WI0600214_DEEMED FILES_20181120

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0600214
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Cecilia Shipman Property-Incident #3366
Location Address
Hwy 20 NCSR 1729
Saint Pauls NC 28384
Owner
Owner Name
Ncdeq Dwm Ust Section-Federal & Stsate Lead Program
Dates/Events
Orig Issue
11/20/2018
App Received
11/13/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
11/20/2018
Permit Tracking Slip
Statu s
Acti v e
Project Type
New Project
Vers i on
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Hassan Osman
1646 Mail Service Ctr
Raleigh
Owner Type
Government -State
Owner Affiliation
Hassan Osman
1646 Mail Service Ctr
Raleigh
Region
Fayetteville
County
Robeson
NC
NC
Issue
11/20/2018
Effective
11/20/2018
27699
27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices .com
N.C . Engineering License No . C-1598
-----------------------------------•·
November 7, 2018
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality-Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Cecilia Shipman Property
Highway 20 and State Road 1729
St. Pauls, Robeson County, North Carolina
NCDEQ Incident #3366
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of the North Carolina Department of
Environmental Quality State Lead Program. The permit application covers the performance of
passive remediation in one monitoring well associated with the above referenced site
If you have questions or require additional infonnation, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Ashley M. Winkelman, P.G.
Senior Project Manager
cc : Hassan Osman, Hydrogeologist for NCDEQ
Attachments
AEcevE~
NOV i 8 2018
Water Qu.:.ti.,y
Reglonai Operations ~action
Notice of Intent to Construct or Operate Injection Wells
Cecilia Shioman Propel. St. Pauls. North Carolina
NOTICE OF INTENT FORM
ATC
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fYiLLRi iiIINCE$ • L:ECIW .Enl4

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 fo rm shall be submitted at least 2 weeks prior to in jection.
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 (15A NCAC 02c .0225) or TRACER WELLS C1 5A NCAC 02c .0229 ):
1) Passive Iniection S ystems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale In jection O perations -Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air In jection 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: November 7 , 201.L PERMIT No. vvJ0Goo214-(to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
___ .Air Injection Well ...................................... Complete sections B-F, K, N
--~Aquifer Test Well ....................................... Complete sections B-F, K, N
(3) X Passive Injection System ............................... Complete sections B-F, H-N
(4)
(5)
(6)
___ Small-Scale Injection Operation ...................... Complete sections B-N
___ .Pilot Test ................................................. Complete sections B-N
___ Tracer Injection Well ................................... Complete sections B-N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER -State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name: Hassan Osman-H vdro geoloe ist. North Carolina Department of Environmental Q uality
Mailing Address: ------=1""'6-'4-=-6-=-M=ai=-l =S-=-erv~ic""e'-C=en=t=er"-----------------------
City: Raleigh State: NC Zip Code: ___ ~27~6=9-=-9~-1~6-'4-=-6 __ County:~W~ak=e ___ _
Day Tele No.: 919-707-8167 Cell No.: --~N_o~t~A~v-'a_il~a~b _le ___ _
EMAIL Address: ___ h_a_s_san_.o_s_m_a_n~@~nc_d_e_nr_.~g~ov ___ Fax No.: ___ N_o_t _A_v_a_il_ab_l_e ______ _
UICI In Situ Remed. Notification (Revised 3/2/2015) Page 1
D. PROPERTY OWNER (if different than well owner)
Name: ____ A_l_h_o_b_is_h_i C_on_v_e_n_ie_n_c_e_S_t_or_e_s_&_R_e_nt_a_ls~, _In_c_.~(~E_adh~l_A_l_h~o~b1~· s=h1=·) _________ _
Mailing Address: ___ 6_5_0 _1 _B_ar_b_o_ur_L_ak_e_R_oa_d ____________________ _
City: Favetteville State: _NC_ Zip Code:_2_83_0_6 ____ County: Cumberland
Day Tele No.: 910-583-7565 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: --~9~1-=-0-.....,_7~9-=-1-__,_7-=-8=65'---
E. PROJECT CONTACT -Person who can answer technical questions about the proposed injection project.
Name: ----=-A=s=hl=e"'"'y'-'M=.--'W-'-=ink=e=lm=an==------=-A=T=---cC=----=-cA=s=so""c=ia=t=es"--=of=---N=--=o=rt=h'--'C=ar=ol=in=a=."""'P__,_.C=-.,_, _________ _
Mailing Address: --~2~72=5~E~-M=il=lb=r-=-o-=-ok==R=o-=ad=."-"S"-"u=it=e"-"l-=2-=-l ________________ _
City: Ralei o-h State: _NC_Zip Code:27604 County:_W~ak=e~---
Day Tele No.: 919-871-0999 Cell No.: 919-816-7915
EMAIL Address: ashlev [e-mail] Fax No.: 737-207-8261
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: Hi ghway 20 and State Road 1729 (P arcel 938988968300 ) County: Robeson
City: St. Pauls State: NC Zip Code: ~2-=-8=---38=---4~------
(2) Geographic Coordinates: Latitude**: 34° ----2.Q' ____±Q_" or 0
Longitude**: 79° ____Q2_' _____Q.2_" or 0
Reference Datum: ___ W_G_S_8_4 ___ Accuracy: ___ 1_0_-_m_e_te_r __ _
Method of Collection: DO O -Acme Mapp er 2.1
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ square feet
Land surface area ofinj. well network: square feet(:::: 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be :-S 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells;
(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; and -There is only one well at the site,
the horizontal and vertical extent of contamination is not known.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells. -There is only one monitoring well at the site; therefore, groundwater flow
direction has not been established. No wells are proposed at this time. ·
See Figures 1 and 2 for site location and injection zone maps.
UICI In Situ Remed. Notification (Revised 3/2/2015) Page 2
I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
A TC will install three Provect ORS sleeves in monitorim . well MW-1 in order to aide in natural attenuation and
reduce com pounds concentrations to below the North Carolina Groundwater Quality Standards (2L Standards ).
Based on the most recent sam pling event performed in Se ptember 2018 . the followin g compounds exceeded the
2L Standards: benzene at 11.9 micro grams per liter (btg/L). toluene at 751 µg/L. na phthalene at 85.6 µg/L .and
1.2.4-trimethvlbenzene at 430 µg/ in MW-1. The sleeves come in 3-foot sections. ATC will install three 3-
foot sections at the base of the well. across the well screen. The socks will release oxidizing solids into the
groundwater for a pp roximately 6 months. at which point the chemicals in the socks will have de pleted.
J. INJECT ANTS -Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found online at
http://portal.ncdenr.org/web/wq/apslgwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
Injectant: ___ P_r~o~v_e_ct_O~R~S_s~l_ee_v_e_s _______________________ _
Volume of injectant: 1.038 in3 -volume of socks
Concentration at point of injection: -------'----75=-------=8=5--'---o/c-=--o-------------------
Percent if in a mixture with other injectants: -----=N~o=t~A=pF-'pl=ic=a=b=le~-------------
See Appendix A for MSDS.
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: ___ O ___ Proposed ____ l ___ Existing
(2) 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
See Appendix B for well construction details.
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Two weeks after submitting this NOL ATC will install the Provect ORS sleeves in monitoring well MW-1.
VIC/In Situ Remed. Notification (Revised 3/2/2015) Page 3
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.
ATC will collect one sam ple approximatel y 6 months after the installation of the Provect ORS sleeves in MW-
I (November 2018 . with sam pling to occur Mav 2019 ). During the sam plin g event, ATC will collect a sample
from monitoring well MW-1 for anal vsis of volatile organic com pounds bv EPA Method 6200B. The sam ple
will be shipp ed to SGS Accustest in Scott, Louisiana. ATC will also measure dissolved oxy gen, conductivity,
tem perature. pH, and oxyg en reduction potential in MW-I during the May 2019 sampling event.
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
docwnent 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 15A NCAC 02C 0200 Rules. "
~Z....----"--------Ashle y Winkelman on behalf of Hassan Osman. NCDEQ
(See Authorization to Sign on Next Page)
Print or Type Full Name Signature of Applicant
PROPERTY OWNER (i f the pro pe rty is not owned b y the permit a pp licant):
"As owner of the property on which the ir,jection 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 ir,jection well(s) conform to the Well Construction Standards
(.1 5A NCAC 02C .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 A endix C Eahdl Alho bishi
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 form.
Submit the completed notification package to:
UICI In Situ Remed. Notification (Revised 3/2/2015)
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page4
Ashley Winkelman
From:
Sent:
Osman, Hassan <[e-mail]>
Tuesday, July 24, 2018 3:16 PM
To: Ashley Winkelman
Subject: FW: WI0600204 NOI Sampson Tire -Provectus ORS
FYI
Thanks
From: Rogers, Michael
Sent: Tuesday, July 24, 2018 3:14 PM
To: Osman, Hassan <[e-mail]>
Cc: Shrestha, Shristi R <[e-mail]>
Subject: RE: WI0600204 NOi Sampson Tire -Provectus ORS
Ok, thanks. Please print out this email and attach to all NOls moving forward when she signs so you will not get
inquiries.
From: Osman, Hassan
Sent: Tuesday, July 24, 2018 3:04 PM
To: Rogers, Michael <michael.rogers @ncdenr.gov>
Subject: RE: WI0600204 NOi Sampson Tire -Provectus ORS
Hi Michael:
I a authrJrizlogAshiey Wlnkelman f om ATC Associate.$, Q sign r;J'QJ as ,ah age 1 for 6wM .Jt :YQJ.Lhav:e,.ariy
ciuestion bt'n"eed rnore lnfqrrn tjond r;ileas_e let_r:ne know .
Thanks
From: Rogers, Michael
Sent: Tuesday, July 24, 2018 2:50 PM
To: Osman, Hassan <hassan.osman @ncdenr.gov>
Subject: RE: WI0600204 NOi Sampson Tire -Provect1,1s ORS
Would you send me a letter or email from you authorizing Ashely to sign as an Agent for DWM. You can use a copy of
this email to attach to all NO ls moving forward.
Thanks
From: Osman, Hassan
Sent: Tuesday, July 24, 2018 2:34 PM
To: Rogers, Michael <michael.rogers @ncdenr.gov>
Subject: RE: WI0600204 NOi Sampson Tire -Provectus ORS
Yes.
1
Notice of Intent to Construct or Operate Injection Wells
Cecilia Shi pman Pro pert . St. Pauls , North Carolina
FIGURES
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IUILDIH SCtlNCH • IIAlllLUJ TESTIH
Notice of Intent to Construct or Operate Injection Wells
Cec ili a Shi pman Pro pertv. St. Pauls, North Carolina
APPENDIX A
MSDSFORM
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IUILDIIC SCIHCES • 111.llUl.W Tllllll
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ENVIRONMENTAL PRODUCTS'
MATERIAL SAFETY DATA SHEET' PROVECT-ORS
Page: 1 of 5
I. PRODUCT IDENTIFICATION: PROVECT-ORS
PRODUCT USE: Soil and water treatment.
MANUFACTURER: EMERGENCY PHONE:
PROVECTUS ENVIRONMENTAL
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
USA: (1.15) 650-2230
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s_ (Calcium Peroxide), Class 5.1, PG II, UN1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Inorganic Nutrients
3. PHYSICAL DATA
Chemical Formula CAS No_ Percentage
CaOx 1305-79-9 75%-85%
15%-25%
Appearance White & brown granules
Physical state Solid
Odor threshold None
Bulk Density 500-650gfL
Solubility in Water Insoluble
pH -11
Decomposition Temperature Self -accelerating decomposition with oxygen release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product con s <1 % non -respirable crystalline
silica. The NTP and OSHA have not classified non -respirable crystalline .' :. , arcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (si i '- a ■ ' S does not
contain respirable crystalline silica. NOv
Potential Health Effects:
■ General Irritating to mucous membrane and eyes
132

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ENVIRONMENTAL PRODUCTS -
rovectus
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 2 of 5
• Inhalation Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
• Eye contact May cause irritation to the eyes; Risks of serious or permanent eye
lesions.
• Skin contact May cause skin irritation.
• Ingestion Irritation of the mouth and throat with nausea and vomiting.
5. FIRST AID MEASURES
• InhalationRemove affected person to fresh air. Seek medical attention if effects
persist.
• Eye contact Flush eyes with running water for at least 15 minutes with eyelids
held open. Seek specialist advice.
• Skin contact Wash affected skin with soap and mild detergent and large amounts of
water.
• Ingestion If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Point
• Not applicable
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -explosive
Extinguishing Media
• Water
Fire Hazards
• Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,

PENVIRONMENTAL PRODUCTS
ravectus
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 3 of 5
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution_ Pressurization if confined when heated or
decomposing. Containers may burst violently,
Fire Fighting Measures
• Evacuate all non -essential personnel
• Wear protective clothing and self-contained breathing apparatus.
• Remain upwind of fire to avoid hazardous vapors and decomposition products.
• Use water spray to cool fire- exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
• Flush remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs.
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper, oils,
etc.). Do not return product to container because of risk of contamination.
S. HANDLING AND STORAGE
Storage
• Oxidizer, Store in a cool, well -ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
• Keep away from incompatible materials. Keep containers tightly closed, Do not store in
unlabeled or mislabeled containers.
• Protect from moisture. Do not store near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Store separately from organics and reducing materials. Avoid contamination that may lead to
decomposition.
Handling
• Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
• Do not swallow. Avoid breathing vapors, mists, or dust. Do not eat, drink, or smoke in work
area.
• Prevent contact with combustible or organic materials.
• Label containers and keep them tightly closed when not in use.
• Wash thoroughly after handling.

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ENVIRONMENTAL PRODUCTS'
rovectus
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 4 of 5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
• General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no respiratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
• Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
• Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical -resistant (Recommended materials: PVC, neoprene or rubber)
Other Protective Equipment
• Eye -wash station
• Safety shower
▪ Impervious clothing
• Rubber boots
General Hygiene Considerations
• Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
• Stable under normal conditions
Condition to Avoid
• Water
• Acids
• Bases
■ Salts of heavy metals
• Reducing agents
• Organic materials
• Flammable substances
Hazardous Decomposition Products
+ Oxygen which supports combustion

• rovectus
ENVIRONMENTAL PRODUCTS'
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
• LD5O Oral: Min.2000 mg/kg, rat
• LD50 Dermal: Min. 2000mglkg, rat
• LD50 Inhalation: Min. 4580 rng/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological Information
• Hazards for the environment is limited due to the product properties of no bioaccumulation, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste Treatment
• Dispose of in an approved waste facility operated by an authorized contractor in compliance with
local regulations.
Package Treatment
• The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Class: 5.1
• Labels: 5.1 (Oxidizer)
• Packing Group: it
15. REGULATORY INFORMATION
• SARA Section Yes
• SARA (313) Chemicals No
• EPA TSCA inventory Appears
• Canadian WHMIS Classification C, D2B
• Canadian DSL Appears
• EINECS Inventory Appears

Notice of Intent to Construct or Operate Injection Wells
Cecilia Shi pman Pro pe rty. St. Pauls. North Carolina
APPENDIXB
MONITORING WELL CONSTRUCTION DETAILS
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IUILIIIIC SCIENCES: • IA.TERIUS TEmlC
,
I- andax
WELL LOG. MW-1
Permit # NIA
Drill Date 09//0/01
Site Shipman
Client NCFTF
Use Monitor Well
Handex Loc. # 123419
Address Hwy 20 and Shaw Road
Total Depth (ft) 20
Drilling Method Hollow Stem
Boring Deena (ft) 20
Boring Diem. (in) 8
Casing/Scrn, Mat Sch. 40 PVC
Csg/Scrn Diem (In) 2
Csg Length(ft) 5
Grout Type Portland
Grout interval (ft) 0
to 1.5
Scrn Length (ft) 15
Csg Seal Type Bentonite
Seal Interval (ft) 1.5
to 3.0
Scrn Slot Size (in) 0.010
Sand Pack Type Sand
Sand Interval (ft) 3
to 20
Static Water Level 7.74
Rmrks FTF #3366
TOC Elevation
Sample Method EPA 8250/5035
Cocialia Shipman Property
Depth (ft.)
Q
m
E
1s
Sample
Depth (ft)
OVA (ppm)
Geologic Description
Typical
Diagram
[
r
grass, packed clay
fdl
"' '
ni.
and sand
7 D —
558-10
8--to
s 13%
Reddish -brown SAND with black organics. Strong petroleum odor.
Depth to Water 7.74 ft on 9/12/01
[�
Y
m
m_
0 ,
0
i
N
Boring terminated and monitor wall Installed to 20.0 feet-
30 —
—
r
In
m
iR
a0 y
i
Dt
50 r
Not to Scala'
Notes:
Geologist M. Fulkerson
Driller. Saedacco, Inc.

Notice of Intent to Construct or Operate Injection Wells
Cecilia Shi pman Pro pe rtv. St. Pauls. North Carolina
APPENDIXC
ACCESS AGREEMENT FROM SITE PROPERTY OWNER
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IUILl.llfliSC:IElftU•IUTEIIALSTEnllUI
Mr. Hassan Osman
Hydrogeologist
DWM/UST Section
2017 JUL 31 PM 3; 05
UNDERGROUND STORAGE TANK SECTION
July 7, 2017
1637 Mail Service Center
Raleigh, NC 27699-1637
Dear Mr. Osman
RE: Former Half-Way Grocery (Cecilia Shipman Residence)
Hwy 20 & State Road 1729
St. Pauls, Robeson County, North Carolina
Incident Number: 3366
I am/We are 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 assessment and/or remediation of the groundwater
and/or soils under the authority ofG.S. 143-215.94G.
I am/We are granting permission to the lands we own or control 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. Any damages will be restored by the Department or its contractor to as close to the pre-work
condition as practicably possible.
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 will notify the land owners
48 hours prior to entry and 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 othezwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and
is a public record, in accordance with 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 landowner. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed,
1/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
d L.- ‘a ASA/
Type/Print Name of Owner or Agent
Lilo
- a�
Phone Number
1 Vtidou tom
Address
City/State/Zip Code
Date
RE: Former Half -Way Grocery (Cecilia Shipman Residence)
Hwy 20 & State Road 1729
St. Pauls, Robeson County, North Carolina
Incident Number: 3366

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LEGEND
— APPROXIMATE PROPERTY BOUNDARY
• = ACTIVE OR UNKNOWN USE WATER WELL LOCATION
= INACTIVE OR IRRIGATION WATER WELL LOCATION
Assumed Location of
Former Halfway Grocery
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