WI0400499_DEEMED FILES_20180803

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400499
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Pantry #441
Location Address
1013 S Main St
Apex
Owner
Owner Name
Cirde K Stores Inc
Dates/Events
NC
Orig Issue
8/3/2018
App Received
7/30/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27523
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
8/3/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Brent Puzak
Director Environmental
1100 Situs Ct Ste 100
Raleigh
County
Alamance
NC
Issue
8/3/2018
Effective
8/3/2018
27606
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasln
ATC
ENVIRONMENTAL - GEGTECHNICAL
B[t3La NA Sf IENCES • MATET+14E 5 TfSIVA
July 20, 2018
609A Finer Road
Suite 115
Wilmington, North Carolina 28409
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C_1598
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Former Pantry #441
1013 S. Main Street
Graham, Alarnance County, North Carolina
Risk Classification: 1150D
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of Circle K Stores, Inc. (Formerly Pantry). The
permit application covers the performance of passive remcdiation in three monitoring wells
associated with the above referenced site
4
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Maureen A. Jackson, \P.G.
Senior Project Manager
cc: Mr. Brent Puzak, Circle K Stores, Inc.
Attachments

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are ''permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200. This fo rm shall be submitted at least 2 weeks prior to iniection.
AQUIFER TEST WELLS (1 5A NCAC 02c .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (ISA NCAC 02C .0225) or TRACER WELLS (ISA NCAC 02C .0229):
1) Passive In· ection S 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 In· ection O erations -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 In jection 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: July 20. 20~ PERMIT NO. N J,O 4: 0 0 'fOI Cf (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
(1)
(2)
(3)
(4)
(5)
(6)
----'Air Injection Well. ..................................... Complete sections B-F, K, N
___ .Aquifer Test Well ....................................... Complete sections B-F, K, N
X Passive Injection System ............................... Complete sections B-F, H-N
___ Small-Scale Injection Operation, ..................... Complete sections 8-N
__ Pilot Test ................................................. Complete sections B.-~CL\VED/NCOEQ/DW
___ Tracer Injection Well. .................................. Complete sections B-N JUL 3 0·2018
STATUS OF WELL OWNER: Business/Organization !\later Quality
-,r\f?-r..-.tff"'!~C
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Brent Puzak Circle K Stores. Inc.
Mailing Address: ------=-1-"-l -=-00;...=S=itu=s=----C==-ou=rt=·'-'S=--=u=it=e-=1=0-=-0 --------------------
City: Raleigh State: NC Zip Code: __ -=2,_,_7=60=6..__County:_W~ak~e ______ _
Day Tele No.: ~91=9_-7~7~4~-6~7-=0-"-0 ______ _ Cell No.: --~N_,__,o=t -'-A"-'v-=a=ila=b=le=-----
EMAIL Address: ___ -b pF--'uz=a=k._,@;.,.c.c=ir~c=le=k=-.c=o=m~_Fax No.: ----=--N=o~t -=--'A"-'v-=a=il=ab=l=e _________ _
UICI In Situ Remed. Notification (Revised 3/2/2015) Page I
D. PROPERTY OWNER (if different than well owner)
Name: GWH Development Co.
Mailing Address : P.O. Box 525
City : Sanford State: _NC_Zip Code:~2~7~3~3 ~1 ___ County:-=L~e=e _________ _
DayTeleNo.: 910-315-5562 CellNo.: NotAvailable
EMAIL Address: Not Available Fax No.: __ ____;:U:..c.n=kn=o...:.:w....,n'-------
E. PROJECT CONT ACT -Person who can answer technical questions about the proposed injection project.
Name: ___ ...:M=au,.,r,__,,e""en~J=ac:::.k,,,s""'on...,__-__,_A...._T.._C::,<....!.A~s""s""o""'ci:.::a=te,.,,s_,,oc.:..f ..o.N.,_,o~rth~C"'"ar=o....,li=n=a ·'---'P'--' . ..:::Cc.:.... ___________ _
Mailing Address : __ ___,6=0=9-'--'A,....,P,....,in=er'-"-'R=o=ad=-==S"-"u::e;it=e__,l,....,1=5 ___________________ _
City: Wilmin t on State: _NC_Zip Code:=2~84~0~9 ____ County: New Hanover
Day Tele No .: 919-561-3893 Cell No.: 919-561-3893
EMAIL Address: maureen .j ackson@ atcassociates.com Fax No.: --~73~7_-=20~7--8~2~6~1 ___ _
F. PHYSICAL LOCATION OF WELL SITE
(I) Physical Address: 1013 South Main Street County:~A=l=am=an=c~e __________ _
(2)
City: Graham State : NC Zip Code: ~2~72=5~3 ___________ _
Geographic Coordinates: Latitude**: 35 ° __ 2 ' -~5~6 " or 0 __________ _
Longitude**: 79° _B' ~" or 0
Reference Datum: __ ~N~/~A~ ___ __,Accuracy: __ ~1 0~-~m=e~t~er~--
Method of Collection :_G~o~o~g_..l~e =E=a~rt=h~P~ro~-----------
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY : A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LI E U OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: ______ __,square feet
Land surface area ofinj. well network : square feet(~ 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be ~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(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.
See Figures I through 4 for site location and injection zone maps.
UICI In Situ Remed. Notification (Revised 3/2/2015) Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
ATC will install Adventus O-SOXs in monitoring wells MW-2 , MW-4. and MW-8 in order to aide in natural
attenuation and reduce compounds concentrations to below ten times the 2B Surface Water Standards (2B
Standards). Based on the most recent sampling event erfonned in A ril 2018 . the followin com ounds
exceedin the a licable 2B x 10 Standards: benzene at 1 300 micro rams/liter L toluene at 880 ~
ethylbenzene at 3,400 µg/L. total xylenes at 8 ,000 µg /L , MTBE at 3,700 µg/L , naphthalene at 790 µg/L , and
1,2.4-Trimethvlbenzene at 4,300 µg/L. The socks come in 3-foot sections. ATC will install two 3-foot sections
at the base of each well across the well screen. The socks will release oxidizing solids into the groundwater for
a roximatel 6 months. at which oint the chemicals in the socks will have depleted.
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets ifnecessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/weblwqlaps/gwprci. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
Injectant: ---=A=d=v-'-'e=n=tu=s'--O=-c-Sa..cO=X'--=-______________________ _
Volume of injectant: 905 in3 -volume of socks
Concentration at point of injection: __ ___,9-=0'--'-o/c-"-o __________________ _
Percent if in a mixture with other injectants: __ _,_N-'-'o=-=t_...A=..,p=h=·c=a=bl=e ____________ _
See Appendix A for MSDS.
K. WELL CONSTRUCTION DAT A
(1) Number of injection wells: ---=-O ___ P.roposed'---------"'3 ___ Existing
(2) Provide well construction details for each injection well in a diagram or table format. A single
diagram or line in a table can be used for multiple wells with the same construction details. Well
construction details shall include the following:
(a) well type as permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
( c) well contractor name and certification number
See Appendix B for well construction details and the well construction record.
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Two weeks after submitting this NOL A TC will install the Adventus O-SOXs in monitoring wells MW-2 ,
MW-4, and MW-8.
UIC//n Situ Remed. Notification (Revised 3/2/2015) Page 3
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 O2L result from the injection activity.
emi-annual salmi ink events of all monitoring wells are performed in April and October each year. AI'C's next
sampling. e'bril will occur October 2018, During the samnline event, ATC will collect a sample from monitoring
wells MW-2. MW-4. and MW-8 for analysis of volatile organic compounds by EPA Method 6200B. The
samples will be shipped to Con -Test Laboratory in East Longmeadow. Massachusetts-. ATC will also measure
dissolved oxvuen, conductivity, temperature, pH, and oxygen reduction potentialin wells MW 2,MW-4. and
M W-8 d dna the October 2018 sampline event
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "1 hereby certify, raider penalty of law, that 1 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, 1 believe that the information is true, accurate and complete. 1 am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
tnforrnation. 1 agree to construct, operate, maintain, repair, and if applicable, abandon the injection well and
all relatedappurtenances in accordance with the 15,4 NCAC 02C 0200 Rules."
Signature of Applicant t . ILraz_S Print or Type Full Name
PROPERTY OWNER ;if the proper , is not owned by the permit ;ipplicantl:
"As owner of the property on which the injection well(s) are to be constructed and operated 1 hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(1SANCICO2C,0200j.
"Owner" means any person who holds the fee or other property rights in the well being constructed. A welt
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.
&1oH Vc-LI Pn cNT ComP4.JY
Signature* ofi'roperty Dinner (if difiet .at (ram applicant) Print or Typo Full Name
* An access agreement between Me applicant and properly owner may be submitted in lieu ofa signature on this form.
Submit the completed notification package to:
DWR -- UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
1 nr'Is.. vie. T?...+,rA Nntife,- I A$, PI?n,o;coA In 7al1 S1
Pnee 4

From: Puzak,ikent
To: Maureen.] son
Subject: RE: Well Permits
Date: Friday, Mardi 04, 2016 8:05:19 AM
Attachments: image003.ena
Maureen,
Thanks for processing. Please use this e-mail as support of Ivy authorization for you to sign permits
on behalf of Pantry / Circle K, If you need additional support please let me know and I'd Le happy to
follow-up further_
Thanks
BRENT PUZAK
Environmental' Director
Circle K, Inc.
Cary Divisional Office
919-566-1549
}rniapkeordeis.com
From: Maureen Jackson[mailto:[e-mail]]
Sent: Thursday, March 03, 2016 4:19 PM
To: Puzak, Brent
Subject: Well Permits
Importance: High
I submitted 2 well permits for the off -site wells at Pantry #161 in Elon. I signed the permit as ATC
Project Manager on behalf of Pantry. I need to get an email from you to send to ❑EQ— Public Water
Supply stating that I could Sign on behalf of Pantry for the well permit. 1 have submitted many of
these signing like that and never needed a letter - guess it has changed.
Can you provide a brief email just saying you all me to sign on behalf of Pantry for the well permit for
Elon.
Thx — if that is a problem, let me know and I will upload well permits to Titan so you can sign and
then l can submit them.
Maureen 3ackson 1 SENIOR PRO3ECT MANAGER j ATC Group Services LLC
[phone] 919 561 3893 mobile
2512 Independence Boulevard, Suite 200-34 I Wilmington, NC 28412
fax ! maureen jackson(atcassociates.com ! www atcgroupservices clzin
- -
11 r

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ADVENTUS
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• 1(t'hbrr tvsr,,;s
I,rrteral H►•tiie:nc ['orreidl I atiuns
• \' .I:;h ►►ith'.L+sil and lt;aier ilelui so i1 ,'m.. and .,t he nd of 4.t.h 2Aorl..;hitt. (it+od
11 Inul.r.t' r l ills_ 11r.(cs; c'•7 r tl l.i f,' r+ •. •..- 1 t+Li!1tg nl aC, • I• ,ni... I t1 i . n skin ;2, soon
pr.t..tk. I, e•slt.'.,alh l,e.li r •:lt+tt tIr �nII+ ln_�
10. ''l'. B l[.1I11 AND RE 1[•'It1 1'I'i
Stability
• bl :,rrit:r rus'tff.ti : +ntii,arr:a
rendition t u Moir!
• VI Ater
• iLLitl.,
• H. ti
• Salts rl he.. ) nil
• Reducing agents
• Or rini: ittdte!'ii51v
• I'l:Intnlahle sLlbtu no:
Har3rtlnurs 11eCutrtpnsitisnt Prndui•l
+ (h tI

ADVENTUS
1LR1i1,SAT El I) I ti1ILEX.
()SOXTh' Page: S tf 5
11. TOXI(OLOGIC.%L INI U1(M 1 1 ION
• I l) it Ord: k1in.2111141
• LI s-;,,! Iht:Fr. Alin. 7( .
• 1.1)zI1 h:halslit rr Ilin_ rt i . r.a
12, ECC)1.OGIr'.il. INFORMATION/
rc+il[i►iculogicai inFnrmati+tn
• liarlyd• for the en.'isttrin. •n [, lilrit.d due to Pr tII r.; rt: F ttlt+tt. ur
•r}1uhifit� and pre'. -IL :S.lir it'., envirl,nnten
('htinical bate Information
• '1. rndkL.ried by c1icitui.rl ri. +crl rile: Li Mt.) I1I. environment.
13. DISPOS.II_ ("t1N‘ID R VI 1f 1 tiff
Wast+, 'I'rr:itment
+, I).o-n ..n -:aprr-. e 1
i0i.I1 rcgt:'. u1
i.i e+i+Lrat.d hv :,t -err vteed c.msr...:utr
me IX! :di
1'i►•Lagt I'rt:itinr nt
• fiie :n p v and .lean I I+ sc. y.:tcLl rn tli.Im,yJ of 'n conformity with lc .tr
n if:eSi tnti,
I L. •IRA%SPQR"t 1ti1•OI01.1T1ON
• Pr. pr:r Sitippin Ills tJ
• 1laf:tr.l 5. I
• Labels; 5.1 t0AiJi cr.
• Parking Group: l i
15. Rl•:(;1'L.t'1Y11i1 1PEYORA1 VI ION
•
•
• EPA 1 SC:1 lmenter• _. ,Lp;+etir.
• Carnahan V,. }HMIS Cli.:,•isiratiun C. 1;_13
• C:l:sadian D.SI. appear%
• 1.INl:('S lmcntr'r.
16. PREPARATION T ION INFORM VI It 11
Psc[).trcd 1' Kerr D 1anl+>-tilt._11-
•liltcmu. .
• DriN e
Sti�•ilattl (lir
L- \\ •
1)..Ic Prcr.IRet 9/12107
Inns 1.),I' WI'in?
now: 905-271 -I

NORM =CUM useimmigar or NAsvAAL ILIU CU2 AND o0iOi UNELV
TAVl$[ X CFENVIRORMINTALKll`iA nrr • ClitaLIId7i1fATRR S9Cfl N
P.D.1![ %37St7 • RALE08.111O.27611. mom [phone]
WELL OONS1RUCfIONRECORD
DRILLING CONTRACTOR Geoloitle_Expiteretion3MIAmbert
DRILLER REC3IS771ATION NUMBER 2437
MW2
MR0171=11E8 ONLY
Qmtd. No. Serial Na
Let. Lang. Po�
Maaor Rada _
Baia Code
Header Et. OW-1 Eat
STATE WELL CONSTRUCTION
PERMIT NUMBER:
1. WELL LOCATION: (Show &soh of tee location below)
Nearest Town: grfhsuo
t 013 Sours Meta ascot
(Road Community. or 9abdsvascn sad Ld No.)
2 OWNER The Panlrv. Lao- - The Nary N441
ADDRESS PO Scot 1410
8aatoli
Cigt arTowe
(Street or Route No.)
NC 27330
Stets Zip Code
3. DATE DRILLED 07JL9.2043 USE OF WELL Maaitor*
4. TOTAL DEPTH . 45' GB 00L ECTED You 0 Na®
3_ DOEB WELL REPLACE 113=NO WELL7YetC71 NAM
F STATIC WATER LEVEL ® TOP 01 CABrN0.
TOP OF CASING IS 0 .. FT. ABOVE LAND SURFACE.
7. YIELD Wog: NIA METHOD OF TEST NIA
8 WATER ZONES (depth): N!e
9 CHLORINATION: 'type 11/1..
10 CASINO:
11. GROUT;
N/A
Well Tbidtaew
Depth Dimmer ar Weight/FL Materiel
FROM 0 TO 35 FT Z" Scb 40 PVC
FROM 0 TO 25 FT 4"
FROM 0 TO 25 F1
i+RI3M TO FT
12. SCREEN:
Materiel
Partial
Method
Sleety
Depth Diameter slot slsa Material
FR01 35 TO 41 FT 3 is .010 4r PVC
FROM TO FT m in
13. GRAVEL PACK:
Dept:
FROM 33 TO 45 FT
FROM TO FT
Size Material
20140 miioe Send
l 4. REMARKS: Bentonite cool Iran 23' to 33'
H �A
DMZ
Awn To
0 1
DRILLING LW
Rarmatim DarxQCan
Cameos
1 1E 14844iiti in lock Rota
Ow* WO
IV 43 Or:54mm sw& ill
eadcBsanenlo ()
1i adRtic i1 spas le 'mild urn lade affirm
LOCATIONIKETCH
(Show &actianand dic osa. Maim st lead two Rea Pvr<k, or dicer
map rcdtrmce sham)
•
neaesuesareaer
lofts
w"".wrff
.. — —�.arer.as►�e
s�tl �i,w
rice ±� w
UP. ern
1 DO HEREBY CES TIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WTCH 15 NCAC 3C, WELL CONSTRUCTION
STANDARDS. AND THAT A COPY OF THIS RECORD HAS E» FRO •:c • TO
OW-1 Revissi 6188
Ith2.
= OFCONTRACTOR 0 'AGENT DATE
Submit original to Divisiao of Enviromzetemal Matagoment Sad copy to well owns.

MW-4
WELL CONSTRUCTION RECORD
North aerobes— repunwn ellbeirr®rd we Hemel Rmusan—Mnero of Won Qudgr — iltaonldrrew Sdiee
WELL CONTRACTOR (INDIVIDUAL) NAME (print) NI Lsmbon
WELL CONTRACTOR COMPANY NAME 0ee4naieEaskeetices. iota
STATE WELL CONSTRUCTION PERbd1T # ASSOCIATED WQ PERMIT #
Ord
CERTIFICATION M 431
PHONE* 170413T7r7686
1. WELL USE (Cheek Applicable Boot4 Rs 1dentLal V MunicigalVPublin V Industrial V
MoikarinJ Roomy V Hest Pump Weser /ejection V Ctser V If Other. lid Use
2. WPLI.LOCATTQN:
Nearest Town: Graham Comity Alsmaaao-
Jil I3 S. Main Street 0tshem. NC
Moro Pine. Tarreas Cauawny. or ibibibANCMand Le1Na, DgrCob)
3 OWNER The Pantry. heo. — The reeky y # 3199
ADDRESS P.O, lox 14I0
Spa
clew omen Ne7
�70
ears con.
oey Nid.A
f41,1774.6?%
Hra cogs— strew }.raker
4. DATE DRILLED 02119473
5. TOTAL DEM I/ 20.0 Fr
6. DOES WELL REPLACE IOLi0TINO WELL? YES V NOID
7. STATIC WATER LEVSi. Ilduwrep atOwing 3.QO FT.
Qi `e'gALaartgarum' In
1. TOP OF CASINO IS 0.0 FT. Above Lend Surface*
oferig orrroledeaamirinwhost.Roarswims a
verso ieaeemis,oewith 1SA1 CAC2CAtla.
9. YIELD (goo): WA METHOD OF TEST J7/A
10. WATER ZONES (depth): iw1A
1 ! DISINFECTION: Type WA
12 CASINO_
13.
14.
GROUT:
Depth
Amount Zti�A
Wall Tbidcaao
Diameter or Wri;trarPL 14141=rial
FROM 0 TO 5 FT Z" Saha PVC
FROM TO FT
FROM 70 rr
Depth
FROM 0 TO 1 irI`
FROM TO P1'
SCREEN:
Mameeis
Pentland
Puny
Method
Depth DisooNa Slat Sae Material
FROM 5 TO 20 Fr 2 in 0.010 in
FROM "I'0 Fr in
15. SANDI0RAVE(, PACK:
FROM 3 TO
FROM
PVC
Size Materiel
20 FT 20/40 Fine Silica Sand
16 REMARKS: Bersrmile Seam -- 3'
Agricultural d
Tupngraphio/ Lard setting
V Ridge V Slope V valley Plat
(check aPprn'priaae box)
Latitndo Iloogilude nr ell location
()
Latitudellooginsde aoutae: V OPS b Topvgrsphio >ue
(check b)
ARILLINQJ.va
From To Formation Dmorrption
0 • 1 Concrete
1 - 20 Med. to RaLly oeo slig60y reedy all
(EWE -rock Iknej
LOCATION SKETCH
Show direction and distance in miles Sae at Iced two State Roach or
County Rcnde, include ills road albmbera sad caao= auaan
.3m.....m,
•
i DO HEREBY CERTIFY TEAT THIS WELL WAS CONSTRUCTED rt4 ACODRDANCE WITH 15 NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND TEAT ACOPY OF THIS RECORD HAS HEST PROVIDED TO THE, WELL OWNER
°NATURE OF CCiNTRACTOR AAOR T
Submit original to Use Division of Water Quality. Oraemdwaater Swim. 1636 Mail Service Center — Raleigh, NC
27699-1636 Phan Na (5019) 733 221, wpm 30 days.
024i9/03
DATE
OW-1 REV.07/2001

WELL CONSTRUCTION RECORD
This form can h! used for -single or multiple wells
I. Wrll Contrnclor lnformalion:
PAUL MCVEY
Well Conlrnclor Name
A-4305
NC Well Contractor Ccrtific,rion Number
GEOLOGIC EXPLORATION, INC
Cou1pnny Nnme
2. Wtll Comtrnclion Permit#: _________________ _
I.isl all appliC'ah/1! u• .. •/1 constr11ctim, 11ermilx (I e. Corm(~'. Stnt1~, Varlnm:e, t'IC)
J. Well Use (check well use):
Wuter Supply Well:
□Arricultural □Mumc1pa!/Pub!tc
OGeothormal (Henting/Coo:ing Supply) □Residential Water Su;:iply (single)
D lnduslrinl/Commercial □Rcs,dentia: Waler Supp:y (simrd)
CJlrri imtion ·-Non-Wiiter Supply Well:
@Monitoring □Recovery
Injection Well:
0 Aquifor Recharge □Groumlwatcr R~mediation
□Aquifor Storage and R<,-covc,y □Sa! inity Bnrrier
□Aquifer Test □Stormwater Drainage
□Expenmental Technology □Subsidence Con1rul
□Geothermal {Closed Loop) □Tracer
□Geothermal (Hea1m wCoohng Return) □Otl1er (exolain under 1121 Remarks)
10/12/16 MW-8 4. Dute Wcll(s) Completed: Well ID# --
5t1. Wdl Lotution:
PANTRY-441
FncUi1y/Owncr Name Focility ID# (ifnprlicable.)
1013 SOUTH MAIN STREE T GRAHAM 27253
l'llys1tnl Adtlres!:, City, r.nd 7..1p
ALAMANCE
County Poree! irl,ntifica1ion No. (PIN)
5b. Lolilude nnd Longitude in degrees/minutes/scrnnds or detim1l degree<;
(if well field, one lat/lontt is sullkienl_)
36" 03' 07. 76" N 79° 24' 16.04" w
6. Is (are) the well(s.): @Pcnnanent 11r □Temporary
7. Is Ibis n repuir to an e;dsting well: □Ye , or l!lNo
Jfthi,,; i.i u rr!pair.jill mu km11ra U't!fl c:011,\·t;•m•lfmi infbrma1itJ11 (1'1d explain 1/w ,ratur11 ofche
repoJr umh!r #2 I nmrark< sec.·limi or 011 th,: bad.; 1,fll1isjiJrm,
8. ;>;umbrr of wrlls const.-ucted: ___ 1 _________ _
For nndtiple i,~Jct·11tm or mm~u·n1cr sur,ply we/.'s ON/; Y wi.th the same c,,m,1rm.:rit11 1, you can
submit OW! JOnu.
[ For Internal Use ONLY:
14. WAl'ERZ0NES ~ fRO~I TO DESCRIP110N
ft. fl.
ft. ff.
,._ -----
IS. OUTER CASING I for mulli-<'l!td wtlls i OR LINER /if D~olkubltl
FROM I TO I DIAMET!sl< I THICKtiESS I MATERIAL
fl. n. in. I I -I~. INNER CASING OR TUBING ,•rcll-,nnol <IOS4'd•loo M
f ROM TO OUMETER 1. Tll!CKNF..:;S
i 0.0 ft. 3.0 ft. 2.0 in. SCH 40
MATERIAi.. J
PVC' ------ft. ff. ilt, l I --"-·-17 SCREEN
FROM
TO ___
lllAMETUt I SLOT SIZE TIIICI\NESS MATEIUAL -j 3.0 fl. 13.0 rt. 2.0 in. .010 SCH 40 PVC -r,. II. 1n. I -18.GROUT
~fil.._ . ...IL_ -MATERIAL l:>IPLACL\1£'• \l_l;:T:1!011 .I. ,\_\l01.1'1
0.0 ft. 1.0 r,. PORT'..NiO ~fOH;rr SI URRY i--·n:------h. ,--I-
ft. ft.
I
--19, SANO/GR.AYEL PACK(iiB1!1!lic.ibk)
FROM I TO MATERIAL ---EMPU.CEM~1'1" MF.T!JOD I I ?.O "· I 13 o fl. 20-40 FINE SILICA SAND J ' . -----r---·
f,. l ft.
?O. DRILi.iN'; LOG lottuch ad<liti~eb ifnece'9urv 1
FR0,1 i TO JlESf'RIPTION (color, h:1n111us, soil/nu:k "'N!• "ntin siu. tt.:.l
0.0 rt. I !3.0 ft. BROWN SILTY CLAY/ROCK --
ft. fl,
---r,. ft. l -
---~ ft. ft. -----
fl. ft.
ft. rt. --i ----n. fi. I
H.REMARKS
I BENTONITE SEAL FROM 1 .0 TO 2.0 FEET
-J
~-;117/2 · 10113116
SiennfilllllfUI \.ert1fl,.:d Well C<1:1tf:\CIOf .; D~te
Hy signiug thi.'i Ji,rrn, I h.:ri:l~l' n.•r1&j• thot 1/w u-e/1(.'>_i 1;as (1?L'l't') ,•r,m•1n1cwil h1 uc.:or~iam·1.•
1d1!, 15A NC'AC 02(' .fJJO!J or J.lA J\.'CAC IJJC .02110 Wt!II C:tmsm:c1im1 Swmionh ,.ml 1/im u
copy af1h:.~· r,.:('tJrtl ltaJ been ,:rm·:dcd 10 ,be U'c// ,,l,'m!r.
23. Sitr di:1gr.i;1: or addilionul well tletnils:
YN1 may use :he back or thi, puge lo r,rovide additi\lnal wen site d~tails or we:'
cMstruction detJ;!,. You m:iy a:so ~tlach ad1.Etiom1l pai:;es ifncccs~ary.
SVUMl"I"r/\L INSTUCTIONS
9. Totul well drplh below land surfn,•e: -..,.........,_1_3_._C _______ (ft.) 24n. For Ail Wells: Submit thi.1 forr.: withi:i 30 d1y.; of completion o,· wdl
Por n111/1iplr u·,•//,, Ii,·, all dcplhs iftflj)rr·cni {example• 3@2/J!r and 2@10/1') constr..:ction to the follov.ing:
I 0. Stutir wulrr level below top of casing: ___ 6_._0 _______ (fl.)
lf,rn/4:r h•,·cl is ,,h<we t·a.tit,g. ust 1
' •·
11. Boreholr diamttrr: __ 7_.0 _____ (in.)
12. Well construction method: __ A_U_G_ .... _E_R _________ _
( i.e. ;mser, rotary, cr,bi !, dtrc:t p1ish. etc.)
FOR WATER SUPPLY WELLS ONLY:
1311. Yirld{gpm) ________ Method oftest: ___ _
JJb. Disinfection typr:
Amounl: ========
Division ofWuttr Q1111lify, lnfor1m1t1on Pro~essing Unil,
1617 1Vl11il Scrvict Centrr, Ru!eigh, NC 27699-1617
24b. For lnittljon Writs: In addition to sending ~he form to the address in 2'1a
abow, olso submit a copy of this form wi1hi11 30 days oi CO.'ilpl~ti-Jn of , .. ell
con:;truction to the following:
Dh·ision ofWattr Quality, Undtrgronnd luje~lion Conlrol Prugrllm,
1636 Mull Ser,ite Centtr, Rnlcigh, NC 27699-16J6
2-lc. For W11ter Supply & ln iution Wells: In addition to sending, the form :o
lht! nddress(cs) above. abo submit or.~ copy of this form \.tthm 30 day.; of
comple:ion of well constructic:1 to the county hc11lth d~pnrtm~nl of the county
where constructed.
F,rmGW-1 Monh Cm·(llil:a Department of Environment h.ld Nnhtrol Rcsour-::es -Oivisiu11 ofWa1cr QutJ;;y Rev ::,ed J:.:1. 20 I J
1
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531b3$3L lrw'S-C
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1

CRASS
1
r r
rpAr
'
E%CAVATIOAI Sl
1 _ \ ;r'
\-,;,-
' 0
r. 'C -1 Z
`% 5
1
1 v
rnn..rr, Mal
1
P[-EIJHE \ ' 1
1
11
FCRME.R� J 73
CANOPY rn
-$ rl
ASP{IALT 1
CRASS Y
>i
I 7
FLORENCE STREET
1
61
1,
-
APAR-WENT AIJ1LOING
APRHIMENT 9UIWI G
PARkNC AREA
0 60 120
APPROXIMATE SCALE IN FEET
GRASS
m
A
1
PANT 441TAG
3
6
03
9
64.

GRASS
eMW-s
94.08)
FORMER
PIPELINE
Fa keiR
olc r40 v`h` ••••
ASPHALT
MW-6
(94 S 0)
v
ti
FLORENCE STREET .0
LEGEND;
ca,= flPF II MOMTORING WELL
= MONIrnRlNC WELL
[01.06) = DEPTH TO GROUNDWATER IN FEEL
GRGUNIJWATER CONTOUR LINE (DASHED
= GROUNDWA1FR FLOW ID+RECTION
WHERE APPROXIMA iE}
----------------------
0
60
GGA55
(95.89)
.PARkII.G AREA
520
APPROXIMATE SCALE EN TEET
e
A
1
H
lA_1
C
EL:
2. TYP! In WELL PAY-5 HOT USE❑ iti CONTOURING