WI0700474_DEEMED FILES_20180608

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0700474
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Todd's Service Center/ Bowen's Grocery·
Location Address
US Hwy 17 NC Hwy 45
Merry Hill NC
Owner
Owner Name
North East Oil Company Inc
Dates/Events
Orig Issue
6/7/2018
App Received
5/22/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27957
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
6/8/2018
Permit Tracking Slip
Status
Active
Version
1.00
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
Bertie
NC
Issue
617/2018
Effective
6/7/2018
27910138
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
North Carolina Department of Environmental Quality -Division of Water Resources
NOTIFICATION OF INTENT (NOi) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are "permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of JSA NCAC 02C .0200. This form shall be submitted at least 2 WEEKS prior to injection.
AQUIFER TEST WELLS C15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION C15A NCAC 02C .0225) or TRACER WELLS Cl5A 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 tr:eatment aireas exceeding 10,000 square feet.
3) Pilot Tests -Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order to develop a full scale remediation plan for future implementation, and where the
surface area of the injection zone wells are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: =M=ae.J.y~1=8 __ _,, 20 18 PERMIT NO. W1 O:J-(J O lf::J-lf-(to be filled in byDWR)
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
=X~ __ Passive Injection System ............................... Complete sections B through F, H-N
___ Small-Scale Injection Operation ...................... Complete sections B through N
___ Pilot Test ................................................. Complete sections B through N
___ Tracer Injection Well ................................... Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
C. WELL OWNER(S) -State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): North East Oil Company, 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
EMAIL Address:NA FaxNo.: NA
Deemed Permitted GW Remediation NOI Rev. 3-1-20 I 6
.cCl:.IVEu/NCUEU/UV\
MAY 2 2 2018
Water Quality Regional
.:)oerations S ction
Page I
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Greenwood Acres , LLC.
Company Name NA
Mailing Address: Post Office Box 328
City: Colerain State: NC Zip Code: 27924 County: Bertie
Cell No.: Day Tele No.: ___________ _ ------------
EMAIL Address: _____________ _ Fax No.: ___________ _
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Holden McClenney
Company Name Geolo gical Resources , Inc.
Mailing Address: 3502 Hayes Road
City: Monroe State: NC_ Zip Code: 28110 County: Union
Day Tele No.: 704-698-1250 Cell No.: __________ _
EMAIL Address: hwm@geolo gi calresourcesinc.com Fax No.: 252-321-6094
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Todd's Service Center/Bowen's Groce ry
US Highway 17 and NC Highway 45.
City: Meny Hill County: Bertie Zip Code: 27957
(2) Geographic Coordinates: Latitude**: ___ 0 ____ " or ~0 .0337037
Longitude**: 0 "or ~0 .7853227
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(::: 10,000 ft 2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be::: 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.
Deemed Permitted GW Remediation NOI Rev. 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-lA. MW-2 , MW-4 , MW-15 and MW-29 in
June 2018. A ground water sam pling event will be conducted on the a 1>plicable monitorin g wells in November
2018 in order to determine the effectiveness of the ORC socks. Based on the results of the September/October
2018 sam plin g event. a determination will be made whether the a pp lication ofORC will continue.
J. APPROVED INJECT ANTS -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
Services can be injected. Approved injectants can be found online at h ttp ://de g.nc .g ov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ ground-water-protection/ ground-water-approved-in j ectants.
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 S pecification Sheets
Volume of injectant: 12oz/foot
Concentration at point of injection: 36oz
Percent if in a mixture with other injectants: NA
Injectant:
Volume of injectant: _____________________________ _
Concentration at point of injection:
Percent if in a mixture with other injectants:
lnjectant:
Volume ofinjectant: _____________________________ _
Concentration at point of injection: _______________________ _
Percent if in a mixture with other injectants: ____________________ _
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: _____ Proposed_i_Existing (provide GW-ls)
(2) For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as-built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(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 NO! 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 June 2018. The socks will be removed in November
2018 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 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 November 2018 prior to the sampling event. Following the completion of the
sampling event. additional socks may be installed. depending on the effectiveness of the socks.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law. that I am familiar with the information submitted in this
document and all attachments thereto and that, based an my inquiry ofthose 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 Me possibility of fares 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
,vdt i /rec 4'ii ey 071(scre.h4
Print or Type Full Name and Title
PROPERTY OWNER (if the property is not owned by the permit applicant):
"As owner of the property an 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 .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.
' i t r We ,i Aiessrd �!� 1 �. ,pea. zerf
Signature'" of Property Owner (if different from applicant)
Print or Type Full Name a� 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 Mall Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Pemurted OW Remediation NO1 Rev. 3-1-2016 Page 4

North Caroflna - Department of Environment. Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27626.0535
Phone (919j 733-3221
WELL CONSTRUCTION RECORD rrlo.41.,,2i)
DRILLING CONTRACTOR: C f'5.41- rta�srtir•n it
DRILLER REGISTRATION NUMBER: 13‘11
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO
Lot Long. RC
Minor Basin
Basin Cods
Header BM_ GM Ent
STATE WELL CONSTRUCTION _
PERMIT NUMBER: ‘..-3m `15 1
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town. M►Q--YCounty: ( L*(tn vO
Rarrtz c' flab RIM: e 46
(Road, Corrim uity, or Subdiwiston and Lot No.)
2. OWNER Leer.1 r s' Sac.
ADDRESG P.0 fax '3
(Street or Route No.)
Clay or Town State Tp Code
3. DATE DRILLED 8 USE OF WELL (••+t>•a, i..,.r►.
+4. TOTAL DEPTH four
5. CUTTINGS COLLECTED YES ® NO❑�-
6. DOES WELL REPLACE EXISTING WELL? YES [] NO®
7. STATIC WATER LEVEL Below Top of Casing: FT. '.?, PS -
Noe '+" If Above Top of Casing)
8. TOP OF CASING IS FT. Above Land Surfaced'
easing Terminated Deer below lend surface Is Iilepet unreel a winos nos Is issued
In accordance with ISA NCAC 2C .Dill a�c6
9. YIELD (Qpm) METHOD OF TEST 3 3
10. WATER ZONES (depth)
DEPTH
From To
Q 3
3 -
1'L
iPCS
11. CHLORINATION: Type Amount
12. CASING:
From
From
Watt Thickness
Depth _ Diameter or Weight/Ft, eerie
To Ft.
From
13. GROUT:
To - Ft.
To Ft.
Depth
From f_ To a' Ft
From To Ft. .. .
14. SCREEN:
Material
Met 1./64
Method
_Depth Diameter Slot Size Material
From +P5 To S Ft g In 0 oro in Sc. MO PJ
From To - Ft in. In.
From To Ft. In. In.
15. SAND/GRAVEL PACK
Depth Size Material
From To 5 Ft. 11:20a4 .5rm,
From To Ft.
16. REMARKS:
DRILLING LOG
Permian Description
LT 0ae. d.s r ,swb + ,�
i.Slerve (L.
Lbvir Ortguet
Lr 4:403. .)
Lr t3Ta...s7 Fade c
Scr.Z 1%21+1
te Si
t.r ep,a- -) Fie rrt 5930
tsi.s 51..7' & C►a..1 LT- en4 F'4 rr'f .5p.i�]
l�f1F- ertw F L"'AD
tt Fib -al 101 .50h)
if additional apace fa needed use back of farm
LOCATION SKETCH
(Show direction and distance from at least two State
Roads, or other map reference points)
$ �"ax co
sums
REEDINCE
_ t�tlLVMw �r_ T
APRKEIDMIli
011171tiRESCURCI
asIV1SwAY
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C, WELL
CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GW I REV. O 1
"In iqg
SIGNATURE OF CONTRACTOR OR AGENT DATE
Subrnit original to division of Environmental Mnnagomem end ropy tow all owner.

North Carolina - Department of Environment, Health, and Natural Resources
Division of Environmental Management - Groundwater Section
P.O. Box 29535 - Raleigh, N.C. 27926-0535
Phone [phone]
WELL CONSTRUCTION RECORD 11-1,,j.r‘s—
DRILLING CONTRACTOR: COP&ITIL LE .ti,`I+rzorInlie+arni+--
STATE WELL CONSTRUCTION
DRILLER REGISTRATION NUMBER; 1 .6" 1 PERMIT NUMBER: LP.] re-1 U-or Uo 1►�
FOR OFFICE USE ONLY
QUAD. NO. SERIAL NO
Lat Long. RO
Minor Basin
Elwin Code
Hinder Ent EIW-1 Ent.
1. WELL LOCATION: (Show sketch of the location below)
Nearest Town: t'"31"'S County: Caktant
7L.1Tt?tbrperu. of (RAJ(Zaire yS (TatoOy
(Road, Community. or Subdlvlakm and Lot No.)
2. OWNER tin3wa o_.5 rr.sc,
ADDRESS f O. QOx ►at
(Street or Rouse No.)
(.;Hci�tit r•jG rplllV
City or Town State Zip Code
3. DATE DRILLED i 21115T USE OF WELL Cv10"3.rorz,..3C.
4. TOTAL DEPTH Fa r�
5. CUTTINGS COLLECTED VES NOD
5. DOES WELL REPLACE EXIST] G WELL? YES ❑ NO® - 1
7. STATIC WATER LEVEL Below Top of Casing: Iii. a' FT.
(Use '+ 11 Above Top of Casing)
8. TOP OF CASING 1S FT. Above Land Surface`
Casing Terminated attar below lend surface la Illegal unless a variance la issued
In accordance with 15A NCAC 20 .C118
9. YIELD (gpm). METHOD OF TEST
10. WATER ZONES (depth)'
6w/A v.46.
DEPTH
From To
0
5
S
11. CHLORINATION: Type Amount
12. CASING: •
From C)
From
Depth _To-1$
To
Diameter
Ft. g'+...5cw
Ft
FromTo Ft.
13. GROUT:
DRILLING LOG
Fgrmatfon oeseription
Tra...)16a-.1,,.I &LT
esna x.ea"
Th-.
enc-Ok an
Tn F,..yt w,LI
If additional space is needed use back of form
Walt Thicluwss
or Weight/FL Material
CS.1►511" &._14 Rin WC
Deptts �j Material Method
From To t Ft. ► acT7< }1 Qo.krL.
From To Ft.
14. SCREEN:
Depth Diameter Slot Size Material
From 1$ To .9% Ft 9 in a, a'‘) i 1 SGH Ma
From To Ft. In. in
From To Ft. in. In.
15. SAND/GRAVEL PACK:
Depth Size Material
From I U To ;048 Ft. Too,putio avv re 5r3.sD
From To Ft.
16. REMARKS:
LOCATION SKETCH
KM
r
• Otaa~Pr no0pittu 713J. war
• p..Sq .04 t
stit44'
..at
tttbM
maw
MOM nn
attitit
•
� ..
.
ucas.ml MORI
-14 MI
0.1. ens 1!
a w
vn
azaa
]
--
SITE PW.
COASTAL EfMROHNENrA
sCRVICEs, ?NC,
q2
S[k uM: roENYS SER. CENTS
WART HLL. N•C,
aim MARCH 4, 1996
5
I DO HEREBY CERTIFY THAT 'THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS, AND THAT A COPY CF THIS RECORD HAS BEEN PROVIDED TO THE WELL OWNER.
GW-1 REV, 9191
SIGNATURE OF CONTRACTOR OR AGENT
Submit orfginel to Division of Environmental Management and copy to weft owner.
DATE

North Catalina - Department of Errvircr+mert, Health, and Natural Res.^uras
C v;avn of Environmental Management -Groundwater S9 ..an
P.O. Bar 25535- Raleigh, N.C. 27525-0535
Phone (gt9) 7.33-0Z2t
WE'_L CONSTRUCTION RECORD
URK ING CQt TRACT`:7R: 5
CHILLER REGISTRATIc fI UUMSE:i: 13 (/
/4 4i—E
FGECM'OF OFT -ICE j5E CftY
OUAD. NO 5527/AL t+X}.�_
Lit Um.. —
Mnor $aa n
Ea
Header Erie
STATE WELL, CONSTRUCTION
PERMIT NUMHEE:
1. WELL LCCATION: 5ket.'"1 of the kacLian below)
Nearest Town: _ 1-1-.i - County_ e ri`, e'
r 1, 5 . /Kt.
(Road, Comte niry. or E. •'x*rriwcv, and Lot tic.}
2 OWNER 1a 5 rrorr .4 'Pi,
AOOFtES} P.O.',(,v13 r6
{Street at Route fdo.)
AO k,'ll,'_ kJ
Ccty ar Inver' State Zp Coda
3. DATE DRILLED q /'.. USE OF WELL
4. TOTAL DEPTH '15.+ 2' .
5. CUTTINGS COLLECTF"D YES Fzi NOD
WELL
5. CC ES RErLAC` EXISTING WELL? YES Ej NO2
7. $ TAT1C WATER LEVfi_ Eeiow Top of Crsing: PT.
•
.Move Top of Casing)
$. TOP OF CASING IS FT. Above Land Sot —race`
• Casing Tormfnsted auor beta--, Lend surface fa nag-1 unLeas a verfenca fs fs_u d
!tt acrardanr_vwith i$A NCAr; 2C
Y«D (Stpm)- ME: 7rHCD OF T S T
11:. WATER ZONES (dept' o ):
11. CHVCRIA7ATION: T; Amount
12. CASING: -
Depth
From 0 .0 To f FL
From To FL
From
13_ GRCiUT:
'Fran: Q .0
To — R.
Warr
Ci.arna*r pee Weight/Vt. Material
Depth Materi I Method
To . 6 ") FL , d t ffati life 'F;;)
Frorn To
14. SCREENl:
Depth
SCREE::
Ta
Ta
To
15. SAND/GRAVEL PACK
Depth
• (5 To
From
From
From
Frorn To FL
16. REMARKS:
0 Ft .2-•D
Ft.
FL
FL
DiameterDiaeter Slot Size Material
0.044 in ,Sc.k. rrrf'FVC
its,
in. rn.
in. . in
Size tvlIeridi
• From ' . f) Ft_ OA 5a .tip
DEPTH
From 7'a
6.n' 2.t9'
6,.ar to •or
r •Q' (4.Q'
1.4-•t;'
La'
•
It additional space is needed use bads of fore
LOCATION SKETCH
{Shaw direction and dstar•.ce !ram at fear: two S- ,
Roads, or other map reference ¢cross)
1 DO HEREBY CERTIFY 'THAT THIS WELL WAS CQNSTFIUCTED !N ACCORDANCE WITH I5A NCAC 2C, WELL
CONSTRUCTION TAB DAFiDS. AND T EIAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL CWN T4.
SIG' k.TuFiECF CONTRACTOR OR AGENT
S+s'm s or1171141to Oivh:ors of Ervironrr+enrat Managemern arsd copy to weft ownor.

tartans - Depar:merrt ci Environment, 1 ie:tl:h, and ih $ aural Fe .cure
• Division of Envircnmenfa1 Management - Grntutewrier Sedan FOR OFFGc USE Ct y
P.O. Box 29535 - Raleigh, N.C. 275254535 CIJAt]. NO SERALNO.
;v. phone (91) 733JV21 Lai Long _ •
Minix $J.Sin
WELL CONSTRUCTION RECORD c
DRILLING CGtirmet TCR: (4 G y A M Ini -• 2. irascler Ent
-r STATE WELL CONSTRUCTION
GRILLER REGrSTRAT1ON NI -MISER:. 1 h �1 l PERMIT NUMBER:
1. WELL LOCA T i r : (Show skate' of the Iocran below)
• Nearest Tcwn: +d r+r �-�t Cannrc L* t r
S. Imo. 17
(Read, Carrrirurtiry, or Str' icn arid L, t Na.)
2 OWNER _r__Jr.n.. FILG (S r ' r-C•.
ADDRESS P. a 3c r r 314.
(Street ar Route Nn.)
Ic.,Sa
Cty arrows Stare Z--7 Code
3. DATE DRILLED V ' 2-1-`f 44 USE OF WELL (c,r; *c n [
4. TOTAL DEPTH 3. O•
S. CIJTTlNGS COLLECTED YES jY - NO El
6. DOES WELL. REPLACE EXISTING WELL? YES [l NO
7. STATIC WATER LEVEL Below Top of Casing: FT,
(Ur.a '+' it Above Tap at CarSng)
e. TOP CF CASING IS FT. Above Land Surface'
'Ca Jng i.rmInatad odor below land surface la Meg& unt.ze a variance Is Issued
In a=rd'anest with 15A',MAC SC .0-1T13
9. YIELD (gprn) MFT HGO CF TEST
10. WATER ZONES (depth):
DEPTH DRILLING LC.
From To F rkn4 _
O. 0' 1. a' 'Dr k:16►,a„ ?.
t• Q I S.O n 70,k o,a�/ F 5
I .;
.a' Il, Q' 'Veflow 6,..., ,
F.s.'2,1 Y s • lT
11.t]' 15.0' an Gam. 5•.liy
I Or 20•0' Ye '(w _5. ley cn
2O4' 25.0' Ve (Iaw ?ve_ 3r0..; .
o..t.;
11. CHLORINATION: Type AI iount If adcitional space is needed use back cf form
12. CASING: •
readThckness LOCATION SKETCH
Dep0 , Ocernewr or wr;5harFtf Material (Shaw direction arrd dance from at toast..o S"., a
From 0.0 To 1'D' CIF' `r . r 5 E(' S.' . YD 9YC Fioads, or other map reference poitrs)
From To FL
From To FL
—
13. GROUT:
Depth � Materi-I Method
From ti • 0 To t - a FL fro?' f a.A,4Tye'd Z r
From . Ta _ FL
14. SCREEN:
Depth Diameter Slot Size Material
From i .O To 25•0Ft.2•°" in. .0•OrD insel, c40?VC.-
Fro
m TO FL in, in
From To Ft in. in
15. SAND/GRAVEL PACK -
Depth _Size Material
From -l3.0 To - •Q Pr IDrQ 49 17.. �
From To Fc.
16. REMARKS:
I ❑O HERESY CERTIFY THAT Ti-ifs WELL WAS CONSTRUCTED IN ACCORDANCE WITH• 15A NCAC 2C. WELL
CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS RECORD HAS BEEN PROVIDED TO THE WELL OW F—
GW.i REV. sr94
SIGNATURE CF CCIITPACTOR OR AGENT
5.. nit originat b Divt:ion of Environment,! Manasemerrt and ccpyr welt owner,
oAT

Yet
❑EF'TH DRILLINGLC
From To Forr-a&re
0.0 3.0 ` a
3. o e Now rd i
S•G:t4TJ CC.o rrsACTORORAGENt
GW- I REV. 5131 I]1v.ion of emiconmentat Management and campy weEI o-oe _
Aicrh Care rta • ❑epartmect cf Err:Ir:,omen% Health, arc'. ,:axsral Reizeurets
Civi an ct Environmental h'tanagerner 1. - Graundvratar Sed!on FCR CFFiCE U C :EX
P.O. 6cx 2q4° • Raleigh, N.'-.. 27525-0S?S QUAD. UO. SaRLAL.
Phone PI ) 723 t Lot try. •�
WELL: CONSTRUCTION RECORD sAi
Basin
DRILL IPiG CCIITRACTCH: Nt<iF4.1cSert�rc c::
STATE WELL. CONSTRUCTION
DRILLER REGISTRATION NUMBER:- I t„I [ PERMIT NUMBER:
1. WEUL LCCATtQN: (5hcw sketch cf the +cry ct below.)
Nave: Towr>: tu. + Caurty: It r
5. R7 I-1
(road, comma 4. or St.dziv an and Ln t No.)
2. OWNER �o- s t et' it- �t.�( S
ACDPES 7 P. O. Ea e r 3"1" C.
(Street or R.aute No.J
Z44,sk;e )1,1C 1is 1 ❑ ^y / - -
ccy or moil Matotp C eo 3. 0 f • 0 yakl !0. y z, <,
3- DATEDRILLED -2"I-S£1 USE OF WELL RAC -f e;n `
4. TOTAL DEPTH Q.5 . in '
S. CUTTINGS COLLECTED s '- ®- No❑ 50.0.01 y s.-(
6 DOES WELL f REPL4CE EXISTING WELL? YES 7 ND ® ID' 174r -ET,A Oro y ..5;1.4
7. STATIC WATER LEVEL Ee!aw Tup 0(Cas;ng: Fr. • -7. a ' 2/. u' lief f o w' 5, /'iy J
(use '« it Atc'ra Tap of Casn )
8. TOP OF CASING IS FT. Above Lend Surface'
•Ctsfng Terminated st'crbelow fend surface rs r1[eCai t:ntaas a rar?anca fa Tested
(n a=ardarrca with 7SA RCA C :C . 118
9. YIELD (gpm)' N1E17-10D OF TEST
10. WATER ZONES (depth):
26.0: Ve((ow r' o-rti
11. CHLORfNA T IQN: Type Ar7itunt tf additional spa is needed use acc of fa:..
12- CASING:-
waif 17 ickrwcs LOCATION S;C. i� CH
Depth Ciarrr.te' or'sv.4•ItrFL hia:erial (Shaw direction and distance from at leas::.+a ST-,1
From 4' 6 To 15' FL "0 '6 • r.6 °! .Sr L.4❑ ?'JC Roads, ar other wrap reference poin:sj
From To Ft,
From To FL
1.3. GROUT:
Depth Ma[erij_ Method
Front O.0 To r i • 0 Ft foci lr,M,0tvpe 1 ?¢ur
From To FL
14. SCREEN:
Depth Diame[er 51ot Size Material
From tE• G To 2 5.0 Ft . .4'' in. 0. Or 0 in SO-40 r NG
From To FL in. in
From To FL in. its.
15. SANCiGR.AVEL PACK
Depth Size I�taterdJ
Frani 13 .0 To ':_
0 FL I o 1 i aIA. LfAl . • 5a.d
From To FL
16. REMMIXS:
I DO HERE3'( CERTIFY 71-1A T i rilS WELL WAS CONSTRUCTED IN ACCORDANCE WEN 1SA NCAC 2C. WELL
CONSTFiLICTION STANOASDS, AND THAT T A COPY OF THJS RECORD HAS SEEr‘t PROVIDED TO THE 1 :IL OwNr- -
6 -3-9�1
DA77.

OXYGEN
RELEASE
ORC Advanced® Technical Description
ORC Advanced is an engineered, oxygen release compound designed specifically
for enhanced, in situ aerobic bioremediation 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, CRC 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 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 rernediation needs of the retail petroleum
industry and include: tank pit excavations, amending and mixing wit) backfdl, direct -injection. bore -hole backfill,
ORC Advanced Pellets for waterless and dustless application, combined ISCO and bioremediation applications, etc.
Example of ORC Advanced
For a list of treatable contaminants with the use of ORC Advanced, view the Ra ge of Treatable Contaminants
Chemical Composition
• Calcium hydroxide oxide
• Calcium hydroxide
• Monopotassium phosphate
• Dipotassium phosphate
Properties
• Physical 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
Stor:• in a cool clry place uut of eirect sunlight
Sto- e in origrroI tightly i 1q4= •i cont !..ier
Stole in a well -ventilated place
Do silt Si!3rC rF�'_3r ; ornIA icrible ma��ri ll�
Store away from int-nmpatilble materials
P.ovltle , ]roprc { Le e::i •'i sf in plor t",
.4-sere dust I:, tor-"- d
Applications
Handling
Minimize dust generation and ac.cu,nulattan
Leer: D+ oay : "OITi tit a:.
Routine housc.kr:epll rg should be i,lsbtuterl to
err,` Ire that dust. due, 5 riot accumulate urt surfaces
FJbsefve gue)d irdustr►7I hvLe:,e F)ra:.n. es
Taw., precaution nu avoid mixing Leith combushilile..
r.eep a ray tram .Iitbing anti cite' comb. icnble
matt -Talc
Avoid contact with water :i' d moist ire
Avg -Ad Col`ot,'i ! rt+ a 'P'i tii id lr. I;llr:g
A� nid i rolonw d ex3ccure
Wear ant., uor latt. personal proter tree egrrlpltla r r1
• Slurry mixture direct -push injection through hollow rods or direct -placement Into boreholes
• In situ or ex situ slurry mixture into contaminated backflll 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
ORC Advanrrsi Safety Oath Sheet for additional storage, usage, and handling requirements,
} REGENESIS
..wq.
1011 [ IF_ Scinma -4n Cie tr .g ;
r R' AN:51. 3 d U ..• 1 r a 4 IF-1 iw 1. L.,s EK .n f• •1 F 9 • :r r 1 . L.• f

.4EGEND
• TYPE 11 MONITORING WELL
• TYPE Ill MONITORING WEL1
DESTROYED MONITORING FFELL
th OBSERVA 170N WELL
O AIR SPARGING KELL
o SOIL VAPOR EVRAOPON NfLL
® WA 1ER SUPPLY WELL
—w— WATER LINE
— v — UNDERGROUND TELEPHONE LINE
— • — OYERNEAD ELECTRIC LINE
• POWER POLE'
—•• — DITCH
BENZEVE
flW'LIFO
5NZE7VE
MINE
NAPNTNALENE
CONARv7RA7ICWs Av py/L
sA 7.1 LESS MAN 771E ,iit7NOCI GX7rcnuv LIMY
AV 77,E EA5LWA7MY RfPA'r
£577VA7£D VAGUE'
Ns Nor SAMPLED
CCAYCZYTIE4 A7VS AY BOW FACE rYPE EXIZEI7E0
7HE $ STAADA1DS
\ MW-21
MW -23A
9,15
CQ,13
CQ13
iY- 25
Jf
\
MW--37
PERRY WELL/WSW-8
tm.
DOW ifELL/WSW-5\
WSFY-18
i
/% MFV
MW-47
MW -34
11 • 46
Agricultural Field
MW-38
WSW-7J
❑o
Vegetation
Geological Resources, Inc.
0 50 WO 200
(IN FEET)
1 inch = 100 ft
GROUND WATER QUALITY MAP (07/12/17)
Todds/8owen's 104-104 NC-45
Incident No. 11963 Merry. NY,, Bartle County.
GW Project Na. 2458 NC
Dote: 08/22/17
Drawn by.
DTH
Figure'

\ mite-2/
MH-24
-G15
$v W• -23A • MW-4
SV--1
7W-1A1
W-1M0 MW--22
MW-39
O
WD-f:
0
OW-1
pute5W-2
MW`T
0./t1 eM� 19 eAMW�-73
0 2ti1H W-1 1W-27
\
LEGENO
O TYPE II MONITORING WELL
2 TYPE I11 MONITORING WELL
0ES)ROYED MONITORING HELL
® 005ERVATTON WELL
O AIR SPARCINC WELL
O SOIL VAPOR EXTRAC77ON WELL
Ei HATER SUPPLY WELL
—w— WA7ER LINE
— — UNDERGROUND TELEPHONE LINE
— a - OPERHEAD ELECTRIC LINE
• POWER POLE
— . — DITC711
Note. -
This Site Mop is based on ❑ Site Plop doted
November 15, 2003 that was completed by
CIS Engineering, Inc.
rMW�-.3.3
z
M -255
/
MW-40
MW-29
MW-44
a
MW-32
0
PERRY WELL iWSW -6
OOND WELL/W5W-5\
®
! MW-31
0
/
\
/
W-.30A
A1W-45
/
/
MW-47
MW -35 M OJ5
i11i01-46
Agricultural Field
WSW-13
Vegetation
Geological Resources, Inc.
p 50 100 200
(IN FEET)
7 inch = 100 ft
S/7E MAP
Todd's//awen's
Incident No. 11953
GRI Project No. 2458
WOO-104 NC-45
Merry HI]`/, 5ertie County,
NC
Date:
08/15/17
Drown by.
Figura. 3