WI0700456_DEEMED FILES_20190107

Shrestha, Shristi R
From:
Sent:
William Regenthal <[e-mail]>
Monday, January 07, 2019 12:32 PM
To: Shrestha, Shristi R
Cc: Welti, Jeff
Subject:
Attachments:
[External] Injection Event Record -RAM #21 (WI0700456)
SKM BT _36319010713330.pdf
CAUTION: ,
Attached is the injection event record for the removal of the ORC-A socks from the site in November 2018. ORC-A
application has been discontinued for th is site .
William Regenthal, P. G.
Branch Operations Manager -Winterville
Geological Resources, Inc.
113 W. Firetower Road, Suite G., Winterville, NC 28590
Main [phone] Office [phone] Fax [phone]
wlr@g eologicalresourcesinc.com
www.geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Magazine 2015 Small Business of the Year Runner-u p Reci pient
From: [e-mail] [mailto:[e-mail]]
Sent: Monday, January 7, 2019 1:33 PM
To: William Regenthal <[e-mail]>
Subject: Message from KMBT_363
RECtilVEolNc OE'Q/oWlit
JAN O 7 2019
A . WaterouaJity
eg1ona1 Operati
onssection
North Carolina Department of Environmental Quality - Division of Water Resources
INJECTION EVENT RECORD ( IER)
Permit Number WI0700456
1. Permit Information
Red Apple Markets, Inc.
Permittee
Red Apple Market #21
Facility Name
NC Highway 561, Saint John, Hertford County
Facility Address (include County)
2. Injection Contractor Information
Geological Resources, Inc.
Injection Contractor/ Company Name
Street Address 3502 Hayes Road
Monroe
City
NC
State
28110
(704 ) 845-4010
Area code - Phone number
3. Well Information
Number of wells used for injection
Zip Code
WellIDs MW--2R, MW-4R, MW-5R
3
Were any new wells installed during this injection
event?
❑ Yes No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify) NA
Please include a copy oft e GW-1 form f each
well installed
Were any wells abandoned during this injection
event?
❑ Yes [No
If yes, please provide the following information:
Number of Monitoring Wells NA
Number of Injection Wells NA
Please include a copy oft e GNl 3d for each welt
abandoned
4. In,jectant Information
ORC-A socks
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration REMOVED
lithe injectant is diluted please indicate the source
dilution fluid._ _ NA
Total Volume Injected (gal) NA
Volume Injected per well (gal) _ NA
5. Injection History
injection date(s) Socks removed on 11 / 17 / 18
Injection number (e.g. 3 of 5) N" (2 Anjectioali were completes(
Is qis the last injection at this site?
Yes ❑ Na
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 i..A31I;} OUT IN THE PERMIT.
SIGNATURE£'F _`CTION CONTRACTOR DATE
William Regenthal
01/07/19
PRINT NAME OF PERSON PERFORMING THE 1NJEEIjPN
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: U1C Program, 1636 Mail Scrvicc Center, Raleigh, NC 27699-1636 Phone No. 919-807-6464
Form UIC-TER
Rev. 3-1-2016

pzpevp r+f IN IC) 4 n <
North Caroling Department of Environmental. Quality -- Division of Water Resources
INJECTION EVENT RECORD (JERI
Permit Number J.I & oa 45Co
I. Permit Information
rej IpP1 f -rkert3, :lit .
Perrnittee
k/M 4421
Facility Name
1-4,4
Facility Address (include County)
Injection Contractor Information
Injection Contractor / Company Name
Street Address 35b, i eyes (ze
City
t7��[ ) e-05 t )
Area code —Phone number
3. Well Information
State zip CacteQiytO
E��
PE-9
�0/8
+alO Qa"ktY
Number of wells used for injection
Well IDs l+i -c7R, folk-yA, Mtn 5i1Q
Were any new weIis installed during this injection
event?
n Yes [] No
If yes, please provide the following information:
Number of Monitoring WellsL) 4
Number of Injection Wells lVI❑�
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify) I
Please include a copy of the GW l form, for each
well installed.
Were any wells abandoned during this injection
event?
❑ Yes L'No
If yes, please provide the following information:
Number of Monitoring Wells I`-'4
Number of Injection Wells
Please include a copy of the Gl T? 30 for each well
abandoned
Injectant Information
QR c-- i4 ,cpc,ks
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration /lH-+:We• -95..143
MM.•`I3acta$
lithe injectant is diluted please indicate the source
dilution fluid._ tvirl
Total Volume Injected (gal) /-0-}
Volume injected per well (gal) 11-44
injection History
Injection date(s)
; 1$
Injection number (e.g. 3 of 5)
Is this the last injection ais site?
❑ Yes J'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
STA1 J)ARDS LAID OL-If H E PERMIT.
—siGNATURE OF INJECTION CONTRACTOR DATE
- zllovni
TNT NAM
IN 1FC'ION
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
Fonn UIC-IER
Rev. 3-1-2016

1]efi_,„1/4.eat i a co-6 LS
North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (LER)
Permit Number if, ) i o7ao Li4S
1 Permit Information
gas d= 1 toMt94147 Inc.
Permittee
Grovtvt
Facility Name
1 4y-5tis 6 reco.f�
1727 �373 i 4$ i 3 N Lu. r+.4. ; price— (s.,,,,t �I
Facility Address (include County) l
2. Injection Contractor Information
c. al act. r..sa -
Injection Contractor / Company Name
Street Address mod° 14-17' 5
ikon rose,
City
lit G •-s{t it,
State Zip Code
(% ) 1b
Area code — Phone number
3. Well Information
Number of wells used for injection 3
Well Ms It? 3 w- o, Au,' 7
Were any new wells installed during this injection
event?
❑ Yes [ 'No
If yes, please provide the following information:
Number of Monitoring Wells Nib
Number of Injection Wells A
Type of Well Installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify) j^
Please include a copy of the GW-J form for each
well installed
Were any wells abandoned during this injection
event?
❑ Yes D'No
If yes, please provide the following information:
Number of Monitoring Wells 11-44
Number of Injection Wells r. 104
Please include a copy of the GW 34 for each well
abandoned.
4. Lnjectant Information
0/1 �' , mks
lnjectant(s) Type (can use separate additional sheets
if necessary
Concentration M‘4,3 ()4 (i) $U i ►7
If the injectant is diluted please indicate the source
dilution fluid. jv.-44
Total Volume Injected (gaIlLtid-
Volume Injected per well (gal) )
5. Injection History
Injection date(s) '27f13i) tC
Injection number (e.g. 3 of 5) °f
Is this the last injection at _Otis site?
❑ Yes �Nv
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 GUT [N THE PERMIT.
siGNA . RE OFF1N:1 :GTIC TCONTRACTOR DATE
PRINT NAMEDI PERSON PER7'ORMING THE INJECTION
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

North Carolina Department of Environmental Quality — Division of Water Resources
INJECTION EVENT RECORD (LER)
1 Permit Information JUL 2 0 2017
r. d41 ga.g¢ o. ! Co. L wnttr Qualltr
1 f4t#f l6rfai •_ peas+• ns Soctson
Perrmittee
gAMAt2i
Facility Name
5(.4_ A4 4 5014n, t (I. L.lL
Facility Address (include County)
2. Injection Contractor Information
loo, 'Lead t e,5 hC.�
Injection Contractor / Company Name
Street Address 35— 1'2
n•Lcol ��r 5D11_j
City State Zip Code
(7-'1) r r 5 - �-1ti t 0
Area code -- Phone number
3. Well Information
Number of wells used for injection
3
Well fDs .k."? P., s+r`ty,
Were any new wells installed during this injection
event?
❑ Yesa
If yes, please provide the following information:
Number of Monitoring Wells k »/
Number of Injection Wells Puy
Type of Well installed (Check applicable type):
❑ Bored ❑ Drilled ❑ Direct -Push
❑ Hand -Augured ❑ Other (specify)
Please include a copy of the GW-1 form for each
well installed
Were any wells abandoned during this injection
event?
❑ Yes EIv
If yes, please provide the following information:
Number of Monitoring Wells iV if
Number of Injection Wells 11/4-31/1
Please include a copy of the GW-30 for each well
abandoned
4. Injectant Information
3~ o-F 5, 5 ORC
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration
Lithe injectant is diluted please indicate the source
dilution fluid. rar4
Total Volume Injected (gal) jUP?
Volume Injected per well (gal) AM
5. Injection History
Injection date(s)
1
7
Injection number (e.g. 3 of 5) I
Is this the last injection at s site?
❑ Yes
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PER 'ORMED WITHIN THE
STANDARDS LAID O IE PERMIT.
r
FG TL - OF IN ONTRACTOR DA E
La:sli 1 G
PRINTNAM F.Ui�PER,SON PERFORMING THE INJECTION
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
Forth U1C-IER
Rev. 3-1-2016

Permit Number
Program Category
Deemed Ground Water
Permit Type
Wl0700456
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Red Apple Market #21
Location Address
NC Hwy 561 W
Halifax
Owner
Owner Name
North East Oil Company Inc
Dates/Events
NC
Orig Issue
6/19/2017
App Received
6/9/2017
Re gulated Activities
Groundwater remediation
Outfall
Waterbody Name
27839
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
6/16/2017
Permit Tracking Slip
Status
In review
Version
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
C Wood Beasley Ill
President
PO Box 1386
Ahoskie
Region
Washington
County
Hertford
NC
Issue
6/19/2017
Effective
6/19/2017
27910138
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha, Shristi R
From:
Sent:
To:
Cc:
Subject:
Shrestha, Shristi R
Friday, June 16, 2017 3:26 PM
'William Regenthal'
Welti, Jeff; May, David; Tankard, Robert
WI0700456 RE: NOi Red Apple Market#21 UST Incident #9785
Thank you for submitting the Notice of Intent to Construct or Operate Injection Wells (NOi) 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://de q .nc.gov/about/divisions/water-resources /water-resources-p ermits/wastewater-branch /ground-water-
protection /ground-water-re portin g-forms
2) Injection Event Records (IER). All injections, including air and passive systems require an IER. The IER can be
modified for air sparge wells (e.g., air flow 'continuous' for date or rate of injection, etc.).
You can scan and send these forms directly to me at Shristi.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 WI0700456. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in re p ly to this email , as it will already have the assigned deemed permit
number in the subject line.
Shristi
Shristl 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 @ ncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
From: William Regenthal [mailto:[e-mail]]
Sent: Friday, June 09, 2017 3:50 PM
To: Shrestha, Shristi R <[e-mail]>
Cc: Welti, Jeff <[e-mail]>
Subject: NOi Red Apple Market#21 UST Incident #9785
Good afternoon,
Please find the attached NOi for the Red Apple Market #21 site in Saint John, Hertford County. Please let me know if
you have any questions.
We intend to install these ORC socks in conjunction with the other site you approved (RAM #12 in Powellsville) at the
same time to help minimize the shipping cost for the socks. We had to wait on the permission from the property
owner for the Saint John site .
Thanks for your help!
William Regenthal, P. G.
Branch Operations Manager -Winterville
Geological Resources, Inc.
113 W. Firetower Road, Suite G., Winterville, NC 28590
Main [phone] Office [phone] Fax [phone]
wlr @g eologicalresourcesinc.com
www.geolo gicalresourcesinc.com
NCPCM 2015 Vendor of the Year Reci pient
Business North Carolina Ma gazine 2015 Small Business of the Year Runner-u p Reci pient
Shrestha, Shristi R
From:
Sent:
To:
Subject:
Attachments:
Please find the attached NOi.
Shristi
Shrlstl R. Shrestha
Hydrogeologist
Shrestha, Shristi R
Friday, June 16, 2017 3:27 PM
Tankard, Robert; May, David
WI0700456 NOi Red Apple market #21
Deemed Permitted In-Situ Application.pdf
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shrestha @ ncdenr.g ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email correspondence to and from this address i.s subject to the
North Carolina Public R ecords I aw and may be rJisclosed to third pattie .
DATE: , 20 PERMIT NO.
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
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 ruk" and do not require an individual permit when constructed in accordance
with the rules of 15A NC4C 02C.0200. T his form shall be submitted at least WEEKS prior to injection.
AQUIFER TEST WELLS (15A 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 e15A NCAC 02C .0229):
1) Passive Injection S\•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 1nlection 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 Wilt Be Returned As Incomplete.
0'Lit.C-45 (to he filled in by DWR)
(1) Air Injection Well Complete sections B through F, K, N
(2) Aquifer Test Well .Complete sections B through F, K, N
(3) X Passive Injection System Complete sections S through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections S through N
(6) Tracer Injection Well Complete sections 8 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): North East Oil Com-on vjInc,
Mailing Address: Post Office Box 1386
City. Ahoskie State: NC Zip Code:27910 County:Hertford
Day Tele No.: 252-862-0236 CeI1 No.: NA
EMAIL Address:NA Fax No.: NA
Deemed Permitted GW Kemediation NOI P.ev. 3-i-2016
6, •
Page 1

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: --------------------------------
Company Name St. John Fire De partment . Inc.
Mailing Address: 1127 NC Hi gh way 561 W
City: Aulander State: NC Zip Code; 27805 County: Hertford
DayTeleNo.: 0<$,;>. 3g, c;,-0~8j Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: __________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: William Regenthal , P. G.
Company Name Geolo gi cal Resources . Inc.
Mailing Address: 3502 Hayes Road
City: Monroe State: NC_ Zip Code: 28110 County: Union
Day Tele No.: 704-698-1253 Cell No.:. __________ _
EMAIL Address: wlr@ geolo gi calresourcesinc.com Fax No.: 252-321-6094
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: ~R=e=d =A-P=P~le~M~ar=k=et~#=2~1 ______________ _
NC Hi ghway 561 W.
City: Saint John County: Hertford Zip Code: 2. t5? 3 q
(2) Geographic Coordinates: Latitude**: ___ 0 __ __nor __JQ0 .306222
Longitude**: 0 __ " or __TI0 .087028
Reference Datum: _______ _,Accuracy: _______ _
Method of Collection: Topographic Map
**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 (~ I 0,000 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.
(I) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and
vertical extent of the contaminant plume in soil and groundwater, changes in lithology, existing and
proposed monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus
existing and proposed wells.
Deemed Pennitted 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.
Oxygen Release Compound Treated socks will be placed in MW-2R, MW-4R and MW-SR in A pril 2017. A
ground water samplin g event wi11 be conducted on the a pp licable monitorin g wells in August 2017 in order to
determine the effectiveness of the ORC socks. Based on the results of the Augu st 2017 samplin g event, a
detennination will be made whether the a pplication of ORC will continue.
J. APPROVED INJECTANTS-Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Sen1ices can be injected. Approved injectanis can be found online at http ://deq .nc.gov/about/divisions/water-
resources/water-resources-pern1 its/wastewater-branch/ground-water-protection/ground-water-approved-in jectan ts.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info
(919~807-6496).
Injectant: ORC-Advanced -See Attached Product Specification Sheets
Volume of injectant: 12oz/foot
Concentration at point of injection: 36oz
Percent if in a mixture with other injectants: NA
Injectant:
Volume ofinjectant: ____________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants: ___________________ _
Injectant:
Volume of injectant: ____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ___________________ _
K. WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: _____ Proposed.]_Existing (provide GW-ls)
For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table fonnat. 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
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
( c) Well contractor name and certification number
Deemed Pennitted GW Remediation NOI Rev. 3-1-2016 Page3
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
The ORC treated socks are scheduled to be installed in A pril 2017. The socks will be removed in Au gu st 2017
to allow for the completion of the semi-annual sam plin g event. Based on the results of the sampling event, a
detennination will be made whether or not to continue the use of the ORC socks.
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 socks will be removed in Augu st 2017 prior to the samp ling event. Following the comp letion of the
samplin g event, additional socks may be installed, de pendin g on the effectiveness of the socks.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "/ 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. 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 ~f applicable, abandon the injection well
and all related appurte I accordance with the 15A NCAC 02C 0200 Rules. " A . ..... v-.:,;,,=wt ;.... ,4 .. J,:.d-
Signat ure of Ap P int or Type Full Name and Tit e /1.,,,,,"75,:.r_
PROPERTY OWNER (if the pro perty is not owned b y the pennit a pplicant):
"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 (15A NCAC 02C .02001."
"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 .
. JJ/~'5.e-~<l... c..,-1 /,edv,.J...__, J1.Tcj o /<'-&.r,1Y1;5 5 ,on ,
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.
Submit the completed notification package to:
DWR -VIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page4
April 6, 2017
St. John Fire Dept., Inc.
1127 NC Highway 561 W.
Aulander, North Carolina 27805
Geological Resources, Inc.
RE: Oxygen Release Compound Application
Red Apple Market #21
NC Highway 561 W
Saint John, Hertford County
Incident No. 9785
Risk Classification: H173R
GRI Project No. 2486
To Whom it May Concern:
Geological Resources, Inc. (GRI) is conducting ground water assessment and remediation activities on
behalf of North East Oil Company to mitigate the effects of a petroleum release from underground
storage tanks (USTs) at the Red Apple Market #21 site, located on NC Highway 561 W in Hertford
County, North Carolina. As part of the assessment, GRI proposes to install socks treated with Oxygen
Release Compound (ORC), in order to facilitate the bioremediation of the remaining petroleum
contaminants at the site .
It is GRl's understanding that you are the owner of Parcel No. 5963-35-4820 in Hertford County. GRI
requests permission to install the treated socks in monitoring wells MW-2R, MW-4R and MW-SR at the
site (a site map is attached). The application of the ORC will be monitored for a period of four months,
initially. Upon the completion of the initial ground water monitoring activities, GRI will determine the
long-term clean up goals for the site. There will be no cost to you for the installation of the treated
socks. The Division of Water Quality branch of NCDEQ requires property owner consent before this
method of remediation is performed. Please indicate in the spaces provided below if you will allow GRI
to use the ORC treated socks at this site. We would greatly appreciate a response, even if you choose
not to allow us to install the treated socks at this time. However1 if you do not wish for GRI to install
the socks, please call me so I can explain the process further.
3502 Hayes Road • M onroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]
Oxygen Releasing Compound Application
Red Apple Market #21
Saint John, Hertford County, North Carolina
Page 2 of 3
Your cooperation in this matter will be greatly appreciated. If you have any questions, please feel free
to contact the NCDEQ incident manager, Jeff Welti at [phone] or me at [phone].
Sincerely,
Geological Resources, Inc.
t/J.:.pb
William Regenthal, P. G.
Project Manager
cc: file
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]
, , . • ', e.. , · · . ; I • · · ,
Oxygen Releasing Compound Application
Red Apple Market ##21
Saint John, Hertford County, North Carolina
Page 3 of 3
V( Yes, I agree to allow ORC socks to be installed at the Red Apple Market #21 5ite at no cost to me.
No, l will not allow ORC socks to be installed at the Red Apple Market #21 Site.
Date
� i 111
(For Parcel No. 5963-35-4820)
_)-2tiS-o
Phone Number
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

ORC Advanced® Technical Description
ORC Advanced is an engineered, oxygen release compound designed specifically
for enhanced, in situ aerobic biorernediation of petroleum hydrocarbons in ground-
water and saturated soils. Upon contact with groundwater, this calcium oxyhydroxi-
de-based material becomes hydrated producing a controlled release of molecular
oxygen (17% by weight) for periods of up to 12 months on a single application.
ORC Advanced decreases time to site closure and accelerates degradation rates
up to 100 times faster than natural degradation rates. A single ORC Advanced
application can support aerobic biodegradation for up to 12 months with
minimal site disturbance, no permanent or emplaced above ground equipment,
piping, tanks, power sources, etc are needed, There is no operation or maintenance
required. ORC Advanced provides lower costs, greater efficiency and reliability
compared to engineered mechanical systems, oxygen emitters and bubblers,
ORC Advanced provides remediation practitioners with a significantly faster and highly effective means of
treating petroleum contaminated sites. Petroleum hydrocaroon contamination is often associated with retail
petroleum service stations resulting from leaking underground storage tanks, piping and dispensers. As a result,
ORC Aovanced technology and applications have been tailored around the remediation needs of the retail petroleum
industry and include_ tank pit excavations, amending and mixing wit backfill, direct -injection. bore -hole backfill,
ORC Advanced Pellets for waterless and dustless applcation, combined ISCO and biorernediation applications, etc.
Example of ORC Advanced
Fora list of treatable contaminants with the use of ORC Advanced, view the Range Of Treatable Contaminants GI hip
Chemical Composition
• Calcium hydroxide oxide
• Calcium hydroxide
• Monopotassium phosphate
• Dipotassium phosphate
Properties
• Physicifi state: Solid
• Form: Powder
• Odor. Odorless
• Color:'Vhite to pale yellow
• pH: 12.5 (3% suspension/water)

ORC Advanced® Technical Description
Storage and Handling Guidelines
Storage
StoJ c- in a cool dry place ut of clrect sunlight
Sta'c rn ontar•,?1 hr;htly 1r35 j contd.'rc'=-
Sto, a in a well -ventilated :Jlace
Dc► .'�t si nor near romf : mibla mat-•ri +k�
tore away from incompatible materials
P ovttic af,rJprl ate '•' • 1 st ''i`r lcllati.:n
►:hPrc dust 13 for--d
Applications
Handling
Minimize dust 6ener3tion and accu,nulation
}peer: : •orn ,`
Routine housckt•epilig Should be I,istitilted to
e>>.'rre that dust doe., riot accurnuIdLe Lrri'urfaces
Observe good rr iLrstrirI I ay€ e,'e
Taiv: precaution Lo avoid mixing with ccimbus+iI►k . ,
t eep a -var gram clothing and other cornb'lstrblo
rna}Frials
Avoid contact with water and moisture
Avoid CO!+;ail :•' 5.0r1 L I:11'r1a
A4 rid proiorigrd exjcsure
‘Vs-ar apt.uni i?tt Ilprsonal pri iter tree ergt.lpp is Inc
• Slurry mixture direct -push injection through hollow rods or direct -placement into boreholes
• in situ or ex situ slurry mixture into contaminated backfill or contaminated soils in general
• Slurry mixture injections in conjunction with chemical oxidants like RegenOx or PersulfOx
• Filter sock applications in groundwater for highly localized treatment
• Ex situ biopiles
Health and Safety
Wash thoroughly after handling. Wear protective gloves, eye protection, and face protection. Please review the
OR Advanced Safety Data Sheet for additional storage, usage, and handling requirements.
REGENESIS
•
tOn [ r_ S4mpra _aa C!,-n a :e
I. -'...i
20• , A i ! a LICid . ti. W.
six! ng ter .r 9 K !i + k St . w •.r • •• ,. + • h

NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFfCATXON # 3270
1. WELL CONTRACTOR:
Justin Radford
Well Contractor (individual) Name
Geological Resources, Inc.
Welt Contractor Company Name
STREET ADDRESS 2301-F Crown Point Executive Drive
Charlotte
City or Town
( 704 ).845-4010
NC
State
28227
Zip Code
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID #(ifapcllcable) MW-2R
WELL CONSTRUCTION P E RMTT#(if ap prcable) N/A
OTHER ASSOCIATED PERMIT #(If applicable) NIA
3. WELL USE (Check Applicable Box) Monitoring[? Municipal/Public°
Industrial/Commercial❑ Agritxiltural0 Recovery° Iniectlon0
irrigator -CI Other° (list use)
DATE DRILLED 10/12/11
TIME COMPLETED 10'15
4. WELL LOCATION:
CITY, Saint John COUNTY Hertford
NC Highway 561 West
(Sireei Narne, Numbers, Community. Subdivision Lot Na-. Parcel, Zip Code)
TOPOGRAPHIC / LAND SETTING.
❑ Slope 0 Valley 0 Flat 0 Ridge CI
(check appropriate box)
LATITUDE 36-308222
AMC PM❑
Other
LONGITUDE 77.087028
May be. m degrees.
minutes, seconds or
in a decimal format
Latitude/longitude source: D GPS 0 Topographic map
(locedon of well must be shown on a IJSGS rope, mep and
attached to this form rf not using GPS)
5. FACILITY- is Oa rani of the euatnass were the nail is located
FACILITY ID #(If applicable) 0-030290
NAME OF FACILITY lied Apple Market #21
STREET ADDRESS NC Highway 561 West
Saint John NC
City or Town
State Zip Code
CONTACT PERSON Red Apple Markets, Inc
MAILING ADDRESS Post Office Box 1386
Ahoskie NC 27910
City ar Town State Zip Cade
(_252 )_ 662-0236
Area code - Phone number
S. WELL DETAILS:
a, TOTAL DEPTH: 20 feet
b. DOES WELL REPLACE EXISTING WELL'? YES]] NO0
c. WATER LEVEL Below Top of Casing: —15.50 FT.
(Use +" if Above Top of Casing)
d. TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated at/orbelow land surface may require
a variance In accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): r7_IS METHOD OF TEST
f. DISINFECTION: Type n/a Amount
g. WATER ZONES (depth)
From 15.50 To 20.0 From To
From To From To
From To From To
7. CASING: Depth diameter Thickness/Werght Material
From 0 To 10 Ft. 2
From To Ft,
From To Ft,
Soh 4C PVC
8. GROUT- Depth Material Method
From 0 To 5 Ft, Cement Pour
From 5 To 8 Ft. Bentonite Pour
From To Ft.
9. SCREEN: Depth
From 10
From
From
Diameter Slot Size Matsrrat
To 20 Ft- 2 in. 0.010 in. PVC
To Ft in in.
ToFt. in. in.
10. SAND/GRAVEL PACK
Depth Size Material
From 8 To 20 Ft. #2 Sand
From
From
11.DRILL)NG LOG
From To
0 1
1 7
7 13
13 20
12. REMARKS:
To Ft.
To Ft.
Formation Description
Tan 9raveily send
Orange Clay
Gray clay
Tan silty sand
DO HEREBY CERTIFY ThAT THIS WELL WAS r0l STRucTEo iN ACCORDANCE WITH
15A NCAC 2C 'NELL CONSTRUCTION s rANDAROS. AND THAT A COPY Rr rHls
RECORD F4AS BEEN PROVIDED TO THE WELL 0W NFR.
JC �,rC�f�
SIGNATURE OF -CERTIFIED WELL CONTRACTOR ' CATE
Justin Radford, Geological Resources, Inc.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt-,
1617 Mall Service Center — Raleigh, NC 27699.1617 Phone No. [phone] ext 568.
Form GW-ib
Rev. I2/07

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Wafer Quality
WELL CONTRACTOR CERTIFICATION # 3270
1. WELL CONTRACTOR:
Justin Radford
Weil Contractor (Individual) Name
Geological Resources, Inc.
Well Contractor Company Name
STREET ADDRESS 2301-F Crown Point Executive Drive
Charlotte
NC 28227
City or Town State Zip Code
t 704 1.845-4010
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID#tlfapplicable) MW-4R
WELL CONSTRUCTION PERMFT#(if applicable) NJA
OTHER ASSOCIATED PERMIT Cif applicable! NIA
3. WELL USE (Check Applicable Box) Monitoring El Municipal/Pubftcl:I
IndusirialfCornmercieil] Agricultural° Recoveryp Infraction°
IrrigolicrO Other❑ (list use)
DATE DRILLED 10/12111
TIME COMPLETED 12:00
AMI] PM:
4. WELL LOCATION:
CITY: Saint John COUNTY Hertford
NC Highway 561 West
(Street Neme, Numbers, Community, Subdivision. Lot No.. Parcel, Tip Coe s)
TOPOGRAPHIC / LAND SETTING:
0 slope 0 Valley p Flat El Ridge ❑ Other
(check appropnate box)
LATITUDE 36,306222
ONGITUDE 77.087028
May be in ds&gr ti.
minutes, seconds or
in e decimal format
Latitude/longitude source: ❑ GPS 0 Topographic snap
[location of weft must be shown on a USGS topo map and
attached to this form if not tieing GPS)
5. FACILDY- lama name ar the business where the well c toCaraa.
FACILITY ID Cif applicable 0-030290
NAME OF FACILITY Red Apple Market #21
STREET ADDRESS NC Highway 561 West
Saint John NC
City rx Town Stale Zip Coda
CONTACT PERSON Red Apple Markets, Inc
MAILING ADDRESS Post Office Box 1386
Ahoskie NC 27910
City or Town
L2_52 ).862-0236
Area code - Phone number
State Zip Code
6. WELL DETAILS:
a. TOTAL DEPTH: 20 feet _
b. DOES WELL REPLACE EXISTING WELL? YES(' NOS
c, WATER LEVEL Below Top of Casing. -15.50 FT.
(use '4' If Above Top of Casing)
d, TOP OF CASING IS 0.0 FT. Above Land Surface'
'Top of casing terminated atlorbelow land surface may require
a variance in aeoardance with 15A NCAC 2C .0118_
e. YIELD (gpm): nla METHOD OF TEST
f. DISINFECTION: -type nla Amount
g. WATER ZONES (depth):
From 15.50 To 20.0 From To
From To From To
From To From To
7. CASING: Depth
Diameter Thickness/Weight Material
From t7 To 10 FL 2 Sot 4C PVC
From To Ft.
From To Ft.
8. GROUT: Depth Motorist Method
From 0 To 5 Ft. Cement Pour
From 5 To 8 Ft. Bentonite Pour
From To Ft.
9. SCREEN: Depth Diameter Slot Size Material
From 10 To 20
From To
From To
Ft.2 in. 0.010 in. PVC
Ft. in. in.
Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size
From 8 To 20 Ft. #2
From
From
11.DRILLING LOG
From To
0 1
1 15
15 20
12. REMARKS:
To
To
Ft.
Ft.
Material
Sand
Formation Description
Tan gravelly sand
Gray_oIay
Tan silt, sand
I Do HEREBY CERTIFY THAT THrS WELL WAS CONSrRUCTeO IN ACCORDANCE Waif
35A NC.0 2C WELL CONS rRUCTION STANDARDS AND THAT A COP,' OF THrS
RECORD HAS SEEN PROVaDED TO THE WELL OWNE
F £ /0A C/•i
SiGNATURbF-CERT{RiED LL ONTRRCTOfi DATE
Justin Radford, Geological Resources, Inc.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: information Mgt.,
1617 Mail Service Center — Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Form GW-'lb
Rev.12/07

NON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3270
1. WELL CONTRACTOR:
Justin Radford
Well Contractor (individual) Name
Geological Resources, inc.
Well Contractor Company Name
STREET ADDRESS 2301-F Crown Point Executive Drive
Charlotte NC 28227 -
City or Town State Zip Code
( 704 045-4010
Area code- Phone number
2. WELL INFORMATION:
S(TE WELL ID #lirappiicable) MW-5R
WELL CONSTRUCTION FERMI-1'W appiicabta) N/A
OTHER ASSOCIATED PERMIT #(if sppllcable) N/A
3. WELL USE (Check Applicable Box) ManitwingE Municipal/Put/Hog
industrial/Commercial[: Agrfcu{turalCI Recaverya Injectiontl
irrigetia^ii OtherIl (Ilsl use) --- - —
DATE DRILLED 10/1211 1
TIME COMPLETED 11:45
4. WELL LOCATION:
ciTY: Saint John
AMI1 PM❑
NC Highway 561 West
COUNTY Hertford
(Street Name. Numbers, Community, Subdivision, Lot Ale Parcel, Zip Code)
TOPOGRAPHIC I LAND SETTING:
D Slope 0 Valley El Fiat I] Ridge ❑ Other
(ct ack appropnate pox}
LATITUDE: 36.306222
LONGITUDE 77,08702E
May be in d tgmes,
minutes, seconds or
in a decimal forma[
Latitude/longitude source' 0 GPS 0 Topographic map
(facatfon at well must be shown on a USGS topo map and
attached to this form if not using GPS)
5. FACILITY- is Ina came or eta bi:amrss where the war' is located
FACILITY ID Cif applicable) 0-030290
KANIE OF FACILITY Red Apple Market #21
STREET ADDRESS NC Highway 561 West
Saint John NC
City or Town Stale Zip Code
CONTACT PERSON Red Apple Markets, Inc
MAILING ADDRESS Post Office Box 1386
Ahoski e NC 27910
City orTown State dip Code
( 252 }.862-0236
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 20 feet
n. DOES WELL REPLACE EXISTING WELL? PESO NDCI
c. WATER LEVEL Below Top of Casing:--15.50 FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS 0 0 FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2G .0116.
e. YIELD (gpm): nfa METHOD OF TEST
f. DISINFECTION: Type I1la Amount
g. WATER ZONES (depth):
From 15.50 To 20.0 From To
From To From To
From To From To
7. CASING: Depth Diameter Thickness/Weight Material
From 0 To 10 Ft, 2 Sch 4C PVC
From To Ft,
From To Ft.
8. GROUT: Depth Material Method
From 0 To 5 Ft. Cement Pour
From 5 To 8 Ft 8entonite POLY
From To Ft.
9. SCREEN: Depth diameter Slot Size Material
Prom 10 _ To 20 Ft. 2 In 0.010 in. PVC
From To Ft. in. in.
From To Ft. in. in.
10. SAND/GRAVEL PACK:
Depth Size Meteriai
From 8 To 20 Ft #2 Sand
From To Ft.
From To Ft.
11.DRIiLING LOG
From To Formation Description
0 1 Tan grayelly sand
1 15 Gray clay
15 20 Tan silty sand
12. REMARKS:
I DO HEREBY CFRT]FY THA7 THIS WELL WAS CONSTRUCTED IN ACCORDANCE W ri p1
7,A NCAC 2C WELL CONSTRUC110N STANDARDS, AND THAT A COPY OF TIES
RECORD HAS BEEN PROVIDED FO THE WELIa0W�1- R
rWIZ fir
S!GNA - tOF CERTIFIED WELL CONTRACTOR DATE'
Justin Radford, Geological Resources, Inc.
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt.,
1617 Mail Service Center -- Raleigh, NC 27699-1617 Phone No. [phone] ext 568.
Farm GWlb
Rev.17107

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