WI0700492_DEEMED FILES_20190822

DATE: June 19 , 20 19
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 I5A NCAC 02C.0200. This form shall be submitted at least 2 WEEKS prior to infection.
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A 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. Illegible Submittals Will Be Returned As Incomplete.
PERMIT NO. 1 / 3-e) 9-6' 0 9-9 2- (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well .Complete sections B through F, K, N
(3) X Passive Injection System Complete sections B through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through N
(6) Tracer Injection Well Complete sections B through N
B. STATUS OF WELL OWNER: Business/Organization
d►
C. WELL OWNER(S) — State name of Business/Agency, and Name and Title of person d
sign on behalf of the business or agency:
Name(s): DHRUV Commercial PropertyLLC
Mailing Address: 1327 North Road Street
City: Elizabeth City State: NC Zip Code:27909 County:Pasquotank
Day Tele No.: 252-335-0009
EMAIL Address:NA Fax No.: NA
Deemed Permitted GW Remediation NOI Rev. 3-1-2016
Cell No.: NA
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Page 1

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Shilpesh Patel. Owner
Company Name DHRUV Commercial Property. LLC
Mailing Address: 1327 North Road Street
City: Elizabeth City State: NC Zip Code: 27909 County: Pasquotank
Day Tele No.: 252-335-0009 Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: William Regenthal, P. G.
Company Name Geolouical Resources, Inc.
Mailing Address: 3502 Hayes Road
City: Monroe State: NC_ Zip Code: 28110 County: Union
Day Tele No.: 704-698-1253 Cell No.:
EMAIL Address: wlrQitgeologicalresourcesinc.com Fax No.: 252-321-6094
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Hop -In Citro 703
1327 North Road Street
City: Elizabeth City;County: Pasquotank Zip Code: 27909
(2) Geographic Coordinates: Latitude**: " or 36°.330095
Longitude**: " or 77°.226588
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 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.
Deemed Permitted GW Remediation NOI Rev. 3-1-2016 Page 2

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-3 in July 2019. A ground water sampling event
will be conducted on the applicable monitoring wells in January 2020 in order to determine the effectiveness of
the ORC socks. Based on the results of the January 2020 sampling event, a determination will be made whether
the application of ORC will continue.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.gov/about/divisions/water-
resourc es/water-resources-permits/wastewater-branch/ground-water-protection/1r round-water-approved-inj 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 Specification 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:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: Proposed 3 Existing (provide GW-1s)
(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 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The ORC treated socks are scheduled to be installed in July 2019. The socks will be removed in January 2020
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 January 2020 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 15,4 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
(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.
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 4

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.020 . This form shall be submitted at least 2 WEEKS prior to injection.
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
INSITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A 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-S ale 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 Infection 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: June 19 , 20 19
PERMIT NO. (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well Complete sections B through F, K, N
(2) Aquifer Test Well .Complete sections B through F, K, N
(3) X Passive Injection System .Complete sections B through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through N
(6) 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): DHRUV Commercial Property, LLC
Mailing Address: 1327 North Road Street
City: Elizabeth City State: NC Zip Code:27909 County:Pasquotank
Day Tele No.: 252-335-00 Cell No.: NA
EMAIL Address:NA Fax No.: NA
Deemed Permitted GW Remediation NOI Rev. 3-1-2016
Page 1

D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Shilpesh Patel, Owner
Company Name DHRUV Commercial Property, LLC
Mailing Address: 1327 North Road Street
City: Elizabeth City State: NC Zip Code: 27909 County: Pasquotank
Day Tele No.: 252-335-0009 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: Monroe State: NC_ Zip Code: 28110 County: Union
Day Tele No.: 704-698-1253 Cell No.:
EMAIL Address: w1rAgeoloaicalresourcesinc.com Fax No.: 252-321-609
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Hop -In Citgo 703
1327 North Road Street
City: Elizabeth City County: Pasquotank Zip Code: 27909
(2) Geographic Coordinates: Latitude**: 0 " or 36°.330095
Longitude**: 0 " or 77°.226588
Reference Datum: Accuracy:
Method of Collection: Topographic Map
**FOR MR 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 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.
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
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.
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

J.
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-3 in June 2019. A ground water sampling
eventwill be conducted on the applicable monitoring wells in January 2020 in order to determine the
effectiveness ofthe ORC socks. Based on the results of the January 2020 sampling event, a determination will
be made whether
the application of ORC will continue.
APPROVED INJECTANTS — Provide a MSDS for each injectant. Attach additional sheets if necessary.
NOTE: Only injectants approved by the NC Division of Public Health, Depurlmeni of Heullh and Humull
Services can be injected. Approved injectants can be found online at hup://deq.nc.gov/abouddivisions/wateer-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-inj 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 Specification Sheets
Volume of injectant: 12oz/foot
Concentration at point of injection: —36oz _
Percent if in a mixture with other injectants: NA
lotautof injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: Proposed 3 Existing (provide GW-1s)
(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 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
The ORC treated socks are scheduled to be installed in June 2019. The socks will be removed in January 2020
to allow for the completion of the semi-annual sampling event. Based on the results of the samplipe 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 January 2020 prior to the sampling event, Following the completion of the
sampling event. additional socks may be installed._devendina on the effectiveness of the socks.,
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "'hereby cert f, underpenalty 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 imprisonmen4 for submitting false
information. I agree to construct, operate, maintain repair, and if applicable, abandon the injection well and
all related appurtenances " a ordance with the 15A NCAC QZC 0200 Rules."
Signature of App Print o ype Full me tusl Titre
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
(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 roperty and its construction on land shall be deemed to vest ownership in the land owner, in the
absen of contrary an writing.
Sig a * of Property toner (if different from applicant)5;ticki eafd ,011A%-r,
Print or Type Full Name pad Title
*An Q ess greement 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 OW Remediation NOT Rev. 3-1-2016
Page 5

North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0700492
1. Permit Information
DHRUV Commercial Property, LLC
Permittee
Hop In Citgo
Facility Name
1327 North Road Street, Elizabeth City, Pasquotank County
Facility Address (include County)
flOJl:,a
Were any wells abandoned during this injection
event? _/
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells __ NA ____ _
NA Number of Injection Wells -------
Please include a copy of the GW-30 for each well
abandoned.
2. Injection Contractor Information · S 8110.llllJtrk .
~!/9r.o.1,!;~l!Ju t ~-
Geological Resources, Inc.6/B,
Injectant Information
ORC-A socks Injection Contractor/ Company Name Jl f g Dnv
Street Address 3502 Hayes R~~03o:;,._,,, ..
G.J/1/3031::1
Monroe NC 28110
City State
~ 845-4010
Area code -Phone number
3. Well Information
Zip Code
a£CE\\Jt.Ol~C'O~QIO R
f).UG I t 'l.ffl~.
Number of wells used for iniection ___ 1_, __ f'•-e\\\y
Injectant(s) Type (can use separate additional sheets
if necessary
ConcentrationMW-3 - 4 2" 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 ____ _
Well IDs MW-3
~ ,.. ec
. ~opetaUons 5. Injection History ~eQ,ona
------------
Were any new wells installed during this injection
event? _/
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells _~_A ____ _
Number of Injection Wells NA -------
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) _N_A __
Please include a copy of the GW-1 form for each
well installed.
Injection date(s) __ 0_7_/_1_1_/_1 _9 ______ _
Injection number ( e.g. 3 of 5) 1
of ? -------
Is this the last injecti2E)lt this site?
D Yes ·~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 LAID OUT IN THE PERMIT.
v~#-,
SIGNATURE OF INJECTION CONTRACTOR
William Regenthal
p
08/20/19
DATE
Submit the original of this fonn to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Fonn UIC-IER
Rev. 3-1-2016