WI0600236_Permit (Issuance)_20220217

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
February 16, 2022
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
Salemburg Food Mart
801 North Main Street
Salemburg, Sampson County, North Carolina
NCDEQ Incident #29719
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 NCDEQ State Lead Program. The permit
application covers injection of air through two existing air injection wells at the Salemburg Food
Mart located at 801 North Main Street in Salemburg, North Carolina.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Brian Buchanan
Staff Scientist
Direct Line: 919-573-1203
Email: [e-mail]
Attachments
Ashley M. Winkelman, P.G.
Senior Project Manager
Direct Line: 919-573-1206
Email: [e-mail]

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
NOTIFICATION OF INTENT 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. This form shall be submitted at least 2 weeks 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.
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: February 16, 2022
PERMIT NO.
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
B.
C.
(1)
(2)
(3)
(4)
(5)
(6)
(to be filled in by DWR)
X Air Injection Well ....Complete sections B-F, K, N
Aquifer Test Well .Complete sections B-F, K, N
Passive Injection System Complete sections B-F, H-N
Small -Scale Injection Operation Complete sections B-N
Pilot Test Complete sections B-N
Tracer Injection Well Complete sections B-N
STATUS OF WELL OWNER: Business/Organization
WELL OWNER — State name of entity and name of person delegated authority to sign on behalf of the business
or agency:
Name(s): NCDEQ — State Lead Program
Mailing Address: 1646 Mail Service Center
City: Raleigh State: NC Zip Code:
Day Tele No.: 919-707-8167 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.:
27699 County: Wake
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 1

D. PROPERTY OWNER (if different than well owner)
Name: Ali Tawfiq Khanshali
Mailing Address: 4670 Roseboro Highway
City: Clinton
State: NC Zip Code:28328 County: Sampson
Day Tele No.: 910-990-7147 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available
E. PROJECT CONTACT - Person who can answer technical questions about the proposed injection project.
Name: Brian Buchanan — 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.: 919-573-1203 Cell No.: 704-517-9236
EMAIL Address: [e-mail] Fax No.: 919-871-0335
F. PHYSICAL LOCATION OF WELL SITE
(1) Physical Address: 801 North Main Street County: Sampson
City: Salemburg State: NC Zip Code: 28385
(2) Geographic Coordinates: Latitude**: 0 " or 35°1' 18.15" N
Longitude**: 0 " or 78°30'8.32" W
Reference Datum: WGS84 Accuracy: Not Available
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
(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.
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 2

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. 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
http://portal.ncdenr.org/web/wq/aps/gwpro. All other substances must be reviewed by the Division of Public
Health, Department of Health and Human Services. Contact the UIC Program for more info (919-807-6496).
Injectant:
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:
Inj ectant:
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
(2) 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:
(a) well type as 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
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 3

L. SCHEDULES — Briefly describe the schedule for well construction and injection activities.
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.
N. SIGNATURE OF APPLICANT AND PROPERTY 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 15,4 NCAC 02C 0200 Rules."
,on behalf of NCDEQ Brian Buchanan, on behalf of NCDEQ
Signature of Applicant Print or Type Full Name
PROPERTY OWNER (if the property is not owned by the permit 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
(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 of contrary agreement in writing.
Ali Tawfiq Khanshali
Signature* of Property Owner (if different from applicant) 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:
DWR — UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
UIC/In Situ Remed. Notification (Revised 3/2/2015) Page 4

Ashley Winkelman
From. Osman, Hassan <[e-mail]>
Sent: Monday December 21, 2020 10:08 AM
To: Ashley Winkelman
Subject: [EXTERNAL] Langley Tire Service # 13623
(External Email] This email originated from outside of the Atlas mail system. Please use caution when
'.opening attachments.
Hi Ashley:
Thanks
Hassan
ATC Associates is granted/approved a permission to act as an agent for NCDEQ to sign a notification for UIC.
Hassan Osman
Hydrogeologist, UST
North Carolina Department of Environmental Quality
919.707,8167 (Office)
I assan.Osnzan(ncdenr,gov

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. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed.
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Signature
Type/Print Name of Owner or Agent
92.-5. 67 92—
Phone Number
og9
Address
�-` N e
City/State/Zip Code
--/Cf '—fq(
DAte
RE: Salemburg Food Mart
801 N. Main Street
Salemburg, Sampson County, North Carolina
Incident Number: 29719

UNDERGROUND STORAGE TANK SECTIO
May 7,2018
Mr. Hassan Osman
Hydrogeologist
DWM/UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
Dear Mr. Osman
RE: Salemburg Food Mart
801 N. Main Street
Salemburg, Sampson County, North Carolina
Incident Number: 29719
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 Environmental Quality (Department) or its contractor to enter upon said
property for the purpose of conducting an assessment and/or remediation of the groundwater and/or soils
under the authority of G.S. 143-215.94G.
I am/We are granting permission to the lands we own or control with the understanding that:
1. The investigation shall be conducted by the UST Section of the Depadtment'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. Any damages will be restored by the Department or its contractor to as close to the pre -work
condition as practicably possible.
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 will notify the land owners
48 hours prior to entry and 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.

PERMANENT AIR SPRAGE WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
L1
L2
L4
L3
L1 =
L2 =
L3 =
L4 =
0
15
5
20
FT.
FT.
FT.
FT.
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
CASING DIAMETER
CASING LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
BACKFILL AROUND CASING
MATERIAL
THICKNESS
SEAL
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
DISTANCE ABOVE SCREEN
TOTAL FILTER PACK FOOTAGE
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
WELL
1- DEPTH TO BOTTOM OF
BOREHOLE
DIAMETER OF BOREHOLE
steel
8 inches
12 inches
2 feet x 2 feet
flush mounted
sch 40 PVC
2 inches
flush threaded
15 feet
cement grout
10 feet
bentonite
3 feet
#2 silica sand
2 feet
7 feet
sch 40 PVC
2 inches
5 feet
0.010 inches
20 feet
20 feet
6 inches
DRILLING SUBCONTRACTOR: Geologic Exploration
DRILLER ADDRESS: 176 Commerce Blvd, Statesville, NC 28625
DRILLER CERTIFICATION #: 4475
TITLE Well Information
AS-1 and AS-2
Salemburg Food Mart
801 North Main Street
Salemburg, North Carolina
ATC
2725 East Millbrook Road, Suite 121
Raleigh, North Carolina 27604
FILE
PREP. BY
BB
REV. BY
AW
DATE
2/14/2022

FORMER
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LEGEND
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APPROXIMATE SCALE IN FEET
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= TYPE II MONITORING WELL
- GROUNDWATER ELEVATION CONTOUR LINE (DASHED WHERE APPROXIMATE)
= GROUNDWATER ELEVATION IN FEET
- GROUNDWATER FLOW DIRECTION
- 90.83
AS-2
-MW-2R
91.04• • 1
HILLS MW-9
0
HILLS MW-13
40
APPROXIMATE SCALE IN FEET
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Project Number
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PROPERry
7VDARY
• SALEMBURG
FOOD MART
FORMER
10, 000—GALLON
USTs
MW-5
317
AS-2
.1
•
HILLS 1MW-8
HILLS MWr9ope
HILLS M -,,2\\R
= TYPE II MONITORING WELL
- BENZENE ISOCONCENTRATION CONTOUR LINE (DASHED WHERE APPROXIMATE)
(<0.50) = BENZENE CONCENTRATION (pg/L)
0
HILLS MW-13
40
APPROXIMATE SCALE IN FEET
80
J
SLC2971901
Project Number
CONTOUR
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