WI0300467_Permit (Issuance)_20211215

North Carolina Department of Environmental Quality — Division of Water Resources
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C.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 are located within an area that does not exceed five percent of the land
surface above the known extent of groundwater contamination. An individual permit shall be required to conduct
more than one pilot test on any separate groundwater contaminant plume.
4) Air Injection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: December 3, 2021
PERMIT NO. (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) X Air Injection Well ....Complete sections B through F, K, N
(2) Aquifer Test Well .Complete sections B through F, K, N
(3) Passive Injection System Complete sections B through F, H-N
(4) Small -Scale Injection Operation Complete sections B through N
(5) Pilot Test Complete sections B through N
(6) Tracer Injection Well Complete sections B through N
B. STATUS OF WELL OWNER: State Government
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): NCDEQ-DWM, UST Section, Federal & State Lead Program Attn: Sharon Ghiold
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8166 Cell No.: NA
EMAIL Address: sharon.ghiold@,ncdenr.gov Fax No.: 919-733-9413
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 1

D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Eastwind United Pentecostal Church, Property Owner
Attn: Reverend Jim Gideon
Company Name
Mailing Address: 6912 Jake Seagle Rd
City: Vale State: NC Zip Code: 28168 County: Lincoln
Day Tele No.: 704-735-1475 Cell No.: 704-530-7775
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Engineering Firm)
Name and Title: G. Matthew James, P.G., Project Manager
Company Name WithersRavenel, Inc.
Mailing Address: 115 MacKenan Drive
City: Cary State: NC Zip Code: 27511 County: Wake
Day Tele No.: 919-469-3340 Cell No.:
EMAIL Address: [e-mail]
F. PHYSICAL LOCATION OF WELL SITE
Fax No.: 919-467-6008
(1) Facility Name & Address: Former Terry's Superette — 3615 E. NC 27 HWY; NCDEQ Incident #7030
City: Iron Station County: Lincoln Zip Code: 28080
(2) Geographic Coordinates: MW-2: Latitude**: 35.472160°
Longitude**: -81.178881°
MW-3: Latitude**: 35.472112°
Longitude**: -81.178942°
Reference Datum: Google Earth Accuracy: +/- 5m
Method of Collection: Google Earth
**FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
H. INJECTION ZONE MAPS — Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells; and
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 2

(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.
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.
J. APPROVED INJECTANTS — Provide a MSDS for each injectant (attach additional sheets if necessary).
NOTE: Only injectants approved by the NC Division of Public Health, Department of Health and Human
Services can be injected. Approved injectants can be found online at http://deq.nc.gov/about/divisions/water-
resources/water-resources-permits/wastewater-branch/ground-water-protection/ground-water-approved-inj ectants.
All other substances must be reviewed by the DHHS prior to use. Contact the UIC Program for more info (919-
807-6496).
Inj ectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Inj ectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
Injectant:
Volume of injectant:
Concentration at point of injection:
Percent if in a mixture with other injectants:
K. WELL CONSTRUCTION DATA
(1) Number of injection wells: 0 Proposed 2 Existing (provide GW-1s)
(2) 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):
Deemed Permitted GW Remediation NOI Rev. 1-06-2021 Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
Air sparge wells to be installed to depths of 15-ft beneath surface grade as 1-inch diameter type II wells with 5-
ft screened sections (see attached well construction diagrams). Air sparge wells to be installed within 24-hours
of starting sparge/MMPE event. Event to be completed over a 96-hour period.
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.
Routine semi-annual or annual sampling to be completed at discretion of NCDEQ incident manager. WR will
advise the NCDEQ incident manager that a sampling event be completed within 30-days following completion
of AS/MMPE event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: `I hereby certify, under penalty of law, that I am familiar with the information
submitted in this document and all attachments thereto and that, based on my inquiry of those individuals
immediately responsible for obtaining said information, I believe that the information is true, accurate and
complete. I am aware that there are significant penalties, including the possibility of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
G. Matthew James, PG, Project Manager, WithersRavenel,
On behalf on NCDEQ-DWM for Incident # 31314
Signature of Applicant Print or Type Full Name and Title
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 ATTACHED NCDEQ STATE -LEAD ACCESS AGREEMENT FOR PROPERTY
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 his 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. 1-06-2021 Page 4

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REFERENCE: 2015 AERIAL PHOTOGRAPH
GIS BASE LAYERS WERE OBTAINED FROM LINCOLN COUNTY AND NC ONEMAP. THIS MAP IS FOR
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THEY ARE NOT BASED ON CIVIL SURVEY INFORMATION, UNLESS STATED OTHERWISE.
Former Lower
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• - • - • Inferred Benzene Isoclines (pg/L)
• Water Supply Wells
® Monitoring Wells
0 Project Parcel
ED
III
BENZENE ISOCONCENTRATION MAP
SCALE:
1"=40'
TERRY'S SUPERETTE TF-7030, UST# MO-3131
3615 EAST HIGHWAY 27
LINCOLNTON, LINCOLN COUNTY, NORTH CAROLINA
DATE:
9-25-20
PROJECT NUMBER
4305-17-095C
FIGURE NO.
6

North Carolina
Department of Environment and Natural Resources
Division of Waste Management
Michael F. Easley, Governor
William G. Ross Jr., Secretary
Dexter R. Matthews, Director
August 21, 2007
CERTIFIED MAIL 7005 0390 0001 3554 2400
RETURN RECEIPT REQUESTED
Eastwind United Pentecostal Church
Attn: Reverend Jim Gideon
4842 Gideon Drive
Lincolnton, NC 28092
RE: Site Access Request
Former Terry's Superette
3615 E. NC 27 Highway (Intersection of Hwy 27 and Hwy 73)
Lincolnton, Lincoln County, NC (MRO)
Incident Number 7030
Dear Reverend Gideon:
ern
NCDENR
The Mooresville Regional Office (MRO) referred the subject site to the State Underground Storage Tank
(UST) Trust Fund Branch, Federal -Lead Program for inclusion on the list of sites awaiting cleanup
pursuant to G.S. 143-215.94G(a). On June 20, 1991, Southern Bell employees reported very strong
petroleum odors while working near the site's USTs, and soil contamination was subsequently confirmed
in the former tank basins. Due to the presence of groundwater users within 1500 feet of the site and based
on the confirmation of contamination remaining at the site, the subject property was accepted into the
Federal -Lead Program in January of 1992. We have been periodically sampling area supply wells since
that time. According to the information on file, you are not considered to be an owner or operator of the
USTs pursuant to G.S. 143-215.94A.
In order to determine the risk posed by the contamination at the subject property, the UST Section will
need to access your property in order to take all reasonable and necessary action(s) to conduct assessment
and remedial activities necessary to protect human health and the environment. Please sign the attached
site access agreement letter and return to the address indicated on the letter. Please understand that failure
to allow access to the property could potentially make you responsible for the cleanup under other State
and Federal regulations. You will be notified when assessment and/or remedial activities begin.
If you have any questions, please feel free to contact me at [phone] or via e-mail at
[e-mail].
Sincerely,
4744 41-
Sharon Ghiold
Hydrogeologist
Division of Waste Management/UST Section
1637 Mail Service Center, Raleigh, North Carolina 27699-1637
Phone: [phone] \ FAX: [phone]
Internet: http://www.wastenot.enr.state.nc.us/
AN EQUAL OPPORTUNITY \ AFFIRMATIVE ACTION EMPLOYER — 50% RECYCLED / 10% POST CONSUMER PAPER

Mrs. Sharon Ghiold
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Mrs. Ghiold:
RE: Site Access Agreement
Former Terry's Superette
3615 E. NC 27 Highway (Intersection of Hwy 27 and Hwy 73)
Lincolnton, Lincoln County, NC (MRO)
Incident Number 7030
I am/We are the owners) of a parcel of property, located at or near the incident in stion,
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.
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 land owner.

Former Terry's Superette, Incident # 7030
August 21, 2007
Page 2
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,
r
Signature
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PAGE 94
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Project: J}j2 ty j Si-/E7teW
Job No: US r'OTD
Location: 44/}v44/W/ Art.
Sxlors Den
leg of Coring Oer
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MATERIAL OESCRIPTION
(TM slrolificalion Ines represent appraximole
bovnaories. The transition may be gradual,)
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Complelion Dep h: 3 y r
Dole Boring Started /oj 401
Dote Boring Cornprated:14' 101
Engineer/Geotogisl:144
Drilling Contractor SCT
Remarks
Revision
Drowney
Dale
Checked
Approved
1