WI0400478_DEEMED FILES_20180123

Permit Number WI0400478
Program Category
Deemed Ground Water
PennitType
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Pennitted Flow
Facility
Facility Name
Grandfather Country Store
Location Address
6371 US Hwy 221 S
Blowing Rock
Owner
Owner Name
Ncdeq State -Lead Program
Dates/Events
NC
Orig Issue
1/23/2018
App Received
1/9/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28605
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
1/23/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Pennit Classification
Individual
Pennit Contact Affiliation
Christina Schroeter
1646 Mail Service Ctr
Raleigh NC 27699164€
Major/Minor
Minor
Facility Contact Afflliatlon
Owner Type
Government -State
Owner Affiliation
Mark Petermann
1646 Mail Service Ctr
Raleigh
Region
Winston-Salem
County
Watauga
NC 27699164
Issue
1/23/2018
Effective
1/23/2018
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
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 15A NCAC 02C .0200. This form shall be submitted at least 2 WEEKS prior to in iection.
AQUIFER TEST WELLS 05A NCAC 02c .0220l
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION C15A NCAC 02C .0225) or TRACER WELLS C15A NCAC 02C .0229):
1) Passive Iniection Sy stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
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: January 4 ,20_1_8~ PERMIT NO. W ;!, 0 '/ 0 0 lf r R (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B through F, K, N
___ .Aquifer Test Well. ...................................... Complete sections B through F, K, N
=X=--__ .Passive Injection System ............................... Complete sections B through F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B~IMiD/NCDEQ/DWR
___ Pilot Test ................................................. Complete sections B througJ1d'N _ 9 2018
___ Tracer Injection Well ................................... Complete sections B through N
Water Quality Regional
STATUS OF WELL OWNER: Municipal Government
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): --=N~C=D~E~O_-~St=a=te~L~e=a=d=P=r~og=r=am~---------------------
Mailing Address: --~1~6~4=6=M=ai=l =S=erv~ic~e~C=en=t=er=----------------------
City: Raleigh State: ~ Zip Code:=2~76~9=9 ____ County:_W~ak=e=-----
Day Tele No.: 919-707-8260
EMAIL Address: christina.schroeter@ncdem.!WV
Cell No.: Not Available
Fax No.: 919-707-8260
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 1
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: -----'S"'-'h=ar=on=B:.:cla=,ir::....c::T..::o"""lb=e==--rt=--------------------------
Company Name ---=B~la=ir~H~o~u-=-se~of~B~o~on~e~L=L~C~--------------------
Mailing Address: --~1~1-=-3~B=l=a=irm~o=n~t ~D_r~iv~e ______________________ _
City: Boone State:~ Zip Code: __ ~2~8~6~0~7 _County: Watauga
Day Tele No.: 828-295-6100 or 828-850-7034 Cell No.: --~N~o=t A='-'-v=a=il=ab=l=e ___ _
EMAIL Address : ___ N"""'""o-=-t =A'-'-v=a=ila=b=l=e ______ _ Fax No.: -----=-Nc.:o-=-t =A=v~a=il=ab=l=e ___ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ___ C=hr=-=i=st=in=ec...cS=c=h=a=e=fe=r ,L..CP'----'r'""o'-'-'je=c=t =M=a=n=a=g=er=---------------------
Company Name ---~A=-=T'--"C"---"---'A=s=so""c=ia=t=es"----o=f"-'N'----'-"-ort"-=h--=C=ar=ol=in=a=·--=-P-=-.C"'-'-. _______________ _
Mailing Address : __ ___;7c...::6:..:::0..::6_Wh:..,...==it=eh=a=ll"-'E=x=e=c=u=ti'-'-v=e--=C=e=n=te=r....:D=r=iv.:...:e=---==S=u=it=e--=8=0=0 ____________ _
City: Charlotte State: ~ Zip Code: 28273 County: Mecklenburg
Day Tele No.: ~70~4~-5~2=9~-3=2~0~0______ Cell No.: 704-421-0698
EMAIL Address: ___ c=hr=is=tin~e-=s~ch=a=e=fe=r ..... @~a~t=cas=so=c=i=at=e-=-s ~.c-=-o=m Fax No.: --~7~04~-~52=9_-=32=7~2 ___ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ---~63"----7~1~U=S~H=i=gh=w'--'--=ay~22=1"----=So=u=th~-------------
City: ------'B=lo'---'-w=in=g-=-R=oc.:c=k _______ County~: ___ W~a=ta=u=g=a'--_----'Zip Code: --~2=8=60=5"'--
(2) Geographic Coordinates: Latitude**: ___ 0 __ __" or 36.120481 0
Longitude **: 0 "or -81.751768 0
Reference Datum: __ _,W..:..G=S=84_,__ ___ .Accuracy: ___ N_o_t _A_v_a_il_ab_l_e_
Method of Collection:_G===-oo""Q""l=e =E=arth='---------------
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SI TE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GE OGRAPHIC COORDINATES.
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 :s_ 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
propo sed injection wells; and
(2) Cross-section(s) to the known or proj ected depth of contamination that show the hori zontal 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.
D ee med Permitted GW Remediation NOI Rev . 8-28-2017 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.
ATC will install Provectus ORS (oxyg en-releasine socks) in monitorin e well MW-1 to promote accelerated
petroleum compound biode g-radation and reduce com pound concentrations to below the North Carolina
Groundwater Quality Standards {2L Standards '). The socks come in 3-foot sections and two socks are antici pated
to be installed in well MW-1 durinl'.! each installation event. de pendin g on water volume in the well. The socks
will deliver controlled-release ox yg en into the gro undwater for four to ei ght months . at which point the chemicals
in the socks will have de pleted.
J. APPROVED INJECT ANTS-Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only irifectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved irifectants can be found online at http://deg.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/gr ound-water-protection/ground-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 (919-
807-6496).
lnjectant: __ ....:Pra...:..:co-'-v=ec=tu=s~O=R=S'------------------------------
Volume of injectant: 2 socks at 113.1 in.3/sock : total volume = 226.2 in.3 per installation event
Concentration at point of injection: ___ 7.:..;5::...-""'8"'5-'-o/c"'"o -"c=al'-=c"""'iu=m=-"p'""e~ro""x""i""d""-e ____________ _
Percent if in a mixture with other injectants:
nutrients )
Injectant:
75-85% calcium peroxide (1 5-25% inorganic
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: _____ Proposed. ___ "'l ___ Existing (provide GW-ls)
(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
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page3
(c) Well contractor name and certification number
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
A pp roximatel y two weeks followin g submittal of this NOL ATC will install two socks in existing well MW-1.
It is antici pated that chani2eouts may occur on a guarterlv basis.
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.
A pproximate guarterl v sam pling events of monitoring well MW-1 will be performed startine three months after
the installation of the socks. Durin rr each sam plin e: event. ATC will collect a sam ple from the well for anal ysis
of volatile ore anic com pounds bv EPA Method 6200B. ATC will also measure dissolved ox gen. conductivil .
tem perature . pH . and oxyg en reduction potential in the well durin g each sam plin g event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I 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 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 15A NCAC 02C 0200 Rules. "
U-i. C .5-l-•-¥'...,z__
L_.l , on behalf ofNCDEQ Christine E. Schaefer. on behalf ofNCDEO
Signature of Applicant Print or Type Full Name and Title
PROPERTY OWNER {if the pro perty is not owned by the permit a pp licant):
"As 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 irif ection 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
(.1 5A 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 land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached access a greement
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 of a signature on this form.
Please send this NOi electronically to Shristi.Shrestha(@ ncdenr.gov AND one hard copy to:
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page4
MW3 FOR%.1f.P.
O. ibJ L.; CANOr
P
•
Ark FORMERr '
2.000-GALLON
KEROSENE UST
FORMER
.4.000
'NE USTS.
<D.037
nJ
''OR1VTEA
❑ISPENS£A
StAND
GRANDFATHER
COUNTRY STORE
LEGEND
MONITORING WELL
LOCATION
WATER SUPPLY
WELL LOCATION
60 MTBE CONCENTRATION
IN pg/L (BOLD VALUES
EXCEEDED THE 2L
STANDARD)
Source: NC Geospatiai Database
0 25 50
100
r>i
APPROXIMATE SCALE IN FEET
TITLE FIGURE 5
MTBE ISOCONCENTRATION MAP - 9/207
GRANDFATHER COUNTRY STORE — NCDEQ INCIDENT #16442
6371 US HIGHWAY 221 SOUTH
BLOWING ROCK, WATAUGA COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P,C,
Cheri:4kt, North Corolla 25273 (704) 00 FAX 1:704) 2
CAD FILE
Grandfather SM
PREP. BY
CES
REV. BY
GA
SCALE
AS SHOWN
DATE
11/3/17
PROJECT NO.
SLP16442

71.53' FORMERMW-3.. CAhGRY
FORMEP.ta_
• 2.00KTGALi_ ON -
• KEROSE NEUSr
FORMER \ �{
4,000-GALLON
.CASOLINE LISTS M�
` r 71
,
MW1
71.41
LEGEND
MONITORING WELL
LOCATION
$ WATER SUPPLY
WELL LOCATION
70— GROUNDWATER
ELEVATION CONTOUR
LINE
TITLE FIGURE 4
GROUNDWATER ELEVATION CONTOUR MAP - 9/28/17
GRANDFATHER COUNTRY STORE - NCDEQ INCIDENT #164-42
6371 US HIGHWAY 221 SOUTH
BLOWING ROCK, WATAUGA COUNTY, NORTH CAROLINA
Source: NC Geospatial Database
0 25 50 100
APPROXIMATE SCALE IN FEET
ASSOCIATES OF NORTH CAROLINA, P.C.
Charlotte,North Carolina 28273 (704) -3200 FAX 0'04) 52,3272

PENVIRcDNMENTAL PRODUCTS'
rovectus
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS
Page: 1 of 5
1. PRODUCT IDENTIFICATION: PROVECT-ORS
PRODUCT USE: Soil and water treatment.
MANUFACTURER: EMERGENCY PHONE:
PROVECI'US ENVIRONMENTAL
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
USA: ($.15) 650-2230
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide), Class 5.1, PG II, UN1479
WIT1lNIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Inorganic Nutrients
3. PHYSICAL DATA
Chemical Formula CAS No.
CaO7 1305-79-9
Percentage
75%-85%
15%-25 %
Appearance White & brown granules
Physical state Solid
Odor threshold None
Bulk Density _ 500-650g/L
Solubility in Water Insoluble
PH - -11
Decomposition Temperature Self -accelerating decomposition with oxygen release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause tire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product contains <1 % non -respirable crystalline
silica. The NTP and OSHA have not classified non -respirable crystalline silica as carcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (silicosis). ORS does not
contain respirable crystalline silica.
Potential Health Effects:
■ General Irritating to mucous membrane and eyes.

rovectus
P
ENVIRONMENTAL PRODUCTS"
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 2 of 5
• Inhalation ____Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
• Eye contact May cause irritation to the eyes; Risks of serious or permanent eye
Iesions.
• Skin contact„„ May cause skin irritation.
• Ingestion Irritation of the mouth and throat with nausea and vomiting.
5. FIRST AID MEASURES
• Inhalation Remove affected person to fresh air. Seek medical attention if effects
persist.
• Eye contact Flush eyes with running watcr for at least 15 minutes with eyelids
held open. Seek specialist advice.
• Skin contact Wash affected skin with soap and mild detergent and large amounts of
water.
• Ingestion _ If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Point
• Not applicable
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• Water
Fire Hazards
• Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Dainp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,

PENVIRoNMETA,
PRODUCTS"
rovectus
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 3 of 5
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution. Pressurization if confined when heated or
decomposing. Containers may burst violently,
Fire Fighting Measures
• Evacuate all non -essential personnel
• Wear protective clothing and self-contained breathing apparatus.
• Remain upwind of fire to avoid hazardous vapors and decomposition products.
• Use water spray to cool fire- exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition, Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory, Avoid making dust,
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper, oils,
etc.). Do not return product to container because of risk of contamination.
S. HANDLING AND STORAGE
Storage
• Oxidizer. Store in a cool, well -ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
• Keep away from incompatible materials. Keep containers tightly closed. Do not store in
unlabeled or mislabeled containers.
• Protect from moisture. Do not store near combustible materials. Veep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Store separately from organics and reducing materials. Avoid contamination that may lead to
decomposition.
Handling
• Avoid contact with eyes. skin, and clothing. Use with adequate ventilation.
• Do not swallow. Avoid breathing vapors, mists, or dust. Do not eat, drink, or smoke in work
arca.
• Prevent contact with combustible or organic materials.
• Label containers and keep them tightly closed when not in use.
• Wash thoroughly after handling.

p
ENVIRONMENTAL PRODUCTS`
rovectus
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 4 of 5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no respiratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
• Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
• Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC. neoprene or rubber)
Other Protective Equipment
• Eye -wash station
• Safety shower
• Impervious clothing
• Rubber boots
General Hygiene Considerations
• Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
• Stable under normal conditions
Condition to Avoid
• Water
• Acids
• Bases
• Salts of heavy metals
• Reducing agents
• Organic materials
• Flammable substances
Hazardous Decomposition Products
• Oxygen which supports combustion

PFNVRONMENTAI
PRODUCTS
rovectus
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
• LD50 Oral: Min.20OO mg/kg, rat
• LD50 Dermal: Min, 2000mglkg, rat
▪ LD5O Inhalation: Min. 4580 mg/kg. rat
12. ECOLOGICAL INFORMATION
Ecotoxieol❑gical Information
• Hazards for the environment is limited due to the product properties of no bioaccumulatiori, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste 'Treatment
• Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations,
Package Treatment
• The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Class: 5.1
• Labels: 5.1 (Oxidizer)
• Packing Group: 11
15. REGULATORY INFORMATION
• SARA Section Yes
• SARA (313) Chemicals No
• EPA '1,SCA Inventory Appears
• Canadian WHMIS Classification C, D2B
• Canadian DST. Appears
• ETNECS Inventory Appears

1 i oiv RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION lli 2589
1. WELL CONTRACTOR_
JASON MANTAK
Well Co -erecter (IrdMduat) Name
GEOLOGIC EXPLORATION. INC,
WeJI Conlracicr Company dame
STREET ADDRESS 176 COMMERCE BLVD
STATESVILLE NC
29625
City or Town State
(704 872-7686
Area code- Phone number
2. WELL INFORMATION:
SITE WELL LD *Cif applicable) MW-I
Zip Code
STATE WELL PERM ITN( it applicable)
DWO a OTHER PERMIT *if applicable)
WELL USE (Check Applicable Box) Mattering Rl MunirdpafiPubilc
IndustrlallCarmanereiei ❑ Agi1ctdtural ❑ Recovery ❑ InjecIion 0
Irtigati0nD Other ❑ (st use}
DATE DRILLED 0911649
TIME COMPLETED AM❑ PM D
3. WELL LOCATION:
CITY,• BLOWING ROCK
8371 HIGHWAY 221 SOUTH 29605
(Street Name, Numbers. Community. Subdwicion, Las No.. Parcel, Zip Code)
TOPOGRAPHIC l LAND SETTING:
0Slope pWilley 0FIa1 pRidge ❑ Other
(shock appropriate nog
LATITUDE May be in degrees,
minutes, seccrlds UT
LONGFTUDE in a decimal format
COUNTY WATAUGA
Latitude/longitude source: ❑GPS ❑Topographic map
(location of wag mast be Shown on a USGS tom map arid
attached to this roars if rrat using GPS)
A. FACILITY. is the name or ire hasiness wnxete *Wl it toe dad.
FACILITY ID f4(1f applicable)
NAME OF FACILITY GRANDFATHER COUNTRY STORE
STREET ADDRESS 6371 HIGHWAY 221 SOUTH
SLOWING ROCK NC
26605
Oily or Town State
CONTACT PERSON NCDEHNR
Zip Code
MAILING ADDRESS I53T MAIL SERVICE CENTER
'RALEIGH µC� $7699
CIEy or Tam StaleZip Code
Area code - Phone number
5. WELL DETAILS:
a; TOTAL DEPTH: 3E0 FEET
DOE5 WELL REPLACE EXISTING WELL? YES ❑
cl WATER LEVEL Bel oNTop of Casing: 28.0 FT
(Use "+ If Above Tap of Casing)
NO
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated attar below laiW surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD;gpmj: N/A _ METHOD OF TEST NIA
f. DISINFECTION: Typo N/A Amount N/A
g. WATER ZONES (depth):
From To Earn To
From To From To
From To _ From To
6, CASING: a,,,,��(t Titichhrttessl Kt"
From 0.0 Depth23.0 FL 21_rCH" s _ Kt
From To FL
Franc To R.
7. GROUT:
From 0.0
Depth Material
To ifi.0 Ft Pasimeuanranlie
From To _ Ft.
From To Fl.
Method
SLURRY
8. SCREEN: Depth Diameter Slot Size Material
From 23.0 To 98.0 FL 20 In, .010 in. PVC
From To FL in. in,
From To R. ln, In.
9. SAND/GRAVEL PACK:
Depth Size Material
Ft. 20 d0
From 20.0 To 38•0
From To Ft_
From To FL
FINE SILICA SAND
i0. DRILLING LOG
From To Formation Dearription
0.0 1.0 ASPNALTIGRAVEL
1.0 22.D
22.0 40.0-
GRAY SILTY CLAY
TAN WEATHERED RACK
1i. REMARKS:
BENTONITE SEAL FROM 16.0 TO 20.0 FEET
I.DO HERE9' CER7rFYT 'r " . ^S OONSTRLICTeo IN ACcOROANr:E WITH
15A NCAC • WELL n TANOARLS, MOD THAT A GOY OF THIS
RECORD -ti -.�"r n Tits WELL OWNER.
09/22109
SIGN r E OF CERTIFIED WELL CONTRACTOR DATE
QM1TA
PRINTED NAME. OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt,
1617,Maii Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 566.
Form GWm
Rev. 7/D5

Christina Schroeter
Hydrogeologist
DWM UST Section
1646 Mail Service Center
Raleigh, North Caolina 27699-1646
RE: Grandfather Country Store
6371 US Hwy 221 South
Blowing Rock, Watauga County, NC
Incident#16442
Dear Ms. Schroeter:
r--.:> = ........
:-:, c::
Ci?
N
C.,..)
I am/We are the owner( s) of a parcel of property, located at or near the incident in question, and hereby
permit the Department of Environmental Quality (Department) or its contractor to enter upon said property for
the purpose of conducting an investigation of the groundwaters under the authority of G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and is a
public record, in accordance with North Carolina G.S. 132-1.
6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the land owner.
1/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
7\Orti faeCV
r
Signature
haroii f1a bed-
Type/Print Name of Owner or Agent
Bay a-615 a100 SA -s50:1-05q
Phone Number
(O11 J44LL\
D-l
Avis
P-)1crov-L;Ic J D4, NI C 9cio0C
City/Stat +1 ip Code
cejt kp-y-)
r dk C.c 4" 00--Lu1 Y � S
]y11 a C�
ODate
LLC
(PX_CX th\k. DIQI"Aet LLc