beck of this page to provide additional well site details or well
oeaselructiun details. You may also attach additional pages if•necemary,
Et/BMITTAL INSTRUCTIONS
24a. for Alt Wth: Submit this fors within 30 days of completion of well
CC sanction to the fallowing:
Division of Water Resources, Information Processing Halt:
1617 Mali Service Center, Raleigh., NC 27699-1617
24h. for Iniostion Way In addition to sending the Gram to to address in 24a
above, also submit one eopy of this Satin within 30 days of eamplcticm of well
construction to the following:
ll vldos of Water Resources, IIodergroeed lnjectioe Coarral Program,
1636 Mail Servke Center, Raleigh, NC 27699-1636
24c. jar W*ter Simply dr_ Ieiietioe Wens: in addition to sending the firm to
the tuldress(es) above, also submit one copy of this form within 30 days of
completion of well conetr-ucrirm to the comity health dap rt,neut of the county
whore canetrocied.
liorm9W-1
North Carolteu Dvattmem ofEmrimarrental Quality - Division. or weer R cot Revised 1.22.2016

Print Farm
WELL CONSTR1 •CT1ON REi `CIRI] i CW-1
1_ Well Contractor lnlbrteration:
Thomas Whitehead
Well common Nc=
2907-A
NC Well CanttptcLx Ctstltuatioa NUMbel
S&ME, Inc.
Con ism, Haan
2. Well Construction Permit fr: W10400485
lift sir asp/Foible ' U consisnenonprrmits (I.r. VIC, (blow Sate. Violence )
3. Well Use (check well use):
Water Supply Well:
Ageicninual
Geothermal (LlmtingfCooiirrg Supply)
radusaiallCousme:cia I
fiTrntiva
Non -Water Supply Well:
Monitoring
▪ tidno cipal/Public
o Residential Water Supply (tingle)
©Residential Water Supply (shared)
Oery
isjo: qua Wen:
RechargeAquifer �
Aqui1 Stange and Rewowery
Aw idea Teel
l3xpesimeotal Technology
3Gratharon] (Closed loop)
Geothermal (Hca;mglCoo1iag Raton"
3Oruunawater Remedithon
riSatinfty Barrier
▪ Swtniwctcr T7ruio gc
Subi idcrlae Control
3Tracer
f Other '.e*Flui�, msdat 021 Rif
4. Date WOO) comp1etet 11i9117 Well SPG-8
5s- Well Location:
HutPs C-Store
FacAky/Ow= Newt
2888 NC Hwy 49 North. Burlington
Facility 1D# (if applicable)
Phaysirsl Address, City, and 21p
Alarnanoe
Count; Pura' McWffcetien No. (PIN)
5b. Latitude sad longitude In degrceriminulestscconds or decimal degreer:
(daft)] field, ore Irllong ie s iciem)
36.154 lti 79.337
6. h(are) the well(s)rPermaeent or °Temporary
7. Is this a repair to ma exhideg weft: fl Yes or Q lYo
tfthis is a swa ,Jill ow horns >+ri[ cossuuction tnjwn;oth'an and ;plain the nasvrr of the
repair under t12.1 remark; section or Go the Houck Litt=rruarn.
ti. Per GtoprobefDPT or Closed -Loop Geothermal Wells baring the store
ca t traction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
gilled:
4. Totalwell depth below land salute:45
(Pt.)
For inittipIE welts lur Q11 depthr tidiB"uen (um+w[s-i01,200'turd2@dirt')
10. Static water level below top of csaing: NIA (tt,)
lJwter Ind re shoe casing we "+ ••
11. Borehole diameter: 12
Auger
12. Well construction method:
(Le. auger, rotary, cable, direct push, site.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Dfectioa type: Amount:
For Internal Use Only:
14. ww1 mix maim
FROM
Tit
DESCRIPTION
R
ft
R.
S.
is,ourseCASENG
Ps ettatiheord welln OR LINI7l L'f ai bit]
FROM
TO
DIAMETER
acism= esnreum,
ft
e.
Ia.
16.DOM
CASINO GRIMING it rued doen# -howl
PPWJMMM
10 D1AMerIR
TWCYNE=
MATERIAL
1 iz
39.8 . 2 fa.
sch 40
PVC
t.
t. ; m.
17. SCRE
FROM
're
MAMMA
FLOTMF
'fincientaS
MATERIAL
39.8
44.8 et
2 IL
.010
I3ch 40
INC
tr.
e.
r~
,
1L. car-int
Tit
staltRIAL
RL►Ct 4ENrr MStROD O modem
0 11.
36 it'
Cement
Pour
36 t-
38 t-
Ben onite Pour
I $, SANDICIRADRIL
PACK
1 *p Il ApY)
PROM
TO
MAITRIAL
W1ilLACEatlmli'METHOD
38 w-
45 IL
#2 Sand
Pour
1e.
ft.
20. MULLING LOG Cornea al seat therm st mmrarrl
MOM
TO pasQalITIOn CIIW, units ,,■uwn. mtcusnr. Om. d1
0 &
5 lr.
Brawn Silty Clay
19 IL
Offinike Silly Sand
5 II•.
19. R:
45 e•
Orange Silt
ft.
ft.
1t
ft.
t'.
ft.
2t. ia&MARIits
Z� Certification:
2/1/17
W m .= of enact Well Coraictor Emir
By Sir rf.mg thk faro 1 hereby eartry6 that the n4R(s) nass (mi) eonsiruued In accorrimtee
wf h 15A NCAC 02C .0I0O or ISA NCAC 07C .4200 Wei Cantle oo,i ilmrdarxh and that a
copy norms retard has beers provided to the well ❑ wner,
13. Site diagram or additional ►rdI detaiia:
You may use the heck of this page to provide additional well site details or well
coustmgbon detals You may also attach additional pages if necessary.
51.I1MITTAL INiSTRUCfl0N
tda For All Was: Submit this farm within 30 days of cumulation of well
cunsunctian to the billowing:
Division of Water Resources, Information Processing Unit,
1617 Msl1 Service Center, Raleigh, NC 27699-1617
14b. 1- or Iaiisetina Was: In addition to sending the form to the add4e13 in 24s
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division or Water Resources, Underground Infection Control Program,
1636 Mall Service Center, Raielgh, NC 27699-1636
24c. For Water Suoity & Iniecdion Willa: In addition to sending the form w
the eddrays(es) above, also submit one copy of this fYnm within 31) days of
completion of well construction co the cwmcy health depmmirot of t e county
where constructed.
FaraOW--I
North Catalina Depsdmen of Envirowwnbl Qwlity - Division of Water knonnrn Revisal2.2 -26ti

WELL CONSTRUCTION RECORD (GW-1)
1. wen Coatraemr bformatio•:
Thomas Whitehead -Well ColltDIClorName
2907-A
NC Well Contractor Certlficfltioo Number
S&ME, Inc.
Compeny Name
2. Well Coa1tr11ctiun Permit Ii: WI0400465
L/$t all applle11b/1t well crmstrucJion pumft.s {I.e. VIC, Cowuy, StaM, Yarlano,, de.)
3. Well Ulll (clleek well 111e):
W•ter S11pply Well:
□Agricultural □Mllllicipal/Public
JGeotbermal (Heating/Cooling Supply) □Residential. Water Supply (single)
Jindu81rial/Commercial □Residcmial Water Supply (sbarc:d)
,Jrrigation
Non-Water Snpply Well:
,Monitoring □Recovery
(Qjecdoll Well:
tJAquifer Rechatge [!]Groundwater Remediation.
tJAqum,: Storage and Recovery □ Salinity Bairie:r
□Aquifer Test □storm.water Drainage
IJExperimeatal Teclmology □subsidence Contro1
IJ)Geothermal {Closed Loop) □Trac«
:,Geothermal {Heatinll/Coolim, Return) nOtber (explain under #21 Remades}
4. Date Well(s) Completed: 1/24117 Wel.lID#SPG-9
5a. Well Location:
Huff's C-Store
F11CJ'lity/Owner Name Facility ID# (tt'appllcable)
2668 NC Hwy 49 North, Bur1Ington
Physical Addmis, City, and Zip
Alamance
County Parcel ldenllficalion No. (PIN)
5b. Latitude ud lo udein d qlt Cl reer/lllinntel/-ds or decimal deg rees:
(ifwell field, ODe l&tllong is sufflcm)
36 154 79.337 _• _________ N ____________ W
6. ll(are) the weJ.1(1){:]Permuent or □Temporary
7. I• 1hin repair to an emtbag weJI: □Yes or l!]No
If/1,is isa N!pflir,ftll out knoMft 111ell construction itlfannaJton and aplain the IIIUIU'e of the
rtpalrwrtler#21 remar/a seclial oron th baclctftldsform.
Print Form I For Internal Use Only:
14. WATltllZONES
FROM TO DEICIUl'l'ION
ft. ft.
ft. ft.
15. OUI'ER CASING (for Jllll)tkoed wellll OR LINER (If 11r11111.rable)
FllOM TO DL\Mn'ER THICKNESS I MATl!RJAL
ft. ft. iii.
1'-Illlff:R CASlNG OR Tl!BlNG fftOlharmal. tlosed•loop)
J'IIOM TO DIAMlITD THICKNESS MATIIJUAL
0.3 ft. 39.3 ft. 2 i■. sch40 PVC
ft. ft. I ■,
17.SCREEN
IIROM TO DLUH:I'ER liLOTSI7.E TBICKNIISS MA'IDIAL
39.3 ft-. 44.3 ft. 2 ill. .010 sch40 PVC
ft. ft. la.
l&GROUT
JlllOM TO MATEIIIAL EMPLACWEIITMETHOD a, AMOUNT
2 ft. 35.5 tt. Cement Pour
35.5 ft. 37.5 ft. Bentonite Pour
ft. ft.
1!1. SAND/GRAVEL PACK <lh11ullclble)
J11tOM TO MATDLU. l!Ml'LA.Cl!MENT METHOD
37.5 tt. 44.5 ft. #2.Sand Pour
ft. ft.
20. DRILLING LOG la.ttill!II llddiliOAII wets If_,._.,,,
anN TO DliSCRIPllON {-lls-_,,,.k ~-0 ~-"'-ft<.]
0 ft. 9 ft. Red Clayey Silt
9 ft. 15 ft. Orange Silt
15 ft. 20 ft. Orani:ie Silty Sand
20 ft. 44.5 ft. Orange Slit
ft. ft.
ft. ft.
ft. ft.
21.REMARKS
22. Certificad.o■:
:1t:.G---:1~ .. c2 -w/fikkar/4-2/1/17
signatule of Certified Well Contnct.:lr Dal,:
By 8Wning thuform, I hereby ,:vttfy that the we/1(3) ,_ fw-) consm,ct«I in acamlfJIII%
will, J 5,1, Net.C 02C .0100 or J $,1, NCA.C 02C .0200 Well Construction Sllllulards and that a
copy of this Tt:t:IDrd has been prm,i,J,:d ID th,: well ownu.
23. Site diagrun or llddititmlll well details:
8. For Geoprobe/DPT or Closed-Loop Geotllenul Wells having lite same Yon may use the bad: of this page to provide addlti-1 -well site ddails or well
CODS1Juction, only 1 GW-1 is needed. Indicate TOT AL NUMBER of wells COIJSIIuetion details. You may also IWICb addltional pages if necessary.
drilled: SllBMlTTAL IN§TRUCTIQNs
9. To1al well deptll below Ind llllfaee: _44_._5 ________ (,ft.) 24a. Fer AD Welhl: Submit 1his furm within 30 daYB of completion of wen
For mulllple welb list all deptl,I if diflmnl (txmnple-3@206 • 111111 2@100') COJIStruction to the fullowmg:
N/A 10. Sutic water level below top of cuing: __________ (ft.)
[fwatu kvel is above azsbrg,. -, "+"
11. Borehole diameter; _1_2 _____ (m.)
12. Well co■straction method: Auger (i.e. auger, rotary, cable, din:ctpush, etc._) ____________ _
FOR WATER SUPPLY WELLS ONLY:
DhWOla of Wat.er Rellources, bd'ormltion Procenlng UDit,
1617 Mal Service Center, R■lelgll, NC 27'9!1-1617
24b. For Inlmioa wen,: Jn addition ID sending 1he form to 1he address in 24a
above, also submit one c;opy of this fimn within 30 days of completion of well
construction to the mllowing:
Dlvldon. of Water RelOUrcet, U■dergromd IDjecdon Control Program.
1636 Mail Service Ceu.ter, Raleigh, NC 27699-1636
13a. Yidd (gpm) ------Method of test:-------24c. For Water Supply & lpJ«tlpg WeJ11: Jn addition 1D SCllding 1he form t.o
the: addresll{es) above, also IIUbmit one copy of this fonn within 30 days of
L1::3.::b·:..:D:..:lsln=fi.::ec:..:6o=ll ..:::ty:.=:pe.:::~=::::=:::::::::......:.Am=ou=•t:.: ==::::::::::::::::::::::J completion of well COJJStroct:ion to 1he eoimty hea1th department of the eount)' where constructed.
FmmGW-1 Notth Caroliwl Department ofEnvlromnemal Quality -Dlvlaloo. ofWmr Rcsomccs Revised 2-22-2016
WELL CONSTRUCTION RECORD fGW-1j
1. Well Contractor [elbr realism
Thomas Whitehead
WcUC'anonetur Name
29O7-A
NC Well Casmactor Ce li5eatitm Number
S&ME, Inc,
Company Nnmc
2. Well Conatrutdan Permit #:
WI0400465
Liar all applir�He well rorrsenicllore permits tt.e. vlr Como., Same, erarlerteee, sir:}
3. Well Use (cheek well nun):
Water Supply Wen:
Q Agrica sal
�Geohutaal (Dwin glcoolmg Supply)
0InatufttievCo run ial
ri Irrigation
Nos -Water Supply Well:
QMMonitoring
Injection Well:
BAquit(a Recl,ssge
Aquifer Storage aid Recovery
HAquifer Test
Experiroesta1 Technology
DG mai (Closed Loop)
3G ma1(HeatiopfCooling R
4. Date Well(s) Completed: 7/17
5a. WcliLocation:
Huffs C-Store
FaettuylOweam Name
2868 NC Hwy 49 North, Burlington
o Municipe1 Public
°Residential Water Supply (single)
o Residential Waster Supply (shared)
3Rmovery
a
Cmoundwatex Remadiatirea
OSalinity Ranier
©Siarznwiter Drainage
QSubsidence Control
o Tral.'rr
flamer fcx')latounder 021 Reuel
Well 1 $i�G-f l}
Family ION (if spplirablc)
Pkyaicsl Address, City, End Zip
Alatriance
County rum/ td nxo. (PIN)
5b. Latitude and longitude it degreedpilnute'lscmnds or decimal degrtti:
[if well Sold, urea lat/long is infidel}
36.154 79.337
6.1W(are) the weii(1)0Perwanent or °Temporary
7.1e this a repair to an existing well: °Yu or No
Yds& is a repair, fill ore !mom mR rr7nuerarrlmr yfarmuunn and coplane the Niger of ripe
rtpaft under#21 remarks aeallon 07 WI rt:8 back eiftbisform
8. For CeoprobefDPT or Closed -hoop Geothermal Write having the same
coautttaetion, only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells
it'llI
9. TOtal well depth below land endue: 014
Forrou(etpk wells Use all &pats Ifdd,(firmt (rrmmpphe. 3@220l1' d 2iIOO')
10. Static wittier level below top of caii ng: NIA ifL)
y maser levet is above casing, u,nc +"
11. Borehole diameter: 12 (in.)
12. Well ennntruetlon method: Auger
(in sager, rotary, cable, decce peril. etc-)
FOR WATER SUPPLY WILLS ONLY:
13a. Yield {gym) .. Method of twit:
13b. Dinfnfeetian type: Amount:
Print Form - t
For Internal Use Only:
14. WATERZUNES
' mom
TO
OREEM1r1O8
IL
R.
O.
is. Duna CASING ger
mein -case walk 911.1.1141ER r
Gale
IRIOM
7'O
D1AMS=
Ia.
THKEN88S
MATERIAL
9.
R.
I fy DINER
CASING OR TUBING
larerhermal cisnw -1ssyl
PROM
TO
T> age= MATa'RXA6
0.5 a-
39.8 et.
�DMAXI!$R
2 la
soh 40 I PVC
rt. a:
in.
17-SCREEN
rem
TO
swan li
star ma
Tni.7a
Bch 40
MATERIAL
PVC
39.8 e-
44.8 a-
2 66
.O10
-
n.
a.
mow
ORMtt
To
turn/AL
EMPIACEMIPer &MOOD r AMOUNT
2 a•
37 s-
Content
. Pour
37 tR.
39 e.
Bentonite
Pour
a.
- -
9.
PACK
IV sapltcARIC
19. 9ANTOGRAVEL
FROM
To
61A7F*LAL
t3M11'L4CWICST>Msi'EOn
45 sti
*2 Send
Pour
39 IL
IL
f
1O1 Ottna.r
C LOG (wrack uIR1tonl garb If sscn+eryi
ritou
TO
ouci.irnort {rear. b edioni, sMA•KA tile. Lrue Am. ne_1
D R.
7 a-
Red Clayey Slit
7 a-
11 a-
Red Sandy Silt
11 a•
30 a.
Red Sandy Silt
30 ft,
45 O'
Orange Slit
ft.
9.
IIt.
it.
!t
it.
M. REMA=
22. Certification:
7-71
21'1 /17
Sigssututs ofadded Well Cantseceos Date
Iy .Agar ibis font, 1 hereby eel* teat the wr04 tar (mere) roweeitetexi rep orcordance
x(th !14 NCAC 62C.0100 or 114 NC4C 02C.0200 N"el1 Chntine:den Semalarek anti that a
cloy ajr his regwel lieu been provided rn the +sea owner.
23. Site diagram or additional well detail':
You may use the back of this page to provide additional wB site details or well
conatn.Gian details You may also attach additional pages ifnecessary.
t3 [UAL MST BUC FIONS
24a_ For All Well: Submit this form within 30 days of completion of well
construction to the fallowing:
Division of Water Resources, Information Processing Unit,
1617 Mall Service Center, Raleigh, NC 17699-1617
24b. For infection War: le addition to wending the form to the address to 24a
above, also se*eiiit one+ copy of atm form within 30 days of completion of well
construction to the following;
Division of Water Resources, Underground rejection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-1636
24e. For Water Supply d, lnieetion Walla: In addition to sending the form to
the add:resics) shove. also submit one copy of this form within 30 days of
eamtpletioe of well construction to the county health department isf the county
where constructed.
Form OW -1
North Carolina Departmma of Emig oat ntal Ono lity - Div/atria Water Reaow ra Revised 2-22 2016

Permit t-!umber WI0400465
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Huff's C-Store
Location Address
2668 Hwy49 N
Green Level
Owner
Owner Name
Hina
Dates/Events
NC
Orig Issue
1/24/2017
App Received
1/20/2017
Regulated Activities
Well Construction
Outfall
Waterbody Name
27217
Patel
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
1/24/20 17
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Hina Patel
2668 Hwy 49n
Green Level
Major/Minor
Minor
NC 27217
Region
Winston-Salem
County
Alamance
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Hina Patel
2668 Hwy49n
Green Level
Issue
1/24/2017
Effective
1/24/2017
NC 27217
Expiration
Requested /Received Ev ents
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Tuesday, January 24, 2017 10:21 AM
To: 'hina,[e-mail]'; '[e-mail]'
Cc: Knight, Sherri
Subject: NOI WI0400465 Huff's C-Store
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (N01) 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
http:!Ided.nc.govr about/divisionslwater-resources water-resources-permitsiwastewater-branch/Around-water-
protectioniground-water-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 welts (e.g., airflow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at 5hristi.shrestharrncdenr.gov 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., WIOXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number W40400465. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in rerily 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
sh risti.shresthaic ncden r. _,ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
-" Not Compares
Email correspondence to and from this address is subject to the
North L errs?Ira Public Records Law and may be disclosed to third parties.

Shrestha, Shristi R
From: Shrestha, Shristi
Sent: Tuesday, January 24, 2017 10:25 AM
To: Knight, Sherri
Subject: NOI WI0400465 Huffs C-Store
Attachments: 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
shristi.sh restha• F :. ncden r... ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
thing CorriPar
Email cnrrespondenco to and from this addrass is subject to the
North Carolina Public Records I. aw and may be disclosed to third parties.

tiFEnf
kMote ibeiNd ai
14 s?Wy
S646 West Market Street, Suite 105
Greensboro, North Carolina 27409
Phone: [phone]
Fax: [phone]
LETTER OF TRANSMITTAL
Date: 1 /19/2017
Project Number: 4358-16-030
From: Wayne Waters(
To:
Copy to:
DWR - i7IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Attention:
Subject:
Transmitted via
First Class Mail
Remarks:
Program Administrator
Notice of Intent to Construct or Operate Injection Wells
Huffs North, 2668 Highway 49 N, Burlington, NC
Incident 37090
Overnight Express
xx
Hand Delivery 1 Other
A Notice of Intent (NOT) to Construct or Operate Injection Wells is attached for your review. This NOI is
being submitted for the proposed air sparging groundwater remediation system at the above referenced
site. A Corrective Action Plan for the referenced incident, which outlines the components of the
remediation system, which was completed by S&ME, is dated December 17, 2015. The Corrective
Action Plan was approved by NCDEQ in a letter dated August 5, 2016.

North Carolina Department of Environmental Quality — Division of Water Resources
NOTiFICATION OF INTENT (NOT) 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 .02W). 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 R.EMEDLATION t 15A NCAC 02C .0225) or TRACER WELLS 05A NCAC 02C .02: 9):
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 ar 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.
DATE:
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
-`= E.
January 6, 2016 PERMIT NO. - _ (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
X Air Injection Well ....Complete sections B through F, K, N
Aquifer Test Well .Complete sections B through F, K, N
Passive Injection System Complete sections B through F, H-N
Small -Scale Injection Operation Complete sections B through N
Pilot Test Complete sections B through N
Tracer Injection Well Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER(S) - State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): Om Aryan. Inc. t Hina Patel)
Mailing Address: 2668 Hiehwav 49 North
City: Burlington State:
NC Zip Code:27217-9198 County Alamance
Day Tele No,: 336-578-2999 Ce11 No.: 336-684-5421
EMAIL Address: hina.uatelua.conehealth.com
Fax No.:
Deemed Permitted GW Remediation NM Rev. 3-1-2016
Page 1

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: --~S=am=e~as~w~el=l~o~wn=e~r ______________________ _
Company Name ---------------------------------
Mailing Address:---------------------------------
City: ____________ State: NC Zip Code: ______ County: _____ _
Day Tele No.: Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ W..:..:....::a,.._yn.:..=..e =H=·--=W..:...=att=e=r=so=n=,-=P--'-'.E==.,-=S=en=i=o"'-r-=E=necm=· n=e=er=/P,,_r=o,....je=c=t -=-M=a=n=a=cg=er=-----------
Company Name ---=S&=ME="""'' In=c~. '--'(G=r=e=en=s=b=o=ro=--).__ ___________________ _
Mailing Address: --~8-=-64~6~W~·-=M=ar=k=et~S=tr=e=e=t ~S=u=it=e~l-=0~5 ________________ _
City: Greensboro State: NC Zip Code:27409 County: Mecklenburg
Day Tele No.: 336-288-7180 Cell No.: 336-908-7653
EMAIL Address: [e-mail] Fax No.: 336-288-8980
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ~H=u=ff'~s~N~ort=h~---------------------
2668 Highway 49 North
City: ___ B_ur~lin_gt-o_n ________ County'-: __ ----=:A=l=am=an=c::..:e'--__ Zip Code: 27217-9198
(2) Geographic Coordinates: Latitude**: 36° .2.' 16 .91"or ________ _
Longitude**: 79° 20' 13.69" or _______ _
Reference Datum: USTs 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 ofinj. well network: square feet(::: 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.
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page2
I.
J.
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.
APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http ://deq .nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ ground-water-protection/ground-water-app roved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the U/C Program for more info (919-
807-6496).
Injectant: ----------------------------------
Volume of injectant: _____________________________ _
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: ____________________ _
Injectant: ----------------------------------
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page3
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: --~8 ___ Proposed ______ Existing (provide GW-1 s)
(2) For Proposed wells or Existing wells not having GW-ls, 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 (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
( c) Well contractor name and certification number
Grout Screen Casing
Well ID Type Driller
(ft-bis) (ft-bis) (ft-bis)
SPG-2 to
Permanent 2" Sch 40 PVC 3-37 40-45 0-40 S&ME
SPG-9 4IJ!to 7
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.
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page4
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, wider penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete. I am aware that
there are signfcant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to construct operate, maintain, repair, and if applicable, abandon the injection well and
all relatedap rurtenances in ac - +rdance with the 1 5ri NCAC u2C 0200 Rules."
Ar • /L 9 g1
Sigltature of App1 ant Print or Type Full Name gja,4 Title
PROPERTY OWNER (if the prope.v is not owned by the permit applicant):
"its owner of the property on which the injection well(s) are to be 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
(15,1 NC,4C 02C _0200, "
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*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 — UTIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediaiion NOt Rev. 3-1-2016 Page 5