WI0501078_Application_20210610

ATC
ENVIRONMENTAL• GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
May 18, 2021
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
County Line Grill
13522 Virgilina Road
Roxboro, Person County, North Carolina
NCDEQ Incident No. 5746
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 the North Carolina Department of
Environmental Quality State -Lead Program. The permit application covers the performance of
passive remediation in one monitoring well 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.
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Linda Blalock, Engineer for NCDEQ
Attachments

Notice of Intent to Construct or Operate Injection Wells
County Line Grill, Roxboro, North Carolina
NOTICE OF INTENT FORM
ATC
E.RON•ENIAL • OEORCMICAI
NII0.61s6iCIENLCi• k11ENatiiE511116

NC Department of Environmental Quality — Division of Water Resources (DWR)
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 (NOTE: This form must be received at least 14 DAYS 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.
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 (Note: Injection Event Records (IER) do not need to be
submitted for replacement of each sock used in ORC systems).
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 is 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.
5) In -Situ Thermal Wells (IST) — Used to `heat' contaminated groundwater to enhance remediation
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: May 18 , 20_21
PERMIT NO. WI0501078 (to be filled in by DWR)
NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:
A.
B.
Permit No. WI Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) Air Injection Well Complete sections B through F, J, M
(2) Aquifer Test Well .Complete sections B through F, J, M
(3) X Passive Injection System Complete sections B through F, H-M
(4) Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) In -Situ Thermal (IST) Well Complete all sections except K
STATUS OF WELL OWNER: State Government
Deemed Permitted GW Remediation NOI Rev. 2-14-2020
Page 1

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: Linda Blalock — Engineer, North Carolina Department of Environmental Quality
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8165 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: Not Available
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Raymond Lowery, Jr.
Company Name Not Applicable
Mailing Address: 714 Mill Creek Road
City: Roxboro State: NC Zip Code: 27574 County: Person
Day Tele No.: 336-599-7347 Cell No.: Not Available
EMAIL Address: Not Available
Fax No.: Not Available
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name: Ashley M. Winkelman — ATC Associates of North Carolina, P.C.
Mailing Address: 2725 E. Millbrook Road, Suite 121
City: Raleigh State: NC_ Zip Code:27604 County: Wake
Day Tele No.: 919-871-0999 Cell No.: 919-830-3576
EMAIL Address: [e-mail] Fax No.: 737-207-8261
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: County Line Grill
13522 Virgilina Road
City: Roxboro County: Person Zip Code: 27574
(2) Geographic Coordinates: Latitude**: " or 36 °. 52142
Longitude**: " or 78 °. 79583
Reference Datum: WGS84 Accuracy: 10-meter
Method of Collection: DOQ — Acme Mapper 2.2
**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)
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 2

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
Included in the Figures section. Soil maps not provided to ATC.
(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)
Cross -sections have not been prepared for this site.
Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing and
proposed wells.
Included in the Figures section.
DESCRIPTION OF PROPOSED INJECTION ACTIVITIES AT THE SITE — Provide a brief narrative
regarding the cause of the contamination, and purpose, scope, goals of the proposed injection activity:
ATC will install three Provect ORS sleeves in monitoring well MW-1 in order to aide in natural attenuation and
reduce compound concentrations to below the North Carolina Groundwater Quality Standards (2L Standards).
Based on the most recent sampling event performed in February 2021, the following compounds exceeded the
2L Standards: benzene, ethylbenzene, total xylenes, methyl tert-butyl ether, isopropylbenzene, n-propylbenzene,
naphthalene, 1,2,4-trimethylbenzene, and 1,3,5-trimethylbenzene. The sleeves come in 3-foot sections. ATC
will install three 3-foot sections at the base of the well, across the well screen. The socks will release oxidizing
solids into the groundwater for approximately 6 months, at which point the chemicals in the socks will have
depleted.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 1 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 10-19
(3)
For Proposed wells or Existing wells not having GW-ls, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 3

Well
Construction
Details
Well
Well
Type
Depth
Grout
Type
Depth
and
Screen Interval
Sand
Interval
Pack
Well
Contractor
name
Certification
and
M W- 1
Permanent
19 feet
Unknown
Depth
0 to
—
Assumed
3 feet
4-19
feet
Unknown
Assumed
19
feet
—
3-
Unknown
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of 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-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS pi for to use.
Contact the UIC Program for more info if you ivish to get approval for a different additive. However, please
note it may take 3 months or longer.
Injectant: Provect ORS Sleeves Total Amt. to be injected (gal)/event: 1,038 in3 (volume of sleeves)
Amt. Water to be injected (gal/event): N/A
Total Amt. to be injected (gal/event): 1,038 in3 (volume of sleeves)
No. of separate injection events:1 Est. Total Amt. to be injected (gal): 1,038 in3 (volume of
sleeves)
Source of Water (if applicable): N/A
L. 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.
Approximately 6 months after the installation of the Provect ORS sleeves, ATC will collect a sample from the
well for analysis of volatile organic compounds by EPA Method 6200B. The sample will be shipped to Pace
Analytical in Mt. Juliet, Tennessee. ATC will also measure dissolved oxygen, conductivity, temperature, pH,
and oxygen reduction potential during the sampling event.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby certify, under penalty of law, that I ain 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 ain aware that there are significant penalties, including the possibility of f nes 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 1 SA NCAC 02C 0200 Rules."
Signature of Applicant Print or Type Full Name and Title
Ashley Winkelman on behalf Linda Blalock, NCDEQ
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 4

Property Owner (if the property is not owned by the Well Owner/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.
See Appendix B Raymond Lowry, Jr.
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.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at least
two (2) weeks prior to injection to:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 5

Liz Allyn
Subject: FW: NOI Signature Authorization
From: Blalock, Linda[mailto:[e-mail]]
Sent: Tuesday, September 25, 2018 4:27 PM
To: Ashley Winkelman <[e-mail]>
Subject: NOI Signature Authorization
I, Linda Blalock, authorize Ashley Winkelman from ATC Associates, to sign Notices of Intent (NOI) as an agent for
DWM. If you have any questions or need more information, please let me know.
Linda Blalock
[e-mail]
Linda Blalock
Environmental Engineer, Division of Waste .tfanagement
North Carolina Department of Environmental Quality
1646 Mail Service Center
Raleigh. NC 27699-1646
919.707.8165 (Office)
Email correspondence to and from M.'s address is subject
North Coair a Public Records Law and may be disclosed to tnrrd parries.
i

Notice of Intent to Construct or Operate Injection Wells
County Line Grill, Roxboro, North Carolina
FIGURES
ATC
E.RON•ENIAL • OEORCMICAI
NII0.61s6iCIENLCi• k11ENatiiE511116

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Notice of Intent to Construct or Operate Injection Wells
County Line Grill, Roxboro, North Carolina
APPENDIX A
MSDS FORM
ATC
En1RON•ENIAL • OEORCMICAI
NII0.61s6iCIENLCi• k11EN14iiE511116

* rovectus
El*1VIRONMENTAL PRODUCTS
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 1 of 5
1. PRODUCT IDENTIFICATION: PROVECT-ORS
PRODUCT USE: Soil and water treatment.
MANUFACTURER: EMERGENCY PHONE:
PROVECTUS ENVIRONMENTAL
2871 W. Forest Rd., Suite 2
Freeport, IL
61032
USA: ($15) 650-2230
TRANSPORTATION OF DANGEROUS GOOD CLASSIFICATION:
Oxidizing Solid, n.o.s. (Calcium Peroxide), Class 5.1, PG II, UN1479
WHMIS CLASSIFICATION:
Oxidizer
2. COMPOSITION/INFORMATION ON INGREDIENTS
Ingredients
Calcium Peroxide
Inorganic Nutrients
3. PHYSICAL DATA
Chemical Formula
CaO2
CAS No. Percentage
1305-79-9 75%-85%
15%-25%
Appearance White & brown granules
Physical state Solid
Odor threshold None
Bulk Density 500-650g/L
Solubility in Water Insoluble
pH —11
Decomposition Temperature Self -accelerating decomposition with oxygen release starting from 275
degrees Celsius
4. HAZARDS IDENTIFICATION
Emergency overview
Oxidizing agent, contact with other material may cause fire. Under fire conditions this material may
decompose and release oxygen that intensifies fire. This product contains <1% non -respirable crystalline
silica. The NTP and OSHA have not classified non -respirable crystalline silica as carcinogenic. Long term
exposure to hazardous levels of respirable silica dusts can cause lung disease (silicosis). ORS does not
contain respirable crystalline silica.
Potential Health Effects:
• General Irritating to mucous membrane and eyes.

rovectus
ENVIRONMENTAI. PRODUCTS"
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS 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 air. Seek medical attention if effects
persist.
• Eye contact Flush eyes with running water for at least 15 minutes with eyelids
held open. Seek specialist advice.
• Skin contact Wash affected skin with soap and mild detergent and large amounts of
water.
• Ingestion If the person is conscious and not convulsing, give 2-4 cupfuls of
water to dilute the chemical and seek medical attention immediately.
Do not induce vomiting.
6. FIRE FIGHTING MEASURE
Flash Point
• Not applicable
Flammability
• Not applicable
Ignition Temperature
• Not applicable
Danger of Explosion
• Non -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,

rovectus
ENVIRONMENTAL PRODUCTS}
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 3 of 5
combustible (wood, papers, cloths etc.) Thermal decomposition releases oxygen and heat.
Pressure bursts may occur due to gas evolution. Pressurization if confined when heated 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 products.
• Use water spray to cool fire- exposed containers.
7. ACCIDENTAL RELEASE MEASURES
Spill Clean-up Procedure
• Oxidizer. Eliminate all sources of ignition. Evacuate unprotected personnel from equipment
recommendations 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.
• Flush 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.
8. HANDLING 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 mislabeled containers.
• Protect from 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 eat, drink, or smoke in work
area.
• Prevent contact with combustible or organic materials.
• Label containers and keep them tightly closed when not in use.
• Wash thoroughly after handling.

* rovers
ENVIRONMENTAL PRODUCTS'
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 4 of 5
9. EXPOSURE CONTROLS/PERSONAL PROTECTION
Engineering Controls
• 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
spaces. Keep levels below exposure limits. To determine exposure limits, monitoring should be
performed regularly.
Respiratory Protection
• For many condition, no respiratory 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 Hygiene Considerations
• Wash with soap and water before meal times and at the end of each work shift. Good
manufacturing practices require gross amounts of any chemical removed from skin as soon as
practical, especially before eating or smoking.
10. STABILITY AND REACTIVITY
Stability
• Stable under normal conditions
Condition to Avoid
• Water
• Acids
• Bases
• Salts of heavy metals
• Reducing agents
• Organic materials
• Flammable substances
Hazardous Decomposition Products
• Oxygen which supports combustion

rovectus
ENVIRONMENTAL PRODUCTS}
MATERIAL SAFETY DATA SHEET:
PROVECT-ORS Page: 5 of 5
11. TOXICOLOGICAL INFORMATION
• LD50 Oral: Min.2000 mg/kg, rat
• LD50 Dermal: Min. 2000mg/kg, rat
• LD50 Inhalation: Min. 4580 mg/kg, rat
12. ECOLOGICAL INFORMATION
Ecotoxicological Information
• Hazards for the environment is limited due to the product properties of no bioaccumulation, 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 authorized contractor in compliance with
local regulations.
Package Treatment
• The empty and clean containers are to be recycled or disposed of in conformity with local
regulations.
14. TRANSPORT INFORMATION
• Proper Shipping Name: EHC-O
• Hazard Class: 5.1
• 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

Notice of Intent to Construct or Operate Injection Wells
County Line Grill, Roxboro, North Carolina
APPENDIX B
ACCESS AGREEMENT FROM SITE PROPERTY OWNER
ATC
En1RON•ENIAL • OEORCMICAI
NII0.61s6iCIENLCi• k11EN14iiE511116

Ms. Linda Blalock
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Blalock:
RE: Site Access Agreement
Former County Line Grill
12810 Virgilina Rd (NC Hwy 49)
Roxboro, Person County, NC
Incident #: 5746
Q
I am/We are the owner(s) of a parcel of property, located at or near the incident in question,
and hereby permit the Department of Environment and Natural Resources (Department) or its
contractor to enter upon said property for the purpose of conducting an investigation of the
groundwaters under the authority of G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.

Former County Line Grill/Incident #5746
6. The activities to be carried out by the Department or its contractor are for the primary benefit
of the Department and of the State of North Carolina. Any benefits accruing to the owner are
incidental. The Department or its contractor is not and shall not be construed to be an agent,
employee, or contractor of the landowner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
.o , .v/ dr
Ty e/Print Name of Owner r Agent
7i /XI/ /0/.
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