WI0600177_DEEMED FILES_20161018

])~
North Carolina Department of Environmental Quality -])ivision of Water Resources
INJECTION EVENT RECORD {IER)
Permit Number WI060 0 t 77
1. Permit Information
S&ME , Inc.
Permittee
TF 29243 Form er Morven Drive In
Facility Name
7856 US Hwy 52 South (Former 103 Hwy 52 South.
Morven {Anson Coumy), NC
Facility Address (include County)
2. Injection Contractor Information
S&ME, Inc.
Injection Contractor/ Company Name
Street Address 409 Chicago Drive . Suite 107
Favetteville, NC 28306
City State Zip Code
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection One
Well IDsMW-1
Were any new weils installed during this injection
event?
0 Yes XO No
If yes, please provide the following information:
Number ofMonitoring Wells _____ _
Number of Injection Wells ______ _
Type of Well Installed (Check applicable type): D Bored O Drilled D Direct-Push 0 Hand-Augured O Other (specify) __ _
Please include a copy of the GW-1 form/or each
well installed.
Were any wells abandoned during this injection
event?
D Yes XO No
If yes, please provide the following infonnation:
Number of Monitoring Wells _____ _
Number oflnjection Wells _______ _
Please include a copy of the GW-.10 for each well
abandoned.
4. lnjectant Information
0-SOX· Ca lci Peroxide Calcium H droxide
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 10-40 mg/L at in jection point
lfthe injectant is diluted please indicate the source
dilution fluid. _..;....a...___ _________ _
Total Volume Injected (gal) 5 socks {2 ''x3')
Volume Injected per well (gal)_ S socks
5. Injection History
Injection date(s) l 0/18/2016
Injection number (e.g. 3 of 5)_1 _____ _
Is this the last injection at this site? (unknown) 0 Yes O No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
s~~h~oNTRACTO{tJ -/i',/~ATE
Jamie. T. Honeycutt {S&ME, Inc.-Agent for NCDEQ)
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this fonn to the Division of Water Resources within 30 days of injection.
Attn: UIC Program. 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Fonn UIC-IER
Rev. 3-1-2016
Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0600177
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
TF-29243 Former Morven Drive In
Location Address
7856 US Hwy 52 S Former 103 Hwy 52 S
Gaston NC
Owner
Owner Name
Ncdeq Dwm Ust Section
Dates/Events
Orig Issue
9/26/2016
App Received
9/20/2016
Re g ulated Activities
Groundwater remediation
Outfall
Waterbody Name
27832
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/26/2016
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Hassan Osman
1637 Mail Service Ctr
Raleigh
Owner Type
Government -State
Owner Affiliation
Sharon Ghiold
1637 Mail Service Ctr
Raleigh
Region
Fayetteville
County
Anson
NC
NC
Issue
9/26/2016
Effective
9/26/2016
27699
27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Monday, September 26, 2015 12:36 PM
To: Osman, Hassan; 'Jamie T Honeycutt'
Cc: Henson, Belinda; Barber, Jim; Rogers, Michael
Subject: WI0600177 NOI TF-29243 Former Mar -yen Drive In
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (Nal) for the above referenced
site.
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-1s and GW-30s if not already submitted (originals go the address printed 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 :I /deq . ncN.ovla bou Jd ivisions/water-resources/Ovate r-resources-perm its/wastewater-bra nch/g rou nd-water-
protectionjgrou n d-water-repo rti ng-forms
2) Injection Event Records (IER). Alf injections, including air and passive systems require an IER. The lER 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 Shrlsti.shrestha@ncdenr,gov 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.,. WIOXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number WI0600177. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in reply to this email, as it will already have the assigned deemed permit
number in the subject line.
Thank you for your cooperation.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shrestha iT:ncdenr.00v
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
"Nothing Compares ��

Email correspondence to and from this addre[;s is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
Shrestha, Shristi R
From:
Sent:
To:
Cc:
Subject:
Shrestha, Shristi R
Monday, September 26, 2016 12:36 PM
Osman, Hassan; 'Jamie T Honeycutt'
Henson, Belinda; Barber, Jim; Rogers, Michael
WI0600177 NO' TF-29243 Former Morven Drive In
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (N01) for the above referenced
site.
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 printed 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: //deg;. nc. Kov/about: d ivisign s!wate r-resou rces/water-resources-p erm its'wastewate r-bra n ch/ground-water-
protecti on/grou nd-water-reporting-forms
2) Injection Event Records (IER). Ali 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 Shristi.shresthancdenr.gov 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., WIOXXXXXX) that has been assigned to the injection activity at this site. This notification has been given the
deemed permit number WI0600177. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in reply to this email, as it will already have the assigned deemed permit
number in the subject line.
Thank you for your cooperation,
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shresthalOmcdenr.:. ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
`` Nathrrtg Cornpares --.1

Email correspondence to and fror,1 this address is subject to tha
North Carolina Public Records Law and may be disclosed to third parties.
Shrestha, Shristi R
From: Shrestha, Shristi R
Sent: Monday, September 26, 2016 12:37 PM
To: Barber, Jim; Henson, Belinda
Cc: Rogers, Michael
Subject: WI0600177 NOI TF-29243 Former Morven Drive In
Attachments: WI0600177 NOI.pdf
Please find the attached NOI.
Shristi
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
sh ri sti .sh resth a tl_ ncden r. o ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
:-'"Nothing Compares -,..
Email correspondence to and from this address is subject to the
North Carolina public Records Law and may be disclosed to third parties.

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 fo rm shall be submitted at least 2 WEEKS prior to in iection.
AQUIFER TEST WELLS {1 5A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION {lSA NCAC 02C .0225) or TRACER WELLS (1 5A NCAC 02c .0229 ):
1) Passive Injection Sy stems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale 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.
DATE: 9-16 , 20_16_ PERMIT NO. W .J.. 0 6 0 0 11 t"' (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
--~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
(1)
(2)
(3)
(4)
(5)
(6) __ Tracer Injection Well ................................... Complete sections B ~gi{ 0/NCDEQ/GWR
B. STATUS OF WELL OWNER: State Government SEP I 9 2016
Water Quality Regional
C. WELL OWNER(S) -State name of Business/Agency, and Name and Title of person del€ganrra tiruh'6~ ti on
sign on behalf of the business or agency:
Name: Hassan Osman. NCDEO. DWM. UST Section
Mailing Address: 1637 Mail Service Center
City: Ralei gh State: NC Zip Code: 27699 County:_W~ak=e~------
Day Tele No.: 919-707-8167 Cell No.: __________ _
EMAIL Address: [e-mail] Fax No.: __________ _
DeemedPennittedGW Remediation NOi Rev. 3-1-2016 Page 1
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Chris Thammavongsa
Company Name __ ____,N'-=ot'-'A'"""p"'"'p""'l=ic=a=bl=e ______________ _
Mailing Address: =-P"'"".O"--'._,,B"-"o=x'-"9'-"-9_,,_0 ___________________ _
City: Ellerbe State: _ NC_ Zip Code: 28338 County: Richmond
Day Tele No.: 910-652-2496 Cell No.: _________ _
EMAIL Address:___ Fax No.: __________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name: Jamie T. Hone ycutt (S&ME, Inc.)
Mailing Address: 409 Chicago Drive, Suite 107
City: Favetteville State: oc__ Zip Code: 28306 County: Cumberland
Day Tele No.: 910-323-1091 Cell No.: 910-977-7614
EMAIL Address: jhoneycutt/@ smeinc.com Fax No.: ________ _
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: TF 29243 Former Morven Drive In . 7856 US H w y 52 South (former 103
H wy 52 South)
City: Morven
(2) Geographic Coordinates:
County: Anson
Latitude**:
Longitude**:
Zip Code: =-27,__,8=3=-2 __ _
___ 0 --__ "or34 °.864180
0 "or 80 °.001578
Reference Datum: ________ .Accuracy: _______ _
Method of Collection:,__,G=o=o"-"g""le"---E=art=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~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification. (Note: The available information is
attached)
(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. 3-1-2016 Page2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
A release of petroleum from a former undergr ound storage tank s stem located on the pro pe rty has im pacted
groundwater above the ISA NCAC 2L .0202 groundwater quality standards. Three monitor wells (MW-1
through MW-3 ) are located on the site . Laborato rv data shows the hi ghest concentrations of contaminants are
located in MW-1. The use of O-SOX {Calcium peroxide or EHC-O chemical) using MW-I is planned to enhance
the de gradation of petroleum contaminant levels in the groundwater.
J. APPROVED INJECT ANTS-Provide a MSDS for each injectant. Attach additional sheets ifnecessary.
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 htt12 ://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/eround-water-protection/ground-water-a pp roved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UJC Program for more info (919-
807-6496).
Injectant: Calcium Peroxide in solid form . b y sock of chemical in monitor well . for oxyg en
Volume ofinjectant: Varies. b y diffusion. 1.75 lb EHC-O or 0.2625 lb Oxyg en p er well
Concentration at point of injection: --~l~0~-4~0~m=--g"'/L=--------------
Percent if in a mixture with other injectants: Calcium peroxide <75%, Calcium Hydroxide <25%
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
(1) Number of injection wells: __ _..::;O __ ~Proposed 1 (MW-l)Existing (provide GW-ls) (Well
Construction Record is attached).
(2) 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):
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page 3
(a)
(b)
(c)
Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
Depth below land surface of casing, each grout type and depth, screen, and sand pack
Well contractor name and certification number
Well
Date
Installed
Type
Grout
(it-bls)-
Screen (ft-
bls)
Casing -
Length
i ft-b1s 1
Coat aletor
Cert. #
MW 1
11 /21/2007
Permanent
0 - 13
15.0 - 25.0
15.0
Palmetto
Drilling
Services, LLC
3213
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Monitoring_ well MW-1 was installed in Mav 2007. Passive oxygen releasing O-SOXs will be placed into the
existing we11 following receipt of the notification permit number from NCDEO_
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.
The injection of oxygen is not expected to result in violations of the 2L Standards. The monitor well will be
sampled on a regular basis and additional O-SOXs installed (as per NCDEOJ. This may be followed by post
remediation sampling without axvven infusion to check for rebound of contaminant levels
N. SIGNATURE OF APPLICANT AND PROPERTY 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 on my inquiry of those individuals immediately responsible
for obtaining said information. I believe that the information is true, accurate and complete. .1 am aware that
there are signif2cant 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 ISA NC/LC 02C 0200 Rules."
^'4 Jamie T. Honeycutt (S&ME.Inc.-Agent for NCDEQ)
Signature of App ;cant Print or Type Full Name and Title
(See attached email from NCDEO authorizing S&ME to sign on their behalf)
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 he 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
(I5A NCA C O2C .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 attached access agreement with Mr. Thammavongsa dated Nov. 27. 2006
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.
Deemed Permitted GW Remediation NOT Rev. 3-1-2016 Page 4

Submit the completed notification package to:
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page 5
WELL CONSTRUCTION RECORD
North Carolina Department of Environment and. Natural Resources -Division of Water Quality
WELL CONTRACTOR (INDIVIDUAL) NAME (print) Todd Allred _ CERTIFICATION Ft 3213
WELL CONTACTOR COMPANY NAME Palmetto Drilling Services. i.LC PHONE q (45) 359-3766
STATE WELL CONSTRUCTION PF.RMIfl ASSOCIATED WQ PERMIT#
(if apptiI.:L*1 J it expticaVIIe)
1. WELL USE (Check Applicable Box): Residential ❑ Municipal/Public E3 Industrial ❑ Agricultural 0
Monitoring liir Recovery 0 Heat Pump Water Injection ❑ Other 0 If Other, List Use
2. WELL LOCATION:
Nearest Town: Mot- ig v7 County Anson_
103 US Highway 52, I 1 even, NC 28119
(Street Narur.. Numbers. Community. Subdivision, Lot No.. Zip Code)
3. ❑ WNER: Chris Thom mavongsa
Address P.O. Box 990
(Sheet or Route No.)
EIIerb . NC 28338
City or Town State Zip Code
652-2496
Area code- Piiem number
4. DACE DRILLED i 11a11¢1
5. TOTAL DEPTH: 25.Q
6. DOES WELL REPLACE EXISTING WELL? YES D NO ❑
7. STATIC WATER LEVEL Below Top of Casing: _ _12.0 FF.
Rise "+" if Above Top of Casing)
8. TOP OF CASING IS 0 FT. Above Land Surface'
"Top nI casing terminated at/or below lend surface requires
variance in eccorrance with ISO NCAC 2C .Old&
9_ YIELD (gpm): N/A METHOD OF TEST N/A
1D. WATER ZONES (depth):
11. DISINFECTION: Type NIA
12. CASING:
Fran
From
Emu:
13. GROUT:
From 0
From
14. SCREEN:
From 25
From
Depth
To 15
T❑ _
To
Depth
To 13
To
Depth
To 16 FL
To Ft.
Diameter
Ft, 2
Ft.
Ft. mm
Material
Ft. Grout
Ft.
Diameter
2 in.
—in
15. SAND/GRAVEL PACK:
Depth
From 25 To 14 Ft,
From To Ft.
16. REMARKS: atoll1
Amount N/A
Wall Thickness
or Weight/Ft. Material
Sch 40 PVC
Method
Tremie
Slot Size Material
0.0113 in. PVC
ire.
Size Material
3 Gravel
Topographic/Land setting
❑Ridge LiSlape °Valley 3Flat
(check apprupnate box)
Latitude/longitude of well location
(degreeslminnreslseaands)
Latitude/longitude source:UGPS0Topagraphic map
(check hex)
DEPTH DRILLING LOG
From Tn Formation Description
0 15_ Mottled red. orange &
gray clayey sand
15' 20' Tan Clayey Sand
20' 25' Tan/Brown Sandy Clay
LOCATION SKETCH
Show direction and distance in miles from at least
two Stale Roads or County Roads. Include the road
numbers and common road names.
1 DO HEREBY CERTIFY THAT THLS WELL WAS CONSTRUCTED !N ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RE 4RD HAS BEEN PROVIDED TO THE WELL. OWNER
SIf'4ATURE OF PESON CONSTRUCTING THE WELL DATE
Submit the original to the Division of Water Quality, Attn: Information Management, 1617 Maki Service Caner -
Raleigh, NC 27699-1617, Phone No. [phone], within 30 days.
GW-1 REV.O9/2004

FIGS, 7I22R4376 11 22:02 AM, 1:1
RESIDENCE
MW-3
acetone
benzene
toluene
ethylbenzene
total xylenes
MTBE
naphthalene
p-isopropyltoluene
isopropylbenzene
1,2,4-Trimethylbenzene
1,3,5-Trimethylbenzene
sec-Butylbenzene
n-Butylbenzene
n-Propylbenzene
NOI'
FORMER AST
FORMER K-1 A
PROX. LOCATION
uglL
20 J
*130
19
97
53
*74
*97
0.38J
29
17
6.5
5.7
3
53
RMER USTsr'I
MW-1
benzene
toluene
ethylbenzene
total xylenes
Diisopropyl ether
MTBE
naphthalene
isopropylbenzene
1,2,4-Trimethylbenzene
1,3, 5-Trimethylbenzene
n-Propylbenzene
2-Methylnaphthalene
2,4-dimethylphenol
Bis(2-Ethylhexyl)phtha late
Naphthalene
1,2-dibromoethane (EDB)
lead
C5•C8 Aliphatic
C19-C36 Aliphatic
C9-C22 Aromatic
MW-2 ug/L
benzene *9.7
ethylbenzene 1.0
MTBE *34
naphthalene 5.9
isopropylbenzene 1.5
sec-Butylbenzene 1.0
n-Propylbenzene 2.2 1
ug/L
*3200
*4500
*860
*2740
*98 ..
*3300
*340
48J
*580
160 •-
*90
*78
13
*10
*260
4.9
4,9
*17000
250
*3140 > J
FORME
NL
GASOLINE
STATION
LEGEND
!y MONITOR WELL LOCATION
ug/L - MICROGRAMS PER LITER
SAMPLES COLLECTED JULY 6, 2016
* INDICATES EXCEEDANCE OF 2L STANDARDS
IMAGE SOURCE: NC ONEMAP, DATED 2015
0
GRAPHIC SCALE
60
120
(IN FEET)
A-5985
SCALE: 1 = 60'
DATE: JULY 2016
D ANlN Far BTR
PROJECT NO:
4305-16-040
$S&ME
WWW. SMEI NC.COM
NC ENGINEER LICENSE #F-0176
3201 SPRING FOREST RD, RALEIGH, NC 27616,
GROUNDWATER CONSTITUENT MAP
MORVEN DRIVE IN TF-29243
NC HWY 145 / US HWY 52
MORVEN, NORTH CAROLINA
FIGURE NO.
3
J

G:Nprojecls\Actiwl,2095\0509081\Monven Drive InVwgs\llerven Drive In Site Map 20Q8.dwg
Z�
Residence
Voeont Field
M4erven Convenience
Steen (Exxon Station)
(I 23186)
Comer Market
{1N 33435)
GRAPHIC SCALE
n 25 sn
1 inch — 50± ft
Residence
(WSW-2 in shed)
.��
A�prpxVmots Pr=Dirt- - ►
r i
�1)
"r- Former Gross i `P i
o AST
Former �_
K-1 AST -Val
G
Asp hol
"S
Former Goa Stollen
uSTs stlil in ground)
(incident Unknown)
1G`�'� N
-� �
Residence
trees
Bushes
Residence
Medical Of Rcee
� E
LEGEND
• PROPOSED WELL LOCATION
gia EXISTING MONITORING WELL
86.47 GROUNDWATER ELEVATION
-- 86.0— GROUNDWATER CONTOUR LINE
a--- GROUNDWATER FLOW DIRECTION
GROUNDWATER ELEVATION MEASURED
DECEMBER 12, 2007
REFERENCE: Base plan for thls drawing was provided by Force Environmental Serv}ce Co. LLC
chrxaabe/
Schnabei Engirnccring
FORMER MORVEN DRIVE-IN SITE
103 US HIGHWAY 52 MAP
MORVEN, NORTH CAROLINA PROJECT NO. 05190081.00-66
NCDENR INCIDENT # 29243 FIGURE 2
©Schnabel Engineering 2009 A!I Rights Reserved

Aullyiul Metkod
C....taml■ .. 1 of Coaeen,
Dole WeO Colledod ID (mm/dd/yy) ! 1 I ~
12/12/2007 NR 1.0\IO 1.080
MW-I
7/612016 <490 3.200 4.!'00
12/1212007 NR 3.8 0.57
MW-2
7/6/2016 <4.9 9.7 <0.17
12/12/2007 NR 322 431
MW-3
7/6/2016 20J 130 19
2LSt■-d■rd, 6,080 1 600
Groos Co■taminatioa Lewis 6,00ll,OOO 5,000 260,000
Note11:
Analytes that are not shown were not detected for the method
All values reported in micrograms per liter (µg/1)
2L Standards== ISA NCAC 2L .0202 Groundwater Quality Standards
MADEP = Massachusettes Department of Environmental Protection
VPH = Volatile Petroleum Hydrocarbons
EPH = Extractable Petrolewn Hydrocarbons
ND= Not Detected
J i
j f
382 2.061
860 2.7-IO
ND 1.91
1.0 <1.0
354 1,611
97 53 -SIX!.
14.,IOO !IS~
TABLE2
SUMMARY OF GROUNDWATER ANALYTICAL RESULTS
Morven Drive In
N.C. Hwy 145/U.S. Hwy 52
Morven, Anson County, North Carolina
NCDEQ Incident No. 29243
S&ME Project No. 4305-16-040
EDBby Semi-Volatile Orpal< Coaipo ■■dl Volal>lo Orp■ie Compoandt by Metkod 6200 or eq,tiv,,1-1 by Metkod 625 Medtod
ll ! I i t 1 J i "' ! ~ a ~
61 2.!'40 178 ND 11.7 ND
'18 3.300 3-IO <22 <19 <15
ND ~-8 ND 0.67 ND ND
<0.18 34 5.9 <0.22 <0.19 <0.15
ND 376 60.6 ND ND ND
<0.18 i4 97 <0.22 <0.19 0.38 J
10 20 6 70 0.4 2!!I
711,000 20,000 6,000 70,000 -11,700
j J l -a .. ..
J
II . i A' J I i! i "!. I i ~
-1 . i t J "" ~ t I i ' ~ :! • .. .I :r
52.1 I.~ 335 ND ND Ill NA NA
48J !'SO 160 <13 <15 90 78 13
ND 1.0 ND ND ND ND NA NA
1.5 <0.18 <0.13 1.0 <0.15 2.2 NA NA
38.9 1158 313 ND ND 995 NA NA
29 17 6.5 5.7 3 53 NA NA
10 400 400 'IO 70 78 JO 100
25,000 28,500 25,000 8,500 6,900 311,000 12,500 100,000
NA= Not Analyzed
NR = Not Reported
NE::: Rcgu]atory standard has not be.en established for the listoi constituent.
Concentrations exceeding the laboratory reporting limits are shown in Bold.
Concentrations exceeding the 2L Standards are shown in Bold and Shaded fields.
!!04.1
I I ,:i
I ..
j I J i 1
7.
NA NA NA
10 260 0.2
NA NA NA
NA NA NA
NA NA NA
NA NA NA
3 6 0.02
170 6,000 50
J = Estimated concentration (value between the laboratory method detection limit and laboratmy method reporting limit}.
Lead by
Metliod MADEi' VPHIEPH
6020
.z ~ ~ i i I i i ~ < g ~ ~ ~ l '-'
NA NA NA NA NA
4.9 17,000 <1,000 250 J ,140
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
NA NA NA NA NA
15 400 700 10,000 200
15,000 NE NE NE NE
Jamie T Honeycutt
From: Osman, Hassan <[e-mail]>
Sent: Monday, August 01, 2016 9:01 AM
To: Jamie T Honeycutt
Subject: RE: TF 9449 Service Oil Bulk Plant and TF 7605 Country Store O-SOX Installation- Need Agent
Authorization
Hi Jamie:
My name is Hassan Osman, UST Section, Trust Fund Branch, I am giving S&ME permission to act as an agent for NCDEQ
to install 0-Sox. If you have any questions you can call me at [phone].
Thanks
Hassan
From: Jamie T Honeycutt tmaTlto:[e-mail]]
Sent: Friday, July 29, 2016 11:58 AM
To: Osman, Hassan <[e-mail]>
Subject: TF 9449 Service Oil Bulk Plant and TF 7605 Country Store 0-SOX Installation_ Need Agent Authorization
Hassan,
I'm working on the notification form to install the O-SOXs in the monitor well at the TF 9449 Former Service Oil Buik Plant and TF
7605 Country Store sites, which has to be submitted to NCDEQ, DWR. In the past, Michael Rogers with DWR has requested that
since S&ME is signing the form as an agent for NCDEQ he needs an email from the NCDEQ Incident Manager giving S&ME
permission to act as an agent for NCDEQ. You can respond to this email stating that you give S&ME permission to act as an
agent for NCDEQ and I'll attach it to the Notification Form when I submit it to Michael Rogers.
Thanks.
Jamie T. Honeycutt
Environmental Professional
t FAME
S&ME, Inc.
409 Chicago Drive. No. 107
Fayetteville. NC 28306 1 71
Ph' (91G) 323-1091
Fax: [phone]
Mobile: [phone]
j-iii il':,�11t¢![}SnielflG.cotn
www.smeinc.cont
This electronic message is subject to the terms of use set forth at www.smeinc.comfemail. it you received this message in error please advise the sender by reply
and delete this electronic massage and any attachments. Please consider the environment before printing this email.
I

•
1 ADVENTUS
i�j 1§•ncrr ace , v-rhrwlft :r r; r krrgrrr.A::r+nr
Safety `':Data
MATERIAL. SAFETY DATA SHEET:
O-SOXXM Page: 1 of 6
1. PROIH1C1' IDENTIFICATION:
PRODUCT USE:
MANUFACTURER:
Adventus Americas Inc.
2871 W. Freest Rd.. Suite 2
Freeport. 11.
61031
d-SOXTsr
Snit and water treatment.
EMERGENCY PHONE:
Office Hours:
After Hours:
li 15=' 15-3503
815-235-35M
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid. n-o... (Calcium Peroxide). Class 5.1, PG H. UN1379
WHMIS CLASSIFICATION:
Oxidizer
COMPOSITION/INFORMATION ON INGREDIENTS
ngredients
Calcium Peroxide
Calcium Hydroxide
3. PHYSICAL. DATA
Chemical Formula
CaO
Cato il;
FOR CHEMICAL EMERGENCY
Spill. Leak. Fire Exposure or Accident
Cali INFOTRAC — 24-)lour Number:
1-800-535-5053
Out.side of the United Stites Call 24-Hour Nwthcr.
001.352423-3' 00
CAS No Percentage
1 zt15-79-t1 45rk-7(1r#
l 3tl•.i-.fit) -- 10-4
Appearance White & brown granules
Physical state Solid
Odor threshold Ncme
Hulk Density 5i1U-6Stlg/I_
Solubility in Water Intinluhle
Pit -11
Decomposition Temperature ... Self -accelerating decontpasilion with oxygcii release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent. contact with other ntarerial n►:ty cause tire. Under tire condition► this material may
decompose and rcleaxe oxygen that intensifies tire. This product also contain, crystalline silica. Lang tern
exposuf: to hazardous lereis of silica dusts can cause lung disease (silicosis). The World Health
Organization had indicated ttrat there is limited evidence that crystalline silica is carcinogenic to humans.
but the NIP tent) OSHA have not classified this ingredient a:: carcinogenic.
Potential Health Effects:
• Ct•ner iI•_._._........... Irritating to, mucous niemhranc and eyes.

(61') ADVENTUS
Safety :,Data
MATERIAL SAFETY DATA SHEET:
O-SOX•r;r Page 2 of ri
■ Inhalation -_Irritating to respiratory Tract. Long tents inhalation at elevated ii it'I.s
may eauNe lung disease (silicosis).
• 1 f, < corn :so May euuse irritation to the eyes: Risks of scrim', or permanent 4yr
lesions.
• kin k.tlntatt May cause skin irritation.
• Ingestion___ Irritation of the mouth and throat with nausea and vomiting.
5. FIRST Aiil MEASURES
■ Inhalation Remove affected person to fresh air. Seek nledi: al attention it effects
persist.
• i.:v'e Ctltuai't-'Ititih reek with running Water for at least 1; tlitllities with eyelids
held open. Seek specialist advice.
• "k m eontai I Wash affected skin with soap and mild 410CIWnt and large a.n unus +if
water.
• I+:g�.:i+iii if the person is conscious and not convulsing. give 2-4 cupfuls aI
water to dilute the chemical and .seek • r •►,•..:+ . nr + ii iiiir,tiri•• ii
i)o not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Paint
• Not apI)IiCahlc
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• W:tler
Fire Hazards
• Oxidizer. Storage vessels involved in a fire inay vent gas or rupture clue u+ ilncrnul prersure-
I)iiinp material may decoInpQ_ye extltherrnically and ignite comhust1Iiles. O vgen release dill" Ito
esutherim- decomposition may support Combustion. May ignite other cintihustihle materials
A%oid contact with incompatible materials Duch as heavy metals. reducing agents, aside. bases.

ADVENTLIS
S.i f ety Data
•
MATERIAL SAFETY DATA SHEET:
O-SOKrM Page: 3 of (,
ctln7humlhle I wood. papers. Cloths etc.) Thermal decomposition release,. 'ksygen and heat.
Pressure bursts may ( ent- glue to gas eLnitttic n, Pressurization if cunf lltcd when Iwated cot
derritnpos tog. Cuntaiuerni may burst violently.
Fire Fighting Measure
• I :s.,r,•ts:itc .111 non-ess nual personnel
• Weal protective clothing and self-contained breathing apparatus.
• Remain tip . titd of fire to ;Avid hazardous vapors and decomposition products.
• 11.e water spr:ly to tool tiro' exposed containers.
7. ACCIDKNTAI. RL I.EASE MEASURES
Spill Clean-up Procedure
• (}xidiw.rr. Eliminate all wiurces of iLalitioii. Evacuate unprotected peru onol from equipment
rtcortintetttuttisnis Found in Secitnn 9. Never exceed any occupational c ■pt,,ure limit.
• Shovel or ~weep material irnu plaqic bags or vented containers for shpps',iiI. Do not return •pi!lctt
rsr contaminated material to inventor). Avoid making dust.
• Flush remnittilt;_ area with water to remove traty residue and dispose or properly. Avoid direct
discharge to sokt i:s sutti Morocco utdrers. Notify authorities if entry octul's.
• t)ts not ti+tt. h .+r +talk through .pilled material. Keep away from combustibles (wood, d, paper,
ete.I_ Do not return product to container because ot'risk of contamination.
S. HANDLING AND STORAGE
Storage
• Oxiitlsrcr. Store in a cool. well-■•cutilatetl area away htmi all sourer oI ignition and out of drleo
sunlight. Store in a dry location :twat' from heat.
• Keep a►tay from incompatible material~. Keep containers tightly closed. Do not acre in
unlabeled or nusluhelcd containers.
• .1rotect I'rnin nhtu Lure. Do not store near combustible materialfi. Keep containers well .sled.
Ensure pressure Mitl'untl arleyttatr ventilation.
• Susw separately fruit organks and reducing materials. Avoid contamination that may lead too
tI ctltiipo itittn.
Handling
Avoid uontaci cocci eyes. skin. and clothing. Use with adequate ventilation.
• ll•r not swallow. Avoid breathing tapnrx, mists. or dust. Do not cart. drink, or smoke in work
alga.
• Prevent contact with cnnthustihle t►r organic- materials.
• I.,hrl containers and keep them tightly closed when not in use.
• Wash thoroughly atter handling.
9. EXPOS(IRF. CON' I'ROI.SIPERSONA1. PROTECTION

1ADVENTUS
JhOW `100 h MO,,i;o/ fdi 4N IfAW+1E&S
Sat-ty '1itData
1
MATERIAL SAFETY 0 %TA SHEET:
D-SQXT'I Page: 4 of [l
Engineering Controls
• General nsinn ventilation iti n. quircd. Local exhaust tientiiatinn. po lo:Ns enclosures or other
CrTinver%contnuI' may he needed to maintain airborne levels below recommended exposure limits.
A%siid crc:isilig• dust or initit. Maintain adequate ventilation. Do not use in closed or confined
•p:iivs. Keep levels below exposure Iiinitt. To determine exposure limit,. it ionitoring shvuiti iti
performed regularly.
Respiratory Protection
• For man) . undition. no respiratory protection may he needed; howev et.. in dusty or unknown
atmosphere, or when expnwure. meet! limit values. wear a NIOSil iipprined respiratnr.
Eye/Face Protection
• Wear chemical safety goggle?, and .i full face shield while handling this product.
Skin Protection
• Pn ►cm contact with Ibis product. Wear glover and protective clothing depending on condition ill
aloe. Proteetive rrli.r Chemical -resistant (Recommended material: PVC. neoprene in. ruttheri
Other Protective Equipment
• I:}c •v .i.h station
• Safety ,Mover
• Liiip iriotu,,,•Iinftiti��.
• Rahhcl' ho it,
I;enerai Hygiene L'onsiderutions
■ Wu,lt with star and water before meal times and at the end of each work shirt. Good
nittitaciui ing practice+ require e gruksc amount,: of any chemical rams. ed from skin as soon as
practical, e•peciall} before ruling or a n tkinl,.
M. STABILITY ANI) REACTIVITY
Stability
• Siahie under nornlal conditions
Condition to Avoid
• Water
• Acids
• 'lases
• Salts of healmends
• Reducing agents
• Organic materials
• hlaninnihle suh,tano:e.
Harardous Decomposition Products
* wltieh supports combustion
11. 1'OXIL.'OLI (lC,\I, iNFORMATION

ADVENTUS
tv ' Data
MATERIAL SAFETY DATA SHEET:
0-.SOX0 a! Page: 5 of b
• 1.1)50 Oral: Min.700(1 mg/kg. iar
• 1.175O Dermal: Min. 20(it)rng/kg. rat
• 1.1)50 Inhalation: Min..4itttl mkt', rat
12. I COIA/GItAL INF()RMA'rIoN
Ecwtnxicological Information
• Ha,:irds for the environment is Iirtutcd due to the product properties of no hivacctst Matson. we.ik
Se+luhilitand precipitation in aquatic en►ironment,
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the enviri+milein
13. I)ISPOS:LI. CONSIDERATIONS
Wnntc Treatment
• 1)i,}suk of in on approved waste facility ❑pera:ed by an authorized crmrracs+ir in conipli:arce ►►ills
kkal regulations.
Package Treatment
• The clapq and eicun containers are to he recycled nr disposed or in vunttnrmity with local
regulations.
14. TRANSPORT INFORMATION
• ['r pvi Shipping Nome: EHC-O
• H:Marel ('lass: 5.1
• lands: 5.1 rC}xidi�ert
• Pocking hero{: II
15. Rf GIJL,VI`I1R1 1NHORM1ATION
• SARA Section Yes
• SARA (1131 Clicinicals No
• IPA TS('A Inventory Appears
• Canadian IL I MIS Classification -- -- C, D213
• Canadian DM.. Appears
• EINF('S to ents,r►• Appears
I(. PREPARATION 1NFORNIATIDN
Prepared By: Kerry 13[+lanns-Shaw Date PrepiRev: I13107
Aih•e+ttus Remediution'Technologies Print Date: 1/3/07
I345 Fewster Drive: Phone [phone]
Mississauga.Ontario Fax. [phone]
L.IGI' 2A5

N ortb ·earolina
Department of Environment and Natural Resources
Division of Waste Management
Michael F. Easley, Governor
William G. Ross Jr., Secretaty
Dexter R. Matthews, Director
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7005 0390 0001 3553 9875
Ms. Chris Thammavongsa
603 Old Cheraw Highway
Rockingham, NC 28379
·RE: State Lead Acceptance
Former Morven Drive-In Property
103 Highway 52 (52 & 145)
Morven, Anson County, NC
Incident# -29243
Dear Ms. Thammavongsa:
November 19, 2006
Ef'A _•;~~ a -sci,,,.. __ _
NCDENR
The Fayetteviile Regional Office (FRO) has referred the subject site to the State Underground
Storage Tank (UST) Trust Fund Branch~ State-Lead Program for inclusion on the list of sites
awaiting cleanup. According to the Anson County Deed of Records, it appears that you are the
current property owner. As you may know, this property was formerly owned by a Mr.David Brown
and was operated as a gasoline · station. Located on this property were underground storage tanks
(USTs). that according to our records were removed during 2005 ·. Due to the documented presence
of contamination remaining at the site, the subject property has been accepted by the State for
inclusion to the list of sites awaiting State-Lead cleanup. According to the information on file, you
are not considered to be an owner or operator of the USTs pursuant to G.S. 143-215.94A.
In order to determine ihe risk posed by the contamination at the subject property, the UST Section
will need to access your property in order to take all reasonable and necessary action(s) to conduct
assessment and remedial activities necessary to protect human health and the:environment. Please
sign the attached site access agreement letter and return it to the address indicated on the. letter.
Please understand that failure to allow access to the property could potentially make you responsible
for the cleanup under other State and Federal regulations. You will be notified when assessment
and/or remedial activities begin.
, Division of Waste Management/UST Scctiun
1637 Mail Scrvic~ Center, Raleigh, North Carolina 27699-1637
Phone:: 919-733~8486 \ FAX: [phone]
Internet:. http://www.wastcnot.cnr.state.nc.us/
AN EQUAL OPPORTIJNITY \ AFFIRMATIVE ACTION EMPLOYER -50% RECYCLED/ l 0% POST CONSUMER PAPER
If you have already received this letter and returned the signed access agreement, please excuse this
correspondence. However, if you would please forward a copy of the signed access agreement, it
would be appreciated. Should there be any questions concerning .this action, please feel free to
contact me at [phone] or Mark.Petermann at (919)-733-1331.
cc: Gene Jackson, FRO
Attachment: Access Agreement
Sincerely,
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WASTE MANAGEMENT
MICHAEL F. EASLEY, GOVERNOR.
William G. Ross Jr., SECRETARY
Dexter R. Matthews, DIRECTOR
A7A
NCDENR
No=Y .. Cmouw. dwmimnrr ar
F MAW." Apart Ma, !n S• Pr.n•�,.r•t
UNDERGROUND STORAGE TANK SECTION
Mr. Mark Petermann
Hydrogeologist
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Mr. Petermann:
RE: Site Aoccss Agreement
Former Morven Drive -In Property
103 I-i,ek,v 52 (52 & 145)
Morven, Anson County - rrto
Incident #-29243
I am/We are the the owner(s) of a parcel of property, located at or near the incident in question, and
hereby permit 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 grouridwaters 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 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 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
DIVISION OF WASTE MANAGEMENT/UST SECTION
1637 MAIL SERVICE CENTER, RALEIGH, NORTH CAROLINA 27699-1637
PHONE. [phone] FAx: [phone]
INTERNET: htd):11WWW.wastenot.enr.state•ne.us
AN EQUAL OPPCRTUNrTY/AFFIRMATIVE ACTION EMPLOYER - 50% RECYCLED/1O%n POST -CONSUMER PAPER

Former Morven Drive -In Property — Incident # 29243
request and is a public record, in 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.
IIWe 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,
Signature
CheIc ! } IZ�-5:4
fypeirrult Noma c.f. owner or Agent
Phone Number
6Q;x 9910
Address
tef�i
Co
de
City !S
// — 2?---
Date