WI0400505_DEEMED FILES_20181108

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400505
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Bradsher Mini Mart
Location Address
5401 NC Hwy 119 N
Green Level
Owner
Owner Name
NCDENR Dwm
Dates/Events
NC
Orig Issue
11/8/2018
App Received
10/26/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27217
Draft Initiated
Scheduled
Issuance
.. ,
Public Notice
Central Files: APS SWP
11/8/2018
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
Government -State
Owner Affiliation
Linda Blalock
1646 Mail Service Ctr
Raleigh
County
Alamance
NC
Issue
11/8/2018
Effective
11/8/2018
27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
/4..TC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES• MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
---------------------------------·-
October 22, 2018
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 oflntent to Construct or Operate Injection Wells
Bradsher Mini Mart
5401 NC Highway 119 North
Burlington, Alamance County, North Carolina
NCDEQ Incident #37442
Dear Ms. Shrestha:
.1.A:IVH l/NCOEQ/tJVt
OCT ~ b 2018
· ter Quauty Reg,0 ,,
'"•Pr,=)tinr,~ C:c-, 1 ·,
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of the North Carolina Department of
Environmental Quality State Lead Program. The permit application covers the performance of
passive remediation in two monitoring wells associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Elizabeth A. Allyn
Project Scientist
cc: Linda Blalock, Hydrogeologist for NCDEQ
Attachments
Ashley M. Winkelman, P.G.
Senior Project Manager
Notice of intent to Construct or ❑perate Injection Wells
Bradsher Mini Mart. Burlinuton. North Carolina
NOTICE OF INTENT FORM
ITC

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 injection.
AQUIFER TEST WELLS (ISA NCAC 02c .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION U SA NCAC 02c .0225 ) or TRACER WELLS (1 5A NCAC 02c .0229 ):
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 (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
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 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: October 22 , 2018_ PERMIT NO. vv'T04-0 0 5"0$' (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 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 through N
----'Pilot Test. ................................................ Complete sections B through N
___ Tracer Injection Well ................................... Complete sections B through N
lJ
Dt.Q/\JV\
2C'8
STATUS OF WELL OWNER: Business/Organization , '1ter Quality
·1 1 :n'""r.-
C. WELL OWNER(S) -State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s ): ~--=L=in=d=a"-'B=la=lo=c=k,_--'H=-'-'ydr==o.,.ge=o=lo=g""i=st."""N"-'-"-o=rth==-o:C=a=ro=l=in=a~D"-'e=p=artm==e=nt=-co=fc..:E=n=Vll'-=·=o=n=m=e=nta==-1 ~0-=u=al=ity'-'--__
Mailing Address: 1646 Mail Service Center
City: Ralei gh State: NC Zip Code: 27699-1646 County:_W'-'-=ak=e~---
Day Tele No.: 919-707-8165 Cell No.: ---=-N-'--'o=t -=-A=v=a=ila=b=le~---
EMAIL Address: [e-mail] Fax No.: __ ....,N'-'-=ot~A~v~a=i=la=b=le~---
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page I

2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598

October 22, 2018

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
Bradsher Mini Mart
5401 NC Highway 119 North
Burlington, Alamance County, North Carolina
NCDEQ Incident #37442

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 the North Carolina Department of
Environmental Quality State Lead Program. The permit application covers the performance of
passive remediation in two monitoring wells associated with the above referenced site.

If you have questions or require additional information, please contact our office at [phone].

Sincerely,
ATC Associates of North Carolina, P.C.

Elizabeth A. Allyn Ashley M. Winkelman, P.G.
Project Scientist Senior Project Manager

cc: Linda Blalock, Hydrogeologist for NCDEQ

Attachments
i\TC
ENVIRONMENTAL • GEDTECHNICAL
BUILDING SCIENCES• MATERIALS TESTING
Notice of Intent to Construct or Operate Injection Wells
Bradsher Mini Mart, Burlington, North Carolina

NOTICE OF INTENT FORM

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Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 1
North Carolina Department of Environmental Quality – Division of Water Resources

Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.

DATE: October 22 , 2018_ PERMIT NO. (to be filled in by DWR)

A. WELL TYPE TO BE CONSTRUCTED OR OPERATED

(1) Air Injection Well……………………………..…Complete sections B through F, K, N
(2) Aquifer Test Well……………………….………..Complete sections B through F, K, N
(3) x 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 through N
(6) Tracer Injection Well………………………….….Complete sections B through N

B. STATUS OF WELL OWNER: Business/Organization

C. WELL OWNER(S) – State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:

Name(s): Linda Blalock – Hydrogeologist, North Carolina Department of Environmental Quality
Mailing Address: 1646 Mail Service Center
City: Raleigh State: _NC_ Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8165 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: Not Available
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 injection.

AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.

IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
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 (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).

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 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.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 2
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Lawrence L. and Georgia M. Bradsher
Company Name Not Applicable
Mailing Address: 5409 NC Highway 119 North
City: Burlington State: _NC__ Zip Code: 27217 County: Alamance
Day Tele No.: 336-421-3842 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available

E. PROJECT CONTACT (Typically Environmental Engineering Firm)

Name and Title: Ashley M. Winkelman, Senior Project Manager
Company Name ATC Associates of North Carolina, P.C.
Mailing Address: 2725 E. Millbrook Road, Suite 121
City: Raleigh State: _NC_ Zip Code: 27604 County: Wake
Day Tele No.: 919-871-0999 Cell No.: 919-830-3576
EMAIL Address: [e-mail] Fax No.: 737-207-8261

F. PHYSICAL LOCATION OF WELL SITE

(1) Facility Name & Address: Bradsher Mini Mart
5401 NC Highway 119 North
City: Burlington County: Alamance Zip Code: 27217
(2) Geographic Coordinates: Latitude**: o ′ ″ or 36 o. 224451 N
Longitude**: o ′ ″ or -79 o. 298373 W
Reference Datum: WGS84 Accuracy: 10-meter
Method of Collection: DOQ-Acme Mapper 2.1
**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 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)

H. INJECTION ZONE MAPS – Attach the following to the notification.

(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells. –Cross-sections were not identified in
previous work conducted at the site.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 3
See Figures 1 and 2 for a site location and injection zone map. A groundwater flow direction map is included
as Figure 3.

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 two Provect ORS sleeves each in monitoring wells MW-1 and MW-3 in order to aide in natural
attenuation and reduce compounds concentrations to below the North Carolina Groundwater Quality Standards
(2L Standards). Based on the two most recent sampling events performed, in August 2017 for MW-1 and
December 2017 for MW-3: methyl tert-butyl ether exceeded 2L Standards (MW-1 at 43.4 g/L and MW-3 at
305 g/L). The sleeves come in 3-foot sections. ATC will install two 3-foot sections at the base of both wells,
across the well screen. The sock will release oxidizing solids into the groundwater for approximately 6 months,
at which point the chemicals in the socks will have depleted.

J. 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 http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-injectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).

Injectant: Provect ORS sleeves
Volume of injectant: 692 in3 – volume of socks per well. 1,384 in3 total
Concentration at point of injection: 75-85%
Percent if in a mixture with other injectants: Not Applicable
See Appendix A for MSDS.

K. WELL CONSTRUCTION DATA

(1) Number of injection wells: 0 Proposed 2 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 (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
See Appendix B for well construction details.

L. SCHEDULES – Briefly describe the schedule for well construction and injection activities.

Two weeks after submitting the NOI, ATC will install four Provect ORS sleeves, two in monitoring well MW-
1 and two in monitoring well MW-3.

M. MONITORING PLAN -Desclibe 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.
ATC will collect one sample approximately 6 months after the installation of the Provect ORS sleeves in MW-
1 and MW-3 (November 2018, with sampling to occur May 2019). During the sampling event, ATC will collect
samples from monitoring well MW-1 and MW-3 for analysis of volatile organic compounds by EPA Method
6200B. The sample will be shipped to SGS Accustest in Scott, Louisiana . ATC will also measure dissolved
oxygen, conductivity, temperature, pH, and oxygen reduction potential in both MW-1 and MW-3 during the
May 2019 sampling event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certijj,, under penalty of law, that I am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquily 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."
C::::--------Ashley Winkelman on behalf of Linda Blalock, NCDEO (see next page)
Signature of Applicant Print or Type Full Name and Title
PROPERTY OWNER (if the property is not owned by the permit applicant):
"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 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 Constn1ction 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 Appendix C Lawrence and Georgia Bradsher
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.
Submit TWO hard copies of the completed application package with an electronic version in CD or
USB Flash Drive to:
Deemed Permitted GW Remediation NOi Rev. 8-28-2017
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page4
1
Liz Allyn
Subject:FW: NOI Signature Authorization

From: Blalock, Linda [mailto:[e-mail]]
Sent: Tuesday, September 25, 2018 4:27 PM
To: Ashley Winkelman <[e-mail]>
Subject: NOI Signature Authorization

I, Linda Blalock, authorize Ashley Winkelman from ATC Associates, to sign Notices of Intent (NOI) as an agent for
DWM. If you have any questions or need more information, please let me know.

Linda Blalock
[e-mail]
~~~~~

inda Blalock
Em•ironm ma/ Engineer, Division of Wast .\fanagem 111
orth lina Department o Environmental Qualit
1646 Mail er ·cc enter
Ralei h. 699 · 1646
919 . 0 16 (0 1cc)
Notice of Intent to Construct or Operate Injection Wells
Bradsher Mini Mart, Burlington, North Carolina

FIGURES

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Notice of Intent to Construct or Operate Injection Wells
Bradsher Mini Mart, Burlington, North Carolina

APPENDIX A

MSDS FORM

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MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 1 of 5
1.PRODUCT IDENTIFICATION:PROVECT-ORS
PRODUCT USE: Soil and water treatment.
MANUFACTURER: EMERGENCY PHONE:
PROVECTUS ENVIRONMENTAL USA: 1-[phone]
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide), Class 5.1, PG II, UN1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
CAS No. Percentage
1305-79-9 75%-85%
Ingredients Chemical Formula
Calcium Peroxide CaO2
Inorganic Nutrients 15%-25%
3. PHYSICAL DATA
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 fire. 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.
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
lesions.
•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 water 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.
Damp 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,
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.
8. 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. Keep 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
area.
•Prevent contact with combustible or organic materials.
•Label containers and keep them tightly closed when not in use.
•Wash thoroughly after handling.
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
MATERIAL SAFETY DATA SHEET: PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
•LD50 Oral: Min.2000 mg/kg, rat
•LD50 Dermal: Min. 2000mg/kg, rat
•LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological Information
•Hazards for the environment is limited due to the product properties of no bioaccumulation, 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: II
15. REGULATORY INFORMATION
•SARA Section Yes
•SARA (313) Chemicals No
•EPA TSCA Inventory Appears
•Canadian WHMIS Classification C, D2B
•Canadian DSL Appears
•EINECS Inventory Appears
Notice of Intent to Construct or Operate Injection Wells
Bradsher Mini Mart, Burlington, North Carolina

APPENDIX B

MONITORING WELL CONSTRUCTION DETAILS

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PERMANENT MONITORING WELL CONSTRUCTION DETAILS - MW-1
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP PROTECTIVE CASING AND CONCRETE PAD
L1 CASING MATERIAL Steel
CASING DIAMETER 8 inches
CASING LENGTH 12 inches
PAD DIMENSIONS 2 feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 10 feet
L2 BACKFILL AROUND CASING
MATERIAL cement grout
THICKNESS 6 feet
SEAL
TYPE OF SEAL bentonite
L4 THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 feet
TOTAL FILTER PACK FOOTAGE 17 feet
WELL SCREEN
L3 SCREEN MATERIAL sch 40 PVC
DIAMETER 2 inches
LENGTH 15 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
WELL 25 feet
DEPTH TO BOTTOM OF
BOREHOLE 25 feet
L1 =0 FT.
L2 =10 FT.DIAMETER OF BOREHOLE 6 inches
L3 =15 FT.
L4 =25 FT.DRILLING SUBCONTRACTOR: TerraQuest Environmental
DRILLER ADDRESS:100 E. Ruffin St. Mebane NC, 27302
DRILLER CERTIFICATION #:3329
TITLE Well Information
Bradsher Mini Mart
5409 N. NC Highway 119 2725 East Millbrook Road, Suite 121
Burlington, Alamance County Raleigh, North Carolina 27604
North Carolina
FILE PREP. BY REV. BY DATE
EA AW 9/24/2018
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repair under #21 remarks section or on the back of this form.
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By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.

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Lawrence D.Opper
NC3322-A
Regional Probing Services
✔
12/19/2017 MW-3'DWH:HOOV&RPSOHWHG
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Bradsher Mini Mart Incident No. 37442
5401 N NC Hwy 119, Burlington
Alamance
36.224471 79.298283
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2
20
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4
Direct-Push
0 10 2 PVCsch 40
10 20 2 PVCsch40.010
0 3 Grout pour
3 8 bentonite pour
8 20 Prepack/pour#2 sand
0 20 Brown/Tan sandy Silt
1/9/2018Lawrence
Opper
Digitally signed by Lawrence Opper
DN: cn=Lawrence Opper, o=Regional
Probing Services, ou,
email=[e-mail], c=US
Date: 2018.01.09 14:33:58 -05'00'
Notice of Intent to Construct or Operate Injection Wells
Bradsher Mini Mart, Burlington, North Carolina

APPENDIX C

ACCESS AGREEMENT FROM SITE PROPERTY OWNER

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Ms. Linda L. Blalock
Environmental Engineer
DWM UST Section
163 7 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Blalock:
RE: Site Access Agreement
Bradsher Mini Mart
5409 NC Hwy 119, North
Burlington, Alamance County
Incident#: 37442
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I am the owner of a parcel of property, located at 5409 NC 119 North, Burlington, NC and hereby'~ermit the
Department of Environment and J\Jatural Resources (Department) and its contractor, to enter upon said property
for the purpose of conducting an investigation of the soil and groundwater under the authority of G.S. 143-
215.3(a)2.
I am 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 Nurth Carolina General Statutes, Tor~ Clair.1s 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, i.n accordance with 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.
Bradsher Mini Mart/Incident # 37442
I agree not to interfere with, remove, or any way damage the Department's we11(s) or its contractor's well(s) or
equipment during the investigation.
Sincer,ly.
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Address
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Phone N umber
Date