WI0400585_Notification of Intent (NOI) – GW Remediation_20220812

MINN
AS
MOM
mg OW
(44 % Y 40-T
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 ISA NCAC 02C.0200 (NOTE: This form must he received at least 14 DAYS prior to infection)
AQUIFER TEST WELLS I0SA NCACOIC.0220) r
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
IN SITU REMEDIATION (IS.NCAC OW .0225) or TRACER WELLS t ISA 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 Iniection 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 _rests -- 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 Infection Wells - Used to inject ambient air to enhance in -situ treatment of soil or groundwater.
5) In -Situ Thermal Wells '1ST i - Used to `heat' contaminated groundwater to enhance remediation.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: 8/9/22 , 20 PERMIT NO , (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:
Permit No. WI Issued Date:
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) X 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) Small -Scale Injection Operation Complete sections 13 through M
(5) Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (1ST) Well Complete sections B through M
B. STATUS OF WELL OWNER: Business/Organization
Deemed Permitted GW Rcmediation NO1 Rev. 2-17-2020 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): Quality Oil Company, LLC (attn: Don McIver)
Mailing Address: PO Box 2736
City: Winston-Salem State: _NC_ Zip Code: 27102-2736County: Forsyth
Day Tele No.: [phone] Cell No.:
EMAIL Address: dmciver(a ciocnc.com Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title:
Company Name Javkiran Inc _
Mailing Address: 3011 Waughtown St
City: Winston-Salem State: NC Zip Code:__ 27107 County: .Forsyth _
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental ConsultinglEngineering Firm)
Name and Title: R. an Kerins
Company Name _ Terraquest Environmental Consultants. P.C.
Mailing Address: 100 E Ruffin St
City: _ Mebane
Day Tele No.: 919-563-9091
EMAIL Address: _ _ rdkerinsiaJterraquesttx:.com
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Jav's
6Q"")
State: NC_ Zip Code: 27302 County: Alamance
Cell No.:
Fax No.:
AAA-
3011 Waughtown St
City: Winston-Salem County: Fors vth Zip Code: 27107
(2) Geographic Coordinates: Latitude**: ° " or 36° 0772
Longitude**: ° "or-80 °. 1792
Reference Datum; WGS-84 Accuracy:39.7 meters RMSE
Method of Collection: Gooele
**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 fe for small-scale injections)
Percent of contaminant plume area to be treated: (must bet 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 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.
I.
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:
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): 45-50
(3) For Proposed wells or Existing wells not having GW-1 s, 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)
(b)
(c)
Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
Depth below land surface of casing, each grout type and depth, screen, and sand pack
Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Ont)' ijeciants approved hl} the epide naiolo y .section of the NC Division of Public Health Deparunent
of Heals/ and Human Services .can he jecied. Approved injectants can he loured ottli»e at
kV, J/deo_nc.Hov/about/divisions/water-resources/water-resources-bermiis!wastewater-branch! round-water-
protectionlvround-water-anproved-inieetants. All eithersubstanccs must he reviewed bl' Mc DINS odor to use.
Cantata the UUC.Pro_cram for mare info it . ou wish to xet•auiiinval_or a di/Jerent additive. However, ukase
note it niav take 3 months Or lonker:.. If no inlectents are to be used use N/A.
Injectant: Total Amt. to be injected (gal)/event:
Injeetant: Total Amt, to be injected (gal event:
Injectant: _ _Total Amt. to be injected (gal)/event:
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

Injectant: Total Amt. to be injected (gal)/event:
Injectant: Total Amt. to be injected
Total Amt. to be injected (gal/event):
No. of separate injection events: Total Amt. to be injected (gal):
Source of Water (if applicable):
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 Subcha; ter 02L result from the injection activity
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "1 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 offtnes and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
'section well and all -elated appurtenances in accordance with the I5A NCAC 02C 0200 Rules."
-Litt% to 'i&l9 VI'-J=?ti �L
Signature of Applicant Print or Type Full Name and Title
Property Owner of 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
(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.
Prouerh owner has release incident cohnn» ngled with Oualit►'s. Oualib_has access as they are treating both incidents.
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 an 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 OW Remediation NO1 Rev. 2-17-2020 Page 4

WELL CONSTRUCTION RECORD (GW-1)
1. Well tractor Information:
Wesley . SarreIIs
Well Conhoctor Name
3577
NC Well Contractor Certification
bar
Terraquest Environm
Company Name
2. Well Construction Permit #:
Lin all app/leoh/e well warlrnattm, remit.? (i.e. (/l(', C. • nay, Stole. Variance, etc.)
3. Well Use (check well use):
tal Consultants
Water Supply Well:
Agric ittural ['Municipal/Pub
❑ Geothermal (Heating/Cooling Supply) ❑ Residential Water
0Industrial/Commercial [Residential Water Su
f Intipatkin
Non -Water Supply Well:
la Monitoring
Injection Welt
IIDAquifer Recharge 0Groundwater Remediation
ID Aquifer Storage and Recovery ['Salinity Barrier
]Aquifer Test Stormwater Drainage
EJExperimental Technology OSubsidence Control
RUCietitterntl (Closed Loop) 'Tracer
eutheI Ji1ai (Heatijt fCaolini::Apturli) I }Other (ett:;ilain under #21 R6ntat(lis,
ppty (single)
y (shared)
IFor internal .Use Only:
I(4 1T+1rigR:]1 O ES`•_ ..
FROM
ft
TO
ft.
n.
n.
DESCRIPTION
-fXOUTER CASING't6irm'u�`ft els4a.Welk;eRrt.
t'ROM TO DIAMETER
ft R. in.
sRk-, tk�6i i
ItNESS
Print Form
MATERIAL.
I6r.INNFRC As1Nti ORTII81NG&llie
mum '(' kargDIP
ft. R. n.
ft.
17.1CREBN
PROM
TO
40 ft
ft
Is, -GROUT
FROM
45 ".
10
DIAM ER
2
In,
in.
.MATERIAL
In.
I e1ait$8� lid
THICKNESS
S1.Irsizg
10 Sift
lNA RI,tG
TRIMNESS MATEH4t
Sch. 40 PVC
EMPL4CEai 1Yr•AILTHOD&AMOUNT-
IDRecovcry
4. Date Well(s) Completed: 4/20/2022
Sa. Well Location:
Quality Mart #18
Well ID#AS1
0-016670
Facility/Owner Name Facility IDII (ifappl. ble)
2985 Kernersville Rd. Winston-Salem, " C 27101
Physical Address, City, and Zip
Forsyth
6854- 9-5111
County Parcel I- ratification No. (PiN)
Sb. Latitude and longitude in degrees/minutes/secds or decimal degrees;
(if well field, are lat/long is sufficient)
36.0772 N 80.179
6.13(are) the wcll(a)JPermanent or t Temporary
7. Is this a repair to an existing well: ■ Yea or ®No
!f lh/s ry o repair.fill out known well came •lion infarnmliun and explain the nature of the
rept& railer b11 remarks Seaton or ran it • hock of thtelbrot.
8. For Geoprabe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is veded. Indicate TOTAL NUMBER of wells
drilled:_ 1 f'
9. Total well depth belo land surface: 45
Air multiple rrellr lies all 'piht jf d(fcreni (cramp/e- 3(7100' and 2@l00')
10. Static water le i below top of casing: N\A
If meet level Le abr • one/ng, toe "1"
11. Borehole rameter, 6.25
12. Well onstrnction method: Solid Stem Auger
(he. eu r, rotary, cable, direct push, etc.)
rFOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Fonn GW-I
. (t)
_ (ft)
36
0.5
ft.
ft
3
6
R.
ft.
Bentonite
Portland
Pour
Pour
R.
OM
ft.
ft
VEIa'PACKttfie dlraitila)_
'ro MATERIAL
45 ".
ft
EMPLACEalevrlrlgnton
No. 2 Sand Pour
IYG 1.IX (litietaddldunarslieetiIfrirea axis) -•- --
TO DESLIOPT,Wi color. hasguenreailintek ay. r alne,
Silty Lean Clay
Silt
ft.
ft. ft
21i REMARKS'
22. Certification:
Signature ofCaYificd Well Contractor
4/20/22
Date
By signing ibix Ann, 1 hereby rem that the wcll(r) wuc (11.' tau.,tnteted in aeco kbniti:
with !SA N(:A(' 02C'.0/00 or iSA NCA(' 02C'.0200 tYe!! ('ow Mon Sta nlar& and that a
copy tf d& record has been provided to the well termer.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well he details or well
construction details. You may also attach additional pages if nr .,sary
SUBMITTAL INSTRUCTIONS
24a. For All Was: Submit this fonn within 30 days of comple n of well
construction to the following:
Division of Water Resources, Information Processing Unil,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection *ells: in addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c.Par WuterSunnly & infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
North Carolina Depamnent ofEnvironmental Quality - Division of Water Resources Revised 2-22-2016

Rogers, Michael
From: Ryan Kerins <[e-mail]>
Sent: Wednesday, September 7, 2022 4:59 PM
To: Rogers, Michael
Cc: 'Don McIver; Snider, Lon; Wes Sorrells
Subject: RE: WI0400585 Quality Mart RE: [External] UIC NOI submittal
Attachments: GW-1 AS1.pdf
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Spoke with driller and had him update GW-1. It's attached. 1"-diamter air sparge well with 1" screen and 1" casing.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
0: 919-563-9091
C: 919-906-0960
From: Rogers, Michael <[e-mail]>
Sent: Wednesday, September 7, 2022 4:41 PM
To: Ryan Kerins <[e-mail]>
Cc: 'Don McIver' <[e-mail]>; Snider, Lon <[e-mail]>
Subject: RE: WI0400585 Quality Mart RE: [External] UIC NOI submittal
Also, add casing info.
From: Ryan Kerins <[e-mail]>
Sent: Wednesday, September 7, 2022 4:35 PM
To: Rogers, Michael <michael.rogers;ancdenr.Rov>
Cc: 'Don McIver' <[e-mail]• >; Snider, Lon <[e-mail]>
Subject: RE: W10400585 Quality Mart RE: [External] UIC NOI submittal
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
1. Yes - The casing information was missing. It is assumed 2 inch PVC casing was installed as it has 5 feet
of 2 inch PVC screen. Is this correct?
2. attached
Ryan Kerins
Terraquest Environmental Consultants, P.C.
0: 919-563-9091
C: 919-906-0960
1

From: Rogers, Michael <[e-mail]>
Sent: Wednesday, September 7, 2022 4:27 PM
To: Ryan Kerins <[e-mail]>
Cc: 'Don McIver' <[e-mail]>; Snider, Lon <[e-mail]>
Subject: WI0400585 Quality Mart RE: [External] UIC NOI submittal
Greetings -
This is to acknowledge receipt of the NOI for conducting groundwater injection remediation at the Jay's
(Former Quality Mart No. 18), 3011 Waughtown Street, Winston-Salem, Forsyth County, NC 27107. The
permit NOI tracking number for this project is . Please use this number on reporting forms
mentioned below, any future correspondence, and in subject line of all emails.
Please respond to the following questions/comments regarding the GW-1, which was attached to the NOI-
1. The casing information was missing. It is assumed 2 inch PVC casing was installed as it has 5 feet of 2
inch PVC screen. Is this correct?
2. The address for the facility is different than this site on NOI. Please clarify and provide corrected GW-
1.
30 days after injection activities commence please provide Injection Event Records (IER). A link to forms is
below. Just 1 IER is needed with the continuous flow rate.
.ittps://deq.nc.gov/about/divisions/water-resources/groundwater-resources/underground-iniection-
co nt ro l-we l l s- u i c-p rog ra m
Regards,
From: Ryan Kerins <[e-mail]>
Sent: Tuesday, August 9, 2022 9:33 AM
To: Rogers, Michael <[e-mail]>
Subject: [External] UIC NOI submittal
LCAUTu External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Another NOI for you. Simple air sparge for this one. Thanks.
Ryan Kerins
Terraquest Environmental Consultants, P.C.
0: 919-563-9091
C: 919-906-0960
2

WELL CONSTRUCTION RECORD (GW-1)
Print Form
For Internal Use Only:
1. Well Contractor Information:
Wesley J. Sorrells
Well Contractor Name
3577
NC Well Contractor Certification Number
Terraquest Environmental Consultants
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
Agricultural 0Municipal/Public
Geothermal (Heating/Cooling Supply) DResidential Water Supply (single)
Industrial/Commercial OResidential Water Supply (shared)
Irrigation
Non -Water Supply Well:
14 Monitoring
Injection Well:
Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Geothermal (Closed Loop)
r Geothermal (Heatini /Coo1ins Retum1
Recovery
Groundwater Remediation
Salinity Barrier
Stormwater Drainage
Subsidence Control
Tracer
f Other (explain under #21 Remarks)
4. Date Well(s) Completed: 4/20/2022 well iD#AS1
5a. Well Location:
Quality Mart #18
0-016670
Facility/Owner Name Facility ID# (if applicable)
3011 Waughtown St Winston-Salem, NC 27107
Physical Address, City, and Zip
Forsyth
County
6854-19-5111
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36.0772 N 80.1792
6. Is(are) the well(s)jPermanent or IDTemporary
7. Is this a repair to an existing well: EjYes or EilNo
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this fonn.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-I is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 45
For multiple wells list all depths if different (example- 3@200' and 2@100')
10. Static water level below top of casing: MA (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 6.25 (in.)
12. Well construction method: Solid Stem Auger
(ft.)
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER
CASING ifor
multi -cased wells) OR LINER (if ap licablel
FROM
TO
DIAMETER
THICKNESS
MATERIAL
0 ft.
40 ft.
1 in•
, Sch 40
PVC
16. INNER
CASING OR TUBING
f I:eothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
40 ft.
45 ft.
1 in.
10 Sin
Sch. 40
PVC
ft.
ft.
in.
18. GROUT
FROM
_ TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
36 ft.
38 ft.
Bentonite
Pour
0.5 ft.
36 ft.
Portland
Pour
ft.
ft.
19. SAND/GRAVEL
PACK
lif applicablei
FROM
TO
MATERIAL
EMPLACEMENT METHOD
38 ft.
45 ft
No. 2 Sand
Pour
ft.
ft.
20. DRILLJNG LOG launch additional sheets if necessary)
FROM
TO
DESCRIPTION Iroise. hardness, willrcrk typr. grain size, etci
0 ft.
0.5 ft.
Topsoil
0.5 ft.
5 ft.
Silty Lean Clay
5 ft.
45 ft.
Silt
fL
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
Signature of Certified Well Contractor
4/20/22
Date
By signing this form, 1 hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Infection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Surill% & Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well construction to the county health department of the county
where constructed.
Form GW-1
North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016