WI0600047_Application_20180305

GMA
Groundwater Management Associates, Inc.
4300 Sapphire Court, Suite 100
Greenville, North Carolina 27834
Telephone: [phone]
www.gma-nc.com
March 5, 2018
Mr. D. Michael Rogers
NCDWQ, DWQ, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Re: UIC Permit Renewal (#WI0600047)
NCDOT Priority Site #32, (Johnson Brothers Utility & Paving Company)
1924 North Main Street, Lillington, Harnett County, North Carolina
Dear Mr. Rogers,
You requested renewal of UIC permit #WI0600047 in a February 8, 2018, email to Mr. Jason
Prosser. Groundwater Management Associates, Inc. (GMA) completed the enclosed UIC permit
renewal application on behalf of the North Carolina Department of Transportation. Please call
me at [phone] or email me ([e-mail]) if you have any questions.
Sincerely,
Groundwater Management Associates, Inc.
Katie T. Hackney, PG
Senior Hydrogeologist
Enclosures: 1) In -Situ Groundwater Remediation Application (2 hard copies, PDF on CD)
cc: CLP Services, Attn: John Wise
Mr. Jason Prosser, PG, NCDOT Roadside Environmental Unit
Z:/1605xx/160502_Site#32_Lillington/UIC permit?UICPermitCover_Site#32Lillington_20180305.docx
The Groundwater Experts

North Carolina Department of Environmental Quality — Division of Water Resources
APPLICATION FOR PERMIT TO CONSTRUCT AND/OR USE A WELL(S) FOR INJECTION
In Situ Groundwater Remediation (15A NCAC 02C .0225) / Tracer Injection (15A NCAC 02C .0229)
Do not use this form for the following:
• In -situ remediation, tracer, or aquifer test injection wells permitted by rule (ref. 15A NCAC 02C .0217)
• remediation systems that reinject treated contaminated groundwater (Non -discharge) (ref. 15A NCAC 02T .1600)
Permit Number (to be completed by DWR): WI
I. APPLICATION INFORMATION
1. Project is: [ ] New [ ] Modification [X] Renewal without modification [ ] Renewal with modification
2. If this application is being submitted for Renewal and/or Modification to an existing permit, provide:
(a.) Existing permit number WI060047 Issued Date: 12/18/2009 & Expiration Date: 11/30/2011
For all Renewals, submit a status report including monitoring results of all injection activities to date.
For Renewal without modification only, fill out sections I & II only, sign the certification on the last page of this form,
and obtain the property owner's signature to indicate consent (if the applicant is not the owner).
II. WELL OWNER(S)/PERMIT APPLICANT (generally the responsible party)
1. Name(s): The North Carolina Department of Transportation
2. Signing Official's Name*: Jason Prosser Title: Environmental Operations Engineer
* Signing Official must be in accordance with instructions in Part X on page 5.
3. Mailing address of Permittee/Applicant: 1577 Mail Service Center
City: Raleigh State: NC Zip: 27601
4. Telephone number: 919-707-2927 Email: [e-mail]
5. Status (choose one): Individual Business/Org. Federal X State County Municipality
III. PROPERTY OWNER(S) (if different than well owners)
1. Name(s):
2. Mailing address:
City: State: Zip:
3. Telephone number: Email:
IV. PROJECT CONTACT — (generally the environmental/engineering consultant).
1. Name: Title:
2. Company:
3. Address:
4. City: State: Zip:
5. Telephone number: Email:
In -Situ Groundwater Remediation Application Rev. 8-28-2017 Page 1 of 6

V. FACILITY INFORMATION
1. Facility name: Phone No. if available:
2. Physical address:
City: County: Zip:
3. Geographic Coordinates: Latitude: Longitude:
Reference Datum: Accuracy:
Method of Collection (i.e., Google Earth, GPS, etc.):
4. Brief description of business:
VI. INCIDENT DESCRIPTION
1. Source and date of contamination:
2. List all contaminants present in soils or groundwater at the site (contaminants may be listed in groups, e.g., gasoline,
diesel, jet fuel, fuel oil, chlorinated ethenes, chlorinated ethanes, metals, pesticides/herbicides, etc):
3. Has LNAPL or DNAPL ever been observed at the site (even if outside the injection zone)?
[ ] Yes If yes, list maximum measured separate phase thickness: feet
[ ] No If no, list maximum concentration of total VOCs observed at site: ppb
4. Agency managing the contamination incident:
[ ] UST Section [ ] Superfund Section (including REC Program and DSCA sites)
[ ]DWR Aquifer Protection Section [ ] Solid Waste Section
[ ] Hazardous Waste Section [ ] Other:
5. Incident manager's name: Phone No.:
6. Incident number or other incident mgmt. agency tracking number:
VII. PERMITS
List all applicable permits or construction approvals issued for the facility or incident:
1. Previous or other UIC permits issued by DWR (e.g., NOIs)
2. Other Non -Discharge or NPDES permit issued by DWR:
3. County or DEH subsurface wastewater disposal permits:
4. Hazardous waste management or other environmental permits required by state or federal law:
In -Situ Groundwater Remediation Application Rev. 8-28-2017 Page 2 of 6

VIII. INJECTION SUMMARY
1. List all proposed injectants/additives.
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 prior to use.
Contact the UIC Program for more info (919-807-6496) if you wish to get approval for a different additive.
However, please note it may take 3 months or longer.
Injectant: Total Amt. to be injected (gal)/event
Injectant: Total Amt. to be injected (gal)/event
Injectant: Total Amt. to be injected (gal)/event
Injectant: Total Amt. to be injected (gal)/event
Injectant: Total Amt. to be injected (gal)/event
2. Number of separate injection events: Duration of Event:
3. Estimated Injection rate per well: gallons per minute (GPM)
4. Estimated Injection pressure: pounds/square inch (PSI)
5. Temperature at point of injection: °F
6. Injection will be via:
( Existing well(s); Total No.: ; Well Type (DPT, Permanent, etc.):
( Proposed well(s); Total No.: ; Well Type (DPT, Permanent, etc.):
7. NC Certified Well Drilling Contractor's Name (if known):
NC Well Contractor Certification No.:
8. Date to be constructed if proposed: (attach GW-ls for existing injection wells)
9. Screened interval/Injection interval of injection wells:
Depth from to feet below land surface (BLS)(if multiple intervals, indicate shallowest
to deepest depth)
10. Well casing (leave blank if Geoprobes®):
Type: ( PVC ( Stainless steel( Other:
Casing depth: to ft. BLS
Type: ( PVC ( Stainless steel( Other:
Casing depth: to ft. BLS
11. Grout (leave blank if Geoprobes):
Type: ( Cement ( Bentonite ( Other:_
Grout depth: to ft. BLS
Type: ( Cement ( Bentonite ( Other:_
Grout depth: to ft. BLS
In -Situ Groundwater Remediation Application Rev. 8-28-2017 Page 3 of 6

IX. ATTACHMENTS — provide the following information in separate attachments. The attachments should be clearly
identified and presented in the order below to expedite review of the permit application package.
1. INJECTION ZONE — Per 15A NCAC 02C .0225(e)(2), specify the horizontal and vertical portion of the subsurface within
which the proposed injection activity will take place and beyond which no violations of groundwater quality standards shall
result from the injection as determined by an approved monitoring plan. The determination shall be based on the hydraulic
properties of the specified zone. Provide any supporting documentation in a separate attachment.
2. HYDROGEOLOGIC EVALUATION — Per 15A NCAC 02C .0225(e)(3), provide a hydrogeologic evaluation of the injection
zone that includes all of the following:
(A) Regional and local geology and hydrology;
(B) Changes in lithology underlying the facility;
(C) Depth to bedrock;
(D) Depth to the mean seasonal high water table;
(E) Hydraulic conductivity, transmissivity, and storativity, of the injection zone based on tests of site -specific material,
including a description of the test(s) used to determine these parameters;
(F) Rate and direction of groundwater flow as determined by predictive calculations or computer modeling; and
(G) Lithostratigraphic and hydrostratigraphic logs of any existing test and injection wells.
3. 1NJECTANT INFORMATION — Per 15A NCAC 02C .0225(e)(5), provide information on each injectant as indicated below:
(A) MSDS, concentration at the point of injection, and percentage if present in a mixture with other injectants;
(B) The source of fluids used to dilute, carry, or otherwise distribute the injectant throughout the injection zone. If any
well within the area of review of the injection facility is to be used as the fluid source, then the following information
shall be submitted: location/ID number, depth of source, formation, rock/sediment type, and a chemical analysis
of the water from the source well, including analyses for all contaminants suspected or historically recognized in
soil or groundwater on the site;
(C) A description of the rationale for selecting the injectants and concentrations proposed for injection, including an
explanation or calculations of how the proposed injectant volumes and concentrations were determined;
(D) A description of the reactions between the injectants and the contaminants present including specific breakdown
products or intermediate compounds that may be formed by the injection;
(E) A summary of results if modeling or testing was performed to investigate the injectant's potential or susceptibility
for biological, chemical, or physical change in the subsurface; and
(F) An evaluation concerning the development of byproducts of the injection process, including increases in the
concentrations of naturally occurring substances. Such an evaluation shall include the identification of the specific
byproducts of the injection process, projected concentrations of byproducts, and areas of migration as determined
through modeling or other predictive calculations.
4. INJECTION PROCEDURE — Per 15A NCAC 02C .0225(e)(6), submit a table with a detailed description of the proposed
injection procedure that includes the following:
(A) The proposed average and maximum daily rate and quantity of injectant;
(B) The average maximum injection pressure expressed in units of pounds per square inch (psi); and
(C) The total or estimated total volume to be injected.
In -Situ Groundwater Remediation Application Rev. 8-28-2017 Page 4 of 6

5. FRACTURING PLAN (if applicable) — Per 15A NCAC 02C .0225(e)(7), submit a detailed description of the fracturing plan
that includes the following:
(A) Material Safety Data Sheets of fracturing media including information on any proppants used;
(B) a map of fracturing well locations relative to the known extent of groundwater contamination plus all buildings,
wells, septic systems, underground storage tanks, and underground utilities located within the Area of Review;
(C) a demonstration that buildings, wells, septic systems, underground storage tanks, and underground utilities will not
be adversely affected by the fracturing process;
(D) injection rate and volume;
(E) orientation of bedding planes, joints, and fracture sets of the fracture zone;
(F) performance monitoring plan for determining the fracture well radius of influence; and
(G) if conducted, the results of geophysical testing or pilot test of fracture behavior conducted in an uncontaminated
area of the site.
6. WELL CONSTRUCTION DETAILS — Per 15A NCAC 02C .0225(e)(8), submit the following information in tabular or
schematic form as appropriate for each item:
(A) number and depth of injection wells;
(B) number and depth of borings if using multi -level or "nested" well systems;
(C) indication whether the injection wells are existing or proposed;
(D) depth and type of casing;
(E) depth and type of screen material;
(F) depth and type of grout;
(G) indication whether the injection wells are permanent or temporary "direct push" points; and
(H) plans and specifications of the surface and subsurface construction details.
7. MONITORING PLAN — Per 15A NCAC 02C .0225(e)(9), submit a monitoring plan that includes the following:
(A) target contaminants plus secondary or intermediate contaminants that may result from the injection;
(B) other parameters that may serve to indicate the progress of the intended reactions;
(C) a list of existing and proposed monitoring wells to be used; and
(D) a sampling schedule to monitor the proposed injection.
Monitoring wells shall be of sufficient quantity and location to detect any movement of injection fluids, injection process byproducts, or
formation fluids outside the injection zone. The monitoring schedule shall be consistent with the proposed injection schedule, pace of
the anticipated reactions, and rate of transport of the injectants and contaminants.
8. WELL DATA TABULATION — Per 15A NCAC 02C .0225(e)(10), provide a tabulation of data on all existing or abandoned
wells within the area of review of the injection well(s) that penetrate the proposed injection zone, including monitoring
wells and wells proposed for use as injection wells. Such data shall include a description of each well's type, depth, and
record of construction or abandonment.
9. MAPS AND CROSS -SECTIONS — Per 15A NCAC 02C .0225(e)(11), provide scaled, site -specific site plans or maps
depicting the location, orientation, and relationship of facility components including the following:
(A) area map based on the most recent USGS 7.5' topographic map of the area, at a scale of 1:24,000 and showing the
location of the proposed injection site;
(B) topographic contour intervals showing all facility related structures, property boundaries, streams, springs, lakes,
ponds, and other surface drainage features;
(C) all existing or abandoned wells within the area of review of the wells listed in the well data tabulation that penetrate
the proposed injection zone;
(D) potentiometric surface map(s) that show the direction of groundwater movement, existing and proposed wells;
(E) contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the contaminant plume in
soil and groundwater, and existing and proposed wells;
(F) 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, major changes in lithology, and existing and proposed wells; and
(G) any existing sources of potential or known groundwater contamination, including waste storage, treatment, or
disposal systems within the area of review of the injection well or well system.
In -Situ Groundwater Remediation Application Rev. 8-28-2017 Page 5 of 6

X. CERTIFICATION (to be signed as required below or by that person's authorized agent*)
NCAC 15A 02C .0211(e ) requires that all permit applications shall be signed as follows:
I. for a corporation: by a responsible corporate officer
2. for a partnership or sole proprietorship: by a general partner or the proprietor, respectively
3. for a municipality or a state, federal, or other public agency: by either a principal executive officer or
ranking publicly elected official
4. for all others: by the well owner.
*If an authorized agent is signing on behalf of the applicant, then supply a letter signed by the applicant
that names and authorizes their agent.
"I hereby certi under penalty of law that I have personally examined and am familiar with the information
submitted in this document and all attachments therein, 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 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(s)
and all related appurtenances in accordance with the approved speccations and conditions of the Permit."
Printed Name and Title: Jason F. Prosser Environmental Operations Engineer
Signature_
Date:
XI. CONSENT OF PROPERTY OWNER (if the property is not owned by the permit applicant)
"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.
"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
(I5A NcAC 02C . 0200). ".
Printed Name and Title: See attached Property Access Agreement
Signature:
See attached Property Access Agreement Date:
Submit TWO hard copies of the completed application package with an electronic version in CD or USB Flash Drive to:
Division of Water Resources — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone [phone]
In -Situ Groundwater Remediation Application Rev. 8-28-2017 Page 6 of 6

THIS MAP IS NOT CERTIFIED SURVEY AND HAS NOT BEEN
REVIEWED BY A LOCAL'GOVERNMENT AGENCY FOR COMPLIANCE
WITH ANY APPLICABLE LAND DEVELOPMENT REGULATIONS.
THIS PRODUCT IS FOR REFERENCE AND ILLUSTRATION PURPOSES
ONLY AND IS ONLY AS ACCURATE AS THE SOURCE DATA FROM
WHICH IT WAS COMPILED.
LEGEND
MWs
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•MW-2332-MW-24y
32-MW-179 3p MW-18
32-MW-7;32-MW-8
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32;MW_25 -
4 K
32-MW'10.32-MW-22 32-MW`13R
<'.›732-MW-9R91110k 9
BUILDING
PARCEL BOUNDARY
SCALE IN FEET
0 150'
GMA
File: DRAWINGS/160502/
SITEMAP
SITE MAP
Project No. 160502
NCDOT PRIORITY SITE #32, LILLINGTON, HARNETT CO., NC
DATE: 3/1/2018
FIGURE 1

SITE ACCESS AGREEMENT
This SITE ACCESS AGREEMENT ("Agreement") made and entered into on the last day
executed below by and between the North Carolina Department of Transportation ("NCDOT"), and.
John: ?n Brothers Utility & Paving Company, Inc. ("Owner").
RECITALS
NCDOT, which shall include any NCDOT authorized agent, including designated
contractors and sub -contractors, desires access to the site described in the attached Exhibit A
("Site") to engage in the activities as described herein; and
Owners are desirous of NCDOT conducting certain surface and sub -surface investigations
concerning suspected contamination on the Site to determine if further action may be warranted.
In consideration of the mutual promises and other valuable consideration, the receipt and
adequacy of which are hereby acknowledged, NCDOT and Owners agree as follows:
TERMS AND CONDITIONS
1. Site Access and Granted Activities.
The Owners grant permission to the NCDOT and any NCDOT authorized agent,
including designated contractors and sub -contractors, such reasonable access as the NCDOT
determines to be necessary, pursuant to state and federal environmental laws and regulations, to
conduct site investigations, and any related corrective action planning, and implementation
arising from the presence of 1,1,1 trichloroethane, trichlorothene or carbon tetrachloride in the
soils and/or groundwater of the subject property. Such access shall include the right to
temporarily remove fences, barricades, or other obstructions which may impede the NCDOT's
ability to conduct the investigation, which activities may include, but not be limited to, locating
potential receptors and land use, installation of monitoring wells, remediation equipment,
collecting soil and groundwater samples, temporary storage of hazardous and non -hazardous
waste and any additional assessment activities approved by environmental regulatory agencies.
The NCDOT agrees that any fences, barricades or other obstructions removed will be replaced by
the NCDOT upon completion of the investigation. Additionally, the NCDOT will give the
Owners at Ieast 48 hours advanced notice of its intent to enter the Site, will abide by Owners'
reasonable instructions and requests regarding the scheduling and location of activities on the
Site, and will obtain Owners' consent prior to placing monitoring wells on the site, which
consent Owner shall not unreasonably withhold.
If the Site is sold or otherwise conveyed to a third party, Owners will obtain for NCDOT
reaso Tlable and necessary nonexclusive access to the Site for the purpose of allowing NCDOT to
fulfil. its obligations hereunder_ Owners shall immediately notify NCDOT, if Owners are unable
to obtain necessary access within a timely manner.
I

2. Release
Except as otherwise provided for herein, NCDOT hereby waives, releases and discharges
Owners, their parent and subsidiaries, affiliates and their respective shareholders, directors, officers
and agents from all claims, causes of action, or demands that NCDOT may hereafter accrue on
account of or in anyway growing out of any and all bodily and personal injuries or property damage
and the consequences thereof resulting, or which may result, from NCDOT's presence upon the
Site, pursuant to this Agreement, or the use of any equipment or procedures while on, entering or
leaving the Site, as authorized under this Agreement. Claims arising out of negligence, or willful
misconduct of Owners, their parent and subsidiaries, affiliates, and their respective shareholders,
directors, officers and agents are excluded from this Release.
3. Owners Responsibility for Damage to Equipment
Notwithstanding the aforementioned Release, the Owners shall reimbursement NCDOT,
within 30 days of receiving a written invoice, for any damage caused by any employee, agent, or
authorized personnel of Owners, whether by act or omission that is deliberate, negligent,
intentional or unintentional, to any equipment, including installed wells, monitoring or sampling
devices, or other equipment used or installed by the NCDOT pursuant to activities specifically
authorized under this Agreement. "Damage" as used herein, means any functional impairment of
aforementioned equipment or device, which would normally require replacement or repair in
order to maintain reliability and/or functionality.
4. Owners Responsibility for Damage to Monitoring Wells
In the case of damage caused to a monitoring/sampling well, Owners shall reimburse
NCDOT for the following activities, as deemed necessary by NCDOT, including, but not limited
to reimbursement for:
(A) Drilling, Rig Mobilization and Per Diem expenses
(B) Private Utility Locator Fees
(C) Mobilization and Equipment including Per Diem expenses
(D) Time for Oversight of Drilling
(E) Project Management
(F) Potential Investigation -Derived Waste Disposal (if source area well)
(G) Abandonment Charges for Damaged Unusable Monitoring Wells
5. Data and Reports
Upon completion of the site investigation activities, NCDOT or its agents, including
designated contractors or sub -contractors will prepare groundwater -monitoring reports for submittal
to the North Carolina Department of Environment and Natural Resources (NCDENR). A copy of
each report will be submitted to the Owners when the reports are submitted to the NCDENR.
2

b. Governing Law
This Agreement and the legal relations of the parties shall be governed by the laws of the
State of North Carolina, applicable to agreements negotiated, executed, delivered, and fully
perfo.. med in such state.
7. Counterparts
To facilitate execution, this Agreement may be executed in as many counterparts as may
be convenient. It shall not be necessary that the signature in behalf of the hereto appear on each
counterpart. All counterparts hereof shall collectively constitute a single agreement.
North Carolina Department of Transportation
By: 1 Date: V/z��
Terry . Gibson, P.E.
Title: State Highway Administrator
Johnson Brothers Utility & Paving Company, Inc.
OWNER- Mr. David Johnson
Date: lv A2._I
Title:
Vi President
3