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HomeMy WebLinkAboutWI0400499_DEEMED FILES_20180803Permit 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: 919-871-0999 Fax: 919-871-0335 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 (919) 871-0999. 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: (919) 807-6464 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:maureen.jackson@atcassociates.com] 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 +1 919 561 3893 4-1 919 561 3893 mobile 2512 Independence Boulevard, Suite 200-34 I Wilmington, NC 28412 fax ! maureen jackson(atcassociates.com ! www atcgroupservices clzin - - 11 r ADVENTUS I1ik.[([tLti.1F'L1 U1I1SH1 0-SOX" Page: 1 of 5 i. PROM 11' I1]F \ 11E'[( 1I 10N: PRODUI.I I SE: M• NI F'1(. "FIRER: Vh. 0 ,1S AMC! it ,:- l itc I Ll. l.,si •t 1t;1.. St 1 ree n. E[_ i1-til-1\ "' F1fi:k(=I 1(71. 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Atili.l it lll:lt I id d: Handling • •1vl,i1.I iI1Rt,1LL 11 ..11c rTitail;:nl_. • i]u nn• sw,llltllt :ikL11 1i • :es:ill:llt? i1r du, -. D+ It e- t. dynk. l+r <rtl• 1,Le alY;:l, • l're■cni .-nnint•t LvIi i . +nlhr;'`�le ur ttr<.L ll& rn.lt rLLI�_ • e 1:tt.li • ..ni.i rcop > I1tkti~cLi Led nnl •n • :eh1L ant:" hat ADVENTUS M11I?R[AL S.1 i:.T1 DATA SitIi.is I: 0-SOX 1 r Page: l rl 9. EXPOSURE CONT R[7I.41PERSLIN.LL PRO UECI 10N !•,nginecring Controls • tirner.il r,Innf ventilation ti 1•tq. iretl, Luca! esinsuat ► ntii:ttiun. pr xe•.., ellelo.ul or t lie, e:t �ineer4 controls fU:tt ?-2c needed to maintain airh[•rn levels hrh•w- recom nendet1 exrt pure lilltlt. Lt •eiLt I f.::Iii1L dt:•t tsf rui;•. II.Iin:.tln .2 lctl:rate ► ccil hull.• n l?ri not t„t: in clOacdl • 1r eontf nul paces. Keep le +u !spo liI r:s. 1 u dGterrnine . spusur: iirni: monitoring .lti+cic! I perl.rnak•d tenul..tly. Respiratory Protection • Fkr 111.If:.. u`ilCtititln no re tt.._I 1 I1r AI, m be itt't'Jc.L it, new in dl:,.► III' tanknown ,.LIni+4llhi ti . or ► hen c pu.ln 11.7 J liruis ►:Il.s: ;, ►►:,Ira . (JSII at►frrtr:cd rt;l+lr,tor ye/lace Protection • Weal elteliI'l:Lh Skin t'niivction ■ Pr: ►ern cont.. iih :I'1 oroduLt. \N e:Ir 1s p► es .end nrutc,;tis a el( ,:11;nf:.lc:pcndittg tin condition If sc.. Pr.• «,t►c . lot es, t 1teroit:d1-iesi2si in itcs.rntlnlcnJed imaerL1 PVC. neoprene or Other P*ote.'ti►c 1.quipmEnt • F:►.-trash :.tation • S::icty slf,PIA cr ■ In11un•fu..- : i,slh•+ • 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 (919) 733.3221 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 U. 1 Eat Fr air 4 - • ippirr ,;* LI S •IM.f.� ,ri.. NQLI. : a"ita • Ya P5 IfJ51 .14 r").4imU ES 4 - weaViyay'1 - ..way - �aV1IWli ..l t�Jply `Y. .Yay.jluVl Aal� IJ mm• •-w. ,.Iwss,rr 40.10.1 i r, 531b3$3L lrw'S-C 'COSKr1Y-VX Rif rei w.uil i► :]if[V7ftIL':10 NOI9Ni'i1!afl r r. ups AY P'a!WM1i�aa'S r • •A .r.r Yi..l.raufd sora� INI1111 o L113.1Y31000'i ..a •s.i . OSO fL 1 I' 1 CRASS 1 r r rpAr ' E%CAVATIOAI Sl 1 _ \ ;r' \-,;,- ' 0 r. 'C -1 Z `% 5 1 1 v rnn..rr, Mal 1 P[-EIJHE \ ' 1 1 11 FCRME.R� J 73 CANOPY rn -$ 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