WI0400467_DEEMED FILES_20170410

·♦-
CH'JIROtl.l£NTM. SCRVI CCS • ctlGINCff<I NG • 1£S11 1,1,G
8646 W. Market Street, Suite 105
Greensboro, North Carolina 27409
Phone: [phone]
Fax: [phone]
Date:
LETTER OF TIµNSMITTAL
4/10/2017
Project Number: 1584-02-045C
From: Lyndal Butler
To: NCDEQ-DWR-UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Attention: UICProgram
Copy to: File
Subject: Notice of Intent to Construct or Operate Injection Wells
1705 Cotton Grove Road, Lexington, Davidson County
Transmitted via
First Class Mail ~I -x~I Overnight Express ~-__,I Hand Delivery Other
Remarks:
Greetings,
S&ME respectfully submits the attached Notification of Intent to Construct or Operate Injection Wells
form for 1705 Cotton Grove Road in Lexington, Davidson County, for your review and approval, please.
The planned construction is for three air injection wells. Please note on the signatures for Section N, one
copy is signed by our client, Steve Majors, for LUST responsible party High Falls Oil Co. The image did
not print well, so the second form is signed by S&ME as agent for High Falls Oil Co. The forms are also
signed by the General Manager of the property owner, ABC Board of Davidson County. We hope that
this is acceptable and provides all of the information needed for approval.
Please contact S&ME at the phone number above should you have any quesitons are require additional
information for this permit application.
1/J~
Lyndal Butler
S&ME,lnc. RECEIVED/NCDEQ/DWR
APR 1 2 2017
Water Quality Region?'
Oper2t;~"'"' c-.v''' ~
North Carolina Department of Environmental Quality-Division of Water Resources
NOTIFICATION OF INTENT (NOi) 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 ISA NCAC 02C .0200. This form shall be submitted at least 2 WEEKS prior to iniection.
AQUIFER TEST WELLS 05A NCAC 02c .0220 )
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION 05A NCAC 02c .0225) or TRACER WELLS {15A 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. lllegible Submittals Will Be Returned As Incomplete.
DATE: --------'M=ar=-=c=h ~2=3 ,~2=-=0=1~7 __ PERMIT NO. ________ (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
c.
(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 thro~ N
___ Tracer Injection Well ................................... Complete secti~~ ~ ~~~DEQJOWR
APR 12 2017
STATUS OF WELL OWNER: Business/Organization
Water Quality Regional
Ooe!"c!i0r"S ~;•~1S""~0r\
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): __ _,AB'--=-=Cc...:B=-o=ar=d=-=-o=-f C=i ty.L,...::;o=-f =Le=x=in=gt=o=n _________________ _
Mailing Address: ----=-P~.O~·~B~o=x~l=-=5~6=2 ____________________ _
City: Lexingt on State: NC Zip Code:27293 County: Davidson
Day Tele No.: 336-249-2528 Cell No.:
EMAIL Address: [e-mail] Fax No.: __________ _
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page 1
' I
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: ___ S=am=e~as~w~e=ll~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 (fypically Environmental Engineering Firm)
Name and Title: ---'E=d=m=u=nd=-=H=e=nn=·"'"g-=ue=s=•-=-P~.G=··~S=en=1=·0-=-r -=-P-=-ro""'j=ec=t"""M=an=a=g=e-=-r _____ _
Company Name ---=S=&=ME=~· In=c~. ('-'Gr~e-=-en=s=b"""o-=-ro=)~--------------------
Mailing Address: --~8-=-64-=-6~W~·-=-M-=-ar~k-=-et~S-tr~ee~t ~S~u=it-=-e ~l -=-05~-----------------
City: Greensboro State:~ Zip Code:27409 County: Guilford
Day Tele No.: 336-288-7180 Cell No.: 336-312-0276
EMAIL Address: ehenrigues @smeinc.com Fax No.: 336-288-8980
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: --=-A=B=--cC=---=S-=to=re-=---------------------------
1705 Cotton Grove Road
City: --~Le=x=in=gt.=o=n=-________ County~: --~D~a~Vl-=-·d=s=o=n __ ~Zip Code: 27293
(2) Geographic Coordinates: Latitude**: 33.77699°
Longitude**: -80.259890
Reference Datum: USTs Accuracy: _______ _
Method of Collection:"_G=o-=-o=-<g=le~E=arth~-------------
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES .
G. TREATMENT AREA
Land surface area of contaminant plume: _______ square feet
Land surface area of inj. well network: square feet~ 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated:_(must be~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
~xtent 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 ACTMTIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
APPROVED INJECTANTS-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 h ttp ://de g.nc .g ov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/gro und-water-a pp roved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (9 I 9-
807-6496).
lnjectant: ----------------------------------
Volume of injectant:
Concentration at point of injection : _______________________ _
Percent if in a mixture with other injectants: ____________________ _
lnjectant: ----------------------------------
Volume ofinjectant: ____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
Injectant: ----------------------------------
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Deemed Pennitted GW Remediation NOI Rev. 3-1-2016 Page3
K. WELL CONSTRUCTION DATA
L.
M.
(1) Number of injection wells: ---=-3 __ _,Proposed ___ 0 ___ 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 Sandpack Casing
Well ID Type Driller
(ft-bis) (ft-bis) (ft-bis) (ft-bis)
AS-1 to AS-3 Permanent 2" Sch 40 PVC 2-38 40-45 38-45 1-40 S&ME
SCHEDULES -Briefly describe the schedule for well construction and injection activities.
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.
NA
Deemed Permitted GW Remediation NO! Rev. 3-1-2016 Page4
N. SibNATIIkE OW APPLICANT AND PROPERTY OWNER
elPPliCANT: 'I hereby car*. ander pe.rdrl•oji w, Mai anfiraulior with rho lnforrearionJul:mi dd in rhu
damwunt acid a& aturc6nenu tnarelo erati L based a,i9 lloltdrY o/bare 04444 . ATAI6b,ua7y reaponribl.
fir ambling qg sa'.ipd Infleasadon, I Watt that the atfornniiawaa r r9 are. carafe and eantplam 1 ow aware Aar
are r1gt(fitara pofaleiar, lwrJneSerg to paunbiffry of fins. otd 1npritoarnene, far ombroXtMg Abe
krmedia . I area m awrdveR operate. m repair, area`V applicable, abandon the Wootton well end
eal.t in cram -donna with the ISDICdC 07C 0gto R443,"
.. , tag �.
SIgn•Nrr Apyyeapr - - Peh•r et typo i.-k..rgg chin
pkora,R-rr QI NR Cljrh9 Y u not owned by dievainitag6liawl
"As owner of the properly on which the iryetsion wdI t) are W be tAzSVarMd mrd operated 1 hereby coward W
allow die appls6anr to can:Irma cad injection well ar autitned rn thi1 appllowon urea agree that II ri rye the
respoeeibl[iry of the applicant m ensure $411 Ot i.decwa yealkel mafoem ro he Brett Conrcx:ovn Standards
{rSA , CO�rz 42sffi1. .
"C>wreer morns nary Person who bolds the fix dr other property tigbts in de well being anti i 1ed. A wall
if rail property and its cauatroction an land shall 6e deePw c 1 to tress awniachlo 1e die land order, in the
shwa= of contrary egretmwns in writing.
S1lwra.e• ea foram Olean IK ei:ture{ ken .PpHnsrj
••Ci nears igrerReu herwoen the opp+ltteni end propertywateraway be
%bon * U. eedpkad aatllleanpn package 1
DWR - DR: Programa
1b30 Malt lterrica Cmw
Ralayk, hlc 2"te9q.1636
T ekphe MO) ROT4e
O*4aM.•.•.11a6.-^•.•.-•h.11zur'LU k►1' 1-1.316
rrw 4-in, Tel salami Deli ;JJ
ni learn afa iirrguri An ( ARIA

N. SIGNATURE OF APPLICANT AND PROPERTY OWNEE.
APPLICANT: "I hereby certify, under penalty oflaw, 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 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 injection well and
all related appurtenances in accordance with the 15,4 NCAC 02C 0200 Rules."
Signature of Applicant'
1 r & . f-Ibs&LCam..
Print or Type full Name and Title
PROPERTY OWNER (if the nroJ r is not owned by the permit aprlicantj:
"As owner of the property on which the injection well(s) are ro be constructed and operated, I hereby consent to
allow the applicant ro 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 wells) conform to the Well Construction Standards
(15ANCACO2C.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,
fr �,� 40.17 rlX/27l
Signature* of Property Owner (If different from applicant} Print or Type Full ame and Title
�eln access agreement between the applicant and property owner may be Di lieu of a signature on this form.
Submit the completed notification package t
DWR-- UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Aeemet1 DA^vtted r,■sr °^`^^7+alion NOI Rev. 3-1•2016
[ 'd 5Z94 '0N
tPd0Z L OZ 'a dki

Permit iu u mber WI0400467
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
ABC Store
Location Address
1705 Cotton Grove Rd
Lexington
Owner
Owner Name
Abe Board of City of Lexington
Dates/Events
NC
Orig Issue
4/12/2017
App Received
4/10/2017
Re g ulated Activities
Groundwater remediation
Outfall
Waterbody Name
27293
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
4/12/2017
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Davidson
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Brenda Leonard
PO Box 1562
Lexington
Issue
4/12/2017
Effective
4/12/2017
NC 27293
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Wednesday, April 12, 2017 12:56 PM
To: 'Allan Lynda' Butler'
Cc: Knight, Sherri
Subject: WI0400467 ABC Store RE: NOI Injection Wells_1705 Cotton Grove Rd Lexington
Thank you for submitting the Notice of Intent to Construct or 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-ls and GW-30s if not already submitted (originals go the address printed on the form). NOTE: Direct
push or Geoprobe wells are considered wefts and require construction (GW-1) and abandonment forms (GW-
3C). If well construction/abandonment information is the same for the weds, 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.
htt; .:;' de❑ , nc. g ov/about/d ivisions/water-resou roes jwater-reso urces-hermits jwastewater-b ra nch/ rou nd-water-
protection/ground-water-reporting-forms
2) Injection Event Records (IER). All injections, including air and passive systems require an 1ER. 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.shresthar'ncdenr.pov 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., WICXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number WI0400467. 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.shrestha Utz ncdenr, q ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
[,Li. ares<

North Carolina Public Records Law and may be disclosed to third parties.
From: Allan Lynda I Butler [mailto:[e-mail]]
Sent: Monday, April 10, 2017 10:21 AM
To: Shrestha, Shristi R <[e-mail]>
Subject: NOi Injection Wells_l 705 Cotton Grove Rd Lexington
Good morning!
S&ME respectfully submits the attached Notification of Intent to Construct or Operate Injection Wells form for 1705
Cotton Grove Road in Lexington, Davidson County, for your review and approval, please. The planned construction is
for three air injection wells. We will mail the form to you also, but also sending by email, because we hope to start
next week, if possible. Also, on the signatures for Section N, one copy is signed by our client, Steve Majors, for LUST
responsible party High Falls Oil Co. The image did not print well, so the second form is signed by S&ME as agent for
High Falls Oil Co. The forms are also signed by the General Manager of the property owner, ABC Board of Davidson
County. We hope that this is acceptable and provides all of the information needed for approval.
Please reply or call should you have any questions or require additional information.
Thank you,
Lyndal Butler
Lyndal Butler
Environmental Scientist
&ME
ENGINEERING INTEGRITY.
We have moved:
S&ME, Inc.
8646 West Market Street, Suite 105
Greensboro, NC 27409
Ph: 336-288-7180 I ext. 11312
Fax: [phone]
Mobile: [phone]
[e-mail]
www.smeinc.com
This electronic message is subject to the terms of use set forth at www.smeinc.com/email. If you received this message in error please advise the
sender by reply and delete this electronic message and any attachments. Please consider the environment before printing this email.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Wednesday, April 12, 2017 12:58 PM
To: Knight, Sherri
Subject: WI0400467 ABC Store
Attachments: NOI Injection Wells_1705 Cotton Grove Rd Lexington_(1.7-4-10),pdf
Please find the attached NCI
-
Shristi
Shristl 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 resthaid7ncdenr.yov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27599 1635
ND
Nothing Cc, ar
Email correspondence tc, and from this ed re is object to tha
North Carolina Public Records Law and may be discics :d to third partie3-

North Carolina Department of Environmental Quality --Division of Water Resources
NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule" and do not require an bullvidual permit when conslnlcted in occordtmu
with the rules of ISA NCAC 02C .0200. Thu fo rm shall be submitted at least 2 WEEKS prior to iniecdon.
AQUIFER TEST WELLS (15A NCAC 02C ,Ql20)
These wells are used to inject uncontaminated fluid into an aquifer to detennine aquifer hydraulic characteristics.
IN SITU REMEDIATION USA NCAC 02c .0225) or TRACER WELLS (ISA NCAC Q.2C .0129>:
1) Passive Injection Systems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks. iSOC systems, and other gas infusion methods.
2) Small-Scale Injection Operations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for teat or treatment areas exceedlq 10,000 square feet.
3) Pilot Tests -Preliminary stlldies conducted for the purpose <Yf evaluating the technical feasibility of a
remediation strategy in order to develop a full scale mnediation plan for future implementation, and where the
surface area of the injection mne wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individu.al permit shall be required to conduct
more than one pilot teat on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Prillt Ckarly or Type Information. IJleglble Sub,nltta/s W",D Be Ret11rnd As lncolllJ.)lete.
DATE: -------=Match==2=3=·=20=1'""7 __ PERMIT NO. ',/\/ J. 0 4-00 'fb 1-(to be filled in by DWR}
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(1) =Xa.,...___,Air htjection Well ...................................... Complete sections B through F, K. N
(2) --~Aquifer Test Well ....................................... Complete sections B through F, K. N
(3) --~Passive Injection System ............................... Complete sections B through F, H-N
(4) --~Small-Scale Injection Operation ..•..•....•...•...••.• Complete sections B through N
(5) --. Pilot Test ................................................. Complete sections B ~INCDEQfDWR
(6) ___ Tracer Injection Well.. ................................. Complete sections B through N
APR 10 2017
STATUS OF WELL OWNER: Business/Organization
Water Quality
Regional Operations Section
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): --~AB~C~Bo~ard~o=f~C=itv""'--"o=fLex==in=gt=o=n~---------------
Mailing Address: P.O.Box 15 62
City: Lexin gton State: _NL. Zip Code:27293 County: David son
Day Tele No.: 336-249-2528 Cell No.:
EMA1L Address: lexab [e-mail]
Deemed Permitted GW Remediation NOi Rev. 3-1-2016
Fax No.: ·-__ _
Page I
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Same as well own.=er.,__ __________________ _
CompanyName ____________________________ _
Mailing Address: ____________________________ _
City: ___________ State: NC Zip Code: _______ Coutity:. ______ _
DayTeleNo.: _____________ _ Cell No.: _________ _
EMAIL Address: Fax No.: ---
E. PROJECT CONTACT (I'ypically Environmental Engineering Finn)
Name and Title: ---=E=dm=un=d=-=H=enn==·g=ues~, =-P-=G=.1._.S"""em=·o.._r "'-Pro=je=c""'t M=an=a""g=er,____ ____ _
CompanyName __ ~S=&=ME=1'-=Jn=c= ..... (O=Jreen==s=bo=r=o,,,__} _________________ _
Mailing Address: ---"8,.,,64'....!.:6"--W-'-'---'-. ""Mark......,,.,,,et..__,S,,__,,._,,"""'--"""Sw..,·""te,_.l...,.0""--_--------------
City: Greensboro State: ..Nk__ Zip Code: 27409 County: Guilford
Day Tele No.: 336-288-7180 Cell No.: 336-312-0276
EMAIL Address: [e-mail] Fax No.: 336-288-8980
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: --=AB~C~S"""t=ore=---------------------
1705 Cotton Grove Road
City. Lexington County~: --~D=a=-vi-=·d=s=on~-~Zip Code: 27293
(2) Geographic Coordinates: Latitude**: 33.77699'>
Longitnde**: -80.259890
Reference Datum: USTs Accuracy: ______ _
Method of Collection:._____,G=o=o,.,..g=le"""E=arth=------------
••FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITIED IN UEU OF GBOORAPIDC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: ______ square feet
Land surface area of inj. well network: _______ square feet CS 10,000 ft 2 for small-scale injections)
Pen:ent of contaminant plume area to be treated:_(must be~ 5% of plwne for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Co11taminant 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 horimntal and vertical
extent of the contaminant plmne 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 Remedill1ion NOi Rev. 3-1-2016 Pagel
L 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. APPROVED INJECTANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injecta'nis 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 ://deg .nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/gro und-water-protection/ground-water-app roved-:in jectants .
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Jnjectant: ------------------------------
Volume ofinjectant: _________________________ _
Concentration at point of injection: -----'-------------------
Percent if in a mixture with other injectants: __________________ _
Jnjectant: _____________________________ _
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: _______________ _
Deemed Pennitted OW Remediation NOi Rev. 3-1-2016 Page3
K, WELLCONSTRUCUONDATA
Number of injection wells: -~3 ___ Proposed ___ O __ Existing (provide GW-ls)
(2) For Proposed wells or Exieting wells not having GW-ls, provide well conslruction details for each
iajection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same conslruction details. Well constroction details shall include the
following [mdicate if construction is proposed or as-built):
(a) WeU 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 numb«
Grout Screen Sandpack Casing
WellID Type Dr:ll.ler
(ft.bis) (ft-bis) (ft-bis) (ft.bis)
AS-I toAS-3 Permanent 2" Sch 40 PVC 2-38 40 -45 38-45 1-40 S&ME
L. SCHEDULES -Briefly descnl>e the schedule fur well construction and injection activities.
M. MONITORING PLAN~ Describe below or in scparatc attachment a mooitcring plan tc be used to dehlmline
if violations of groundwater quality standatds specified in Subcbapter 02L result &om the injection activity.
D<:emed PcrmiUcd OW Rcm:dio!ion NOi Rev. 3-1-2016 Pagc4
R. =Ittw-mu 01 itm.rc hr Mm noway ovipaot
Ap ulc Mn-0.v6yaati¢. nt.Ir FamtAyo flow. ape IJine rimy aaH e4 ie se *Word u tioz
Ieamewealeiratenerena &misled q bead mubad" often adi+a4perenr a*vapa l6k
,thr GUMS" sofa irybemadttn I afae,r iiew k true wawa aid maphk l at ew.- a1e
Sol eer 111141bmg Pm02144 kitbag ela parkia& gifiner eat eventemeaae. Jbr 44.61Nfhg Ake
iytvmaxi lAtom eahr/MieaAea•. ropes; air kable. nFallae de eykamr we/ wad
1 N K �1{lti•
Sprsr. .r3ir,:/4aise
"At argryr a $0,Prat** MS raiGF the holgaiga 1O QV N be meto:14 sal epaeiri, I kraibreammf to
ea* e5a cppi)onti Waft=earl lataNies welter eeI iiJ OP Ode aPPAISMOR 011 rrr$i if AdUda 6r
NetopteggItey reftAi insiicmll to *mom ligl eat frAct iui %ON roodiNm fo ae wee CcNai iottoo gwdw*
"Dwa r nusr i, y Tamara's,/ boills the Of other pocerty d!% 'rep tiewrl! Izebe crmiCkcud. A aeli
k reed perm sad Pet sonareake, on Goo OW be dermal 9C weet emase,3tip k aye. !end owner, in the
damns td celarnry akessant n viilinj.
e-Zed224I—Zi ,.rr1l 41lQe �]cw/v/f+'
%%wive.1 rpepu-p avow sra ash.e+ trOD ri�Ywa4 ['Nat is 71pe l�7IA J
•k+, rea¢i staammetxt wape illy >ari aadpreprr711~etq ede &srofaAgeasart tut Yar frnr.
IL tee ellaaBGcaioninane
DWI —U1CP pa.,
sine Phan 3 a*a Cleeaw
TueyYaar Vi7-ieie
— & te:;u: nrhl Pwe.3. 7016

N. SIGNATURE OF APPLICANT AND PROPERTY ONMR
APPLICANI.i "I hereby certff ,, testier penalty of law, that I am familiar with the bveormation submitted in this
document and all attachments thereto and that, based on my inquiry of those tndMfduals immediately responsible
for obtaining said f for►madon I believe that the inforneation is true, accurate and complete. I am aware that
there are significant ?whim Mandist' the possibility of Hiles and iinprfsonmen4 jbr submitting false
information, r agree to easuiruc4 operate, maintain, repair, and V applicable, abandon the injection well and
aft related appurtenances in accordance with the 15.:LMAC O2 Q2O0 Rrtks. "
(6 till e) Acy4 frr
Sigoatore of Ap¢licet 1' Mat 6e Type runNema mg Title
PROPERTY OWNER [if the oronerry is not Mimed by tho_pe mit s pi cant}:
'As owner of the property on which the injection well(s) are to be constructed and operated, hereby consent to
allow the applicant to construct each injection well as outlined in ate application and agree that it shall be the
responsibility of the applicant to ensure that the *chair well(t) conform to the Well Construction Standards
a IICACO2C, )."
"Ownee' meads any portion who holds the tee 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* ef Property Owner Of afforest dram ;ppikaat)
obi access agreement bewail the applicant and property owner may be s the lieu of a Signe:herd an thtrPrm.
Submit the completed notification paekage
DWR— UIC Program
1636 Mail Service Center
Raleigh, NC 27699.1636
Telephone: [phone]
Prtat or Type Puf Nazis W'r d.
Newt t o is Z 9 4 —tiasian NOI Ray. 3-1-3016
Wdt� t1ig 'ha,