WI0700475_DEEMED FILES_20180727

D~
North Carolina Department of Environmental Quality -Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number wro 7oo475
I. Permit Information
North East Oil Companty, Inc.
Permittee
Miller's Country Store
Facility Name
1706 US Hwy 17 N, Merry Hill, Bertie County
Facility Address (include County)
2 . Injection Contractor Information
Geological Resources, Inc.
Injection Contractor/ Company Name
Street Address 3502 Hayes Road
Monroe NC
City State
~ 845-4010
Area code -Phone number
3 . Well Information
WdiOe.olNCDE
Zip Code
JU( 2·7 2018
, Water Ouality
Regfonet OP8ratJons
Number of wells used for injection _3 ___ _
Well IDs MW-IM, MW-3M, TW-lM
Were any new wells installed during this injection
event? .-./ D Yes ~ No
If yes, please provide the following information:
Number .of Monitoring Wells _____ _
Number of Injection Wells. _______ _
IxPe of Well Installed (Check applicable type): U Bored D Drilled O Direct-Push D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for eaclr
well installed.
Were any wells abandoned during this injection
event?
D Yes ~No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number oflnjection Wells. ______ _
Please include a copy of the GW-30 for each well
abandoned.
4. Injectant Information
Regenesis ORC-A treated 2" socks
lnjectant(s) Type (can use separate additional sheets
if necessary
MW-lM-6 socks; MW-3M -6 socks
Concentration TW-1 M -12 socks
If the injectant is diluted please indicate the source
dilution fluid. NA ------------
Total Volume Injected (gal)_N_A ______ _
Volume Injected per well (gal)_N_A _____ _
5. Injection History
Injection date(s)._0_7_!_25_1_1_8 _______ _
1 Injection number (e.g. 3 of 5). ______ _
Is this the last injection atthis site? 0 Yes E(No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS L 'OUT IN THE PERMIT.
~ 07/27/18
DATE
William Regenthal, P. G.
PERFORMING TH JECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection. Fonn UIC-IER Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464 Rev. 3-1-2016
Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0700475
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
MIiiers Country Store
l_ocation Address
1706 US Hwy 17n
Merry Hill
Owner
Owner Name
North East Oil Company Inc
Dates/Events
NC
Orig Issue
7/3/2018
App Received
7/2/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27957
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
7/3/2018
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
7/3/2018
Effective
7/3/2018
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 15A NCAC 02C .0200. This torn shall be submitted at Least 2 WEEKS prior to infection.
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncoil aminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229i:
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. Illegible Submittals Will Be Returned As Incomplete.
DATE: May 18 , 20 18
PERMIT NO. i- 'u - 4-( (1 - `' , (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well
(2) Aquifer Test Well
(3) X Passive Injection System
(4)
(5)
(6)
.Complete sections B through F, K, N
Complete sections B through F, K, N
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: CCEIvED,C,N
Name(s): North East Oil Company, Inc. J ! { N
Mailing Address: Post Office Box 1386
City. Ahoskie State: NC Zip Code:27910 County:Hertfford
Day Te1e No.: 252-862-0236 Cell No.: NA
EMAIL Address:NA Fax No.: NA
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page l
' Jtetir �t9.
-1Rr-�tl

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Shirley Miller
Company Name NA
Mailing Address: 2105 US Highway 17 N
City; Merry Hill State: NC Zip Code: 27957 County: Bettie
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: Holden McClenney
Company Name Geological Resoureestinc.
Mailing Address: 3502 Hayes Road
City: Monroe State: NC_ Zip Code: 28110 County: Union
Day Tele No.: 704-698-1250 Cell No.:
EMAIL Address: hwrnio ceolo2icalresourcesinc.com Fax No.: 252-321-6094
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Millers Country Store
1706 US HiehwaN 17 N
City: Merry Hill County: Bertie Zip Code: 27957
(2) Geographic Coordinates: Latitude**: ° " or 36°.0337437
Longitude**: 0 " or 76°.785819
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 ofinj. well network: square feet (5 10,000 f12 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 -sections) 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 Page 2

I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES -Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
Oxye:en Release Com pound Treated socks will be placed in MW-1. MW-3M , TW-1 and MW-22 in June 2018.
A ground water sam pling event will be conducted on the a pp licable monitorin g wells in November 2018 in order
to determine the effectiveness of the ORC socks. Based on the results of the November 2018 sam pling event. a
determination will be made whether the application ofORC 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
Services can be injected. Approved injectants can be found online at http ://de q.nc.gov/about'divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-a pp roved-in jectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Injectant: 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 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-1 s, 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 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 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 property is not owned by the permit applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) conform to the Well Construction Standards
(.l 5A NCAC 02C .0200;."
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
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 fonn.
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 Page4
L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The ORC treated socks are scheduled to be installed in tune 2018. The socks will be removed in November
2018 to allow fo the completion of the semi-annual semolina evens. Based on the results of the sampling event,
a determination will be made whether nr not tosontinue the use of the ORC socks.
M. MONITORING PLAN — Describe below or in separate attachment a monitoring plant to be used to determine
if violations of groundwater quality standards specified in Subchapter 02L result front the injection activity.
The socks will be removed in November 201 h_prior to the sampling cvgnt. Poaliwing the completion of the
sampling event, additional socks may be installed, depending on the effectiveness of the socks.
N. SIGNATLIRE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty of law. that f con familiar with the information .submitted in this
document and all attachments thereto and that, based on my inquiry ofthose individuals immediately responsible
far obtaining said intbrination. f believe that the tnfor'malton is true, accurate and complete. I am aware that
there are significant penalties.. including ike passibility of fines and imprisonment for submitting false
information. I agree to construct, operate, maintain, repair and f applicable, abandon the injection welt and
all related appurtenances in accordance with the I5A NC4C 02C 0200 Rides."
5lgnetsrc of Applicant Print or Type Pall Nome and Title
PROPERTY OWNER (if the property is not owned by the permit applicant);
" As owner of the property on which the injection well(s) are to be constructed and operated. I hereby consent ro
allow the applicant to construct each injection well as outlined in this appllealian and agree that it shall be the
responsibility of the applicant to ensure that the injection well(s) confarni to the Well Construction Standards
05A NCciC 0,2C.02001'.
"Owner" means any person who holds the fee or other property rights in the well being constructed. A well
is teal property and its construction on land shall be deemed to vest ownership in the land owner, in the �y
of Fgrttcary agreement in writing, ,�,,((i6ivry IcroCO3- Ca t/yt.� t Irv_ REP
ar-
cfAitivfaA
Aviator** of Property Owner of dtfteresi from applicant) Print or Type Full Name and Title F�s
*An access agreement between the applicant and property owner may be submitted in lieu of a signature out this form. iJ"' .
Submit the completed notification package to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Pertained G01 Rernediarion NOT Rev. 3• t-20I t+
Page 4

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DATE bRILLED 9- 14-ic
:! •►' �+or REs� '.�4L WELL CONSTRUCI1DNRECORD
C rLna LcpA•! '%mE offani.milloot and NIturs u F iC - Divialon of Wotor Quality
WELL CONTRACTOR CERTIFICATION ff
a. 'TOP OF OW IS CLe 0 FT. Above Lend Surfae9'
'Top o' Ceslrp terminated &Jor 5rinvr landaurfax may •aryulra
vanilla inecc-va awiihiPANOAC2v.C•
e. Y:ZL '4pm): METHOD 6F TEST '
f. D",SINFELTIOh: Type Amount
c. IN;s:TERZONES (dop€h•,
Top_ /0 BOtttirr_A Top __ Iio",orll
JoutuLaav`
Ant.. API gall
Siete • ZIP Cie • Top 9otiurr _,,, Top - 9ottn-I
' To SDitont -Tom 5otam-rdo knee al
:_
7. ,CASdNQ: Depth - %tira itor WOO( Mate *1a1
Top D Bottom /D _ FL_4 _` sc'6+-' ''YC-
Tca _ DottOp1 FL_ .
TV Bottptt�, _ F:
4. WELL ..QCATtQN:•
ubdviarrzn, Lcr rk{.. PareelArOod
S. GROUT: Daph
Top CI Bottom.+5_ -Ft.
Top • Bpt:oAtri FL
ivp 6oxcrTt_.. FfL__
Mineral
method
N. SCREEN: zoo], ' r estimator '.STo(-etxe /� .g'aiertet'
7 /C Sottotrt ' FLU "; irr,o-:oi t7''to 1. .r
Top 'Eottvm 1. _�. - ..,E
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• J� GGFt4F'h.0 f Uh sF it•:No: (chid(appropti.ae tk•I' + • . " '•1L''; {,rs ,el . • , ' •
D5n;tt4 ,:lei ex -OFrae' �Ridae ©inter • • • • �� sAbio113F�Jt1rEl P�4Clt:
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stiG.TJCE 7$ '4DNIB'OR7tx?0:0?Wifx. CD
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xado"' of ken mi41 Aa-thowr, cra.e USGS i pq mop Andetteched fa
s iY+�r rllfof ua rI GPSJ
5. r.:v I L fY (Name o`tho bin near whore (tie wall II located.)
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8 a�iitr I ;rno Fae- llIty ION of appllcabI )
roan AC d 5•5
State Ztp Coda
▪ Ste'
Contest rJE•4II
Ma irrg Maras
y17 ..r Tvh:i Stale Zip Code
• 7 ;ore- s P+ticrte nr.mber
• ❑ETA.'LS:
a. '0-ALDEPTl1:
t•.Ots WELL REPLACE EXISTING WELL? Y'WS c NO❑
WATTR LEVEL 6610w Tap pf Casing:. %0.f FT.
;us, Ne if Above Top of Casing)
T9A ct 9o>Yorrt FLi:: ' G .,•
_Tip Lfi otiAltL • . F'I I I;: Inv:. •�w+� • .,, ..__ �.
l'up 9otion Ft _ .
�,. DR+LLING LOC
Top 8atirtal
I5
/0 /
.'1 i 49.5`"
1
i?. REMARKS:
Fanra1on Description
100 HEREBY CERr1•^I THAT TM6157.1 WA9 C0145TRUCTED Yr CCC0 ,00: E l# H
ISr, hi.+1G 2C, WELJ. CANST7iUCT•o' 1TMDAR0S, AND TK T *COPY Car THIS
liEGOR: ruo BO DEOTO • T - - -
SIGNATURE OF L.ERTIF1FaMWEI.L CONTRAC1 DATE
l i
PfilHTEO NAME Cr P£ h Cp ltTRUCTIN3 THE WELL
s+-'-rnit within 3r. days of.,cDroprotian,Lo: i Y &ortof Wator Qpality • lafo atlorl-Processing,
T ,1. Ma.! Service Ceriter, Raidlph, N.G II/009441, Phone : [phone]'0
orrn OW:'
Rev, VC9
• +f

NON ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 3A g9
1. WE L ONTRACTOR:
-Well Contractor (individual) Name
Well Contractor Company game
I33 ..wt_
S et Address
City or Town State Zrp Code
(5c2) 39S- toOAa
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMiTO_
OTHER ASSOCIATE[] PERMIT#(Ir applicable)
SITE WELL ID till appsicaibbef 07(4)
3. WELL USE (Check One Box) Monitoring 0 MunlclpaliPublic p
Industrial/Commercial © Agricultural ❑ Recovery 0 Injection 0
Irrigationp Other 0 (list use)
DATE DRILLED et+ V•1 ^ dCt
4. WELL LOCATION:
5 /r7 SIC 45-
:Strerat Narna,,8umbers• Community, Subdivision, Lot No., Percel, Zip Code)
C:F Y: • • __- COUNTY
f'OP(X RAPHtC / LAND SETTING: (check appropriate box)
,Slope C Valley ciFlat °Ridge ©Other
LATi1I IDE 36 • , " DMS OR 3X•X60() XXXXX DD
LONGITUDE 75 ° " DMS OR 7x.xXxxxXXxx DD
Latitudeliongltude source: COPS Cfopographic map
(location of well must be shown on a USG$ fopo map andattached to
this'form if not using GPS)
6. FACWTY (Name of the business where the well is located)
Facility Name
Cf S P-7 91- e_ -45"
strut dress
' at'79 V3
City or Town State Zip Code
Facility 10# (If applicable)
Contact Name
Mailing Address
City or Town State Zip Code
( )
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: GI S 1
b. DOES WELL REPLACE EXISTING WELL? YES 0
r
c. WATER LEVEL Below Top of Casing: /0 FT.
(Use "+" if Above Top of Casing)
NO ❑
d. TOP OF CASING IS 0 -0 FT. Above Land Surface'
*Top of casing terminated atior below land surface may require
a variance in accordance! with 15A NCAC 2C .0118,
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type Amount g. WATER ZONES (depth):
Top ! D Bottom 615 Top Bottom
Top Bottom Top Bottom
Top Bottom Top Bottom
Thic k need
7. CASING: Depth Diameter Weight Material
Top ❑ Bottom 10 Ft. o'I £'H .413
40 9r�
Top Bottom Ft.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0 Bottom (0 Ft, &
Top (1, Bottom Ft.
Top Bottom Ft.
Method
9. SCREEN: Depth Diameter - Slot Size Material
Top 10 Bottom S Ft. a in. +0.0 I D in. 'i 'C..
Top Bottom Ft.. ° •tic.'in.
Too Bottom Ft: • In._ _--
IQ. SAND/GRAVEL PACK:
•
Depth ize
Top. Bottom c9.5 Ft. '-
Top Top Bottom
Top Bottom Ft. •
11. DRILLING LOG
Top Bottom Formation Description
14c. -Tarn
1,3
13 i IS 0
l $ !
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE YYrH
ISA NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECO BEEN PROVIDED TO THE WELLO ER,
SIGNATURE OF CERTIFIED WELL CONTRAC' OAR DATE
r ,� t ','= E' �� /7cI r" flit `
PRINTED NAME OF PERSON CONSTRUCz'ING THE WELL

1 ■ ON RESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resov a- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2103
1, WELL CONTRACTOR:
Stuart Spruill
Well Contractor (Individual) Name
SGI
Well Contractor Company Name
STREET ADDRESS 3593 Wildcat Road
Williarnston NC 27892
City or Town State
( 252 )- 809-3608
Zlp Code
Area code- Phone number
2. WELL 1NFORMATlON:
SITE WELL ID rto applicable) TW-1 M
WELL CONSTRUCTION PERM1TII(dapplicabre:
OTHER ASSOCIATED PERMIT a(il applicable]
3. WELL USE (Check Applicable Box) Monitoring[]
Industria11Commerciald Agricultural° Recovery°
Irrigaliort0 Other° (list use)
MunicipaUPubiiccD
In}ectionp
DATE DRILLED 09/15-16110
PP
Bettie
TIME COMPLETED 12.30 AMU
4. WELL LOCATION:
CITY: Merry Hill COUNTY
1706 Hwy17 N
(Street Name. Numberx, Community, Subdivision, Lot No., Pascal. Tip Code]
TOPOGRAPHIC /LAND SETTING:
0 Slope 0 valley 0 Flat l] Ridge 0 other Bertie
(tack appropriate bout)
LATITUDE 36.03417
May be in degrees,
minurts. seconds or
to a decimal format
LONGITUDE 76.78540
Latitude/longitude source: 0 GPS R Topographic map
(location of well must be shown on a IJSGS topo map and
attached to this form if not using GPS)
S. FACILITY- is or ntra>,a Of we buurnewediere me wall +e located.
FACILITY ID Cif applicable)
NAME OF FACILITY Millers Country Store
STREET ADDRESS 1706 Hwy 17North
Merry Hill NC 27957
City or Town Slate Zip Code
CONTACT PERSON EaStem FeutS
MAILING ADDRESS PO Box 1386
At]oskie NC
City or Town State
( 252 ) . 862-0236
Zip Code
YES° N08
FT.
Area code - Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 45ft
b. DOES WELL REPLACE EXISTING WELL?
c. WATER LEVEL Below Top of Casing:
(Use '+' it Above Top of Casing)
4. TOP OF CASING IS -,3_ FT_AboveLand Surface'
"Top of casing terminated MUor below land surface may require
a variance In accordance with 1 SA NCAC 2C .0118.
e. YIELD (°pot): METHOD OF TEST
t. DISINFECTION: Type Amount
g. WATER ZONES (aepth):
From To From To
From To From To
From To From To
7. CASING: Depth Diameter ThicirnesalWeigl Material
From 0 TO 24 Ft. 6" sch40 pvC
From C To 40. ft Ft. 2" sch40 pVC
From To Ft.
li. GROUT: Depth Material Method
From 0 To 3511 FL grout pumped
From 35ft To 38 ft FL bentonite poured
From To Ft.
9. SCREEN: Depth Diameter Slol Size Material
From 4C it To 45ft Ft. 2" in. . 10 In. pVC
From To Ft in_ in.
From To Ft. In. In.
10. SAND(GRAVEL PACK:
Depth Size Material
From, 38ft To45ft Ft.#2 sand
From To Ft.
From To Ft.
11.DRILLING LOG
From To Formation Description
0 20 tan fine silty clay
?D 24 pray clay_ .
24 38 gray silty clay
38 45 gray silty day with shell
12. REMARKS:
i DO IIEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WITH
15A NPAC 2C WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF T HIS
REQ�HAS BEEN PRo'llIQEQ TO THE WELL OWNER.
10/26/10
SIGNATURE OF RTiF1ED WELL CONTRACTOR DATE
Stuart Spruill
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Mgt„
1817 Mail Service Center — Raleigh, NC 27699.1017 Phone No. [phone] ext 568.
Fonn GW-1h
Rev.12/07

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. 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 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 with backfill, direct -injection, bore -hole backfill,
ORC Advanced Pellets for waterless and dustless application, combined 1SCO and bioremediation applications, etc.
OXYGEN
RELEASE
COMPOUND
011
Example cf ORC Advanced
For a list of treatable contaminants with the use of ORC Advanced, view the Range of Treablhle Cnntaminants Guide
Chemical Composition
• Calcium hydroxide oxide
• Calcium hydroxide
• Monopotassium phosphate
• Dipotassium phosphate
Properties
• Physical state: Solid
• Form: Powder
• Odor: Odorless
• Color White to pale yellow
• pH: 12.5 (3% suspension/water)

ORC Advanced° Technical Description
Storage and Handling Guidelines
Storage
Store in a cool dry place cut of direct sunlight
Store in original tightly ctos,7:d cont:,la le r
Stole in a well -ventilated place
Do ,1•-st slorr• near : orrb=sttbla mat'ri ih.
Store away from incompatible materials
Provide ip,)roprk to "enttl+itie n in
~,+here dust iJ furlred
Applications
OXYGEN
RELEASE
�:OMPOUNO
Handling
Minimize dust generation and accumulation
Keel. ;gray i rom bea'
Routine housekeeping should be instituter) to
en,,ure that dust dries riot accumulate un furfaces
Observe good industrial hyg erne prac.nces
Take precaution to avoid mixing with combushble;
Keep a.'vav trom zlothing and other comb' istible=
materials
Avoid contact with >'vater and moisture
Avoid coil tact ',i th Pies sLin and .li' ,hirag
PALoid prolong9d exposure
Wear appi opriate personal proter tivt' equipment
• 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 PersukfOx
• 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 Arivanceti_Safety Data Sheet for additional storage, usage. and handling requirements.
REGENESIS
ror-riesis.t• n
1011 C Ste Sombrr. _an ClemenTe C ' .Zbi.
.JC7
2 16 41 i hr _ I. REGENESi_ and QP.0
+I.r : x^ trnrl..fig+
`REG£M 'IS Bro��m li d 1 R =u•' I, _ the r lem rk . th_ p t pc r of rkvir r pcLti der

Wo We!!
W&)I dictrol
2S'tal
Peptk
J-)-ickric tuaf a l evei5 !vv. kviii le-2.0'

— w -
- _
•
EXAM
EXYLM
LEGEND
O TYPE 11 MONTORINO SELL
• TYPE 111 MONITORING HELL
DEST1?0YED MONITORING WELL
• OBSERVA 17011 HELL
9 AIR SPARGYNG WELL
9 SOIL VAPOR £XTRAC770N ilELL
WATER SUPPLY PDFLL
WATER LINE
UNDERGROUND TELEPHONE LINE
OVERHEAD ELECTRIC LINE
POKER POLE
DITCH
BENZENE
TOLUENE
ranz
ATIENEMS
NAPHTHALENE
CN7RAT!WVS AV pyjl
cR 13 LFSS MAN ME MEMO OET C1/LW veer
set-ar Ea re RE LAMOBAWGwr REPORT
ESTIMAnro VALUE'
NS NOT SAMPLED
COV4EN7RAAWVS ffif BOLO FACE TYPE EXCEEDED
1NE T1 SrANDAROS
\ MW-021
MW--23A
OEM
CAME
!
\
\
MW-24
r
k.:174:1;
MW-39
4
e MH-
MW-10A
W-1
M1_8. i W. 11
0M -
MW-3�OW 1 -2
2
MW-77 ("s]
iP-341 oW-19DMw-13
w_ 1W--27
DMW--..5
J
MW-20
J
f WW-43
/ MWe250
M11-40
e
J
J
J
\
\
MW-32
PERRY HfLLW--6
D
DOWD 11ECL/WSW-5\
A W-31
D
z
-"*">\ \
J \
M11-44
WSW-18
J
W-3a4,
MW-45
J
MW- 47
AIW-34
MH-46
Agricultural Field
J
WSW-13
0
KAI,/
maks
J
J
N
Geological Resources, Inc.
D 50 100 200
(IN FEET)
1 Inch = 700 ft
GROUND DATER QUALITY ASAP (07/12/17)
Miller's Country Stare
Incident No, 31939
0RI Project No. 2727
1706 Highway 17 North
Marry Bettie County,
NC
Date:
08/15/17
Drown by.
DTH
Figure.- 5