WI0700462_DEEMED FILES_20180104

D~ fNio-roo4-G 2.
North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number ---------
1. Permit Information
/\d v,-t l,,_ £,<';t ".,-+ Q; ~ Cowvpe;wt, I 1l C,
Pennittee
f!_:e..-6 h ' '5 G ~ <·> Uuf. ) / kle..r r--c, ll '5 bu I 't
Facility Name
0 9b ~ (_ 11»7 Lid, U)!-eG<,l'I , &Hi'L-~y·
Facility Address (include County) RECEIVED/NCB>E
Were any wells abandoned during this injection
event? _/
D Yes [2t'No
If yes, please provide the following infonnation:
Number of Monitoring Wells __ /Ji_'rt ___ _
Number of Injection Wells._---,LJ(j __ ,LJ.ILA---'-----
Please illclude a copy of the GW-30 for each well
abandoned.
2. Injection Contractor Information JAN _ 4 ZO S
4
_
~ha,' ?a.I ~.dULs ,;!:fl.<:..• Weter'Quality
Injectant Information
Injection Contractor I Company NameReglonal Operations
Street Address • 5.5p,;:;, /1,..,1 e 'S /<). '
City State
(ft)'{ ) gc.t5-'-tt> /0
~de -Phone number
3. Well Information
Zip Code
Number of wells used for injection -~{o~· __
Well IDs B-7, l3·'\ C,·tJ/-<, fl'll.<.:>·\5/f'<' Mw•'"',
• ll11u-J1
Were any new wells installed during this injection
event?
0 Yes g-1fo'
If yes, please provide the following information:
Number of Monitoring Wells A/fl
Number of Injection Wells _ _,/1~.fi~~----
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) /l..!pl/:
Please include a copy of the GW-1 form for each
well installed.
Q t:.c-1! 0:~1,:.s -~e,<;,s
Injectant(s) Type (can use sepa 7additional sheets
if necessary
Concentration -----------
If the injectant is diluted please indicate the source
dilution fluid. __ __,_µ=....L:A__.__ ______ _
Total Volume Injected (gal)._-+--'f!,..?=-i;4--L-___ _
Volume Injected per well (gal)__,_/L71/-----=....:..._ ___ _
5. Injection History
Injection date(s) / cl/;;Jo( 17
Injection number ( e.g. 3 of 5) __ _,,__ ___ _
Is this the last injection at this site?
0 Yes a-1'fo
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
ST AN ARDS LAID THE PERMIT .
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
Permit Number
Program Category
Deemed Ground Water
Pennlt Type
WI0700462
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Pennltted Flow
Facility
Faclllty Name
Perry's Grocery/Harrell's Gulf
Location Address
Intersection Of NC Hwy 42 And NCSR 1312
Colerain NC
Owner
Owner Name
North East Oil Company Inc
Dates/Events
Orig Issue
12/1/2017
App Received
11/15/2017
Re g ulated Activities
Groundwater remediation
Outfall
Waterbody Name
27924
Draft Initiated
Scheduled
Issuance Publlc Notice
Central Files: APS SWP
12/1/2017
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Pennlt Classification
Individual
Pennlt Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Non-Government
Owner Afflllatlon
C Wood Beasley Ill
President
PO Box 1386
Ahoskie
Region
Washington
County
Bertie
NC
Issue
12/1/2017
Effective
12/1/2017
27910138
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasln
Shrestha. Shristi R
From:
Sent:
To:
Cc:
Subject:
Shrestha, Shristi R
Friday, December 01, 2017 11:17 AM
'William Regenthal'
May, David; Tankard, Robert
WI0700462 Perry's Grocery/ Harrell's Gulf
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-ls and GW-30s if not already submitted (originals go the address printed on the
form). NOTE: Direct push or Geoprobe wells are considered wells and require construction (GW-1) and
abandonment forms (GW-30). If well construction/abandonment information is the same for the wells, only one form
needs to be completed-just indicate total number of injection points in the Comments/Remarks section of
form. These forms can be found on our website at
h ttp ://deg .nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ ground-water-re porting-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 [e-mail] 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 WI07004 62. This number is also referenced in the subject line of this email. You may if you
wish, scan and send back as attachments in reply to this email. as it will already have the assigned deemed permit
number in the subject line.
Shristi
Shrlsti 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
Emafl correspondence to and from this address is subject to the
North Carolina Public R ecords Law and may be disclosed to third parties.
From: William Regenthal [mailto:[e-mail]]
To: Shrestha, Shristi R <[e-mail]>
Subject: RE: [External] NOi Form-Perry's Harrels B-13R, MW-16, MW-31 -DOT
r=A UTION: External email. Do not.click li~s or ope; attachments unless verified. Send all suspicious email as an attachment to
[![e-mail].
I believe the mailing address is Colerain, 27924.
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@geolo gicalresourcesinc.com
www .geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Ma gazine 2015 Small Business of the Year Runner-u p Recipient
From: Shrestha, Shristi R [mailto:[e-mail]]
Sent: Wednesday, November 29 2017 10:36 AM
To: William Regenthal <wlr@geolo gi calresourcesinc.com>
Subject: RE: [External] NOi Form -Perry's Harrels B-13R, MW-16, MW-31 -DOT
Please provide a Zip code of the facility address. I am not able to locate the facility. Is it the intersection of NC
Highway42 &NCSR 1313? OrNCSR 1312.
Thank you,
Shristi
From: William Regenthal ( mailto:wlr@geologi calresourcesinc.com]
Sent: Wednesday, November 15, 2017 2:47 PM
To: Shrestha, Shristi R <[e-mail]>
Subject: RE: [External] NOI Form -Perry's Harrels B-13R, MW-16, MW-31 -DOT
I-CAUTION; E~temal emailDo not~lick links or open attachme;;:nless verified. Send all suspicious email as an attachment to
L~[e-mail].
And of course I forgot to sign ... Here you go again!
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@geolo gicalresourcesinc.com
www .geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Magazine 2015 Small Business of the Year Runner-up Recipient
From: Shrestha, Shristi R [mailto:[e-mail]]
Sent: Wednesday, November 15, 2017 12:52 PM
To: William Regenthal <wlr@geologi calresourcesinc.com>
Subject: RE: [External] NOi Form -Perry's Harrels B-13R, MW-16, MW-31 -DOT
It looks like the permittee is North East Oil company for all these NOl's. If that is the case then they can be included
in one NOi listing all the wells and the number of ORC socks. Please revise the NOi and send it to me.
Shristi
Shrlstl 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 .shrest ha@ 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 Carpli.na Public Records Law and may be disclosed to third parties.
From: William Regenthal [mailto:wlr @geolo gicalresourcesinc .com]
Sent: Wednesday, November 15, 2017 11:26 AM
To: Shrestha, Shristi R <[e-mail]>
Subject: [External] NOi Form -Perry's Harrels B-13R, MW-16, MW-31 -DOT
~AUTION: External email. Do not click links or open attachments unless verified . Send all suspicious email as an attachment to
[![e-mail].
Shristi,
Here is the last one, for B-13R, MW-16 and MW-31 located in the NC DOT Right of Way. Please let me know if you
have any questions.
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@ geolo gicalresourcesinc.com
www .geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Magazine 2015 Small Business of the Year Runner-up Recipient
Shrestha, Shristi R
From:
Sent:
To:
Subject:
Attachments:
Please find the attached NOi.
Shristi
Shristi R. Shrestha
Hydrogeologist
Shrestha, Shristi R
Friday, December 01, 2017 11:23 AM
May, David; Tankard, Robert
WI0700462 NOi Perry's Grocery/ Harrell's Gulf
NOI -Full Revised.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.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.
North Carolina Department of Environmental Quality-Division of Wafer Resources
NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are ''permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C. 0200. This form shall he submitted at least 2 WEEKS prior to iniection.
AQUIFER TEST WELLS (15A NCAC 02c .02201
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION f15A NCAC 02C .0225> or TRACER WELLS f15A NCAC 02C .0229):
1) Passive Injection Systems -In-well delivery systems to diffuse injectants into the subsurface. Examples include
ORC socks, iSOC systems, and other gas infusion methods.
2) Small-Scale Injection Operations -Injection wells located.within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. megible Submittals Will Be Retumed As Incomplete.
DATE: November 15
byDWR)
, 20 17 PERMIT NO. IJV 10.:J-O O C/--02-(to be filled in
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
___ .Air Injection Well ...................................... Complete sections B through F, K, N
___ .Aquifer Test Well ....................................... Complete sections B through F, K, N
=Xa,.._ __ .Passive Injection System ............................... Complete sections B through F, H-N
___ .Small-Scale InjectionOperation ...................... Complete sections B through N
___ .Pilot Test ................................................. Complete sections B through N
___ 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 ~™ft~Bfi.{¥1lW R
sign on behalf of the business or agency:
Name(s): North East Oil Companv. Inc.
Mailing Address: Post Office Box 1386
City: Ahoskie State: NC Zip Code:27910 County:Hertford
Day Tele No.: 252-862-0236 Cell No.: NA
Deemed Permitted GW Remediation NOi Rev. 3-1-2016
NOV 15 2017
Water Quality
Regional Operations Section
Pagel
EMAIL Address:NA Fax No.: NA
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Nita Brown
Company Name NA
Mailing Address: 752 NC Highway 42
City: Colerain State: NC Zip Code: 27924 County: Bertie
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: __________ _
Name and Title: NC DOT
Company Name NA
Mailing Address: 230 NC Highway 42 West
City: Ahoskie State: NC Zip Code: 27910 County: Bertie
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: __________ _
Name and Title: Herman E. Davidson
Company Name NA
Mailing Address: 1401 Meadow Road
City: Colerain State: NC Zip Code: 27924 County: Bertie
Day Tele No.: ___________ _ Cell No.: __________ _
EMAIL Address: _____________ _ Fax No.: __________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: William Regenthal. P. G.
Company Name Geological Resources, Inc.
Mailing Address: 3502 Hayes Road
City: Momoe State: NC_ Zip Code: 28110 County: Union
Day Tele No.: 704-698-1253 Cell No.: __________ _
EMAIL Address: wlr@ geologicalresourcesinc.com Fax No.: 252-321-6094
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Perrv 's Grocery/Harrell's Gulf
Intersection ofNC Highway 42 and NCSR 1312
City: Trap County: Bertie Zip Code: 2 T C/ 2-4-
(2) Geographic Coordinates: Latitude**:
Longitude**:
___
0
--__ " or ------1§0 .206222
" or ____.1§_0 .869722
Reference Datum: ________ Accuracy: _______ _
Method of Collection: Topographic Map
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page2
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITIED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: _______ .square feet
Land surface area ofinj. well network: square feet (:s 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.
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 B-7, B-9, MW-lSAR , MW-16 and MW-31 in
December 2017. A gr ound water sampling event will be conducted on the a pp licable monitorine wells
approximatel y 6 months following the installation of the ORC socks in order to determine their effectiveness.
Based on the results of the subsequent sampling event, a determination will be made whether the a pplication of
ORC will continue.
J. APPROVED INJECT ANTS -Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only irif ectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at h ttp ://deg.nc.g ov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ gr mmd-water-protection/ gr ound-water-approved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
lnjectant: ORC-Advanced -See Attached Product Specification Sheets
Volume ofinjectant: 12oz/foot
Concentration at point of injection: 36oz
Percent if in a mixture with other injectants: NA
lnjectant:
Volume ofinjectant: ____________________________ _
Concentration at point of injection: _______________________ _
Percent ifin a mixture with other injectants: ___________________ _
lnjectant:
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page3
K.
Volume ofinjectant: ____________________________ _
Concentration at point of injection: ______________________ _
Percent if in a mixture with other injectants : ___________________ _
WELL CONSTRUCTION DATA s
(1)
(2)
Number of injection wells: _____ Propose(PE.xisting (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 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
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Deemed Permitted GW Remediation NOi Rev . 3-1-2016 Page4
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The ORC treated socks are scheduled to be nsstaUed in December 2017. The socks will be removed
approximately 6 months following the installation to allow for the completion of the semi-annual sampling event.
Based on the results of the sampling event_ a determination will be made whether or not to continue the use of
e 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 approximately 6 months followinK installation prior to a sampling event. Following
the eomvletian of the sampling event. additional socks may be installed. depending on the effectiveness of the
socks.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "'hereby certifr, under penalty of law, that 1 am familiar with the information submitted in this
document and all attachments thereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that the information is true, accurate and complete, 1 am aware that
there are significant penalties, including the possibility of fines and imprisonment, for submitting false
information. I agree to constr ICt, operate, maintain, repair, and f applicable, abandon the injection well and
all related appurtenantr� Incordance with the 15A1YC4C 02C 0200 Rules,"
d I
Print or Type Fui Name and TOE
Signature of'.
PROPERTY OWNER (if the property is not owned by the permit applic ptj
"As owner of the property on which the injection well(s) are to be constructed and operated, 1 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 .0200)."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached RTE agreement
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
'.4n access agreement between the applicant andproperty owner may be submitted in lieu of a signature on this form.
Submit the completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediatian NO1 Rev. 3-1-2016 Page 4

October 5, 2017
Mr. Scott Emory, PE
N.C. Department of Transportation
230 NC Highway 42 West
Ahoskie, North Carolina 27910
Geological Resources, Inc.
Re: Oxygen Release Compound Application
Perry's Grocery/ Harrell's Gulf
696 NC Highway 42
Colerain, North Carolina
Incident Number: · 11916 ·
Risk Classification/Ranking: Hl 90D
GRI Project Number: 2518
Dear Mr. Emory:
nEce,vEn n OCT O 9 2017 u
BY:-_......, __
Geological Resources, Inc. (GRI) is conducting ground water assessment and remediation activities on
behalf of North East Oil Company, Inc. to mitigate the effects of a petroleum release from underground
· storage tan.ks (US Ts) at the Perry's Grncery/Hartell' s Gulf site, located at 696 NC Highway42 in Colerain,
Bertie County~ North Carolina. As part ofthe 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 GR I's understanding that a portion of Parcel Nos. 692080264, 6920805430, and 6920804624 in Bertie
County ate located in the Department of Transportation right-of-way. GRI will be installing the treated
socks in monitoring wells B-13R, MW-16, and MW-31 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 m0nitoring activities, GRI will determine the long-term clean up goals for the site.
Your cooperation in this matter will be greatly appreciated. If you have any questions, please foel free to
contactthe NCDEQ incident manager, Jeff Welti at [phone] or me at [phone].
Sincerely,
Geological Resources, Inc .•
p~ ... -/4J
William L. Regenthal, P. G.
Project Manager
enclosures
cc: file
3502 Hayes Road o Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax (704) 845•4012
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
The ORC treated socks are scheduled to be installed in December 2017. The socks will be removed
a pproximately 6 months followin g the installation to allow for the completion of the semi-annual sampling event.
Based on the results of the sampli ng event, a determination 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 Subcha pter 02L result from the injection activity.
The socks will be removed a pproximatel y 6 months followin g installation prior to a samplin g event. Following
the com letion of the sam lin event additional socks ma be installe d de endin on the effectiveness of the
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law, that I am familiar with the ieformation 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 15A NCAC 02C 0200 Rules."
Signature of Applicant Print or Type Full Name and Title
PROPERTY OWNER (if the pro perty is not owned b y the permit a pplicant):
"As owner of the property on which the iryection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each iryection 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. 0200)." .
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See attached RTE agreement
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 -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOi Rev. 3-1-2016 Page 5
Oxygen Releasing Compound Application
Perry's Grocery/ Harretl's Guff
Cole rain, Bertie County, North Carolina
Page 2 of 2
Yes, I agree to allow ORC socks to be installed at the Perry's Grocery/ Harrell's Gulf site at no cost
to me.
n No, I will not allow ORC socks to be installed at the Perry's Grocery/ Harrell's Gulf site.
Signature
DOT Section Engineer
/2 z- 53z-4zi�
hone Number
7;13 P mi5/5
ro.z ]'�� G f c c^l oyt. 71/1c a
f'44'Ay 6A.ie-.1 L5 a4-emd y 0's�
/ r7
3502 Hayes Road • flonroe, North Carolina 281 :8
Phone [phone] • [phone] • Fax [phone]
L

October 27, 2017
Herman E. Davidson
1401 Meadow Road
Geological Resources, Inc.
Colerain, North Carolina 27924-9017
RE: Oxygen Release Compound Application
Perry's Grocery/Harrell's Gulf
Intersection of NC Highway 42 & NCSR 1312
Colerain, Bertie County
Incident Nos. 11916/3174/12969
Risk Classification: H190D
GRI Project No. 2518
Dear Mr. Davidson,
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 Perry's Grocery and Harrell's Gulf sites, located at the intersection of NC
Highway 42 & NCSR 1312 in Colerain, Bertie 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 Nos. 6920-80-4624 and 6920-80-2641 in
Hertford County. GRI requests permission to install the treated socks in monitoring wells B-7 and 8-9 at
the site (a site map is attached). The application of the ORC will be monitored for a period of four to six
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. However, if you do not wish for
GRI to install the socks, please call me so I can explain the process further.
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 {252) 946-6481 or me at {888) 870-4133.
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]
Oxygen Releasing Compound Application
Perry's Grocery/Harrell's Gulf
Colerain, Bertie County, North Carolina
Page 2 of 3
Sincerely,
Geological Resources, Inc.
t/,J.:.jb
William Regenthal, P. G.
Project Manager
cc: file
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] e Fax [phone]
Oxygen Releasing Compound Application
Perry's Grocery,Harreit's Gulf
Colerain, Bertie County, North Carolina
Page 3 of 3
Z-Yes, l agree to allow ORC socks to be installed at the Perry's Grocery/Harrell's Gulf Site at no cost
to me.
No, $ will not allow ❑RC socks to be installed at the Perry's Grocery/Harrell's Gulf Site_
Y_1(
a_
Signature Date
(For Parcel Nos. 6920-80-4624 and 6920-80-2641)
r
Phone Number
3502 Hayes Road u Monroe, North Carolina 28110
Phone [phone] c [phone] u Fax [phone]
-72

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF BERTIE
We, the undersigned, being all of the fee simple owners of certain tracts or parcel designated as 6829-89-
8409 of the County of BERTIE, recognizing the benefits to said properties by reason of conducting
subsurface investigations hereby grant to North East Oil Company, Incorporated and the agents the right
to enter said property in accordance with the requirements of the State of North Carolina. North FAst's
agents may include Geological Resources, Inc,
The undersigned hereby covenant and warrant that they are the sole owners of said property; that they
solely have the right to grant this right to enter for conducting subsurface investigations against the lawful
claims of all persons whomsoever-.
It is agreed that North East Oil Company, Incorporated shall be responsible for restoring any damage
done to the ground of said property by its employees or its agents during the subsurface investigation and
monitoring period, and that North East Oil Company, Incorporated shall abandon monitoring welts on
said property in accordance with NCDEQ requirements at the conclusion of the monitoring period.
It is agreed that North East Oil Company, Incorporated shall hold harmless the owner of the
aforementioned property for any personal injury that might be sustained during the course of conducting
or proximately resulting from the conduct of subsurface investigations.
Right to Enter denied.
/1ight to Enter granted.
1,i;tg h ,n - -
Signature
phone : S 7- 33% - (414,5 c)
717
Date
3502 Hayes Road o Monroe, North Carolina 28110
Phone [phone] o (888) 870-4 i 33 0 Fax [phone]

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WELL CONSTRUCTION RECORD (GW-1)
t. Well Contractor lnfonnatton:
Jimmy D. Hines
Well Contractor "lal1)C
4149-B
NC Well Co111111c10rCcrtific11tion Number
Geological Resources, Inc.
Company'lamc · WMQ?Q1176
2. Well COnst.ructlon Permit/#:
UsI nil opplicable well con.s1n1ctfan ptrm/ts (i,t, UIC. Comt!)', Stnte. Varia11c~, ttc.)
3. Well Use (check well use):
Water Supply Well:
D Agri~lmntl t-JMunicipal/Public
□Geothermal {Heatinw"Cooling Supply) □Residentia!Water !:>upply (single)
p lndustrialiC'ommercial QResidential Watet Supply (shared)
;...,Jni m1tion
Noa-Wa"r Suppl~ Well:
~"'1onitoring u .Recovcry
Injection Well:
~Aquifer Recharge □Groundwater Remediation
t}Aquifer Storage and Recovery :}Salinity Burrier
Aquifer T<:st L]Stonnwater Drainage
Experimental Technology Qsubsidence C'ontrol
□Trac.er p,Geothennal (Closed Loop)
Geothermal (Heatin it/C'oolin~ Return ) n other (explnin under #21 Reinarl,;s}
4. Date Well(s) Con1pleted: 04/0S/17 Well lD#MW-15AR
Sa. Well Location:
Perry's Grocery/Harrell's Gulf 0~022919
Faeilit) Owner Name Facility ID# (If applicable)
NC Hwy 24 & SR 1312 Trap/Colerain, NC 27924
Physical Addicss. City ond Ziir
Bertie 6829-89-9531
<"ounty Pa,cel lde1uificatfon Ne (PIN)
. e nnd Ion ltude ·n e tee$/minutes/sewnds or dcciruRl de 5b Latitud g ! d g grc es:
(ifwoll Rold. 0111) lat1ong is sufficient)
36.206222° N 73.869722° w
6. b(are) tbf wellM@Pennanent or QTemporary
7. Is this a repair to llrt existing well: DY c~ or @:-lo
Jf this is o rrpair, JUI ouc kn amt ll'tl/ consInic1ian ieformalion and ~pla/11 1/r,: /la/W'I! ef rht
l'l!pair undtr ~:U nniarks re.aon or ()fl tire bade qfthis/o; m.
8. For tJeoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only I GW-1 i~ needed. Indicate TOTAL NUMBER of wells
drilled:._NIA __________ _
9. Total well depth belo\\; land surface: 12.18 (ft.)
ror nrullipl• mdls list oil depths !f a;Utmrt /e:romp/11• J '" iw· und 2'.!!, JOI/')
10.Staticwater level below top ofcnsing: 3 -13 (ft,)
,(1 HY1ter Je1 -.•I is abo,1e casing. use ·• • ''
U . Borehole diameter: 3 .25 (in .}
12. Well construction method: _H_a_n_d_A_u_g_e_r _______ _
(I.e. auger, rotary caMe d"""r push, etc.)
FOR WATER Sl'PPLY WELi SONLY :
13a. Yield (gpm) _______ '\iJerbod or test: ______ _
PrmtForm
For Internal Use Only:
--------14 WAlfR Z.O:-.Lr,
!'ROM TO DESCRIPTION
10.00 ft, 12.18 fl. Saturation zone
ft. ft,
ts Ol FER C' \SING 1fo1 mlllti-c:.std •1elM OR LI ... ER lit -"111.~btr)
FROM I TO I l>IM1E:l'ER T TIIICKNESS I MAT&:RIAI.
ft. ft. 111.
16 1,NP It ( .\SC'i~ OR l'l Bl'IG ••totbeuaal closed-loo n> -FROM TO DIAllfETER TlllCK.'IESS MATERIAL
0 re. 12 n. 2 In. Sch. 40 PVC
ft. ft •. 111.
17 '>CRFt'I
PltOM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
2 ft. 12.18ft. 2 In, 0.010 Sch. 40 PVC
ft. ft. in.
18 f.ltOt T
FROM TO lllATERIAL EMPLAC£Mil\'1' ME'l'HOI> &: AllfOI '1'
0 ft. 0.5 ft. Cement Grout pour
0.5 !t. 1 ft. Bentoni le chips pour
ft. (t.
19 ',,\,01(,R,4\Ff P\(.((l1hnnJ1citlblo\
FROM TO MATERIAL EMPLACE.',IENT METl-lOO
1 8. 12 .18 ft. #2 Sand pour
ft. ft.
20 DIUU .l',h UK, ••n•,b lddilion1lsbeH'll ti a1cc,-s.u.\)
FRO~l TO Ol!SCRlmON (tolor. ••..t11cu. solVn.k ~. c robl •tu. rt<,\
0 ft. 1 fl. Light Brown Topsoil
1 It. 3 ft. Tan fine sandv cla v
3 ft. 6 ft. Grev-Tan fine sandv ctav
6 ft. 12 ft. Grey Clayey sand
It. rt.
n. n.
n. n.
21 QF\hlU,.~
,.... ,_ , . . .,\Af A,-A
I -rl,_..._,.._. vTR-V1 · ,.,.....,.w '-'I""''"' v • T-
22. Certification:
-0~ ~' 04/24/2017
sr1ur.,enm,;;niractor Date
t· signing this form , I ht1'1!b)' a,rt1li• 1/,at the 11 ¥fl($) ll'IIS (11 .••-.r} cons1111c1ed m accordance
u'ith I .5.4 NC,tt 02(' .()/(/0 or J SA NC',IC O:J.C .I/WO Well C.'o11.Str11cuo11 S1111Kiards and that a
cop_,. ofrhis rtt0rd has been prtntded 10 the 1'VII on·ner.
23. Site lllagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction detail s. You may also atta,;h additional pages if necessary .
SUBMITTAL lN ,SJ:R UCTIONS
24a . for All Wells: Submit this fonn \ ithin 30 days of completion of well
constmction to th, following:
Division of Water Resource$, lnfor!nlltion Processing l'.nit,
1617 Mail Service Center, Raleigh, NC 2769~-1617
l4b. For lpicdion Wells: In addition to sending lhc fonn to the address in 24n
above, also submit one copy of this fonn within 30 days of completion of well
construction to the following :
Division of Water Reso11n:es, Underground Injection Control Program,
1636 Mail Service Centei·, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells: In addition to sending the fonn to
1l1e address(es) above, also submit one copy of this fo,,n within 30 days of
Ll~J:'.b'.:.. ::_D~tsi'.'.'.'~nf~e'.:.'c1::io~n'..:t~n~1e:::=:.======-..'.Arno:::::n:n:::t::_: =======:=..l completion of well construction to the county health department of the "vunty where constructed.
FomtGW-1 i>:otth Carolina Department of'Environmontal Qualilv • Division ofW~tor Rcsoun:'ts Revised 2-22 -20 16
•
LE. CONTRACTOR:
Wen Contractor (In vtdUal) Na o,
Wel Contractor gorppan
13 Raw
,tiy'tre89
RECEIVED NOV 2 3 nog
.1 Y ONRkSPE TI4L WELL voNSTRUiGUON RECORD
Nmili Cerolinatepartroant of Sevironc ant and iaturat Ranntrcos-Diviaioa of Watcr Quality
WELL CONTRACTOR CERTIFXCAT[ON # + dA 79
d, TOP OF CASENo IS D . D FT. Above,Lsnd Surface'
`Top of casing terminated at/or below lend•surrac,e may require
a vurlanCe !f al000rdence writ' t tu4 NCAC 20 ,ai f 8.
City or Town
state • . Zip Code
(a ) 3gg-�oaa
Area cod e Phone number
2. WELL INFORMATION:
.WELL CONSTRUCTION PERMITtt
OTHER ASSOCIATED PERMIT#(Ef eppA )'
SITE WELL ID #(ff appIo ate) ila
3. WELL USE (Cheat On BgrQ Monitoring lAfun[cipaHPublfa L1
lnduslrtatfComrnerdal D Agricultural D Recovery is Injection ❑ :
IrrisatlonOther D (11st use)
DATEbRILLE;D O -",�Qi n�
'4. WELL LQCATh N: _
jiW
i
•
{Street Nerna, Nurobsre,;00,0,47, Supolielon; Led NA„ Pam; 20.
.,, 3 9POGRAF Irr f ),AND rSE ON Q: Inc ap )'
I. YIELD (B _
METHOD OF TEST
f, DISINFEt`.TION:ljrpa Amount
g. WAT@RZONES (daplh);
Top a &Worn 1 . Top Bottom
Tapes Bottom Top Bottom
Top Boat - 'Top Bottom'
• .Thlckneaal •
7, CASING Depth • 0ternater Weigh Material
Bottom - - Ft• $ 5ct� • ri5 "PVC.
Top natiorn
Top Work
Ft. '
Ft.
8.OROLZT: Depth
Top.. _ Bottom b 5 Ft
Tope BoIRnm 1 Ft
Top . BoltonFL
8- 8CRr3E'N: '•Depth r farnetar•'•S1a19Ira: ARtI#atral
T4Ps -- liothori . n.. ?Vt.,..
'OP . - . Bottom, �w r ' .. ,_ .. �r
• :-Ddiope F 3darlkiy : rtFlat xiAldta : pottiO 109J�j1i4C1PAVEL PACK; r . . •
t • LATIT(.10E. 36 ' -.' ? "OMB OR GX.X QCx. 0000t'DD, • : Top J nottorniFt: '- ,5
•
torstOrT:U 76 , . r . :OMB OR :7x,xratxx)atX DD :TaI> i atta
lap Ft• f•
dRIWNG LOO
Top Bot96m
Metertai
r 4 A•
L3htudenongliude source: 1:0PS,;. Dropopreptiie map. • • '
(tocabon of well awed be shown on ('1SQ$ logo map andeit chedt
this' form IfgotiaimaPS) •
5. FACILITY (Name of the buoInaea whore the well 19 located,)
l��lfr1� a
Foci n ' Name Facility Ip# (1 appl[i:abla)
Sttrreet�Address
City or frown
Strata Zip Code
Contact Name
Mslgng Address
City or Town - - State Zip Code
Area code Phone number
8. WELL DETAILS:
a. TOTAL D iP11f: LA 1
b. ODESWELL REPLACE EXISTING WELL?' YES ❑ NO to
C. WATER LEVEL Below Top of Casing: i FT.
• (Elsa'+• If Aboya lop of Casing)
Method
12. REMARKB:
Formation Description
r DO HCRE9YCERTWY THAT THIS WEU WA9 CONSTRUCTED IN ACCORUANCE tePhli
tW NCAC2C, WELL OCr+i8TRriCTION STANDARDS, 1 O THAT A COPY OF THIS
RECA3D H13 sEEN I.ROYrDED TOME 1yELL OWNER. :
4r
SIGNATURE OF CER IFIED W 1, CONTRA001 DATE
PRINTED NAME OF PERSON
NSTRUCTING THE WELL
Silbifllt within 30 da. s of_ o1Pip1aijon to: Divislan.of Water 4paiiiy, - tnformatlan•Processltr8+
3'517 Nfali•Senrfva Center, Ffeldtgh; NC 27.80S461• Phone : (ST9) 807-E 3'fl0
Form f3W.1 b
Rev. 2/09
a �'
4

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ORC Advanced® Technical Description
ORC Advanced is an engineered, oxygen release compound designed specifically
for enhanced, in Situ aerobic blaremediation of petroleum hydrocarbons in grourid-
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 Example of ORC Advanced
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 hydrocarbon contamination is often associated with retail
petroleum service stations resulting from leaking underground storage tanks, piping and dispensers. As a result,
ORC Advanced technology and applications have been tailored around the remediation needs of the retail petroleum
industry and include: tank pit excavations, amending and mixing wit backfili, direct -injection bore -hole backfill,
ORC Advanced Pellets for waterless and dustless applcatian, combined iSCO and bioremediation applications, etc.
For a list of treatable contaminants with the use of ORC Advanced, view the Range of- Cnntarinantj Thiirie
Chemical Composition
• Calcium hydroxide oxide
• Calcium hydroxide
• Monopotassium phosphate
▪ ❑ipotassium phosphate
Properties
a Physic:l state: Solid
• Form: Powder
• Odor: Odorless
• Colon'Vhite to pale yellow
• pH: 12.5 (3% suspension/water)

0RC Advanced' Technical Description
Storage and Handling Guidelines
Storage
S+ur ? in d C0o1 dry placP L ut of Cirect atrnlight
to-,± in orrz ik=i tr ;htly 1•34-: t cont.. ac-•
5t,, e in a well -ventilated ;glare
[)-� , ,•�r s.,r� rlu3rr 3rr:l.+ r��ib1� m�it n Ir
!lore awav from incompatible materials
o►,iJc il..ror-,r:1Le _'1 IIi I►l,�; I,S
•.'herk t.st Is fo---r d
Applications
•
AO `01:212
Handling
minimize dust eener3tion and accu Iiulat3on
ht a.
Routine housckkepirtg chouid be institute=l to
e is • rre that du4L due., riot accumulate vn �ur€,ices
bsc- e g 'd Ire iu5triyl fib* e •e orr..l s. es
Tai precaution Lo avoid ,nixing with crJmbii i rle,
s.ep ,i va y f i orn . Lfrts Trig aryl 0 re. cji nb' 14 r tt►l'}
i nat -rrai s
A,c ir! contact with eater Irioistl rrp
Hu�rS:J Ltu'i:9i 1 ri 1 H •i-, :v+Ir. r•r Id L Ir i '» r+.;
A+ nid prolonys1zA exxcrtire r y5
r *F'ar e�f�. vol t pP,son_ii rjl�i, ~r ti et egLklorn r l
• Slurry mixture direct -push injection through hollow rods or direct -placement into boreholes
• in situ ar ex situ slurry mixture into contaminated backfill or contaminated soils in general
• Slurry mixture injections in conjunction with chemical oxidants like RegenQx or PersulfOx
• Filter sock applica.ions in groundwater for highly localized treatment
• Ex situ bioplies
Health and Safety
Wash thoroughly after handling. Wear protective gloves, eye protection, and face protection. Please review the
9RC Arivanrrrl Sarty Data Sheet For additional storage, usage. and handling requirements.
t :GEP'5i5`
•
ins. f t..omora..4" C. - e e :
• i I l . I, R..N.56 2 d V.
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GROCERY
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MW— 10
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FORMER COMM. UST's
EXCAVATION LIMITS
MW-5
NOTE: SFTE MAP BASED ON MAP PREPARED BY COASTAL ENVIRONMENTAL SERVICES, INC., DATED 3-6-97.
TRIANGLE
ENV{RONMENTAL
INC.
RA E} H. N.C,
CHARLOTTE, N.C.
FIGURE 4
SOIL SAMPLE LOCATION MAP
PERRY'S GROCERY
PROJECT NUMBER: TF615-4317
BATCHRLE: HOGGARO.BAT CA0FILE: PLAN.PRO MACROF1LE FIC4,I4AC
DATE ALA17EOo 6--S0-97

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0 50
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1+00
2+00
TRIANGLE
ENVIRONMENTAL.
INC.
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CHARL0TTE N.C.
32
FIGURE 6
CROSS SECTION TRACE A - A'
PERRY'S GROCERY
PROJECT NUMBER TF615-4317
BATCHFILE HOGOARD.BAT COALE: PLAN -PRO MACROME: F1CS:MAC
DATE PLOTTED: 6-10-97

NOTE: SITE MAP BASED ON MAP PREPARED BY COASTAL ENVIRONMENTAL SERVICES, INC., DATED 3—B-97.
TEMPORARY WELL
-
TW-1 (ABANDONED)
+B-7
+M1 FIRE
I DEPT. B-1
(DESTROYED)
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US? MW-4
.,Atior--....0,
ORMER PERRY'S
GROCERY EXCAVATIO
•MW-7
+MW-6
8-19
B-24
MW-2
MW-10
FORMER COMM. UST's
A'
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N.C. 42 R/w
RlW
q.
LEGEND
MW , MONITORING WELL —SHALLOW
MW MONITORING WELL —TELESCOPING
❑n D.W. DOMESTIC WELL
❑ INTERCEPTION TRENCH RECOVERY WELL
GRAPHIC SCALE 1"=50'
0 50'
TRIANGLE
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RALE!GH. H.G.
INC, CHARLOTTE. N.C.
FIGURE 5
CROSS SECTION MAP
PERRY'S GROCERY
PROJECT NUMBER: TF615-4317
BATCHFLE PERRYS.SAT CAEFRLE PLAN.PRO L(ACROFILE: FIGS.MAC GATE PLOTTED: 8-10-97

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Dotes 04/20/17 Drawn by
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