WI0800488_DEEMED FILES_20180601

])~
North Carolina Department of Environmental Quality -Division of \Vater Resources
INJECTION EVENT RECORD (IER)
Permit Number lU:r O C-oo ~<?
Permit Information
Coru1ov.LL, Llt.,, __ _
Permittee '
WO PtrcltJc/lW.... lh.uCf U.J1f·kl, tJ;"dt2-r
Facility Address (include County) d,vr-L~
2. Injection Contractor Information
Injection Contractor/ Company Name
Street Address laD7A Rr:ar ?r-0 5k \\S
2 '6L\CA.
State Zip Code
(~ '7....o.\ -~£5<; 3 AE'CEIVEOINcoe-Q/QwR
Area code -Phone number
JUN .. ~ l '201s
3. Well Information ~
Re91ona1 ~r Oua111y
Number of wells used for injection ~s~n
Well IDs \J, u,'.) ~ ~ H., )...'.) \.0~
Were any new wells installed during this injection
event?
D Yes 'ft! No
If yes, please provide the following information:
Number of Monitoring Wells
Number of Injection Wells
Type of Well lnstalled-(Check applicable type):
0 Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify)
Please include a copy oftlie GW-1 form for each
well i11sta/lecl.
Were any wells abandoned during this injection
event?
D Yes [ZNo
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 . lnjectant Information
--!......z::...::\,l=~~'::, (.)-~
lnjectant(s) Type (can use separate addjtional sheets
if necessary
Concentration O.o S" ~-~
If the injectant is diluted please indicate the source
dilution fluid.
Total Volume Injected (gal)
Volume Injected per well (gal) __ -
5. Injection History
Injection date(s) DS \ '::>\ \2-0\ ~
Injection number ( e.g. 3 of 5) 3
Is this the last injection at 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
j ANDARIJS LAID OUT IN THE PERMIT.
'"2~~ le/4l r
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn : UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
North Carolina Department of Environmental Quality — Division of N'vater Resources
INJECTION EVENT RECORD (IER)
I. Permit Information
Permit Number 1
Ck ire
PLrnntree
Facility Name
q a-Nar1f: L L_ -c Lea-44
l-a
Facility Address I include ('otuity) taA
Injection Contractor information
Injection C,ntractor Comport) Name
Street Address (IC41.-a. .+1� - d S] . (I T
City State E�rlN 1EOIOWR
Rl±CEIY
Area code - Phone number
Well Information
JiAN 15 2018
Water quality
Regional Operations Section
Nu:nber of wells used For injection
Well IiDs k•-.14.1-"51\ y3•-s.s- --lo w
W ore any new wells installed during this injection
exent''
Yes
If yes, please provide the following information:
Number ofMoititoring Wells
Ntnnbei ,if Injection Wells_ -
'Type of Well it -Bullied (Check applicable type):
Bored L' ❑t fl led ❑ Dire.:t-Push
Ei I -land -Augured j Other 1�pt�ify] _
Please include a copy of the GFI=1nrm for each
well installed.
Wert anN N4ells abandoned during this injection
dent:'
L Yes [ No
If yes_ please provide the following ;nformation:
Number Of Monitoring Wells
Number of Infection Wells
Please rtrclzuk a copy of the GF'I- 30l for each will
abandoned.
I. injeetant information
lnjectant(s) Type (can use separate additional short,
if necessary
Concentration 91.k.�. tc _
II the inje..tant is diluted please indicate the source
dilution llnid._
fatal Volume Injected (sal)._
Volume lttjeetc.d per well (gal) _
injection. History
l l
Injection date(s) 1 g \ Z c-
Injection numberte.g. 3 of5)- _
is this the last :njcction at this site"--
— fie, N('
I DO 1Il:REBY CFR my THAT ALL no:
1NiORM.1'IION ON THIS FORM IS CORRECT T()
TKI BEST (.)l' MY KNOWLEDGE AND -FHA 1" I.11F:
IN.IE-['I IONI WAS PI-RI-ORMED WITHIN Tiir
F WS LAID OirstiV THL PERM 11.
'I N —17t '!t i' t )I' 1\,II1" !'1 . ($lt I),l IT.
�?- C_ -
s'ftl \ 1'`•tl-, IA P! g J\ i'l:tt{=t�IiV11\t, I't If:1 Ji d i'!t]•:
Submit the original of this form to the Division o1'WVater Resources within 30 days or inj::ctiun.
Attu: LAC Program, 1636 Mail S'c:rviee Center. Raleigh, INC 2 t,99-i636. Phone No. 0:9-#fl7-616.1
i tom L'i('-II:R
Rev. 3-1-2016

D tz.yv,e,c wsadao cz-g8
North Carolina Department of Environmental Quality — Division o1'Vvater Resources
INJECTION EVENT RECORD (IER
Permit Number. (3_
I. Permit Information
P rmittec
l acility Name
-a ` \S u 1 LrRa
facility Address (include Count))) arta t=`{
▪ Injection Contractor Information
Injection Contractor / Company Name
Street Address_ W.A. ` `` s1 f \ '
City Crate
krea code - Phone number
1, Well Information
1
Dec s2o1
1412,°4e 0aa g0&"4,
Number of Hells used for injection °n9
Well ID5 {�I�l.�- -`7 �LL.L. _-I &
Were any new wella installed during this injection
evens?
❑ Yes
If yes. please provide the following information:
Number of Monitoring, Wells _
Number of Injection V. ells
1 �pc elf Well Installed [Check applicable type):
❑ Bored L7 Drilled ❑ Direct -Push
❑ Hand -Augured E Other tspechyi
Please include a copy of the GPI -I Limn far each
well installed
We% an) wells abandoned during this injeetit'n
e:nt,'
117:, Yes
If)es. please pros isle the following information:
Numbur of Monitoring Wells
Numl'ei of Injection Wells
Please include a copy of the GW -3oJor each well
abandoned.
i. tnjectant Information
InjectanUsJ 1 ype (can use. separate additional sheets
if necessary
Concentration L'r1- �
�
lithe injectant is diluted please indicate the source
dilution fluid.
Total Vaulunte lnjcctcd 4gal)
Volume Injected per well (gal)
5 Injection I fistory
Injection datcl sl
Injection number (e.g. ? ui'5)___
Is this the last inject on at this site?
n Yes No
•
i DO HERL-:BY ('1• RTII.Y I HA I AI".I.
INI-URMA.rkt)\; ON MN Il5 FORM IR ('DIRE[" 1.10
1 Etl: BEST t)i MY KNOWI.I.DGL AND "I I IA I 'I HE
1NJFC 1 ION WA's PER1 URMLP WI - MIN IF*
S f'INDARI)S LAID flt'1 IN THE PLRNMIT.
'4Ifill
SI NSi t li J1 [NM( I i 1 RA TOR
. PK \ 1 N \ 1L ()I- 1 Ll LZ. Pt•,itt"(JRMlv(, I1I:_ I lI C t7(t�
Submit the original of this farm to the Division of Water Resources- within 30 days of -injection.
Nun. t' [f Program. 1 b_ 6 4Prv[te Center, Raleigh. NC 769tr-1 b T6. Phone No_ 919-S(r-646,1
I urn) 1.21L•-11 R
Rev, 3-1-2016

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0800488
Injection Deemed In-situ Groundwater Ren:iediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Horsebranch Grocery
Location Address
4990 Penderlea Hwy
Owner
Owner Name
Cenama LLC
Dates/Events
Orig Issue
9/22/2017
App Received
9/11/2017
Re gulated Activities
Groundwater remediation
Outfall
Waterbody Name
Draft Initiated
Scheduled
Issuance Public Notice
Central Files: APS SWP
9/22/2017
Permit Tracking Slip
Status
Active
Project Type
New Project
Version
1.00
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Facility Contact Affiliation
Owner Type
Non-Government
Owner Affiliation
W Cecil Worsley Ill
123 Shipyard Blvd
Wilmington
Region
Wilmington
County
Pender
NC
Issue
9/22/2017
Effective
9/22/2017
28412
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
Shrestha. Shristi R
From:
Sent:
To:
Cc:
Subject:
Shrestha, Shristi R
Friday, September 22, 2017 1:51 PM
'[e-mail]'; '[e-mail]'
Gregson, Jim; King, Morella s
WI0800488 NOi Former Horsebranch Grocery
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) 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 (ori ginals 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-p ermits/wastewater-branch/ ground-water-
protection/ ground-water-reporting -forms
2) 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 [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 WI0800488. 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
Shristi R. Shrestha
Hydrogeologist
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shrestha @ ncdenr.gov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.
ATC
ENVIRONMENTAL • GEOTECHNICAL
August 28, 2017
809A Piner Road
Suite 115
Wilmington, North Carolina 28409
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Former Horsebranch Grocery
4990 Penderlea Highway
Watha, Pender County, North Carolina
Risk Classification: H115R
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of Cenama, LLC. The permit application covers
the performance of passive remediation in two monitoring wells associated with the above
referenced site
If you have questions or require additional information, please contact our office at [phone],
Sincerely,
ATC Associates of North Carolina, P.C.
Maureen A. Jackson, G.
Senior Project Manager
cc: Ms. Greta Stanley, Cenama, LLC
Attachments
RECENEDINCDEQ/DWR
SEP 112017
Water Quality Regional
Operations Section

NOTICE OF INTENT FORM
''WAfC ... -·· ......... _ ...
~ ·~ .. -
NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTEI\'T TO CONSTRUCT OR OPERA TE 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 (12C .021)(). This form :~/tall be submitted at least 2 weeks prior to iniection.
AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to detennine aquifer hydraulic characteristics.
IN SITU REMEDIATION 115A NCAC 02c .02251 or TRACER WELLS ( ISA NCAC 021.. .0229):
I) Pas-.ive lnj~tj_pn S, stem~ -fn;.well delivery systems to diffuse injectarits into the subsurface. Examples include
ORC socks, iSOC systems. and other gas infusion methods.
2) Small~Scale Injection O erations -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) Pilpt 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 \vhere 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 e>.."tent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air lnjecti_on Wells -Used to inject ambient airto enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: .July 3 I , 20J.l_ PERMIT NO. VV J. _Q_$. 6 0 <t&L(to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERA TED
B.
C.
( I) ___ Air Injection Well ..................................... Complete sections B-F. K, N
(2) __ ------'Aquifer Test Well.. ..................................... Complete sections B-F, K, N
(3) X Passive Injection System ............................... Complete sections B-F. H-N
(4)
(5)
(6)
___ .Small-Scale Injection Operation ...................... Complete sections B-N
___ Pilot Test ................................................. Complete sections B-N
Tracer Injection Well ................................... Complete ~~"EbfNCQEQ/DWR
STATUS OF WELL OWNER: Business/Organi1.ation SEP 11 2017
•
OJ,!~}~ ~e_glc;mal WELL OWNER -State name of entity and name of person delegated authority t ft~fut\tlnWS~iness
or agency:
Name: Greta Stanle1 Vic~ President C_enam9 ._ L__LC
Mailing Address: 123 Shipr_ard Boulevard
City: Wilmington State: ~ Zip Code: 28412 County: New Hanover
Day Tele No.: 910-343_-1221_ Cell No.: Not Available
EMAIL Address: __ __.g=s=ta=n=le ... y . .,_@.,.,s""p::.,..n::.:c· n,..g""er,.,,o""'il~.c:.::oe>.:m.,__ Fax No.: _N~o.,_.t A'-'-'-'va=i=la=b=le:........ ___ _
lJIC/111 Sit11 Rcmed. Notification (Revised 3/2/2015) Page I
D. PROPERTY OWNER {if different than well owner)
Name: Thomas ~ ang_}.nnette Slles
Mailing Address: 32_87 Cor§ Grove Jwa=d __
City: Watha State: _NC_.lip Code:28471 _ County: Pend_!::!"
Day Tele No.: Unknown Cell No.: Not}.vailab.JL
EMAIL Address:'--_ __._,N ... ot A v.=ai..,la...,b'""le::-_____ _ Fax No.: ---=U...,.,n=kn=o=--w'"'-n'-"--____ _
E. PROJECT CONT ACT -Person who can answer technical questions about the proposed injection project.
Name: Maureen Jackson -ATC Associates of North Carolillih P.C._
Mailing Address: 609A Piner Road. Suite 1 I 5
City: Wilmington _ S1ate: _NC _ Zip Code:28409 County: New Hanover
Day Tele No.: ~19-561-3893 Cell No.: 919-561-3893
EMAIL Address:__ maureen.jacksont@;:i,tcassociates.com Fax No.: 919-871-0335
F. PHYSICAL LOCATION OF WELL SITE
(I) Physical Address: 4990 Penderlea Hi hwa, __ County:.""P__,e=n=de=r ________ _
City: Watha State: NC Zip Code: l84 7 I
(2) Geographic Coordinates: Latitude**: 34° ~• ___ J9" or 0
Longitude**: 77° --22' ____ll" or __ _
Reference Datum: N/A Accuracy: IO-meter
Method of Collection: Goo •le Earth Pro
**FOR AIR INJECTTON AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WJTI! PROPERTY
BOUNDARIHS MAY BE SUBMITTED IN LIElJ OF GEOGRAPIIIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: ~-square feet
Land surface area ofinj. well network: _______ .square feet (.5 10.000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: {must be .5 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS -Attach the following to the notification.
(I) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells. and existing and
proposed injection wells; and
(2) Cross-section(s) to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells, and existing and proposed injection wells.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement. plus existing
and proposed wells.
See Figures I through 4 for site location and injection zone maps.
lJlCl/n Situ Remcd. Notification (Revised 3/2/2015) Pagc2
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.
AJC will instalj Adventus O-SOXs in monitoring W!!Jls MW-Se,. and MW-lOA in order to aide in natural
attenuation and reduce gmmQUnds con~~ntrations to below t_hc North Carolipa Grou11_qw~tc~r Qualit, Standard~
~L StandardsJ. BaseJi on_!_~ most recent samnling even!.Jl_erformed in_ Jul) 2017. the following comp__gµnd:S
exceedin • the a licable 2L Standards: benzene at 9.0 mic.r9grams/liter ll!g/LJ l.2.4-Trimethvlbenzene at 89.Q
!lS!L lso iJ:QP't !benzene _at 92 µg. L. n-Prop, I benzene at 150 " L and naphthalene at 250 µ g, L. The socks come
in 3-foot sections. _ATC will install two 3-fQOt sections at tb~base of each well, across the well screen. The
socks will reJcase oxidjz_in~ solids into th~groundwater _for approximatelv 6 months, at which point th~
chemicals in the socks will have deplet~g.
J. INJECTANTS-Provide a MSDS and the following for each injectant. Attach additional sheets if necessary.
NOTE: Approved injectants (tracers and remediation additives) can be found Online at
l11Jp:1 -'pmtul.ncdttnr.vn; weh.WiJ ,'11/JS·','liIJro. All other substances must be reviewed by the Division of Public
Health. Department of Health and Human Sen•ices. Contact the UJC Program for more info (919·807-6496).
[njectant: Advcntus O-SOX
Volume of injectant: _ 905 in 3 -volume of soc~
Concentration at point ofinjection: 90%
Percent if in a mixture with other injectants: Not Applicable
See Appendix A for MSDS.
WELL CONSTRUCTION DATA
(1)
(2)
Number of injection wells: __ .zo ___ Proposed __ ~2~ ___ Existing
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. Wetl
construction details shall include the following:
(a) well type a-; permanent, direct-push, or subsurface distribution system (infiltration gallery)
(b) depth below land surface of grout, screen, and casing intervals
(c) well contractor name and certification number
See AppendL-c B for well construction details and the well construction record.
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Two week~ ~fte1.s@mittinu this N_OL_ A TC will install the Adventus o~SQXs in mqnitorin • wells MW•5A and
MW-JOA.
UIC//n Situ Rcmcd . Notification (Revised 3/2/2015) Page 3
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_
Semi-annual sampling events of all monitoringywells are performed in July and January. ATC's next sampling
event will occur January 2018_ During the sampling event, ATC wilt collect a sample from monitoring wells
MW-5A and MW-1OA for analysis of volatile organic compounds by EPA Method 62008. The samples will
be shipped to Con -Test Laboratory in East Longmeadow. Massachusetts. ATC will also measure dissolved
oxygen, conductivity. temperature. pH.. and oxygen reduction potential in wells MW-5A and MW-10A during
the January 2018 sampling event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I hereby certify, under penalty oflaw, that Iam familiar with the information submitted in this
document and all attachments thereto and that, based on 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 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 Rides."
Signature of Applicant
G rte4Gt Sal61)7/10141
Print or Type Full Name
PROPERTY OWNER [if the prroperty is not owned by the permit applicant):
"As owner of the properly 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) C— r% Print or Type Full Name
* 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:
D WR — LIJC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
UIClin Situ Remed. Notification (Revised 3/2/2015) Pagc 4

FIGURES
C -•·-• --
f
•
I
Image courtesy of the 1 c Geological Survey
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dit
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MQNlrOVNc WELL (FYFE 0.)
• *QNRVTNG WILL (TYPE
oVERHCAD auLTRICAL L+NE
--- W— - WATER LIME
SYN1 5
rc e� $ "
AF PMaA 4TE sou Ai sECf
Lssx73
CO U
Cr 14-1
0.
d
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IX O
pt3

Mt 6
(Witt
?No'
Mt 7
(Nu)
ig'
MONITORING WELL (TYPE ll)
MONITORING WELL (*TYPE III)
(. - GROUNDWATER ELEVATION IN FEET
= NOT MEASUREO
GROUNDWATER ELEVATION CONTOUR LINE (DASHED WHERE APPROXIMATE)
= GROUNDWATER FLOW ❑RREGTlON
xAUTF =ME ru FFF7
N

Of, tllfr
• MONITORING WELL (TYPE II)
• MONITOPI G WELL {TYPE NI)
— - PRWPERrl LINE
- NO CONrAA) 4NTS EXCEED PL STANDARD
NOT .SAMPLED
1
A1�
Aft h
)
04'. /
rwrnWlwft C f
&
d 3
1
•r

APPENDIX A
MSDSFORl\1
ADVENTUS
Safety Data
MATERIAL SAFETY DATA SHEET:
O-SOXTM Page: 1 of 5
1. PRODUCT IDENTIFICATION: O-SOX"
PRODUCT USE: Soil and water treatment.
MANUFACTURER: EMERGENCY PHONE:
Adventus Americas Inc.
2871 W. Forest Rd.. Suite 2
Freeport. IL
61032
USA: 1-800-424-9300 (CHEMTREC°)
Canada; 1-613-996-6666 (CANUTEC)
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid. n.o.s. (Calcium Peroxide), Class 5.1, PG II, UN1479
WHMLS CLASSIFICATION:
Oxidizer
2. COMPOSITIONIINFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide Ca09
Calciusn Hydroxide
3. PHYSICAL DATA
Chemical Formula
Ca(OH):
CAS No, Percentage
1305-79-9 4S .7fl%
1305-62-0 10%-20%
Appearance White brown granules
Physical state Solid
Odor threshold None
Bulk Density 500-6508Ji.
Solubility in Water Insoluble
PH -l1
Decomposition Temperature_____ Self -accelerating decomposition with oxygen release stoning from'275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause_ fire. Under fire conditions thismaterial may
decompose and release oxygen thus intensifies fire. This product contains el% non -respirable crystalline
silica. The NTP and OSHA have dot classified non•respirable crystalline silica as carcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (silicosis). eHC-0 does not
contain respirable crystalline silica.
Potential Health Effects:
• Gcnrral Irritating to raucous membrane and eyes.

ADVENTUS
Safety Data
MATERIAL SAFETY DATA SHEET:
Q-SOXTm Page: 2 of 5
• Inhalation Irritating to respiratory tract. Long term inhalation of elevated levels
may cause lung disease (silicosis).
• Eye contact May cause irritation to the eyes. Risks of serious or permanent eye
lesions.
• Skin contact May cause skin irritation.
• Ingestion Irritation of the mouth and throat with nausea and vomiting,
5. FIRST AID MEASURES
• Inhalation
,Remove affected person to Fresh au Seek medical attention it efler iti
persist.
• Eye cantacx _ Flubh eyes with running water for at least 15 minutes with eyelids
held open Seek specialist advice'
• Skin contact...._,....,..,.,... Wash affected skin with soup and mild detergent and large amounts of
water.
• Ingestion If she person is conscious and not convulsing. give 24 cupfuls of
water to dilute the chemical and seek medical attention immediately
Do not induce vomiting.
4. FIRE F[GFITING MEASURE
Flash Point
• Not applicable
Flammability
• Not applicable
ignition Teniperature
• Not applicable
Danger or Explosion
• Nun explosive
Extinguishing Media
• Water
Fire Hazards
• Oxidizer. Storage vessels involved in a fire may vent gas or rupture due to internal pressure.
Damp material may decompose exothermically and ignite combustibles. Oxygen release due to
exothermic decomposition may support combustion. May ignite other combustible materials.
Avoid contact with incompatible materials such as heavy metals, reducing agents, acids, bases,

(ADVENTUS
Safety Data
MATERIAL SAFETY DATA SHEET:
O—SOXTM Page 3 of
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gar: evolution. Pressurization if confined when heaved or
decomposing. Containers may burst violently.
Fire Fighting Measures
• Evacuate all non -essential personnel
• Wear protective clothing and self-contained breathing apparatus.
■ Remain upwind of fire to avoid hazardous vapors and decomposition product,.
• Use water spray to cool tire- exposed containers,
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendsitiuns found in Section 9. Never exceed any occupational exposure limit.
• Shovel or sweep material into plastic bags or vented containers for disposal. Do not return spilled
or contaminated material to inventory. Avoid making dust.
• Flwh remaining area with water to remove trace residue and dispose of properly. Avoid direct
discharge to sewers and surface waters. Notify authorities if entry occurs,
• Do not touch or walk through spilled material. Keep away from combustibles (wood, paper. oils,
etc.)_ Do not return product to container because of risk of contamination,
HANDLLNG AND STORAGE
Storage
* Oxidizer. Store in a cool. well -ventilated area away from all source of ignition and out of direct
sunlight. Store in a dry location away from heat.
• Keep away from incompatible materials. Keep containers tightly closed. Do not store in
unlabeled or mislabeted containers,
• Protect froth moisture. Do not store near combustible materials. Keep containers well sealed.
Ensure pressure relief and adequate ventilation.
• Store separately from organics and reducing materials, Avoid contamination that may lead to
decomposition.
Handling
• Avoid contact with eyes, skin, and clothing. Use with adequate ventilation.
• Do not swallow. Avoid breathing vapors, mists, or dust. Do not eatdrink, or smoke in work
area.
• Prevent contact with combustible or organic materials.
• Labe1 containers and keep them tightly closed when not in use.
• Wash rhorouehly after handling.

U, ADVENTUS
......._...,,._..., r, f] l!( .. ,,,, ,;fl: I \1f , ''• rt
~ ,,_•tO)f.l'1J:;tJl(l"frl/'IJi,.il""
Safety Data
MA TERIAl, SAFETY DATA SHEET: 0-SOXTM Page: 4 of5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Control~
• General room ventilation is required. Local exhaust ventilation, process enclosures or other
engineers controls may be needed to maintain airborne levels below recommended exposure limits.
Avoid creating dust or mist. Maintain adequate ventilation. Do not use in closed or confined
spacei1. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no re$piratory protection may be needed; however, in dusty or unknown
atmospheres or when exposures exceed limit values, wear a NIOSH approved respirator.
Eye/Face Protection
• Wear chemical safety goggles and a full face shield while handling this product.
Skin Protection
• Prevent contact with this product. Wear gloves and protective clothing depending on condition of
use. Protective gloves: Chemical-resistant (Recommended materials: PVC. neoprene or rubber)
Other Protective Equipment
• Eye-wash station
• Safety shower
• Impervious clothing
• Rubber boots
General Hywene Considerations
• Wash with soap and water before meal times and at the end of each work shift . Good
manufacturing practices require gross amr,unts of any chemical removed from skin us soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
• Stable under normal conditions
Condition to A void
• Water
• Acids
• Bases
• Salts of heavy metals
• Reducing agents
• OrgaI1ic materials
• Flammable substances
Hazardous Decomposition Products
• Oxygen which supporti; combustion
ADVENTUS
Safety Data
MATERIAL SAFETY DATA SHEFT:
OSOXTM
Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
• LD54 Oral: Min.2(]0(] mg/kg, rat
• LDSO Dermal: Min. 2000mglkg. rat
• LDS) Inhalation: Min. 458O mg/kg. rat
12. ECOLOGICAL LNFORMATION
Eco toxi col ogical Information
• Hazards for the environment is limited due to the product properties of no bioaccumuiatinn, weak
solubility and precipitation in aquatic environment.
Chemical Fate Information
• As indicated by chemical properties oxygen is released into the environment.
13. DISPOSAL CONSIDERATIONS
Waste Treatment
• Dispose of in an approved waste facility operated by an authori,.ed contractor in compliance with
local regulations.
Package Treatment
• The empty and clean containers ore to be recycled or disposed of to conformity with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EPIC-O
• Hazard Gass: 5 I
• Labels: 5.1 {Oxidizer)
• Packing Group: II
15. REGULATORY INFORMATION
• SARA Section Yes
• SARA (313) Chemicals No
• EPA TSCA Inventory Appears
• Canadian WHMIS Classification C, D2B
• Canadian DSL Appears
• EINECS Inventory Appears
16. PREPARATION INFORMATION
Prepared By: Kerry Bolanos-Shaw
Adventus Rernediatinn Technologies
! 345 Fewster Drive
Mississauga. Ontario
L4 W 2A5
Date Prep./Rev:
Print Date -
Phone:
Fax:
9112107
9112/07
905-273-5374
905-27 34367

APPENDJXB
MONITORING WELL CONSTRUCTION DETAILS
-----
1 ► ON ESWEIVTJAL WELL CONSTRUCTION RECORD
North Carolina Deparirnen! c1 Erlvirunrnerrt find Natural Resources- Division of Wr!lor QuaIity
WEt.L CONTRACTOR CERTWWICATION # 3550
1. WELL CONTRACTOR:
JAMES HE$S
Weti Contractor (individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD7
Street Address
STATESViLLE
NC 28625
City or Town Slate Zip Corte
L704 ) 872-76B6
Area cede Phone number
2. WELL INFORMATION-
WELL CONSTRUCTION FERMIT# NIA
°THEE. ASSOCIATED PERMIT#(it apPileRV.)
SITE WELL ID ifapptkaaie) MW-5A
3. WELL USE (Cheek One Box) Monitoring 1i Municipal/Public Q
industrial/Commercial G Agricultural Q Recovery 3 Injec6cn G
Intgalion0 Other 0 (list use)
RATE DRILLED 06/30/11
4. WELL LOCATION:
4890 PENOERLEA HIGHWAY 28478
(S st Home, Ncumbere, Community. suhdivtsicn. Lot No., Aarcd. Zip Cadet'
CITY: WATHA COUNTY PENDER
TOPOGRAPHIC I LAND SETTING: (check appropriate sox)
DSlope °Valley ❑FIai GRldge Q0ther
LATITUDE ` DMS OR
LONGITUDE • "EMS OR
OD
DO
Latitude/longitude source- E PPS Qfupograph c map
(location of welt must be drown on a IISGS taps map andettacted to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
HQRSEBRANCH GROCERY N/A
Featly Namo Facility ICsa [If applicaote)
4990 PgNtiERLEA HIGHWAY
Street Address
WA_Tk-IA NC 26478
City or Town State Zip Cade
WCRSL Y FAMILY HQL0INGS
Contact Name
123 SHIPYARD 81.V0
Mailing Address
WILMINGTON NC 28412
Ctiy or Town State Zip Code
Area code Phone number
s. WELL DETAIL&:
a, IOTAL DEPTH: 12.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NOW
c. WATER LEVEL iielow Top of Casing: _ 4,0 FT.
(Use `+-It Above Tap DI Casing)
d. TOP OF CASING IS 0.0 FT. Above Land Surface*
'Top or casing termlaated allor below land surface may require
a variance in accordance with 15A NCAC 2C ,0118.
e. YIELD (gpm): N/A METHOD OF TEST NIA
f. DISINFECTION: Typo N/A
g. WATER ZONES {depth):
Top Bellom Top Bottom
Top Bottom Tap Bottom
To Bottom Top Bottom_
Thickness!
�. CA91NG: Depth Diameter Weight Material
Top 0.0 Bottom 2.0 Ft. 2 INCH li SCH 40 PVC
Tops Bottom Ft.
Top Bottom_ Ft.
8. GROUT: Depth
Tap 0.0 tiatmm 0.5
Amount N/A
Malarial
Ft rcwTuwo SarrnHore
Top Bottom Ft.
Top bottom Fl.
Method
SLURRY
S. SCREEN: Depth Diameter Slot Size Metertai
Top_ 2.0 Bottom_ 12.0 F1. 2.0 in. .010 in. PVC
Top Bottom Ft. in. in.
Top Bottom , Ft. In. in.
10- SANOIGRAVEL PACK:
Depth Stae Material
Top 1; ,Bottom 12.0 Ft. 20-40 FINE SILICA SAND
TnT r3Hf!rram r f
Top Bottom Ft.
11, DRILLING LOG
Top Bottom
_ 0.0 / 3.0
3.0 / 5.0
5.0 / 9.0
9.0 r 12.0
I
1
1
Formation Desorption
BROWN SILTY SAND
GRAY CLAYEY SAND
BROWN/RED CLAYEY SAND
GRAY CLAYEY SAND
12. REMARKS:
BENTONITE SFAL FROM it 5 TO 1 0 FEET
no rrtREeY RTTY THAT THIS WELL WAs CotrSTRI. AD IN ACCORDANCE WITH
t NCAC Wr« cONSTR r r nionRas. A+ -AT R COPY OF THIS
REcoeD)» BEEN PR• '•;; Yp LL CNME-
_ 071Q5111
ATURE OF CE t 1HEl7 WELL C. OA1 E
is JAMES MESS_
PRINTED NAME OF PERSON CONSTRUCTING THE WELL,
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mall Service Center, Raleigh, NC 27698.161, Phone : [phone]
From GW- i G
Rev. 2109

&ATC
MW-5A
Detain) Drdled ' 6130l11 Baling Donator 5.5 Inapt'
Willing Contractor • Geoloos donation Sampling Method Hand Auger Cuttings
Dn}Irng Method : Hollow Stem Augur Sampling tntrval 5'
Logged Sy Maureen daelesor
Depth In Feel
Grass and Qrganlcs
DESC RI PTI ON
Drill. Method:
1-/SA:
Srvvn SILTY SAND. no odor
BM
Gray CLAYEY SAND, no odor
Gray CLAYEY SAND, moist, no odor
SC
to
11
12
SC
f
Brownish gray Cs.AYEY SAND. slight weathered petroleum odor
Reddish brown CLAYEY SAND. petroleum odor
Tan CLAYEY SAND
Gray slightly CLAYEY SAND, strong petroleum odor
End of boring at 1 2' bgs

•
}
1. WELL CONTRACTOR:
JAMES HESS
.NONRESIDENTIAL WEW,CON+FRIICTIO;N RECORD
Nuntt Carolina Deportment of 6nvironlnctll and Nrttural Resources- of Water Quality
WELL CONTRACTOR CSit i'i ii ICATIONT # 3550
Wait Contractor (Irullviduat) Name
GEOLOGIC EXPLORATION. INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town
t704 1 872-7686 _
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT# NIA
OTHER ASSOCIATED PERMIT#(!r applicable)
SITE WELL ID Of appliralble) MW-10A -
3. WELL USE (Check One Bolt) Monitoring ur Muntdpal/Publlc
Industrlal/Cummercial 0 Agricultural f1 Recovery 0 Injection
Irl IgaIIOn0 Other 0 (list use)
DATE DRILLED 06130/11
4. WELL LOCATION:
4990 PENDERLEA HIGHWAY 26478
(Street Nurse. Numbers. Community. subdirislon. LD1 No. Parcel, lip Code)
CITY: WATFSA COUNTY RENDER
Slate Zip Code
TOPOGRAPHIC / LAND SErflNG: (chauk app•npriata box)
°Slope OVatley OFlat °Ridge °Other
LATITUDE • DMS CR OD
LONGITUDE OMS OR DO
Latitude/longitude source: CUPS OTopographic map
(location of well must he shown on a L/SGS ton) map andattached ro
this fo/'rn if not uslrg GPS)
5. FACILITY (NerrE of the business where the welt is located.)
HQRSEBRANCH GROCERY N/A
Facility Name Facility IDS (if applicable)
4990 PENUERLEA HIGHWAY
Street Address
WATHA N(. 28478
City or Town Slate Zlp Cade
WQRSLEY FAMILY HOLDINGS
Contact Nacre
123 SHIPYARD BLVD
Mailing Address
W ILM}NgTON NC 28412
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 12.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES° NO
c, WATER LEVEL Below Top of Casing: 4.0 FT
(tlse "+" iF Above Top of Casing}
d. TOP OF CASING IS 0.0 FT. Above Land Sutfaoe'
"Top of casing lerrnfnated al/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e_ YFELO tgpm): N/A METHOD OF TEST NIA
f. ❑fSINFEGTION: Type NIA Amount NIA
g. WATER ZONES (depth):
Top Bottom Top Bottom
Top Bottom Top Bolton/
Top Bottom Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top 0.0 _ Bottom 2.0 FL 2 INCH SCI' i0 PVC
Top Bottom FI.
Top Bottom Ft.
8. GROUT: Depth Material
Top 0.0 Bottom 0.5 Fl.
Tov tin Ram f
Top Bottom R.
vaetw+v 9EIROI!E
6. SCREEN: Depth
Method
SLURRY
Olameter Siot Site Material
Top 2.0 Bottom 12.0 Ft. 2.0 In. .010 in. PVC _
Top- .� Bottom Ft. in. in. _ _
Top Bottom___ Ft. in. _ _ _ In.
10. SANDIGRAVEL. PACK:
Depth
Top 1.0
Top
Size Material
Bolcom 12_0 _ FI. 20-40
Bottom Ft.
Top Bottom R.
11. DRILLING LOG
Top Buttorm
0.0 1 5.0
5.0 1 7.0
7.0 1 9.0
9.0 1 12.0
1
1
FINE SILICA SAND
Foimalion Description
BROWN SILTY SAND
GRAY CLAYEY SAND
BROWN/RED CLAYEY SAND
GRAY CLAYEY SAND
12. REMARKS;
LIEL TONITE.SF ' itf 5 TO 1.0 FEET
r DOHER rtr CERTIFv THAT T:s5 WELL. WAS CONS«tt6TEDIN ACCORDANCE uMTH
13A NCArA... WELL CHC-INUCT rANoARRs.JJ'THAT A CORY CV ±HIS
{y'�S FR• if
RECO .9r.FJl
07/06111
f5rGNATURE OF CERTIFIED WELL, ONTRALIOR DATE
{ JAMES HESS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Information Processing,
1617 Matt Service Center, Raleigh, NC 27699-161, Phone : [phone]
Form GW-itr
Rev. 2/cg

&ATC
Depth In Feet
7
Grass and Organics
GP
1—
Grave(thard)
Brown SILTY SAND
MW-1 OA
Dates) Drilled 5130111 BotFng Diameter 6.6 inches
Onlling Contractor Geologic Exrtormtion Sampling Method Hand Auger Cuttings
Orftling Method Hollow Stem Augers Sampling Interval 5'
Logged By Maureen Jackson
DESCRIPTION
L3
1
Gray CLAYEY SAND. no edor
SC ,/
Brownish gray CLAYEY SAND. wet, no odor
Reddish brown CLAYEY SAND, no odor
6--
Brown CLAYEY SAND. no odor
/ 1
10
12
Gray CLAYEY SAND
Gray slightly CLAYEY SAND
End of baring at 12' bgs
Dria. Method:
NSA:

Shrestha, Shristi R
From:
Sent:
To:
Subject:
Attachments:
Please find the attached NOi.
Shristi
Shristi R. Shrestha
Hydrogeologist
Shrestha, Shristi R
Friday, September 22, 2017 1:55 PM
Gregson, Jim; King, Morella s
WI0800488 Former Horsebranch Grocery
NOI.pdf
Water Quality Regional Operations Section
Animal Feeding Operations & Groundwater Protection Branch
North Carolina Department of Environmental Quality
919 807-6406 office
shristi.shrestha@ ncdenr.g ov
512N. Salisbury Street
1636 Mail Service Center
Raleigh, NC 27699 1636
Email correspondence to and from this addre::;s is subject to the
North Carolina Public Records Law and may be disclosed to third parties.