WI0500824_DEEMED FILES_20150401

Permit Number WI0500824
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
michael.rogers
Coastal SWRule
Permitted Flow
Facility
Facility Name
Hautar's Grocery
Location Address
3305 US Hwy 401 S
Henderson
Owner
Owner Name
Laura
Dates/Events
NC
Orig Issue
4/1/2015
App Received
4/1/2015
Regulated Activities
Groundwater remediation
·<
Outfall
Waterbody Name
27537
Tyson
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
4/1/2015
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Individual
Owner Affiliation
Laura Tyson
3304 us Hwy 401 S
Henderson
Region
Raleigh
County
Warren
NC
Issue
4/1/2015
Effective
4/1/2015
27537
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Wednesday, April 01, 2015 5:01 PM
'Ryan Kerins'
Cc: Smith, Danny; Bolich, Rick
Subject: RE: UIC air sparge well notice submittal WI0500~24 NOi
Thank you for submitting the Notic_e of Intent to Construct or Operate Injection Wells (NOi) at the Hautar's Grocery'.
This facility is located at 3305 US Hwy401 South, Warrenton, Warren County, NC 27537. We received your complete
NOi on April 1, 2015. Please remember to submit the following regarding this injection activity:
1) Well Construction Records (GW-1) and Abandonment Records (GW-30} when completed. Please provide copies of ·
the GW-ls and GW-30s if not already submitted (originals go the address printe_d on the form). NOTE: Direct push
or Geoprobe wells are considered wells and require construction {GW-1) and abandonment forms {GW-30). If well
construction/abandonment information is the same for the wells, only one form needs to be completed-just
indicate total number of injection points in the Comments/Remarks section of form. These forms can be found on
our website at http://portal.ncdenr.org/web/wg/aps/gwpro/reporting-forms.
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at michael.ro gers @ncdenr.gov, send by fax to my attention at 919-
807-6406, or via regular mail to. address below. When submitting the above forms, you will need to enter the nine-digit
alpha-numeric number on the form (i.e., WIXXXXXXX) that has been assign·ed to the injection activity at this site. Thi.s
notification has been given the deemed permit riumber WI0500824, This number is also referenced in the subject line of
this email. You may if you wish, scan and send back as attachments in re p ly to this email , as it will already have the
assigned deemed permit number in the subject line.
Thank you for your cooperation.
Michael Rogers, P.G. (NC & FL)
Hyd rogeo logist
NCDENR-DWR
Water Quality Regional Operations Section
1636 Mail Service Center
Raleigh, NC 27699
Direct No. 919-807-6406
http://portal.ncdenr.org/web/wq/aps/gwpro/reporting-forms
NOTE: Per Executive Order No. 150, all e-mails sent to and from this account are subject to the North Carolina Public
Records Law and may be disclosed to third parties.
From: Ryan Kerins [mailto:rdkerins@terra q uestpc.com]
Sent: Wednesday, April 01, 2015 2:43 PM
To: Rogers, Michael
Cc: rdkerins @terra quest pc.com
Subject: UIC air sparge well notice submittal
1
Michael:
Please find the attached Notification to Construct or Operate Injection Wells.
Feel free to call or email me with any questions or concerns. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
2
Ro gers, Michael
From: Rogers, Michael
Sent:
To:
Wednesday, April 01, 2015 4:57 PM
Smith, Danny; Bolich, Rick
Subject: FW: UIC air sparge well notice submittal WI0500824 NOi
Attachments: In Situ Remediation Notification-20131119 (13) -air sparge.pdf
Please find attached a NOi for the above permit.
From: Ryan Kerins [mailto:rdkerins @terra g uestpc.com]
Sent: Wednesday, April 01, 2015 2:43 PM
To: Rogers, Michael
Cc: rdkerins @terra q uestpc.com
Subject: UIC air sparge well notice submittal
Michael:
Please find the attached Notification to Construct or Operate Injection Wells.
Feel free to call or email me with any questions or concerns. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563.9091
1
Ro gers, Michael
From:
Sent:
To:
Cc:
Subject:
Attachments:
Michael:
Ryan Kerins [[e-mail]]
Wednesday, April 01, 2015 2:43 PM
Rogers, Michael
[e-mail]
UIC air sparge well notice submittal
In Situ Remediation Notification-20131119 (13) -air sparge.pdf
Please find the attached Notification to Construct or Operate Injection Wells.
Feel free to call or email me with any questions or concerns. Thank you.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
100 E Ruffin St, Mebane, NC 27302
919.563 .9091
1
~) I) y/; )J.J:"'
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NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATIJRAL 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 form shall be submitted at least 2 weeks prior tv iniection.
AQUIFER TEST WELLS OSA NCAC 02c .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION OSA NCAC 02C .0225) or TRACER WELLS USA 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.
2) Small-Scale Injection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests: An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater ·contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: =A_pr=il~l~ _ _, 20 15 PERMIT NO. w.1 o{r 18, t~be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
(1)
(2)
(3)
(4)
(5)
(6)
~X,___~Air Injection Well ...................................... Complete sections B-F, K, N
___ Aquifer Test Well ....................................... Complete sections B-F, K, N
___ Passive Injection System ............................ , .. Complete sections B-F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B-N
___ Pilot Test ................................................. Complete sections B-N
___ Tracer Injection Well ................................... Complete sections B-N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the
business or agency: · ·
Name: -----"Lae.:a==ur=a=--"'T~so=nce.__ ___ _
Mailing Address: ----"'-3::.:30,,__4,_U=S-".H"-'wv.!.J-4.!.'0"-'lc..!S~.-'.,'H=en""d""e:,.,rs,.,,o~n...,N'-'-C=---=2=.,7'-"5c:::.3..,_7 _________ _
City: Henderson State: NC __ Zip Code: =2~75=3~7 ___ County: Warren
Day Tele No.: [phone] Cell No.: _________ _
EMAIL Address: _______ _ FaxNo.: ________ _
UIC/fn Situ Remed. Notification (Revised 11/19/2013) Pagel
D. PROPERTY OWNER (if different than well owner)
Name: __________________ _
Mailing Address: _________________________ _
City: _____ _ State:· NC_ Zip Code: ______ County: ___________ _
Day Tele No.: Cell No.: __________ _
EMAIL Address:. ______________ _ Fax No.: ___________ _
E. PROJECT CONT ACT-Person who can answer technical questions about the proposed injection project.
Name: ------~R=v~an~K=er=in=s~-------------------------
Mailing Address: -----~l0~0~E ... R=u=ffi=1=n ___ S~t ____________________ _
City: ---~M=e=b=an=e~-----· State: NC Zip Code: 27302 County: Alamance
Day Tele No.: ______ 9 ___ 1~9-~5~63~-~9=09"-'1~------Cell No.: 919-906-0960
EMAIL Address: __ ~r=dk=e=rin=s®=te=rr=a=g=u=e=stp=c~.c=o=m~--Fax No.: --""""9""'"19._-=-56=3'--9"'"'0=9=-5 ___ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: ___ 3~3~0_..5_H~W_Y_4_0~l_S~o~u~th~-----------------
________________________ County: Warren
City: Henderson State: NC Zip Code: ~2~75=3~7 _____ _
(2) Geographic Coordinates: Latitude**: ___
0
-----· -,, or 36 ° ----'2=6=-=2=8=5 ___ _
Longitude**: ___ 0 ______ " or 78 ° 24327
Refen;nce Datum: North American Datum of 1927 Accuracy: 1/2 of
a contour interval from actual elevation. and/or more than 1/40 of an inch (0.6 mm ) horizontally from actual position
Method of Collection: USGS 7.5 minute to po -Afton, NC
* *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 ofinj. well network: square feet (:s 10,000 fl: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 · Jines 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.
UIC/In Situ Rcmcd. Notification (Revised 11/19/2013) Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity .
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/web/wq/aps/gwpro. 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: __________________________ _
Volume of injectant: _________ _
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 of injectant: ____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: ----=l ___ Proposed~_~O __ ~Existing
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
VIC/In Situ Remed. Notification (Revised I 1/19/2013) Page3
L. SCIIEDIJLES — Briefly describe the schedule for well construction and injection activities.
M. MONITORING PLAN — Describe below or iu 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
APPLICANT; 'I hereby certif , under penalty of law, that am familiar with the information submitted in
this document and all attachments thereto and that, Based on niy inquiry of those individuals immediately
responsible fer• obtaining said Information, I believe that the information is true, accurate and complete. 1 am
aware • t there are gniftcant penalties, including the possibility of fines and imprisonment, far submitting
false int rrnation. 1 gree to construct, operate, maintain, repair, and if applicable, abandon the injection well
and all f elated app lernances in accordance with the 15A NCAC O2C 0200 Rules."
Ryan D. Kerins
Signaturof Applicant Print or Type Full Nome
PROPERTY OWNER (if the property is not owned by the pern3it applicant;
"As owner of the property on which the infection well(s) are to be constructed and operated, l 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) car form to the Well Construction
Standards (15A NCAC 02C .0200X "
"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.
��j� Laura Tyson
Signature* of Property °rydel (ff different from applicant) Print or Type Full Name
An access agreement between the applicant and property owner may be submitted in•lien ofa signature on this four.
Submit one copy of the completed notification package to:
DWR—C]IC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: (9I9) 807-6464
UIC11n Situ Remed. Notification (Revised 11/1912013) Page 4

\iNA,1jN/ LAND SURFACE
1- INCH INSIDE DIAMETER SCHEDULE 40 PVC
70% NEAT CEMENT, 30% BENTONITE
HYDRATED BENTONITE PELLETS
GRADE 20/30 WASHED SILICA SAND -
0.010--INCH SLOTTED PVC SCREEN
�(/
rr rr
rr% r
r fry
�rr rrrl' �-1
7-8 INCHES
8" STEEL MANHOLE (SEE NOTE)
A W
41'
APPROXIMAIIELY 2.0 FE• T
43'
APPROXIMATELY 2.0 7EET
45'
APPROXIMATELY 5.0 FEET
50'
N CES
1. THE TOTAL DEPTH 07 HE WELL
WILL. BE 50 FEET AND WILL BE
CONSTRUCTED WITH FIVE FEES OF
SCREEN. AS INDICATED ON THE
DIAGRAM, SAND WILL BE BROUGHT
UP TWO FEET OVER THE SCREEN
(TO A DEPTH OF 43 FEET BGL) TWO
FEET OF BENTONITE WILL THEN BE
PLACED ON TOP OF THE SAND AND
THE REMAINING WILL BE GROUTED.
2. THE WELL WILL BE COMPLETED WITH
AN EIGHT INCH MANHOLE AND WILL
[3E PERMANENT.
3, THE WE, L WILL BE INSTALLED BY:
DR'LLER NAME: NICK PERRY
CERTIFICATION NUMBER: 3329
HENDERSON, NC
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