WI0600197_DEEMED FILES_20190117

[>~ w:1000019.:J..
North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD U ER)
Permit Number WI O lo 00 l q 7
1. Perm.it Information
f\flOJV\
Pennittee
Facility Name
UJ w. @i14h6Jh (+. Oin:IM INC '2130
Facility Address (include County)' ~~)~ Co\ltl,i.)
2. Injection Contractor Information
&\tAir m;-kht\\ I Redo"" Te,h, L.L.C
Injection Contractor/ Company Name
Street Address i oo ~~, Or,-ie
C11Y\.l kt '21&, ~
ci4, State B~INcoEQ/o
d1iJ ~J1-0ll40
JAN 17 2019 Area code -Phone number
3 WU Jnr. • o Water a . e ,ormation "eg;0 na/ 0 ua1;ry
Perations S .
Number of wells used for injection 1 ] ecr,on
Well IDs :t'H -\ -1~ -21
Were any new wells instalJed during this injection
event?
9"Yes D No
If yes, please provide the following infonnation:
Number of Monitoring Wells N ) ~
Number oflnjection Wells,_---=2.=1---=----
Type of Well Installed (Check applicable type):
D Bored D Drilled g1)irect-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form/or each
well installed.
Fl
,---------------....!-------,
Were any wells abandoned during this inj' ction
event? i
uJ.;fes D No I
If yes, please provide the following info · ation:
Number of Monitoring Wells _ ___,....___..,. __
Number of Injection Wells i
Please include a copy of the GW-30 fo~
abandoned. 1
ach well
4. lnjectant Information
Injectant(s) Type (can use separate additi nal sheets
if necessary
I
If the injectant is diluted please indicate · e s urce
dilution fluid. '
Tota) Volume Injected (gal),__.,.JK..t___a_:~~flll-.JL--
Volume Injected per well (gal)_i.u-u-00.yJ~~....,Or¥-#,...o=:i.~.1
Injection number (e.g. 3 ofS), _ ___.,,_----+1---
Is this the last injection at this si~ · ,
D Yes D No U::f' 'To jb e dekrm,
I DO HEREBY CERTIFY THAT ! LL THE
INFORMATION ON THIS FORM IS CO
1 CT TO
THE BEST OF MY KNOWLEDGE AND ' T THE
INJECTION WAS PERFORMED WI'li IN THE
STANDARDS LAID OUT IN THE PERMI
1
' oht
DATE
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
WELL CONSTRUCTION RECORD (GW-1 j
1. WdI Contractor Information:
? \air 0-610
Well Contractor Name
NC Well Cwmactor Certification Number
O , ~ ec� , LLC
Company Name V.4
_ V I LI A (�
2. Well Construction Permit I : Y1 0 Y� 1 - `1
LW ail ag,plratble welt cmrur+vcuon permits (le, (BC. Cotory, Sarre. Varlwhce, etc)
3. Well Use (check well use):
Water Supply Well:
Agricultural f MunicipaNPublic
Geothermal (HeatingtCooling Supply) [Residential Water Supply (single)
Olndusbrial/Catnmeraial °Residential Water Supply (shared)
[lirrigatian
Non -Water Supply Well:
Monitoring f Recovery
igjaon Welk
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
Geothermal (Heating/Cooling Return)
riroundwater Remedietion
Salinity Barrier
OStornlwater Drainage
D5trbsidesioe Control
QTracer
nOther (explain under 021 Remarks)
4. Date Well(s) Completed: ioltla' �bflblweil lDlf 1%4 4.. �W-L
5a. Weil Location:
Few aft LI Fatt 11
Fecility/Owsrer Name Facility ID# (if applicable)
W1 \red._ F. I i he441 S+- t 1+n+0n,ilC 2132$
Physical Address. City, and Zip
County Parcel Idrntification No. (PIN)
5b. Latitude and longitude in degreeilmiauteslseconds or decimal degrees:
(if well fled, one iallleng is sufficient)
� 314. gg4a49 N - 73.32 3a1IR
6. fa(art) the weil(s)OPermanent errfemporary
7. Is this a repair to an existing well: Q Yea or d%
Obis is a repair, fill our Spawn rail conarruerfon imf mctIon and explain the n istre of the
repair Fader .2i remarks seaim or on the back aphis form.
8. For Geaprabe/DP'T or Closed -Loop Geothermal Wells having the same
oonslluctioni, on1 t Vif-I is needed Indicate TOTAL NUMBER of wells
drilled• �r■�
9. Total well depth below Iaad surface: '1 " / Fa'ias W (It.)
For mild* wells Ilse all depths ifdifere t (example- 3 200' and2r100)
SO. Stadc water level below top oreaeing: I (R-)
if %goer level lr above easing, rose " "
I I, Borehole diameter: 1- 26 (ia.)
12. Well construction method: DP 1
auger, mtsy, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
LFor Internal Ilse Only:
16. WATER ZONES
FROM
TO
DESCRIPTION
R
R
fL
fr.
i
IS, OUTER CASING (lor
ulll-paed wells s OR LINER (ff agpllrable}
1
FROM
TO
PIAMETIR 1
THICI0IU$
MA3t1AL
iL
It
In.
16. INNER
CASING OR TUBING
(ivibennat
DIAMETtR
Wsai-watt)
THICKNESS
MATtA:AL
FROM
10
U.
ft.
In.
O.
0.
in.
17. SCREEN
FROM
TO
DUMMER
SLOTHICKNESSE
THICKNESS
MATERIAL
7114 11-
,
2 l ` 4'
'alb id
P91"}
ft.
ft.
le.
IA. GROUT
FROM
TO
MATERIAL
EMFIACEMENT METHOD & AMOUNT
$ k9 ft.
o . h ft.
00.14 beebrirt,
c` qij,, itkt 1 oisett4C it Pat
15
0.5
;c
R.
R.
19. SANIMGRAVEL
FACE (if epviintile) i -1
FROM
To
MATERIAL
EMMACEMENT METHOD
!t.
R.
B.
ft.
20.DRi LING LOGsatts
addtfleaal sheets if oeemoryj 1
FROM
tts
u crab T1ON Cedar. hareem_ bVroci rypc,
pain me. as)
0 ft.
^ 25 ft
sand
'AID '
5 ft-c1a�
Ior,sBY '
�.
ft.
,
f1.
ft.
It.
fL
fL
ft.
ft.
n
11. REMARKS
1
33, Certifcatlon:
4.-06
Somme- of Care WdFCanvaetne
Date
By signing this farm, 1 hereby terrify that the we7(s) WaT (were) coati In accordance
with LIA NCAC 02C .01110 or 1SA NCAC 02C.0200 Well Cwrsrrvralnms 9 • s awl Ali a
ropy of this record bar been provided to the well owner.
23. Site diagram or additional well details:
You may use the beck of this page to provide additional well Site details or well
construction details. You may also attach additional pages ifner any_
S 11811 I1'FALINS11WSTlONS
24a. Far All Wells: Submit this form within 30 days or Corti
construction to the following:
Action of well
Division of Water Resources, Ifnforrnatloa Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-164
24b. For Infection Wells: in addition to sending the form to the address in 24a
shove, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground injection Control Program,
1636 Mall Service Center, Raleigh, NC 27699-16
I,
24c. }'or Water Supply & injection Wells: In addition to send erg the form to
the address(es) above, also submit one copy of this form wi in 30 days of
completion of wall construction la the county health department of the county
where constructed. ,•
Form OW -I North Carolina Department of Environmental Quality - Division of Water Resources
!toiised 2-22-2016

WELL ABANDONMENT RECORD
For Interest Use ONLY:
1. Well Contractor Information:
our MiAshell
Well Connactm Name (or well owner personally abandoning vxfl oo bidder prcpctty)
t LtiglO-C
NC Weil Cuatreeter Certification Number
Rk(lo), Tec4, , LLC.
Company Name 2. Well Construction Permit 0: VI0 60 D I g 1
21st all applicable well cenatrucuron permits R.e, WC. County. State, Varlt+tacw, or.) Valour
3. Well use it heck well use):
Water Supply Wetb
❑Agricultural
❑ Geothennal (Heating/Cooling Supply)
❑tndushialIContinerc ia1
°Irrigation
Non -Water Supply Well:
DMonitoring
t]Municipei/Public
°Residential Water Supply (single)
°Residential Water Supply (shared)
❑ Recovery
Injection Well:
❑Aquifer Recharge
°Aquifer Storage and Recovery
°Aquifer Test
❑ Experimental Technology
11Geothermal (Clasen Loop)
❑ Geothermai (Heating/Cooling Return)
Rennundwater Remediaticti
CISaiinity Ranier
❑Stormwner Drainage
o Subsidence Control
❑Trace'
°Other (explain under 7g)
4. Date well(s) abandoned: 10 14, — I 0124,1a
5a. Wen location:
_RI. Pier Cml-Gs anti h4j
FesilitylOwnerName Facility IDd1(ifappliable)
11� 1 J Elraab414 54, Cllri+on,N C 2132
Physical Address. City. and Lip
Sarni-)
cO
County Parcel Identification No. (PIN)
She Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, our latlloug is sufficient)
;a lig 41444 N—77'523 1q w
CON4TRUCT1OlJJBTA,iLS OF WELL(S) BEING ABANDONED
Attach well coascratrion record(y ►rtrwrttahfe. Far emaipte enjecvr'on omen -warm supply wells
ONLY with the scree cwrrrrugiiawdLnndanmenr• you con .whsut one form.
6a. Wellfllff: — 1 �� -� t
6b. Total well depth: 241V%(lt.)
6c. Borehole diameter:
.25 on.)
6d. Water level below ground surface: 1
} ❑ (fL)
6e. Outer casing length (If known): N [ f�l (ft.)
6f. Inner rasing/tubing length (if known): NIA 01.1
6g. Screen length (i r lwown): NIA (ft.)
WELL BA1_{DQNMENT DETAILS
7a. For GeoproPT or Closed -Loop Geothermal Weller having the same
well construction/depth, onlyiGW 3O is needed. Indicate T1Y .� NUMBER of
writs abandoned: �`LL
7b. Approximate volume of water remaining in well(s): N let (gni.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type ofdislnfectent used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that appI ):
D Neat Cement Grout ellentonite Chips or !lets
CI Dry Clay
0 Drill Cuttings
0 Gravel
Nor other (explain under 7g)
0 Sand Cement Grout
6rfancretc Grout
El 5pecialry Grout
❑ Bentonite Slurry
7L For each material selected above, provide amount of mate ' Is need:
Ile berrion; 4P W5a 1b'
7g. Provide a brief description of the abandonment pracednrr
bee holes ut'e l ben-kn1X pAckfri
alb re.-V;llecl• Alt +op (pi' wIAA►'1
concse;e 5rou} ancl cdp}r I-i pa-41 c+
t3. Ceriificntion:
Sigoature ofCoufied Welt Contractor orWeil Owner �
3 11
By signing tilRtArm. f hereby certojt that the wells} was (wev+e abandoned In
accordance with ISA NCRC 02C .0,00 or 2C .0200 Well Coast r* fiver Standards
and that a copy of rhes record has been provided to the well ow.
9. Site diagram Or additional welt details:
You may use the back of this page to provide additional wcil site details or well
abandonment details. You may also .mach additional pages if nee:sexy.
5uBMTTTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following
Division of Water Resources, Information Processing 'Unit,
1617 Mao Service Center, Raleigh, NC 27699-161h
10b. For injection Wells: In addition to sending the forth to the address in l0a
above, also submit one copy of this form within 10 days of cornpletion of well
abandonment to the following:
Division of Water Resources, Underground injection Conti- bl Program,
1636 Mail Service Center, Raleigh. NC 27699-1636
Inc. For Water Supply & lnitctlon Wells: In addition to sendin the form Iodic
addresses) above. also submit one ropy of this form within 30 da of completion
nn of well abandonment to the county health department of dui county where
abandoned.
Farm GW-30 Nonh Carolina Department of Environmental Quality - Division of Wrier Resources
surd 2-22-20 t 6

North Carolina Department of Environmental Quality - Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number VI I 0 Ui 00 c 7
Permit Information
Re CO
Perrnittee
r tter �1rc'i1Cr
in2nYtex__CLAils FGt ,i 4j
Facility Name
\364 ;4 CN C 279)21
Facility Address (include County) Sot, ton ourr t-j
Injection Contractor Information
Blair iiii4L611 J Pedax Tech, LLC
Injection Contractor / Company Name
Street Address
2-uu Qu►c+s►t Ori Ja
Cart), c 23 51 S
City State Zip Code
(°1 U9 ) te7t -lCLI a
Area code - Phone number
. Welt Information
Number of wells used for injection 21
Well IDs T - 1 — Iuv - 21
Were any new wells installed during this injection
event?
v❑"Yes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells Z1
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled irect-Push
LI Hand -Augured ❑ Other (specify)
Please include a copy of the GW-.I (orm for each
well installed
Were any wells abandoned during this injection
event?
❑j Xes ❑ No
If yes, please provide the following information:
Number of Monitoring Wells 0
Number of Injection Wells 1-1
Please include a copy of the GW-30 for each well
abandoned
4. Iojectant Information
k'Peron g N1 N Pern
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration 2j- 7 /0
If the injectant is diluted please indicate the s urce
dilution fluid. vi o#-er C4rom h iAr �
Total Volume Injected (gal) lop GI 60 1
Volume Injected per well (gap)
5. Injection History Injection date(s) 1[ji It — } D 12 Ll
Injection number (e.g. 3 of 5) L
Is this the last injection at this site?
❑Yes ❑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.
SIGNATURE OF INJECTION CONTRACTOR DATE
12*-
Submit the original of this form 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
Form UIC-IER
Rev. 3-1-2016

WELL CONSTRUCTION RECORD.{GW-11
1. Well Contractor Information:
)Vte11
WcII Contractor Name
NC Well Contractor Certification Number
Company Name _
2. Well Construction Permit 4: ' tJ 0 0 b l ° 1
List all applicable well construction permits (i.e. UJC, County, State. Variance, err)
For Internal Use Only:
14. WATER ZONES
4i�'r\s{ FROM T TD
(1 1 N A'V 4 .1 _
\-1 LA- Nate( 4UaclFl, ,n=4
r/Det 14annc
3. Weil Use (check well use):
Water Supply Well:
Agricultural
Geothermal (Heating/Cool ing Supply)
Industrial/Commercial
Irriktation
DMunicipalYPublic
OResidential Water Supply (single)
DRcsidential Water Supply (shared)
Non -Water Supply Weil:
Monitoring DRecovery
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
EKroundwater Remediation
DSaiinity Barrier
0IStormwater Drainage
QSubsidence Control
Tracer
Geothermal (Heating/Cooling Return) Other (explain under #21 Remarks) ft,
4. Date Well(s) Completed: 1O[Itr IbIz JJ�Wetl ID# 114-.4. I 2 / ] R.
rite+t
fi.
ft.
ft.
R.
DESCRIPTION
5. OUTER CASING for multi -cased weds) OR LINER Of so liable}
TRIf-1:1F51 MATERIAL
ft.
ft.
is.
i
16. INNER CASING OR TUBING aceothremit dosed-Ioo
FROM
TO
'DIAMETER
TUICKNFSS
MATERIAL
ft.
ft.
in.
rt.
ft.
in.
17. SCREEN
FROM
fr.
ft.
TO
r-21 ft,
ft.
DIAMETER
1-25
in.
SLOT SIZE
�vir►li
TUICENk S
MATERIAL
I& GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD m AMOUNT
5‘1, ft.
15ft.
o.6ft.
0 5 rt.
Oft. lb berrlunit.
�• 11
Ti1�[�t�7Ak@�1 tomtit-1'A cal
♦� is
ft,
ft.
19. SAND/GRAVEL PACK ;if applicable)
FROM TO f MATERIAL
EMPLACEMENT METHOD
ft.
ft.
R.
itl. tfRn.t-1\G I.OG !attach additional sheets if necessary
5a. Well Location:
¶ f f f ei AO FAL%111j
Facility/Owner Name Facility Ott (if applicable)
\11 In ET I t2abe4h SA-. C1in+on,lyC 27327
Physical Address, City, and Zip
cclan i inn
County Parcel Identification No. (FIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well held, one lat/Iong is sufficient)
314. q 40yyq N 73. 32 362 i q
6. Is(are) the well(s)fIPermanent or 4mparary
7. Is this a repair to an existing well: °Yes or ENn
("this is a repair, flit out known well construction information and Explain the nature of the
repair under =21 remarks section or an the back of this form.
R. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, onI. 1 GW-1 is needed, Indicate TOTAL NUMBER of wells
drilled: Zj rj `,,
9. Total well depth below land surface: 3 e z5 26)3 W (ft.)
For multiple welk list all depths if different (example- 3@200' and 2@104')
11 Static water level below top of casing:
If water level is above casing, use
11- Borehole diameter: l - 2 i (in.)
12. Well construction method: DPI
(i.e. auger, rotary, cable, direct puah, etc.)
11
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type. Amount:
eteont
n
TO DIAMETER
TO ! DESClitint NJwlur. baroness, soillrnek itEr, grain size, ere!
7..,5 (3,,na
143 ft.
ft.
ft.
ft.
ft.
ft.
ft.
n.
R.
21. REMARKS
22. Certificatinn:
signature of Cenifi
ell Contractor
lois)) Ii
5y signing this farm, 1 hereby rernfy that the well(s) was (were) constructed in accordance
with till NCAC 02C .0100 or ISA NCAC 02C .0200 Well Construction Standards and char a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the hack of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For AU Welts: Submit this form within 30 days of completion of well
construction to the following:
Division or Water Resources, information Processing Unit,
1617 Mall Service Center, Raleigh, NC 27699-1617
24b, For Injection Wells: In addition to sending the form to the address in 24a
above. also submit one copy of this form within 30 days of completion of well
construction to the following•.
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Stunk & Injection Wells: In addition to sending the farm to
the addresses) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
i'1
e
Form GW-I
North Carolina Department of Environmental Quality - Division of Water Reacirces Revised 2-22.201e

ABANDONMENT RECORD
For lateral use ONLY_
I. Well Contractor Information:
Well Contractor Name (or well owner personally abandoning wets on iiii/ho property)
icC
NC Weil Contractor Certification Wernher
Rk box Tech , LLC
Water twtuolio.
Operation
Company Name
2. Weil Construction Permit #: V i 0 V1 ❑ b 1 g 1
Lis: all applicable well construction permits (Le. WC, County. State, Vor•iwrce, etc.) II -known
3, Well use (check well use):
Water Supply Well:
❑Agricultural
{SGeothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
Cllrriaation
Non -Water Supply Weil:
°Monitoring
❑Municipal/Publin
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Aquifer Storage and Recovery
°Aquifer Test
❑Experimental Technology
°Geothermal (Closed Loop)
°Geothermal (Heating/Cooling Return)
Mesroundwater Remediation
❑Salinity Barrier
DStormwater Drainage
❑Subsidence Control
JTracer
DOther (explain under 7g)
4. Date wells) abandoned: 10 ] 1 W -- y b /2 W 1(1
5a. Well location:
�nr met �t+f1G5ri t l �i
Facility/Owner Name
Facility ED# if applicable)
11� Vr1 eimat2e#iel 54. Cjin-�c,r+,N C 2X 327
Physical Address, City, and Zip
SarrlpSon
County
Parcel identification No. (PLY)
3b, Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one latticing is sufficient)
3g. q cligtig9 N —77.32 3 q
ONSTRUtTIQN D T ILS OF WELtISi BEING ABANDONED
Attach well construction record(s)lfuvallabie. For mafrrpleinjection ornon-watersupply wells
ONLY with the same construcriwvabandanmenl, you can .sobert one foray.
6a. We1i IDIf: �W ` 1 Iw 27
► nn
lib. Total well depth: 25 2uEE±27tft.)
6c. Borehole diameter: 1 25 (in.)
6d. Water levet below ground surface: l 1 (t1.)
Ge. Outer casing length (if known): N IA (ft.)
6f, Inner casing/tubing length (if known): NIA (rt.)
6g. Screen length (if known): (\J I fi (ft.)
WELL ABANDONMENT DETAILS
7a, For Gcoprobe/DPT or Closed -Loop Geothermal Wells having the same
well construction/depth. only 1]GW-30 is needed. Indicate TOTAL NUMBER of
wells abandoned:
76. Approximate volume of water remaining in well(s): W 1 fi (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e, Sealing materials used (check all that apply):
D Neat Cement Grout
❑ Sand Cement Grout
LW oncrete Grout
❑ Specialty Grout
❑ Bentonite Slurry
Cf Bentonite Chips or Pellets
0 Dry Clay
0 Drill Cuttings
0 Gravel
Ether (explain under 7g)
7t: For each material selected above, provide amount of materials used:
N. i10 ben krn;4P L160 035
7g. Provide a brief description of the abandonment procedure:
F; fl ed hr>ire hak Am.rah ben 46 ni C QactreL
re-V;11€d. Pao ,e *Dp 4911
w,.W1
05nCce4e ?u and pekil c+
8. Certification:
Signature of Certi$ed urell Contractor ❑r Well Owner
!obi) I�
I1ate
By signing this form, 1 hereby certf that the well(s) was (were) abandoned in
accordance with I SA NCAC 02C .0100 or 2C .0200 Well Construction Standards
and that a copy rfthis record has been provided to the well owner.
9, Site diagram or additional well details;
You may use the back of this page to provide additional well site details or well
abandonment details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTION
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center. Raleigh, NC 27699-1617
10b. For Inlection Wells: In addition to sending the form to the address in I0a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
10c. For Water Sunnh & Injection Wells: in addition to sending the form to the
address(es) above, also submit one copy of this form within 30 days of completion
of well abandonment to the county health department of the county where
abandoned.
Form GW-3Sr
North Carolina Ueparrment of Environmental quality - Division of Ware. u

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0600197
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Rental Uniform Services
Location Address
117 W Elizabeth St
Clinton
Owner
Owner Name
Cintas Corporation
Dates/Events
NC
Orig Issue
3/27/2018
App Received
3/15/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
28328
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
3/27/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Fayetteville
County
Sampson
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
Lisa Autrey
27 Whitney Dr
Milford
Issue
3/27/2018
Effective
3/27/2018
OH 45150
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
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 ISA NCA C. 02C.021I0 This form shall be submitted at least 2 WEEKS prior to infection.
AQUIFER TEST WELLS 1154 NCAC 02C .0220i
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 12C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) Passive lnyection S4 stems - 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 feel.
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: March 12 ,2018 PERMIT NO. Y �.' r- Y (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well Complete sections B through F, K, N
(2) Aquifer Test Well ..Complete sections H through F, K, N
(3) Passive injection System Complete sections 13 through F, H-N
(4) X Small,Seale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections H through N
(6) Tracer Injection Well Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): Cintas Corporation (LisaAutr‘. Chemical/Environmental Eneineer)
Mailing Address: 27 Whitney Drive
City: Milford State: OH Zip Code: 45150 County: Clermont
Day Tele No.: 513-965-4964 Ce1I No_: N/A
EMAIL Address: Autre\ L+ucintas.com Fax No.: 866-844-9604
Deemed Permitted OW Remediation NOI Rev. 8-28-2017
Page 1

D. PROPERTY OWNER(S) (if different than well owner)
Parcel 15030660502 (123 West Elizabeth Street)
Name and Title: ----=R=u=d=o=l p=h"-'K=--". S=tru=·t=h -"(RK=-==S--=L=a"--'-w-'-')--=i=-s =own-'==er"-'c=o=n=ta=c-'-t _
Company Name ___ W-'--'---"is=e=m=an==---.,M=ortu=--==a=r4-y-'--', In=c_,_. _________________ _
Mailing Address: ___ RK_S_L_a_w~: l_0_0_H_ay~Str_ee_t _-_S_u_it_e_8_0_1 ____________ _
City: Favetteville State: NC Zip Code:_2=-8=3~0~1 ____ County: Cumberland
Day Tele No.: 910-486-3230
EMAIL Address: rksmith @rkslawpllc.com
Parcel 15041958002 (117 West Elizabeth Street)
Cell No.: Not available
Fax No.: Not available
Name and Title: ----=L=e=o=n=ar=d'-'H=e=d""g""·e~p=eth==-. p"'r'-"o_,._p=er'-"-ty'"---=-ow-'-'=ne=r~-------------
Company Name --~L=&=S--=o=f~N-'-'o=rt=h'-'C=a=r=o=lin=a=·---=L=L=C,c__ _______________ _
Mailing Address: -------=--P--=O'-'B=-o=x-"-----"-'12=6"--'1'---------------------------
City: Favetteville State: NC Zip Code:_2_8_3_0_2 ____ County: Cumberland
Day Tele No.: 910-978-9430
EMAIL Address: lshedt!epeth1a gmail.com
Cell No.: Not available
Fax No.: Not available
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Jasen Zinna Senior Engineer
Company Name: AECOM Technical Services
Mailing Address: 1600 Perimeter Park Dr. Suite 400
City: Morrisville State:~ Zip Code:27540 County: Wake
Day Tele No.: 919-461-1285 Cell No.: 561-271-9662
EMAIL Address: Jasen.Zinnatal,aecom.com Fax No.: 919-461-1415
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Former Rental Uniform Services
11 7 West Elizabeth Street
City: Clinton County: Sampson
(2) Geographic Coordinates: Latitude**: ___ 0 --__ " or
Longitude**: 0 __ "or
Zip Code: 2_8~3_2~8 __ _
34 °. 996449
-78 °. 323619
Reference Datum: ________ Accuracy: _______ _
Method of Collection: _________________ _
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page 2
G. TREATMENT AREA
Land surface area of contaminant plume: 190 000 square feet
Land surface area ofinj. well network:_----'8=·=-50=-0=---------'square feet(~ 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: ____ (must be~ 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 3
r
Legend
TETR ACHLOROETHYLENE TETRACHtOROETHYLENE
CONCENTRATION IN
(MICROGRAMS PER LITER)
GROUNDWATER ELEVATION,
JUNE 1, 2015 (dashed %tere Inferred)
CONCENTRATION LESS THAN
LABORATORY REPORTING LIMIT
ISOCONCENTRATION CONTOUR
PROPOSED ISCO INJECTION
Lithology Legend
Sand, Silty & Clayey Sand,
Interbedded Sands and Clays
Clay
Clays, Sifts, and Sandy Clays
North South
v
9
9
0
— 139 Ti
120
m
g
2
3
co
100 g
G
m
600 Too 800 slap 1000
Proposed Injection Cross Section

I. DESCRIPTION OF PROPOSED INJECTION ACTMTIES -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.
The purp ose of injecting potassium permang anate into the eroundwater at the site is to reduce concentrations
of PCE onsite and to prevent further mi gration offsite. For the 20'-25' injection locations . a pproximately 250
gallons of 4 wt°/4 potassium permanganate will be in jected. For the 20'-36' in jection locations. a pproximately
750 gallons of 4 wt°/4 potassium permanganate will be in jected. For the 24'-36' injection locations .
a pproximately 650 gallons of 4 wt% potassium permanganate will be injected. A total of 17 . 250 gallons of 4
wt°/4 potassium permanganate is expected to be injected. The injection should be completed within ten days.
Following the injection, the area will be monitored for a reduction in PCE and manganese concentrations in the
e roundwater.
J. APPROVED INJECTANTS -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 hup ://deq .nc.gov/about/divisions/water-
resources/water-resources-oermits/wastewater-branch/l!.round-water-protection/1.!round-water-a pp roved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info
(919-807-6496).
Injectant: potassium permanganate
Volume ofinjectant: ~17~·=2~50~g=al=lo=n=s _____________________ _
Concentration at point of injection: ~4~~~1/c~o _____________________ _
Percent if in a mixture with other injectants: NA
K WELL CONSTRUCTION DATA
(1) Number of injection wells: ---=2.,_7 __ Proposed ______ Existing (provide GW-1 s)
(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):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
The in jection will occur throul!h direct push rods via a Geo probe
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
The in jection will occur ofan interval of20'-36' below ground surface . see attached table for
additional details.
(c) Well contractor name and certification number
Redox Tech. LLC ( CWC 4167-B)
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page4
Section K: Injection Point Details
Facility: Former Rental Uniform Services
117 West Elizabeth Street
Clinton, North Carolina
Number of Points
Three
Nine
Fifteen
Site#: NONCD0001171
In jection Interval
20'-25' below ground surface
20'-36' below ground surface
24'-36' below ground surface
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Once a permit is issued the Pre-Construction Re port will be submitted to NCDEO to document the final
desi gn. At that point. Redox Tech. LLC will be contacted to schedule the in jection.
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 fl roundwater will be monitored for PCR PCE daug hter products , and manganese quarterly in y ear 1 and
semi-annuall in vear 2. See attached table for additional details. PCE and PCE dau ghter products currently
exceed 2L standards. After two years. the data will be evaluated to determine if an additional in jection event is
necessarv to further reduce PCE concentrations.
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page 5
Section M : PERFORMANCE MONITORING AND SCHEDULE
Facility: Former Rental Uniform Services
117 West Elizabeth Street
Clinton, North Carolina
Site#: NONCD0001171
Task Method Frequency
ISCO Monitoring 8260,6010 Baseline/Quarterly Year 1/Semi-Annual Year 2
Sampling schedule and parameters subject to change based on actual system performance.
(a) = Sampled and analyzed for voes and manganese (MW-11 and MW-13 through MW-20)
Sample
Locations
(a)
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certi, 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. 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 154 i CAC 02C 0200 Rules."
Signature of Applicant
Lisa Autres.. Chemical/Environmental Engineer
Print or Type Fuli Name and Title
PROPERTY OWNER (if the propert' is not owned bs the permit applicant};
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent
to allow the applicant to construct each injection well as outlined in this application and agree that it shall be
the responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction
Standards ( _ ..
"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 a.reements
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 this NOI electronically to Sit risti.Sltrestha'a ncdennaps AND one hard copy to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted G W Remediation NOI Rey. 8 28.20i 7 Page 6

SITE ACCESS AGREEMENT
THIS SITE ACCESS AGREEMENT, made this 21 st day of April, 2016, by and
between Wiseman Mortuary, Inc. (the "Grantor") and the Cintas Corporation (the "Grantee");
WHEREAS, the Grantor is the owner of two (2) contiguous property parcels being
identified as 15-0306605-02 and 15-0419580-01; as such parcels are listed in the Sampson
County Register of Deeds Book 1938-Page0402; and such parcels having a primary business
address of 111 and 123 West Elizahcth Street in Clinton, Sampson County, North Carolina ("the
Property") and;
WHEREAS, the Grantee has requested access for continued environmental testing,
monitoring and remediation activities, including but not limited to sampling of Grantee's
existing groundwater monitoring wells located on the Property, related to the operations of the
former Rental Unifonn Services, Inc. ("Facility") business previously located at the Property
(the "Work"), and;
WHEREAS, the Grantee bas entered into an Administrative Agreement (AA) with the
North Carolina Department of Environmental Quality (NCDEQ), Division of Waste
Management (DWM) that requires the Grantee conduct environmental investigations and
remediation at the Property, to the extent that such Work relates to past Rental Uniform Sc..~rvicci.
Facility operations and to the extent required by State laws and regulations, and;
WHEREAS, Grantor and Grantee arc desirous of executing a written Agreement
providing Grantee with access to the Property for the purpose of performing the Work on the
Property.
NOW THEREFORE, in consideration of good and valuable consideration, the receipt
and sufficiency of which is hereby acknowledged, the parties hereto, intending to be legally
bound, agree as follows:
1. Grantor, the owner of the Property with street addresses 111 and 123 Wcsl F.lin1hcth
Street, Clinton, Sampson County North Carolina, grants to Grantee, its employees, agents.
representatives, successors, and assigns, as well as to Grantee's contractors, subcontractors,
invitees, and contractors' subcontractors for the duration of the required Work, the right. liberty,
privilege, license, and authority to enter upon the Prope11y to do such acts necessary for
perfom1ance of the Work, together with a reasonable right of ingress and egress and the right to
take any reasonably necessary action to minimize impacts of such ingress and egress.
2. If Grantee determines that installation of additional soil borings, monitoring wells. and/or
soil gas monitoring points are required, separate written notification that describes these
requirements shall be made to the Grantor prior to conducting such installations. Permanent
Rcvi~d Clinlon. Nt' A/\
L
l
..
installations such as &,rroundwater monitoring wells and soil gas monitoring points will be made
only at location(s) mutually agreed upon in advance by Grantor and Grantee in accordance with
applicable environmental laws. All operations by or on behalf of Grantee shall be carried out in
such a manner so as not to unreasonably interfere with the Grantor's use and enjoyment of the
Property.
3. Upon Grantee's request, Grantor agrees to provide Grantee with all information in
Grantor's possession or the possession of its representatives regarding the location of
underground utility lines and subsurface obstructions and infrastructure at the Property in the
event that subsurface borings and/or wells are to be installed in the future.
4. At the completion of the Work, and when approved by relevant regulatory agencies,
Grantee shall, at its cost and expense, properly abandon the existing and future monitoring wells
and restore the Property or cause the Property to be reasonably restored to the condition it was
prior to the performance of the Work.
5. Grantee wilJ promptly provide Grantor with copies, at no cost, of all laboratory analytical
reports resulting from environmental samples collected on the Property under this Agreement.
6. Grantee agrees to at al1 times conduct the Work on the Property in compliance with
applicable environmental laws and regulations, and will indemnify and save hannless Grantor
from any and all claims, damages, fines, judgments, penalties, costs, liabilities or losses arising
out of this Agreement or in any way connected with Grantee's activities on the Property.
7. In the event that any provision of this Agreement is found to be invalid or unenforceable,
the validity and enforceability of the remainder of this Agreement shall not be affected thereby,
and each other term and provision of this Agreement shall be valid and shall be enforced to the
fuJlest extent permitted by law.
8. Nothing in this Agreement is intended or shall be construed to be an admission of any
law or fact, nor a waiver of right, claim or defense, in any dispute, proceeding or litigation
regarding potential liability for conditions on the Property.
9. Grantor agrees that if the Property is considered for sale or transfer from the Grantor to a
new owner, the Grantee will be notified at least 30 days in advance of a pending change in
ownership, which would materially affect this Agreement.
10. This Agreement, which cannot be amended without the written consent of both parties,
shall be construed and enforced in accordance with the laws of the State of North Carolina.
2
l •
L •
l
I
l .
IN WITNESS WHEREOF, and intending t.o he h.~gally bound hereby. the parties hereto have
executed this Site Access Agreement on the date first above mentioned.
Wiseman Mortuary, Inc.
C/0:
RKS Law, PLLC
PO Box 2095
FayettevilJe, NC 2830
"~/;,/;,,9 t4 ,??.~
Cintas Corporation
27 \Vhiney Drive
Milford, Ohio
By:
James A. Buckman,
Director. Chemical and Environmental Engineering
Rc,·ised (.linu1n. Nl' AA 3
vv� v.4• +vy� as. sV a'(y1 va.0 !J tL V V V ...,n. 2A", •
SITE ACCESS AGREEMENT
TfaS SITE ACCESS AGREEMENT, made this i " '-day of To ' E , 2010, by
and between LBWS of North Carolina, LLC. (the "Grantor") and the Ciutas Corporation (the
"Grantee");
WHEREAS, the Grantor is the owner of six contiguous property parcels being identified
as 15-0306605-02, 15-0306605-03(1), 15-0306605-03(2), 15-0419580-01, 15-0419580-02, and
15-0419583-01; as such parcels are listed in the Sampson County Register of Deeds Book 1671-
Pages 0555, 0561, 0558, 0548, 0551, and 0564, respectively, and such parcels having a
combined primary business address of 117 West Elizabeth Street in Clinton, Sampson County,
North Carolina ("the Property—) and;
WHEREAS., the Grantee has requested access for continued environmental testing,
monitoring and remediatian activities, including but not limited to sampling of Grantee's
existing groundwater monitoring wells located on the Property, related to the operations of the
former Rental Uniform Survioea, Inc. ("Facility") business previously located at the Property
(the "Work"), and;
WHEREAS, the Grantee has entered into an Administrative Agreement (AA) with the
North Carolina Department of Environment and Natural Resources (NCIENR), Division of
Waste Management (DWM) that requires the Grantee conduct environmental investigations and
remediation at the Pr s petty, to the extent that such Worlc relates to past Rental Uniform Services
Facility operations and to the extent required by State laws and regulations, and;
WHEREAS, Grantor and Grantee are desirous of executing a written Agreement
providing Grantee with access to the Property for the purpose of performing the Work on the
Property.
NOW THEREFORE, in consideration of good and valuable consideration, the receipt
and sufficiency of which is hereby acknowledged, the parties hereto, intending to be legally
bound, agree as follows:
I , Grantor, the owner of the Property with primary business address 117 West Elizabeth
Street, Clinton, Sampson County North Carolina, grants to Grantee, its employees, agents,
representatives, successors, and assigns, as well as to Grantee's contractors, subcontractors,
invitees, and contractors' subcontractors for the duration of the required Work, the right, liberty,
privilege, license, and authority to enter upon the Property to do such acts necessary for
performance of the Work, together with a reasonable right of ingress and egress and the right to
take any reasonably necessary action to minimi7P impacts of such ingress and egress.
LeS or NCJ1was fgeenxaLn4„Y- I (Vac

., ...• . 4.. YV i•. i olu.SVY[!VU.f
2. if Grantee determines that installation of additional soil borings, monitoring wells, and/or
soil gas monitoring points are required, separate written notification that describes these
requirements shall be made to the Grantor prior to conducting such itallations. Permanent
installations such as groundwater monitoring wells and soil gas monitoring points will be made
only at location(s) mutually agreed upon in advance by Grantor and Grantee in accordance with
applicable environmental laws. All operations by or on behalf of Grantee shall be carried out in
such a manner so as not to unreasonably interfere with the Grantor's use and enjoyment of the
Property.
3. Upon Grantee's request, Grantor agrees to provide Grantee with all information in
Grantor's possession or the possession of its leoLesentatives regarding the location of
underground utility lines and subsurface obstructions and infrastructure at the Property in the
event that subsurface borings and/or wells are to be installed in the future,
4. At the completion of the Work, and when approved by relevant regulatory agencies,
Grantee shall, at its cost and expense, properly abandon the existing and future monitoring wells
and restore the Property ar cause the Property to be reasonably restored to the condition it was
prior to the performance of the Work.
5. Grantee will promptly provide Grantor with copies, at no coat, of all laboratory analytical
reports resulting from environmental samples collected on the Property under this Agreement.
6. Grantee agrees to at all times conduct the Work on the Property in compliance with
applicable environmental laws and regulations, and will indemnify and save harmless Grantor
from any and all claims, damages, fines, judgments, penalties, costs, liabilities or losses arising
out of this Agreement or if any way connected with Grantee's activities an the Property.
7. in the event that any provision of this Agreement is found to be invalid ar unenforceable,
the validity and enforceability of the remainder of this Agreement shall not be affected thereby,
and each other term and provision of this Agreement shall be valid and shall be enforced to the
fullest extent permitted by law.
8. Nothing in this Agreement is intended or shall be construed to be an admission of any
law or fact, nor a waiver of right, claim or defense, in any dispute, proceeding or litigation
regarding potential liability fox conditions on the Property.
9 Grantor agrees that if the Property is considered for sale or transfer from the Crrantor to a
new owner, the Grantee will be notified at least 30 days in advance of a pending change in
ownership, which would materially affect this Agreement.
l0. This Agreement, which cannot be amended without the written consent of both parties,
shall be construed and enforced in accordance with the laws of the State of North Carolina.
LJS orTNC_AOGetf Agnc+..du W-.U.+94x
2

.. ,....••••. A.S. -a.. a.w
p a . v .
IN WITNESS WHEREOF; aazd intending to be legally bound hereby, the parties hereto have
executed this Site Access Agreement on the date ftxst above mentioned.
L&S of North Carolina, 1 LC
I.O. Box 1261
Fayetteville, NC 28302
By:
l+E rat a jlefae o,„
By.
Cintas Corporation
6800 Cintas Boulevard
Mason, OR 45040
By:
P Th c.+C -4 P P.E.
raer+ti ■ cp c Ek v lqc L Ems+ CI.r EE re...

ANSI Qz2• X 34"
DEPARTMENT OF HEALTH
ANO HUMAN SERVICES
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GROCNCYYITER ELEVATION (II NM)
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ABBREVIATIONS
4w FFE- ABOVE SEA LEVEL
NOTES
1 C.ROO'ANOTER ELEVATIONS WERE MEASURED
Al WINE 2010.
VERIFY PRINTED
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COMA. MAMAS
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Remedial Action Plan Addendum
3
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June 2015

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1- DATA 6P1EN Ire eeL.
2 SAMPLF3141.H Rem PREFIX %SER€ SOLNPLEC IN
MNI/ARY 2019. SAPLEB WITH TO{90 PREEIX WERE
BAIAPLED IN ARE 2017. SAMPLES W1Tr1 ER41'
PREPI% HERE SAMPLED PO WREN 2014.
7. Mom 15 000GN INADA HERE SAMPLED W MAT
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IR JIME 201s
4. SOLOED VALVES INDICATE A P£-IECA4N
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OF THE WAD 2L OR0116VNATR 5TAIAARD3
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