WI0500974_DEEMED FILES_20180319

Permit Number WI0500974
Program Category
Deemed Ground Water
Permit Type
Injection Deemed Air Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Han-Dee Hugos #40
Location Address
401 Benson Rd
Gamer
Owner
Owner Name
NC
Sampson Bladen Oil Company Inc
Dates/Events
Orig Issue
3/19/2018
App Received
317/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27529
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
3/19/2018
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Haddon M. Clark Ill
PO Box469
Clinton
Region
Raleigh
County
Wake
NC
Issue
3/19/2018
Effective
3/19/2018
28329046
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
MINERAL
SPRINGS
environmental, p.c.
March 5, 2018
4600 Mineral Springs Lane Raleigh, NC 27616 919-261-8186
Michael Rogers
North Carolina Department of Environmental Quality
Division of Water Resources
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notification of Intent To Construct or Operate
Air Sparge Pilot Test
Han Dee Hugo's # 40
Garner, North Carolina
MSE Job # 706
Dear Mr, Rogers:
Please find attached a Notification of Intent (NOI) form to perform an air sparge pilot
test at the above referenced site. If you have any questions regarding the report, please
contact me at [phone].
Sincerely,
Mineral Springs Environmental, P.C.
/'Pt 6. &&Q/i&
Kirk B. Pollard, L.G.
President

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 form shall be submitted at least 2 weeks prior to injection.
AQUIFER TEST WELLS USA 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 (ISA 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.
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. lllegible Submittals Will Be Returned As Incomplete.
vv.roso-o'f :J--4
PERMl'f{ e•'\' ,r-· 1 ,,.. ~"'',/ ,. \ (to be filled in by DWR) DA TE: __....aL..-FJ_u ___ __,, 20 _lB_
7
A. WELL TYPE TO BE CONSTRUCTED OR OPERATEi R O 7 201J
(1)
(2)
(3)
(4)
(5)
(6)
..J Wa ·-· Qualitv ~.A~_-Air Injection Well ................. ·······.:\:-, L . £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
X Pilot Test. ....................................... , ........ Complete sections B-N
~--Tracer Injection Well ................................... Complete sections B-N
B. STATUS OF WELL OWNER: Choose an item.
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the
business or agency:
Name: 6 cur,,pSD1L /3..ui.dMt_ {) i£ t_o /"fl f tMt 'd-I ..!kx, C..,
Mailing Address: Pa Bo:Jt J../(p q
City: tl/At. tt5rv State: /Jt., Zip Code: L 8 32 q County: .SIJhH;f Sl»L
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.:
UICI In Situ Remed. Notification (Revised 11 /19/2013) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: S GAG �t.VG
Mailing Address:
City: State: Zip Code: County.
Day Tele No.: Cell No.:
EMAIL Address; Fax No.:
E. PROJECT CONTACT - Person who can answer technical questions about the proposed injection project.
Name: X 1:rie8 . rQ /la ird .
Mailing Address: 111100 atu L
City: State: A) -Zip Code: T ep County: &
Day Tele No,: ?I 9 - 2 i, l - 8186 Cell No.:gig -No 0551
EMAIL Address: / D 1Ia are Pt. rte., Gd Pt Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address:
4_01 B&n4o a_ Road (An - Pee hys
County: 4, )2.1-.•
City: & lL State: NC Zip Code: 2 5 2 -c1
(2) Geographic Coordinates: Latitude**: 36 ° 412 ' /S.7b " or °.
Longitude**: or °.
Reference Datum: Accuracy:
Method of Collection:
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED EN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: ZD, 000 square feet
Land surface area of inj. well network: JJ4 square feet ( I0,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: Ilift (must be < 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS — Attach the following to the notification.
(I)
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.
1i1Clln Situ Reined. Notification (Revised 1 II19120t3) Page 2

I.
J.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity.
~'~H'J/fj)e!ft~ U &Ud cwpaAI1f tlu-
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.orglweb/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).
lnjectant:
Volume of injectant:
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ___________________ _
lnjectant:
Volume of injectant: ___________________________ _
Concentration at point of injection:
Percent if in a mixture with other injectants: ___________________ _
lnjectant: --------------------------------
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: _____ Proposed_--,,,.,..k:~ __ 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
UICI In Situ Remed. Notification (Revised 11/19/2013) Page3
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
r� -18 i.L -a -10
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
APPLICANT: ' I hereby certii., under penahy 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. I believe that the information is urea, 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 ifapplicable, abandon the injection well
and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules. " rl�/y' ]} yy
- cC -L 1"'1 Z, Li Q 1 t' 1 • C / a ! / /C
Signature of Applicant Print or Type Full Name
PROPERTY OWNER of the vroperr. is not owned b,; the oe-nit applicant):
"As owner of the property on which the injection wells) 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 Construction
Standards (.SANCAC 02C .(12O01_ "
"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
* An access agreement between the applicant and property owner may be submitted in lieu of a signature. on this four:.
Submit one copy of the completed notification package to:
DWR -- WC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
tllCffn Sias Rerned. Notification (Revised 1 l/19/2413)
Page 4

LEGEND
MW-1
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a SVE-1
MW-19
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Gb IMW-9
0 SVE-1
*M-3
M-2*
@ AS
BUILDING
6 •
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• •
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MONITORING WELL LOCATION
CONCRETE
SPARGE PILOT TEST WELL
MANOMETER WELL
SOIL VAPOR PILOT WELL
MW-1R
CAD DATE: MARCH 2018
PROJECT NO: MSE708
CAD FILE: MSE-708-019
DRAWN BY: BAM
APPROVAL:
PILOT TEST WELL LOCATION
HAN-DEE HUGO #40
GARNER, NORTH CAROLINA
SCALE 1� 2v
INERAL
PRINGS
REFERENCE: MSE FIELD NOTES
environmental. p.c.
DRAWING NO: 1

WELL CONSTRUCTION RECORD
This-fimn can be11Sed for single« multiple wells
1. Well Contractor Information:
Lawrence D. Opper
Well Contractor Name
NC3322-A
NC W~ll Conttactor Certification Number
Regional Probing Services
Company Name
2. Well Construction P~rmit #:
Lfs1 all applicable well comtruclirm pennils (i.e. Cmmiy, State, Variance, e:tc.}
3. Well Use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply(shared)
□Irri ~tion
Non-Water Supply Well:
0Monitoring □Recovery
Injection Well:
□Aquifer Recharge □Groundwater Remediation
□Aquifer Storage and Recovery □Salinity Barrier
□Aquifer Test □Stormwater Drainage
□Experimental Technology □Subsidence Control
□Geothennal (Closed Loop) □Tracer
□Geothermal (Heating/Cooling Return) 1!'.JOther (ex.plain under #21 Remlllks)
4. Date Well(s) Complmd: 10/23/2017 ( Well ID: SP-1)
5. Well Location:
Han-Dee Huges #40
Facility/Owner Name Facility ID# (if applicable)
401 Benson Road, Garner, 27529
Physical Address, City, and Zip
Wake
County Parcel Identification No. (PIN)
Sb. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.705296 -----------N 78.612512 w
6. Is (are) the well(s): @Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or ~No
If this Is a repair, ft// OUI biown well constructton Information and explain the nature of the
repair under #2 J remarks section or on the back of this form .
8. Number of wells constructed: _1,-----------,-,-----
For nw/tiple injection or non-water supply wells ONLY with the""""' constnldion, you can
submit ane form.
9. Total well depth below land surface: 4 0 (ft.)
For multiple wells list all depths ifdifferenl (example-3@200 ' and 2@100')
10. Static water level below top of casing: approx. 25 (ft.)
If water/eve/ Is above casing. use "+"
11. Borehole diameter: __ 5 _____ (in.)
12. Well construction method: auger-dp
(i.e. auger, rotary, cable , direct push, etc-.)---------------
13. FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) _______ Method of test: _______ _
I For Internal Use ONLY:
14. WATER ZONES
FROM TO DESCRIPTION
ft. ft.
ft. ft.
l!,1 --.,:-ri.~,ll Dl~INCUormw~o-weJi.) 1111 J -INKll "llfanl'i o■hlo)
FROM TO I DIAMETER THICKNESS MATERJAL
ft. ft. .In.
16.JNN~ CA.SING O"RTUBISG ,_rmal clOled-10011)
FROM TO DIAMETER THICKNESS MATl!llW.
0 ft. 35 ft. 2 in. sch40 PVC
ft. ft. in.
17.~
FROM TO DIAMETER SLOT SIZE nucxm:ss MATIIIRIAL
35 ft. 40 ft. 2 1 •• .010 sch40 PVC
ft. ft. la.
13,GROUT
FROM TO MATERIAL EMPLACEMENT MEfflOD & AMOUNT
0 ft. 34 ft. cement grout tremie
ft. ft.
ft. ft.
l 9. SAND/ORA VEL..PACK (lhMlll,,,,ble)
FROM TO MATERIAL EMPLACEMENT ME1110D
34 ft. 40 ft. fine sand fonnation
ft. ft.
211. DRILLING LOG I-di addlri""•' 1llma II'
FROM TO DESCRIPTION !color, banlnrn, soillN>Ck h'>"'-ualn m,, nc.)
0 ft. 15 ft. Orange silty Clay
15 ft. 40 ft. tan sandy Silt
ft. ft.
ft. ft.
ft. ft.
ft. ft.
ft. ft.
l l .UMAJtKS
Air Sparge Pilot Study well SP-1
22-Ctrtlflcatioa: Lawrence ~==---= --... Opper :; =-=:.~:,:.~ 11/1/2017
Sipann ofe«tified Well Comnctor Dare
By .rtgning thb for,,,. I hereby catify that the wd/(1) -(wen} CtJllllnlt:tWI In ...-.:orda,a
villi /$A NCf.C OX: .0100 or /$A Ne.AC 02C ,0200 Well Co,alnlCtion SuattJa,d, and that a
copy of 11,u ra:ord Am MIii pt'CIVltMd to the_,, --
23. Site ....,._ or adclltlonaJ welJ details:
You may use the back of this pap to provide .sditiooal well site &tails or well
~on details. You may also attKh additional pages if necessary.
24. Submittal lntnlcdou:
24a. For All Wells: Submit this furm within 30 days of completion of well
construction to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form witliin 30 days of completion of well
construction to tbe following :
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Su pp lv & Geothermal Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b. Disinfection type: _______ Amount: completion of well construction to the county health department of the county i.:.::..::..:..=-:.===:....:::.~-=======-.....::==:.::.:========...l where constructed.
FormGW-1· North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan. 2013