WI0400540_DEEMED FILES_20200225

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400540
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Vitafoam
Location Address
2222 Surrett Dr
High Point
Owner
Owner Name
M 5 Corporation
Dates/Events
Orig Issue
2/25/2020
NC
App Received
2/18/2020
Regulated Activities
Groundwater remediation
Outfall
waterbody Name
27263
Draft Initiated
\
Scheduled
Issuance Public Notice
Central Files: APS SWP
2/25/2020
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
County
Randolph
Facility Contact Affiliatron
Owner Type
Non-Government
Owner Affiliation
Kevin Gaskill
PO Box 126
Spencerville
Issue
2/25/2020
Effective
2/25/2020
OH 45887
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
February 7, 2020
Mr. Mike Rogers
NCDEQ
Division of Water Resources-UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Subject: Notice of Intent for Injection
Former Vitafoam / Current Innocor Facility
2222 Surrett Drive
High Point, Randolph County, North Carolina
Site ID #NONCD 0002676
Dear Mr. Rogers:
--..
1-Ea 1 s zoza
On behalf of M.5 Corporation, Blue Ridge Geological Services, Inc. (Blue Ridge) is planning to perform
additional assessment and remediation activities at the subject site. Attached is a Notice of Intent (NOi)
application form and the required attachments for performing injection activities at the site. Per our
discussion, we plan to use existing well(s) at this time but may drill / install additional wells / injection
points if this work is successful.
Please contact the undersigned if you have any questions and / or if you need any additional information.
We appreciate your review of this information.
Attachments-NOi Form, Figures, MW-17 construction record
cc: Ms. Candace Moeller, M.5 Corporation
7356 Belmont Drive, Trinity, NC 27370 * Phone: [phone]
NC Department of Environmental Quality-Division of Water Resources (DWR)
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 (NOTE: This form must be received at least 14 DAYS prior to in jection )
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 Cl SA NCAC 02c .0229):
1) Passive Injection S ystems -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 is 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: February 7 . , 20..lQ PERMIT NO. t-v ]..(?)t.J-Q 0 ,5'tf0 (to be filled in by DWR)
NOTE-If this NOI is being submitted as notification ofa modification ofa previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
Permit No. WI. ____________ Issued Date: _________ _
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B through F, J, M
____ Aquifer Test Well ....................................... Complete sections B through F, J, M
""X=--__ .Passive Injection System ............................... Complete sections B through F, H-M
___ Small-Scale Injection Operation ...................... Complete sections B through M
___ .Pilot Test. ................................................ Complete sections B through M
___ Tracer Injection Well ................................... Complete sections B through M
B. STATUS OF WELL OWNER: Choose an item.
FEB 1 s 2020
Deemed Permitted GW Remediation NOi Rev. 10-14-2019 Page I
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): M.5 Corp oration -Jeff Gerlock of Blue Ridge Geol Services auth to si gn on behalf ofM.5
Mailing Address: ~P=O'-'B=o=x=--=12=6'------------------------
City: Spencerville State: OH Zip Code: 45887 County: Allen
Day Tele No.: ________ _ Cell No.: 336-382-6849 Jeff
EMAIL Address: [e-mail] Fax No.: __________ _
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: -----=s=am=e-=a"'-s =ab""o""'v""e _______________________ _
Company Name ______________________________ _
Mailing Address: ______________________________ _
City: ____________ State: __ Zip Code:. _______ County: _____ _
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address: ____________ _ Fax No.: __________ _
E. PROJECT CONT ACT (fypically Environmental Consulting/Engineering Firm)
F.
Name and Title: --~J=eff~G=e=rl=o=ck=·-=P~r=es=id=e=n=t ________ _
Company Name --~B=lu=e~Ri="=dg=e~G~eo=l=o=gi=ca=l~S=e~rv1=·~ce=s~. I=n=c~. _______________ _
Mailing Address: --~73=5~6~B=el=m=o=n~t D=ri~v,~e __________________ _
City: Trini ty State: _NC_ Zip Code: 27370 County:~R=a=nd=o=lp=h=-----
Day Tele No.: ___________ Cell No.: 336-382-6849
EMAIL Address: [e-mail]
PHYSICAL LOCATION OF WELL SITE
Fax No.: __________ _
(1) Facility Name & Address: Innocor 2222 Surrett Drive
City: Hi gh Point
(2) Geographic Coordinates: Latitude**:
Longitude**:
County: Randol ph/ Guilford Zip Code: --=27=2=63"'------
___
0
--__ "or.}L0 .~9~17=-------
___ 0 __ " or ..filL._0 .~00~0=-------
Reference Datum: MW-17 Accuracy: _______ _
Method of Collection: USFWS Wetlands Map per
**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: ___ ~N~A~_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)
Deemed Permitted GW Remediation NOi Rev. 10-14-2019 Page2
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.
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE -Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
We plan to install potassium permanganate (RemOx) cylinders (1.35" x 18 inch) in one existin g monitorin g
well (M W-17) to enhance biode gradation of the chlorinated solvents (TCE and 1.4-dioxane) in the
groundwater at the site. We will install two to four c ylinders in well MW-17: the c ylinders will to placed in a
mesh and set to depths of approximatel y 20. 25 , and 30 feet in the well. If successful. we would like to install
c ylinders in one or more existing or pro posed wells in or near the contaminant plume.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: -------'Proposed 1 to 2 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 15 , 20 , 25, and/or 30 feet
(3) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
( c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Onl y in iectants app roved b v the e pidemiolo gy section o f the NC Division o f Public Health .
Department o f Health and Human Services can be in iected. A pp roved in iectants can be found online at
http://deg .nc.gov/about/ divisions/water-resources/water-resources-permits/wastewater-branch/ ground-water-
11 rotection/ ground-water-app roved-in j ectants. All other substances must be reviewed b y the DHHS p rior to
use. Contact the UIC Pro gram for more info i f you wish to get app roval /o r a di fferent additive. However.
please note it ma v take 3 months or lon ger.
Injectant: Potassium Permanganate -RemOx Total Amt. to be injected (gal)/event: 1-5 c ylinders
Injectant: Total Amt. to be injected (gal)/event.,_: __________ _
Injectant: Total Amt. to be injected (gal)/event.,_: _________ _
Injectant: Total Amt. to be injected (gal)/event.,_: _________ _
Deemed Permitted GW Remediation NOI Rev. I 0-14-2019 Page 3
Injectant: Total Amt. to be injected (gal)levent_
Amt. Water to be injected (gal/event): _ _ 0
Total Amt. to be injected (gal/event): 0
No. of separate injection events: Est. Total Amt. to be injected (gal): _
Source of Water (if applicable):
L. 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.
We plan to collect groundwater from adjacent and down=uradient weIIs following the injection activity. We
will analvze the samples for VACS by Method 8260. We will provide a summary report to the NCDEQ.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well 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 an 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 I 5A NC. -IC 02C 0200 Rules."
Signs(tir/it Applicant
Jeff Gerlock. BRCS. Agent for M5 Corporation
Print or Type Full Name and Title
Property Owner (if the property is not owned be the Well Owner/Applicant):
"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 wells) conform to the Well Construction
Standards (14 q NC AC 02C . 0260 )."
"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.
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 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
FEB 18 2DZQ
Deemed Permitted GW Remediation NOI Rev. 10-14-2019 Page 4

868.8
Main
Fiber Line (n• n use)
mirage
MW-22
862
J709307251
222
ibO
MW-23
854.11
7708399425
Amok
868.83
lend
Groundwater Flow Direction
Groundwater Elevation on March 24, 2017
A --- A' Subsurface Profile Line (see Figure 7)
REF.: Randolph County GIS Aerial
Scale: I" = S4 feet
77098025
Groundwater Contour Map
Former Vitafoam
2222 Surrett Drive
High Point, North Carolina
April 2017
Figure 5

Met•
Fiber Line (not in use}
Bun Storage
4 MW-21
7709307251
‹1
-CORPORATION-OR.
r
-
i
Legend
1116 Groundwater Flow Direction
51.3 TCE - Trichloroethene concentration (ug/L) in groundwater
in March 2017
REF.: Randolph County GIS Aerial
Scale
1" = 80 feet
T709403391
77095025
1'
TCE Isapleth Map - 3/2017
Former Vitafoam
2222 Sorrell Drive
High Point, North Carolina
April 2017
Figure 6A

MW-18
7708397712
Fiber Line (not in use)
Bun Storage
7709307251
uttlng1Saw1ng
7708399425 — -
Legend
1j Groundwater Flow Direction
11.1 1,4-Dioxane concentration (ug/L) in groundwater
in March 2017
REF.: Randolph County GIS Aerial
Scale
1 " — 80 feet
'77095025
1,4-Dioxane Isopleth - 3/2017
Former Vitafoam
2222 Surrett Drive
High Point, North Carolina
Apfil 2017
Fgure BB

ELEVATION (FT)
106
A (SOUTHEAST)
110 —
105 —
100 --
95 --
90
85
80
75
70
65 —
60 —
55 —
50 —
ND
AR
BT
■
MW-1
t
1 t
1 1
MO j 1
1 1
?,
— t- — is
a
GRANITIC aE1TO c ►►
MONITOR WELL &
SCREEN INTERVAL
MW-20
PWR
OFFICE BUILDING
MW-16 DW-2
Curer srl,T1
SILTY MAY
GROUNDWATER TABLE
13.8/1§,1
PARTIALLY
AR WEATHERED
•
•
•1 R■■
• •
ter*
GRANITIC BEDROCK
TCEl1,4:QIQXANE CONCENTRATION (ug►L) IN GROUNDWATER
NOT DETECTED
AUGER REFUSAL
BORING TERMINATED
DEPTH TO WATER (FT BG$) ON 3124/17
TCE ISOCONCENTRATION
1,4-D IOXAN E ISOC ONC ENT RATION
15
ROCK
1'
SILTY CLOY
12.1i1§,y
ND ------
open hole
in rock
NOTES: XI7{�TE SCALE30
1) MONITORING WELLS SAMPLED ON MARCH 24AND 27, 2017. d APPROIN1ET
2) SEE FIGURE 5FOR CROSS SECTION LOCATIONS.
3) ELEVATIONS ARE REFERENCED TO AN ASSUMED DATUM (GROUND SURFACE IN MW-1= 100.0 FEET). ▪ ► BT
ND12.3
•
(NORTH) A'
PLANT
BLDG
MW-2 DW-1 MW-17
SANDY sir
47
BT 1
FD
AR t +
PARTIALLY ! 1
WEATHERED I
ROCK 1
GRANITIC BEDROCK
] fir.;
i+ 1
•
1
! r
r
i
i
---------- r
BT L
Cross S lion A -A'
Former Vitaroanl
Surreu Drive.
Ili _ Dins, North Carolina
110
— 105
- 100
— 95
— 90
— 85
— 80
r 75
— 70
— 65
60
55
- 50
.Se 2017 1 Figure ?A
45
40
35

i
i
1
SOIL BORING LOG
WITH MONITORING WELL CONSTRUCTION NOTES
PROJECT : Flexible Foam - High Point., NC
BORING NO. I4J--17 7 B-17
BORING LOCATION : Truck Unloading Area
METHOD OF DRILLING : 8 INCH ID HSA
WATER ELEVATION: 9.35' BOB
SURFACE CONDITIONS : Concrete
RIC & Associates, Inc.
2 South 631
Route 59, Suite
V1larrerlville, Illinois 60555
DATE: 2/7/06
GROUND SURFACE ELEVATION: 99.10'
OEPTH
ELEVATION
SOIL
SYMBOL
SOIL OESCIBPTI011
0
u
11.1
re
ua
a
WELL
CONSTRUCTION
WELL
DESCRIPTION
0-
- 100
- 96
SZ
10-9u
16 1
J
20
rt0
J
25 -'
76
CONCRETE
'
_
f
ocloo.37
serlonlip se
RED BROWN SILTY CLAY1CLjiFILL3
Cmcnlr
Possiblachemical odor 3-d' BBS,
120
'
4'
240
BROWN SILTY CLAY (CI.)
x
2
d'
:Attu 6.0 r I
7 Ind} Fitt
2'
2
x
x
x
x
r
4'
'
a'
a'
Top of ieras
2'
r
a'
IMMO Pacts
7lncaa.oI S
Solon
x
Sottom ot,4
u.Ia' MS
NOTES: Stratification lines approximate; in -situ transition map be gradual. Blue
Ridge logged boring and installed groundwater monitoring wells. GeoproYsed to
a' then e+ugered to depth.
it
DC
rim]
strut
I
J

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400539
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former County Cupboard INcident#24248
Location Address
9681 NC Hwy 700
Pelham NC
Owner
Owner Name
27311
Ncdeq Dwm Us! Section-Federal & State Lead Program
Dates/Events
Orig Issue
2/24/2020
App Received
2/16/2020
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
2/25/2020
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
Herbert Berger
1646 Maile Service Ctr
Raleigh
County
Rockingham
NC
Issue
2/24/2020
Effective
2/24/2020
27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
DATE: January 29 , 2020
A.
B.
C.
North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT (NOD 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 MOO (NOTE: This form must be received at least 14 DAYS prior to injection)
AQUIFER TEST WELLS t15A NCAC 02C .0221»
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION GSA NCAC 02C .0225) or TRACER WELLS c 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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
PERMIT NO. ✓tV-1--0414" 6C 5 ` (to be filled in by DWR)
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) x Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well Complete sections 13 through F, K, N
(3) Passive Injection System. , ._Complete sections B through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test .Complete sections B through N
(6) Tracer Injection Well Complete sections B through N
STATUS OF WELL OWNER: State Government
ifEE2
, t
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):
NCDEO/DWM/UST Section/Trust Fund Brand: Incident Manager- Herbert Berber
Mailing Address: 1646 Mail Service Center.
City: Raleigh State: NC Zip Code:27699 County: Wake
Day Tele No.: 919-707-8170 Cell No.:
EMAIL Address: Herbert.Beri er!a ncdenr.eov Fax No.: -
Deemed Permitted OW Rentediation NO1 Rev. 3-21-2018 Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: ---=Sh=a=i=kh~Am=i~a~d=M~as~o~u~d~o=n~b~e=h=a=lf~o=f~A=b=i=d ~M=a=s~o~u=d ___________ _
Company Name ---------------------------------
Mailing Address: ----=2=2=5_W:...:....:ce=stc..-=Ri=·=d'°ge=--=D=n=·v'-=e'-----------------------
City: Burlington State: _NC_ Zip Code: 27215 County: Alamance
Day Tele No.: -----=3=3-=6---=5--=-1=-2--=2-=-044-'-'----Cell No.: 336-512-2044 _____ _
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: ----=L=-y,_,_n=d=a~l B=u=t=ler=--------------------------
Company Name ---=S=&=ME=-'-· In=c_,_. _________________________ _
Mailing Address: -----=-8-=-64-'-'6=--W--'-'--'e=st=M=ar=k=e-=-t =S=tr-=-ee=t"-=-Sm=·=te"--1"-'0=5'------------------
City: Greensboro State: _NC_ Zip Code:=27~4~0-=-9 ____ County: Guilford
Day Tele No.: -----=3--=-3--=-6--=2-=-8-=-8-~7-=-18=--0~---Cell No.: 336-312-0276
EMAIL Address: ___ =lb~u~tl~er~@ ......... sm~e _in~c~.c~o_m ____ _ Fax No.: ___________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ____ In=c=id=e=n-=-t #=2=-4=2:..:4-=-8--=-N=am=e~: --=F'--"o=rm=er=--C=-=-oun=LTV"-'-C=u=p=b"-'o=a=rd=-------
9681 NC High way 700
City: ___ P_e~lh=a=m= ______ County: Rockin gh am Zip Code: __ 2~7~3--=-1~1 _
(2) Geographic Coordinates: Latitude**: ___ 0 --__ " or 36.5173 ° ___ _
Longitude**: 0 __ " or -79.5477 ° ___ _
Reference Datum: ________ Accuracy: ________ _
Method of Collection:~G~o~o=g=le=--E=a=rt=h~------------
**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 :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
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.
Deemed Permitted GW Remediation NOi Rev. 3-21-2018 Page 2
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.
J. APPROVED INJECT ANTS -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 ://deg.nc .gov/about/divisions/water-
resources /water-resources-permits/wastewater-branch/2round-water-protection/ground-water-a pproved-injectants .
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: ----------------------------------
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 :
Injectant:
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants : ____________________ _
K. WELL CONSTRUCTION DATA
Number of injection wells: ---=-l __ ~Proposed __ ~l __ -'Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-1 s, 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
Deemed Pennitted GW Remediation NOi Rev . 3-21-2018 Page 3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
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.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby cert , 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, 1 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."
L� ndal Butler; Environmental Scientist. S&ME. Inc. (Agent for NCDEO 1
Signature of Applicant Print or Type Full Name and Title
Proven\ Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property an 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 he the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(15A NCAC 02C .0200t. "
"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.
titu ►sii a t tea!
l'p s
Signature* of Property f +ner (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 1 (one) hard color copy of his NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 3-21-2018
Page 4

, NORTH CAROLINA
r. DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WASTE MANAGEMENT
MICHAEL F. EASLEY, GOVERNOR
William G. Ross Jr., SECRETARY
Dexter R. Matthews, DIRECTOR
A,YA
MCDEMR
NORTH CAROLINA ~ARTMENT OF
F"fJVIJll""'n•JMF"MT ANn NMl"I IAAl RF~ JRr.11"'!':.
UNDERGROUND STORAGE TANK SECTION
Herb Berger
Hydrogeologist
DWM UST Section
163 7 Mail Service Ctr
Raleigh, NC 27699-1637
RE: State Lead Referral Notification
Former Country Cupboard
9681 NC Highway 700
Pelham, NC 27311, Rockingham County, NC
DWM Incident# 1"9£73-J. "t ~ ~.<l
Dear Mr. Berger:
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and hereby
pennit the Department of Environment and Natural Resources (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 othetwise 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.
DIVISION OF WASTE MANAGEMENT/UST SECTION
1637 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA27699-1637
PHONE: [phone] \ FAX : [phone]
INTERNET: http ://www.wastenot.enr.state.nc.us
AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER -50% RECYCLED/10% POST-CONSUMER PAPER
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.
UWe 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,
5 .4.z► N A/1JAP I'IASoo .
Type/Print Name of Owner or Agent
33 d S3 9 ^ /5',DAIE
336-372^ . 49 _ cELLE
Phone Number
07;S'-- vv$40e4my XN
Address / < 2 72 / (•
City/State/Zip Code
3 -!7-
Date

NONRESIDENTIAL WELL CONSTRUCTION RECORD
North CaralinaDepartment of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2907
1. WELL CONTRACTOR:
Thomas Whitehead
Well Contractor (individual) Name
SJ&MFE In
Well Contractor Company Name
3201 Snrina Forest Road
Street Address
Retelah NC 27616
City or Town State Zip Code
(919 ) 872-2660
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT* N/A
OTHER ASSOCIATED PERMIT11{Irapplicable) N/A
SITE WELL 1D ifit applicable) AS-1
3. WELL USE (Check One Box) Monitoring 6/Municipal/Public ❑
Industrial►Commercial 0 Agricultural ❑ Recovery ❑ lnjection 0
Inlgationi° Other o (list use)
DATE DRILLED 7/18/14
4. WELL LOCATION:
9681 Hiahwav 700
tStreat Nemo, Numbers, Community, Subdivision, Lot No, Parcel, ZJp Code)
CITY: Pelham COUNTY Rodcinaham
TOPOGRAPHIC f LAND SETTING: (check appropriate box)
❑Slope EiValley elat ORidge ❑Other
LATITUDE 38 ° 51 •7,290.0000 DMS OR 3XXXXI00000t DO
LONGITUDE 79 ° 54 7,500.naa13 ° DMS OR 7X300.0000DD( OD
Latitud&IongItude source: 3PS Ofapographlc map
(location of well must be shown an e USGS rapt, map andetteched ro
this fonn If not using CPS)
5. FACILITY (Name of the business where the well is located.)
FnrmRr Cnuntry Ciinhnard
Facility Name
9881 Hiahwav 700
Street Address
Pelham
City or Town
Abid Masnud
Contact Name
225 West Ridne Drive
Facility ID:F (if applicable)
NC 21111
State Zip Code
Meiling Address
Burlinntnn NC 27215
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a, TOTAL DEPTH: 55 feet
b. DOES WELL REPLACE EXISTING WELL? YES o NO GI
c. WATER LEVEL Below Top of Casing: N/A FT.
(Use'+" If Above Top of Casing)
d. TOP OF CASING IS 0 FT. Above Land Surface'
Top of casing terminated at/or below land surface may require
a variance in accordance with 16A NCAC 2C .0118.
e. YIELD (gprn); N/A METHOD OF TEST
f. DISINFECTION: Type N/A Amount
g. WATER ZONES (depth):
Top N/A Bottom Top Bottom
Bottom Top 9ottam _
Bottom Top 9ottam
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0 _ Bottom 59 Ft..2L,_ soh 40 PVC
Top Bottom FL
Top Bottom Ft.
Top
Top
8. GROUT: Depth Material Method
Top_Q_ Bottom 45 Ft. poritand Pour
Top 45 Bottom 48 Ft bentonite Pour
Tap Bottom FL
9. SCREEN: Depth Diameter Slot Size
Top 50 Bottom 55 Ft. 2 in. .01 ❑ in.
Top Bottom Ft in. In.
Tap Bottom Ft. in. In.
Material
sch40 pvc
10. SAND/GRAVEL PACK:
Depth Size Material
Tap, 48 Bottom 55 Ft. Coarse Sand
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0 110
10 / 39
1
1
1
12. REMARKS:
Formation Description
R.eit Fill
Orange Sill
Orange Sandy Silt
I oo HEREBY CERTIFY THAT THIS WELL WAS co
15A MACE . WELL CONSTRUCTION STANDA
RECORD EEN PROVIDED TO TbI EL
VFW CM] IN ACCORDANCE WITH
AND THAT A COPY OF THIS
ER.
NATURE OF CERTIFIED WELL CONTRA T[. O
/1419
OA
Thomas Whitehead
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Duality - Information Processing,
1617 Mail Service CSltt'ar, Raleigh, NC 27699-161, Phone : [phone]
Form GW-1 b
Rev. 2/09

COMPLETION REPORT OF WELL No. AS-1
Sheet 1 of 1
PROJECT; Country Cupboard
PROJECT NO:
PROJECT LOCATION: Pelham, Rockingham County, NC
DRILLING CONTRACTOR: T. Whitehead
DRILLING METHOD: 41/4" H.S.A.
DATE COMPLETED: 7/17/14
WATER LEVEL:
LATITUDE:
LONGITUDE:
TOP OF CASING ELEVATION: 99.36
DATUM:
LOGGED BY: L. Butler
MONITORING WELL 2 4305-14.164 COUNTRY CUPBOARD DINT LOGS GPJ WITH CPT.GOT 12/10/14
STRATA
DESCRIPTION
0
m
N
WELL
DETAILS
w
a--
a
z
W
w
TOPSOIL
FILL: FINE SANDY
SILT
brown prance. dr
FILL: CLAYEY SILT
gray green, moist, with
rack fragments and
ufganic debris fuel odorr
f �
5.11
orange tan, damp,
oxidation staining, fuel
odor
SANDY SILT
gray tan, moist
0
- 5
-10
-15
- 20
25
30
- 35
SANDY SILT
gray tan, moist, difficult
drilling at 52 feet
40
45
-50
55
.4/
0.00
0.26
0.75
45.00 ;
49.00 I
50.00
55.00
55.20
GS
TOC
CG
BS
TSC
BSC
TD
99.62
99.36
98.87
54.62
50.62
49.62
44.62
44.42
WELL CONSTRUCTION DETAILS
PROTECTIVE CASING
Diameter:
Type:
Interval:
RISER CASING
Diameter: 2-inch
Type: SCH 40 PVC
Interval: 0.26-50.0
GROUT
Type: cement grout
Interval: 0.75-45.0
SEAL.
Type: Bentonite
Interval: 45.0-49.0
FILTERPACK
Type: #2 Sand
Interval: 49.0-55.2
SCREEN
Diameter: 2 •in c h
Type: 0.010
Interval: 50.0-55.0
LEGEND
1 '; FILTER PACK
■ BENTONITE
CEMENT GROUT
Ski CUTTINGS / BACKFILL
y STATIC WATER LEVEL
ENNVRONM IFAL SctVIC1
3
TOC
GS
BS
BOC
TSC
BSC
TD
CG
TOP OF CASING
GROUND SURFACE
BENTONITE SEAL
BASE OF OUTER CASING
TOP OF SCREEN
BOTTOM OF SCREEN
TOTAL DEPTH
CEMENT GROUT
COMPLETION REPORT OF
WELL No. AS-1
Sheet 1 of 1