WI0100621_Permit (Issuance)_20210630

DATE: June 11,2021
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 1SA 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.
PERMIT NO. W10100621 (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) Passive Injection System ..Complete sections B through F, H-M
(4) X 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: Business/Organization
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(s): Corn, Michael R; Corn, Mary Louise; Johnston, William F.; Johnston, Nancy M; Johnston,
Timothy M.; Johnston, Bradley A.; and Johnston, Bradley A. Trustee
Mailing Address: 93 Tap Root Dairy Road
City: Fletcher State: NC Zip Code: 28732 County: Henderson
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Same
Company Name
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Chris Singleton, Professional
Geologist Company Name Singleton Environmental
Group Inc. Mailing Address: P.O. Box 604
City: Fletcher State: NC Zip Code: 28732 County: Henderson
Day Tele No.: 828-508-4510 Ce11 No.: 828-508-4510
EMAIL Address: chris@,singletonenvironmental.com Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: 125 Tap Root Dairy Rd
City: Fletcher
County: Henderson
(2) Geographic Coordinates: Latitude**: 35 ° 24 ' 28 " or
Longitude**: 82 ° 31 ' 46 " or °.
Zip Code: 28732
°
Reference Datum: GoogleEarth Accuracy:
Method of Collection:
**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: 15,750 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
(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.
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:
Singleton will inject approximately 5 kilograms of Enviro-BAC mixed with fifty gallons of
water into monitoring wells MW-2 and 28 injection points. The hydrated Enviro-BAC
be injected into the monitoring wells. The aqueous Enviro-BAC will mix with groundwater
within the aquifer to assist in reducing dissolved phase groundwater contamination.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 28 Proposed 1 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 5' - 15'
(3)
For Proposed wells or Existing wells not having GW-1s, 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
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-resource s/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHSprior to use.
Contact the UIC Program for more info if you wish to get approval for a different additive. However, please
note it may take 3 months or longer.
Injectant: Enviro-BAC Total Amt. to be injected (gal)/event: 145 kilograms
Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected (gal)/event:
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 3

Injectant: Total Amt. to be injected (gal)levent.
Injectant: Total Amt. to be injected (gaI)levent:
Amt. Water to be injected (gal/event): 1,450 gallons
Total Amt. to be injected (gal/event):
No. of separate injection events: 1 Est. Total Amt. to be injected (gal):
Source of Water (if applicable): Adjacent Water -Supply Well
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.
Singleton Environmental will collect a groundwater sample from the monitoring wells in December 2020, The
groundwater samples will be analyzed for volatile organic compounds using Standard Method 620013. The
groundwater samples will also be analyzed for bacterial counts before injection and following injection.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "I hereby cert, 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 chose 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 y li and all rated appurtenas in accordance with the 15A NCAC 02C 0200 Rules."
t
M7.r^r�jgL�e►"�f?rim)►
Print or Type Full Name an Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection wells. 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
(15,4 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,] f contrary greement intting.
7
I fire ti� fillov L.gi.Ci 5 t fit It?ana.21
St atu of PropertyOwner if different from applicant) Print or Type Full Na and Title ��
Stan I
*An access agreement between the applicant and property owner may he submitted in lieu of a signature n this firm.
Please send 1 (one) hard color copy of this NOI along with a copy on an attached CD or Flash Drive at Ieast
two (2) weeks prior to injection to:
DWR—UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Deemed Permitted GW Remediation NO1 Rev. 2-14-2020 Page 4

LEGEND:
SOIL SAMPLE LOCATIONS O SHRUB
1 WATER WELL
SCALE (feet)
TREE
a
25 50
UST SYSTEM
(Tank Pit, Product Lines, etc.)
DRAWN BY: C. Singleton
CHECKED BY: C. SINGLETON
INGLETON ENVIRONMENTAL, INC
FIGURE 2
Potentiometric Map
Tap Root Dairy
Fletcher, NC

LEGEND
Mw_1 Monitoring Well Location
with I.D.
A Cross —Section ID point
Product Piping
loon
— — — Groundwater Level
Levels above GCLs
Tank Pit Backfill
Silt
Saprolite
Fill Material
A
NA W —
HORIZONTAL SCALE: 1" = 30'
VERTICAL SCALE: 1" = 5'
NA W — 1
Grovel
Tan Silty Sand
Groundwater Above NCAC 2L GCLs
Above NCAC 2D MC1.s
Tan Silty Sand
Surface
15 ft
DRAWN BY: C. Singleton
DATE:
CHECKED BY: C. SINGLETON
PROJ. NO.: SEI-1155
SINGLETON ENVIRONMENTAL, INC
FIGURE 3
HYDROGEOLOGIC CROSS SECTION
Tap Root Dairy
Fletcher, NC
DWG

]VONR.ESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of i.{.nvironment and Natural Resources- Di -vision of Water Quality
WELL CONTRACTOR CERTIFICATION # 3328-B
1, WELL CONTRACTOR:
Chris Sin s leton
VVII Contractor Individual) Name
Sirs Teton Environmental, Inc.
We#1 Contractor Company Name
PO Box 2012
Street Address
Enka
City or Town State Zip Code
(82 ) 667-5001
Area code Phone number
2. WELL INFO MATZO :
ELL CONSTRUCTION PERMIT#
NC 28728
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) MW-2
3, WELL USE (Check One Box) Monitoring Municipal/Public ❑
Industrial/Commercial ❑ Agricultural 0 Recovery ❑ Injection ❑
Irrigation❑ Other ❑ (list use)_ -
DATE DRILLED 21 2020
4. WELL LOCATION:
125 Tap Root D a i r Road
(Street F anie Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Fletcher COUNTY Henderson
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
p Slope Malley ❑ Flat p Ridge ❑ Other -.-
LATITUDE 3 " DMS OR 35.4080 DD
LONGITUDE 4 "DMSOR 82.5296 DD
Latitudellongitude source: VGPS LJTopo raphic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
Tao Root Dairy
Facility Name Facility #D# if applicable)
12 Tap Rout D .
Street Address
Fl t r NC.. -- .28732
City or Town State Zip Code
Mary Corn
Contact Name
- --- - Mailing Address
Fletcher NC 28732
City or Town State Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 15.0
b. DOES WELL REPLACE E EXISTING WELL? YES ❑ NO
c. WATER LEVEL Below Tap of Casing: 6.14
(Use "-CI if Above Top of Casing)
FT.
d. TOP OF CASING IS FT. Above Land Surface*
*Top of casing terminated at/or below land surface may require
a variance in accordance with 1 A NCAC 2C .0118.
e. YIELD (p ) N/A
METHOD OF TEST
f. DISINFECTION: Type Amount
. WATER ZONES (depth) :
Top 6.14 Bottom 15 Top Bottom
Top Bottom Top Bottom
Top Bottom — -. Top Bottom
Thickness/
7. CASING: Depth Diameter Weight Material
Top Bottom 5 Ft. 2 sch 40 PVC
: Top Bottom F=t-
= Top- - Bottom Ft.
{ 8. GROUT: Depth Material Method
Top Bottom 3 Ft- Portland Pour
Top Bottom Ft
Top Bottom Ft.
9. SCREEN; Depth Diameter
Slot Size Material
Top 5 Bottom 15 . Ft. 2 in. .01 0 in, PVC
Top Bottom Ftin, in.
Top Bottom Ft. in. in, -- -
10. SAND/GRAVEL PACK:
Depth Size Material
Top 4 Bottom 15 Ft #2 Quartz Sand
Top
Top
Bottom Ft,
Bottom Ft
11. DRILLING LOG
Top Bottom Formation Description
1 feet Gravel
I 1 15 feet Tan Silty Sand
1
12. REMARKS:
-Monitoring-Wel-HVIVV-
•
• I DO HEREBY CERTIF
• 15A NCAC 2C, VVE
• REOR -
AT THIS VVEL
STRUCTION
OVIDEDTOT -
AS CONSTRUCTED IN ACCORDANCE WITH
ANDAROS, AND THAT A COPY OF THIS
LL OWNER.
3/5/20
- SIG ATURE OF CERTD WELL CONTRACTOR DATE
•
Chris Sin let s - - --
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - information Processing,
1617 Mail Service Center, Raleigh, h 9 -'1 5 Phone : [phone]
Form W-1 b
Rev. 2109