WI0501108_Notification of Intent (NOI) – GW Remediation_20221003

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 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 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.
DATE: February 10 , 2022
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:
A.
B.
Permit No. WI WI0501108 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) X Pilot Test Complete sections B through M
(6) Tracer Injection Well Complete sections B through M
(7) In -Situ Thermal (IST) Well Complete sections B through M
STATUS OF WELL OWNER: Business/Organization
Deemed Permitted GW Remediation NOI Rev. 2-17-2020
Page 1

C. WELL OWNER(S) — State name of Business/Agency
sign on behalf of the business or agency:
Name(s): L&L Food Stores / Dan Daly
Mailing Address: PO Box 699 — 706 E Church St.
City: Nashville
Day Tele No.: 252-459-3146
EMAIL Address: [e-mail]
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: L&L Roses, LLC / Trey Watkins
Company Name
Mailing Address: 613 US HWY 158 Bypass
City: Henderson State: NC Zip Code: 27537 County: Vance
Day Tele No.: 252-438-7141 Cell No.: 919-610-1033
EMAIL Address: [e-mail] Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Ryan Kerins, Project Manager
Company Name Terraquest Environmental Consultants, P.C.
Mailing Address: 100 E Ruffin St
City: Mebane
, and Name and Title of person delegated authority to
State: NC
Zip Code: 27856 County: Nash
Ce11 No.: 252-903-8432
Fax No.: 252-459-2675
State: NC Zip Code: 27302 County- Alamance
Day Tele No.: 919-563-9091 Cell No.:
EMAIL Address: [e-mail] Fax No.: 919-563-9095
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: L&L Food Store #5
109 W Nash St
City: Spring Hope
County: Nash
Zip Code: 27822
(2) Geographic Coordinates: Latitude**: " or 35 °. 944322
Longitude**: " or -77 °. 112849
Reference Datum: Accuracy:
Method of Collection: GIS Site Map is included
**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: Approx 8,000
square feet
Land surface area of inj. well network: Approx 150 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: Approx 2% (must be < 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.
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:
Terraquest Environmental is remediating a petroleum release at the site. To promote in -situ degradation
of the contaminants, Terraquest proposes to inject OBC. Additionally, Terraquest proposes to conduct an air
sparge pilot test to determine the suitability of future remediation activities.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 8 Proposed Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 29
(3) For Proposed wells or Existing wells not having GW-Is, 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-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 if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no injectants are to be used use N/A.
Injectant: air sparge — ambient air Total Amt. to be injected (gal)/event: continuous
Injectant: Oxygen Biochem (OBC) Total Amt. to be injected (gal)/event: 1,500
Injectant: Total Amt. to be injected (gal)/event:
Injectant: 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 (gai)/event:
Total Amt to be injected (gal/event): lba / 5 o 0>3C
No. of separate injection events: Total Amt. to be injected (gal): // 6 co
Source of Water (if applicable): fret `t rf r v(
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.
VOC Monitoring will be regulated by NCDWM-UST. Semi-annual sampling of monitoring wells for 6200B
analysis is anticipated.
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 of fines and imprisonment,
for submitting false information. I agree to construct, operate, maintain, repair, and ifapplicable, abandon the
inje f tion w i an' all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Signature ofplicant
•
Stage; 274w#a1 D4 ao, 62,410101-Adimoi
Print or Typelull Name and Title
Properly 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, '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 ction on Iand shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement - 1
1. LS lc,?f✓( e& WGc 0►15
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 ofa signature on 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 Pennitted OW Remediation NOI Rev. 2-17-2020
Page 4

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MAP SOURCE: USGS 7.5 MINUTE TOPOGRAPHIC MAP OF SPRING HOPE & BUNN EAST, NC
GRAPHIC SCALE
0' 2,000' 4,000'
TERRA_ crest
SITE LOCATION MAP
L&L FOOD STORE #5
109 W. NASH STREET
SPRING HOPE, NASH COUNTY, NC
L&L FOOD STORES NASHVILLE, NC
��
_ - W
• �
PROJECT NO, 00618
DRAWN BY: JTL
DATE: 5/21/20
E NVI RONMENTAL CONSULTANTS, P.C.
SCALE: 1" = 2,000'
CHECKED BY: JRG
FIGURE N0.

•
4#*,
LEGEND
CIO ACTIVE; MUNICIPAL SUPPLY WELL
C ACTIVE; IRRIGATION WELL
0 -CORRESPONDS TO MAP ID NUMBER ON
SURROUNDING PROPERTY OWNERS TABLE
ZONING
R-8; R-MF = RESIDENTIAL
SU-LI; LI = LIGHT INDUSTRIAL
CB = CENTRAL BUSINESS
GRAPHIC SCALE
0' 200' 400'
= 400'
800'
TERRA9uest
1111...11.111
ENVIRONMENTAL CONSULTANTS, P.C. II
SITE VICINITY MAP
L&L FOOD STORE #5
109 W. NASH STREET
SPRING HOPE, NASH COUNTY, NC
&L FOOD STORES
NASHVILLE. NC
ROJECT NO. 00618
DRAWN BY: JTL
DATE: 5/21/20
CALE:
1" = 400'
CHECKED BY: JRG
FIGURE NO. 2

Hashpot, Inc. formerly
Little River Corp. site
NCDWM—UST Incident
46596
LEGEND
V.J
TYPE II MONITORING WELL
(" LRMW#" associated with Incident #46596)
TYPE III MONITORING WELL
UST LEGEND
CURRENT TANKS INSTALLED '937'97:
('97)
22,000—GALLON COMPARTMENTALIZED
T51 — 6,000—GALLON GASOLINE
T52 — 10,000—GALLON GASOLINE
T53 — 6,000—GALLON GASOLINE
('93)
T54K — 2,000—GALLON KEROSENE
1st GENERATION TANKS INSTALLED '77:
(removed '97)
77T51 — 6,000—GALLON GASOLINE
77T52 — 6,000—GALLON GASOLINE
77T53 — 6,000—GALLON GASOLINE
Little River (#46596) UST LEGEND
T1 — 2,000—GALLON ?GASOLINE?
T2 — 3,000—GALLON ?GASOLINE?
T3 — 2,000—GALLON DIESEL
T4 — 550—GALLON HEATING OIL
T5 — 550—GALLON HEATING OIL
TANKS OUT OF USE PRIOR TO
REGISTRATION REQUIREMENTS.
GRAPHIC SCALE
0' 20' 40'
1" = 40'
80'
0
z
NASHVILLE
SPRING HOPE, NASH COUNTY, NC
L&L FOOD STORES
N)
O
w
CD
CHECKED BY:
GO
O
0
PROJECT NO
0
N
w
0
0
0
II
w
J
0
U
cn

LEGEND
TYPE II MONITORING WELL
TYPE III MONITORING WELL
CO
CO
0
0
0
z
I-
0
w
0
CC
d
UST LEGEND
CURRENT TANKS INSTALLED '937'97:
'97)
22,000—GALLON COMPARTMENTALIZED
T51 — 6,000—GALLON GASOLINE
T52 — 10,000—GALLON GASOLINE
T53 — 6,000—GALLON GASOLINE
('93)
T54K — 2,000—GALLON KEROSENE
1st GENERATION TANKS INSTALLED '77:
(removed '97)
77T51 UL — 6,000—GALLON GASOLINE
77T52R — 6,000—GALLON GASOLINE
77T53S — 6,000—GALLON GASOLINE
GRAPHIC SCALE
0' 10' 20'
1" = 20'

Hashpot, Inc. formerly Little River Corp.
i site NCDWM—UST Incident 46595
FAIL SPILL
BUCKETS
\ \
\ \ \
\ \ \
\ \ \ \ \
\
\ \ \
\ \ \ \ \
\
V A v A V A v A V A A
\\ \ \I*4ttIttttth
A A\ \ V A A \ V A
\ \V A A\ \V \ A A\ \\
\
\ V A \ \_
V A ESTIMATED EXTENT OF
2L STANDARD VIOLATION'
DISPENSERS
1 00.00'
90.00
70.00
60.00
50.00
40.00
MW7
V A
\
V A
V A
A
V A AV
\
V A V A
V A V A
\ A
\
A
\ \ \
ESTIMATED EXTENT OF\
DISPENSERS
MW3
MW1
B4
ESTIMATED
EXTENT OF GCL
• VIOLATION
Hashpot, Inc. formerly
Little River Corp. site
NCDWM—UST Incident
. sa
0'-10' BGL
Lean Clay (CL)
Mostly medium
silt.
10' — 15' BGL
Lean Clay (CL)
Mostly medium
stiff
stiff
15' — 55' BGL
Silt (ML)
Mostly stiff to soft,
sand.
i
i njectant
breakthrough
into MW14.
slowed
pumping and
/ got all 250
gallons in
9 �♦
Injectant ♦�
breakthroughW13 ♦
Into •
MW6
after
15
gallons
ESTIMATED
EXTENT OF
STG MSCC
VIOLATIONS
ESTIMATED
EXTENT OF
moved '`'\ STG MSCC
here and TS S� VIOLATION
MWtried again\un � -
W5
Eng
reddish —orange —tan clay, with few fine sand
and
red —white —tan clay with some silt and few sand.
red —white —tan silt, with some clay and trace
WELL ID
�-MW5
\D
GROUND LEVEL
BORING ID
B12
CASING OUTER
cAslrG
SCREEN
INTERVAL
PHREATIC AQUIFER
POTENTIOMETRIC
SURFACE
SAMPLE
INTERVAL
INNER
CASING
Estimated extent of STG
MSCC violation
Elevations are referenced to an
arbitrary datum plane of 100.00'.
A detailed discussion of site
geology along with boring logs are
included in the CSA Report.
This drawing is a fence diagram.
The distances between wells do
not correlate with a straight line
between the first and last well of
the cross section. Some features
have been projected onto the
traces.
15'
7.5'
0'
GRAPHIC SCALE
HORIZONTAL: 1" = 30'
VERTICAL: 1" = 15'
2x VERT EXAGERATION
15'
30'
GEOLOGICAL
NASHVILLE, NC
SPRING HOPE, NASH COUNTY, NC
L&L FOOD STORES
O
W
CC
CD
PROJECT NO
0
CV
N
0
0
CC
m
z
AS NOTED
W
U

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
Geothermal (Heating/Cooling Supply)
kilndustriaUCommercial
I Irrigation
Non -Water Supply Well:
IMonitoring
Municipal/Public
QlResidential Water Supply (single)
EIResidential Water Supply (shared)
QRecovery
Injection Well:
(Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Ell Geothermal (Closed Loop)
b Geothermal (Heating/Cooling Retum)
© Groundwater Remediation
❑I Salinity Barrier
❑I Stormwater Drainage
El Subsidence Control
❑I Tracer
❑ I Other (explain under #21 Remarks)
4. Date Wells) Completed: 5/3,23-24/a, Well ID# 1 NJ 1-8
5a. Well Location:
L&L #5
00-0-0000022386
Facility/Owner Name Facility ID# (if applicable)
109 W. Nash St. Bus. 64 Spring Hope NC.
Physical Address, City, and Zip
Nash 2769062957763
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.944339 N-78.112804
6. Is(are) the well(s):QPermanent o
►�I
Temporary
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
ft.
ft.
ft.
ft.
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
ft.
ft.
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft.
15 ft.
LEAN CLAY
15 ft.
30 ft.
SILT
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
Tcmporary borings for injcction.
22. Certification:
W
7. Is this a repair to an existing well: QIYes or ► iNo
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 form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 8
9. Total well depth below land surface: 30
For multiple wells list all depths if different (example- 3@200' and 2@100')
(ft.)
10. Static water level below top of casing: 20 (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 2.25 (in.)
12. Well construction method: direct push
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
5'B21R1Z
Signature of Certifie / ell Contractor
5/25/22
Date
By signing this form, I 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 Injection 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 Supply & 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

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
Geothermal (Heating/Cooling Supply)
kilndustriaUCommercial
I Irrigation
Non -Water Supply Well:
Monitoring
Municipal/Public
QlResidential Water Supply (single)
EIResidential Water Supply (shared)
QRecovery
Injection Well:
CI Aquifer Recharge
Aquifer Storage and Recovery
Aquifer Test
Experimental Technology
Ell Geothermal (Closed Loop)
bGeothermal (Heating/Cooling Return)
▪ Groundwater Remediation
❑I Salinity Barrier
❑I Stormwater Drainage
El Subsidence Control
❑I Tracer
❑ I Other (explain under #21 Remarks)
4. Date Well(s) Completed: 5/2/2022 Well ID#AS 1
5a. Well Location:
L&L #5
00-0-0000022386
Facility/Owner Name Facility ID# (if applicable)
109 W. Nash St. Bus. 64 Spring Hope NC.
Physical Address, City, and Zip
Nash
2769062957763
County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
35.944339 N-78.112804
6. Is(are) the well(s)
Permanent or ElTemporary
14. WATER ZONES
FROM
TO
DESCRIPTION
ft.
ft.
ft.
ft.
15. OUTER CASING (for multi -cased wells) OR LINER (if ap licable)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
16. INNER CASING OR TUBING (geothermal closed -loop)
FROM
TO
DIAMETER
THICKNESS
MATERIAL
ft.
ft.
in.
ft.
ft.
in.
17. SCREEN
FROM
TO
DIAMETER
SLOT SIZE
THICKNESS
MATERIAL
35 ft-
40 ft.
1 in.
10 Slat
SchdAi
PVC
ft.
ft.
in.
18. GROUT
FROM
TO
MATERIAL
EMPLACEMENT METHOD & AMOUNT
31 ft.
33 ft.
Bentonite
Pour
0.5 ft.
31 ft.
Portland
Pour
ft.
ft.
19. SAND/GRAVEL PACK (if applicable)
FROM
TO
MATERIAL
EMPLACEMENT METHOD
33 ft.
40 ft.
No. 2 Sand
Pour
ft.
ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM
TO
DESCRIPTION (color, hardness, soiVrock type, grain size, etc.)
0 ft.
0.5 ft.
Asphalt
0.5 ft.
10 ft.
Lean Clay (CL)
10 ft.
40 ft.
Silt (ML)
ft.
ft.
ft.
ft.
ft.
ft.
ft.
ft.
21. REMARKS
22. Certification:
W
7. Is this a repair to an existing well: QIYes or ► iNo
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 form.
8. For Geoprobe/DPT or Closed -Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled: 1
9. Total well depth below land surface: 40
(f-)
For multiple wells list all depths ifdifferent (example- 3@200' and 2@100)
10. Static water level below top of casing: N/A (ft.)
If water level is above casing, use "+"
11. Borehole diameter: 4.25 (in.)
12. Well construction method: Solid Stem Auger
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
Signature of Certified Well Contractor
5/2/2022
Date
By signing this form, I 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 Injection 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 Supply & 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

Table 5 MONITORING WELL CONSTRUCTION INFORMATION
Date: 9/28/22 Incident Name: L&L Food Store #5 Incident No. 46271 Facility ID No: 0-0022386
Top of
Depth to
Date Water
Casing
Water from
Free Product
Level
Well Casing Depth (ft.
Screened Interval (x
Bottom of Well
Elevation
Top of
Thickness
Groundwater
Well ID
Date Installed
Measured
BGS)
to y ft. BGS)
(ft. BGS)
(ft.)
Casing (ft.)
(ft.)
Elevation (ft.)
Comments
MW1
4/30/18
-
15
15-30
30
99.33
-
-
-
2"-diameter Type II monitoring well
MW2
4/30/18
8/9/22
15
15-30
30
100.42
21.20
-
79.22
2"-diameter Type II monitoring well
MW3
4/30/18
-
15
15-30
30
99.68
-
-
-
2"-diameter Type II monitoring well
MW4
4/30/18
-
15
15-30
30
98.67
-
-
-
2"-diameter Type II monitoring well
MW5
7/9/19
-
15
15-30
30
100.26
-
-
-
2"-diameter Type II monitoring well
MW6
7/10/19
8/9/22
15
15-30
30
100.55
21.85
-
78.70
2"-diameter Type II monitoring well
MW7
7/10/19
8/9/22
15
15-30
30
99.03
22.35
-
76.68
2"-diameter Type II monitoring well
MW8
7/10/19
-
15
15-30
30
99.81
-
-
-
2"-diameter Type II monitoring well
MW9
7/10/19
-
15
15-30
30
97.85
-
-
-
2"-diameter Type II monitoring well
MW10
7/10/19
-
15
15-30
30
96.14
-
-
-
2"-diameter Type II monitoring well
MW11
7/10/19
-
15
15-30
30
96.12
-
-
-
2"-diameter Type II monitoring well
MW12
7/8-9/2019
-
IC: 40 OC: 50
50-55
55
99.27
-
-
-
2"-diameter Type III monitoring well
MW13
4/14/20
-
15
15-30
30
101.03
-
-
-
2"-diameter Type II monitoring well
MW14
4/14/20
8/9/22
15
15-30
30
100.28
20.53
-
79.75
2"-diameter Type II monitoring well
MW15
4/14/20
-
15
15-30
30
99.96
-
-
-
2"-diameter Type II monitoring well
AS1
5/2/22
-
35
35-40
40
100.03
-
-
-
1"-diameter air sparge
SVE1
5/2/22
-
5
5-20
20
99.86
-
-
-
2"-diameter SVE
SVE2
5/2/22
-
5
5-20
20
100.24
-
-
-
2"-diameter SVE
SVE3
5/2/22
-
5
5-20
20
100.11
-
-
-
2"-diameter SVE
Notes:
1. All units in feet.
2. "-" = not detected

REDOX TECH, LLC
"Providing Innovative In Situ Soil and Groundwater Treatment"
1. Identification
Product identifier
Other means of identification
Recommended use
Recommended restrictions
Material Safety Data Sheet — Oxygen BioChem
Oxygen Biochem (OBC)TM
Not available.
Oxygen Biochem (OBC)TM is used to promote chemical oxidation
petroleum compounds in groundwater.
Use in accordance with supplier's recommendations.
Manufacturer/Importer/Supplier/Distributor information
Manufacturer/Supplier
Address
Telephone
E-mail
Contact person
Emergency Telephone
2. Hazard(s) identification
Physical hazards
Health hazards
OSHA defined hazards
Label elements
Signal word
Hazard statement
Precautionary statement
Prevention
Response
and aerobic bioremediation of
Redox Tech, LLC
200 Quade Drive Cary
NC 2751
[phone]
[e-mail]
Dr. John Haselowi
For Hazardous Materials [or Dangerous Goods] Incidents ONLY
(spill, leak, fire, exposure or accident), call CHEMTREC at
CHEMTREC®, USA: 001 [phone]
CHEMTREC®, Mexico (Toll -Free - must be dialed from within country):
01-800-681-9531
CHEMTREC®, Other countries: 001 [phone]
Oxidizing solids Category 3
Acute toxicity, oral
Skin corrosion/irritation
Serious eye damage/eye irritation
Sensitization, respiratory
Sensitization, skin
Specific target organ toxicity, single exposure
Not classified.
Category 4
Category 2
Category 2
Category 1
Category 1
Category 3 respiratory tract irritation
Danger
May intensify fire; oxidizer. Harmful if swallowed. Causes skin irritation. Causes serious eye
irritation. May cause allergy or asthma symptoms or breathing difficulties if inhaled. May cause an
allergic skin reaction. May cause respiratory irritation.
Keep away from heat. Keep/Store away from clothing and other combustible materials. Take any
precaution to avoid mixing with combustibles. Wear protective gloves/eye protection/face
protection. Wash thoroughly after handling. Do not eat, drink or smoke when using this product.
Avoid breathing dust/fume. In case of inadequate ventilation wear respiratory protection.
Contaminated work clothing must not be allowed out of the workplace. Use only outdoors or in a
well -ventilated area.
In case of fire: Use foam, carbon dioxide, dry powder or water fog for extinction. If swallowed: Call
a poison center/doctor if you feel unwell. Rinse mouth. If on skin: Wash with plenty of water. If
skin irritation or rash occurs: Get medical advice/attention. Take off contaminated clothing and
wash before reuse. If in eyes: Rinse cautiously with water for several minutes. Remove contact
lenses, if present and easy to do. Continue rinsing. If eye irritation persists: Get medical
advice/attention. If inhaled: If breathing is difficult, remove person to fresh air and keep
comfortable for breathing. If experiencing respiratory symptoms: Call a poison center/doctor.
Oxygen Biochem (OBC)TM
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Storage
Disposal
Hazard(s) not otherwise
classified (HNOC)
Store in a well -ventilated place. Keep container tightly closed. Store locked up.
Dispose of contents/container in accordance with local/regional/national/international regulations.
None known.
3. Composition/information on ingredients
Mixtures
Chemical name
CAS number
0/0
Sodium persulfate
7775-27-1 70 - 90
Calcium peroxide
1305-79-9 10 - 20
Composition comments
4. First -aid measures
Inhalation
Skin contact
Eye contact
Ingestion
Most important
symptoms/effects, acute and
delayed
Indication of immediate
medical attention and special
treatment needed
General information
5. Fire -fighting measures
Suitable extinguishing media
Unsuitable extinguishing
media
Specific hazards arising from
the chemical
Special protective equipment
and precautions for firefighters
Fire -fighting
equipment/instructions
General fire hazards
All concentrations are in percent by weight unless ingredient is a gas. Gas concentrations are in
percent by volume.
Move to fresh air. Do not use mouth-to-mouth method if victim inhaled the substance. For
breathing difficulties, oxygen may be necessary. Call a physician or poison control center
immediately.
Remove and isolate contaminated clothing and shoes. For minor skin contact, avoid spreading
material on unaffected skin. Wash clothing separately before reuse. If skin irritation or an allergic
skin reaction develops, get medical attention.
Immediately flush eyes with plenty of water for at least 15 minutes. Remove contact lenses, if
present and easy to do. Continue rinsing. Get medical attention if irritation develops and persists.
Rinse mouth. Do not induce vomiting without advice from poison control center. If vomiting occurs,
keep head low so that stomach content doesn't get into the lungs. Do not use mouth-to-mouth
method if victim ingested the substance. Induce artificial respiration with the aid of a pocket mask
equipped with a one-way valve or other proper respiratory medical device. Get medical attention if
any discomfort continues.
May cause redness and pain. Symptoms may include coughing, difficulty breathing and shortness
of breath.
Provide general supportive measures and treat symptomatically.
Ensure that medical personnel are aware of the material(s) involved, and take precautions to
protect themselves.
Water fog. Foam. Dry chemical powder. Carbon dioxide (CO2).
None known.
Contact with combustible material may cause fire.
Self-contained breathing apparatus and full protective clothing must be worn in case of fire.
In the event of fire, cool tanks with water spray.
May intensify fire; oxidizer.
6. Accidental release measures
Personal precautions,
protective equipment and
emergency procedures
Methods and materials for
containment and cleaning up
Environmental precautions
Keep unnecessary personnel away. Keep people away from and upwind of spill/leak. Wear
appropriate protective equipment and clothing during clean-up. Do not touch damaged containers
or spilled material unless wearing appropriate protective clothing. Avoid skin contact and inhalation
of vapors during disposal of spills. Ventilate closed spaces before entering them. Local authorities
should be advised if significant spillages cannot be contained. For personal protection, see Section
8 of the SDS.
Stop the flow of material, if this is without risk. Prevent entry into waterways, sewer, basements or
confined areas. Following product recovery, flush area with water. For waste disposal, see Section
13 of the SDS.
Avoid discharge into drains, water courses or onto the ground.
Oxygen Biochem (OBC)TM
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7. Handling and storage
Precautions for safe handling
Conditions for safe storage,
including any incompatibilities
Avoid inhalation of vapors/dust and contact with skin and eyes. Wash thoroughly after handling.
Keep away from clothing and other combustible materials. Use only with adequate ventilation. Do
not taste or swallow. Wear appropriate personal protective equipment (See Section 8). Observe
good industrial hygiene practices.
Store in original tightly closed container. Store away from incompatible materials (See Section 10).
Keep locked up.
8. Exposure controls/personal protection
Occupational exposure limits
US. ACGIH Threshold Limit Values
Components
Type Value
Sodium persulfate (CAS
7775-27-1)
Biological limit values
Appropriate engineering
controls
TWA 0.1 mg/m3
No biological exposure limits noted for the ingredient(s).
Observe occupational exposure limits and minimize the risk of exposure. Ensure adequate
ventilation, especially in confined areas.
Individual protection measures, such as personal protective equipment
Eye/face protection
Skin protection
Hand protection
Other
Respiratory protection
Thermal hazards
General hygiene
considerations
9. Physical and chemical
Appearance
Physical state
Form
Color
Odor
Odor threshold
pH
Melting point/freezing point
Initial boiling point and boiling
range
Flash point
Evaporation rate
Flammability (solid, gas)
Wear safety glasses with side shields (or goggles).
Wear protective gloves.
Neoprene or rubber gloves are recommended. Apron and long sleeves are recommended.
In the case of respirable dust, use self-contained breathing apparatus. Wear positive pressure
self-contained breathing apparatus (SCBA).
Wear appropriate thermal protective clothing, when necessary.
Always observe good personal hygiene measures, such as washing after handling the material
and before eating, drinking, and/or smoking. Routinely wash work clothing and protective
equipment to remove contaminants.
properties
Off-white, granular solid.
Solid.
Solid.
Off-white.
Odorless.
Not available.
11.7±0.4 (1-40% solution, slurry)
Not available.
Not applicable.
Not available.
Not available.
Not available.
Upper/lower flammability or explosive limits
Flammability limit - lower
(0/0 )
Flammability limit - upper
(%)
Explosive limit - lower (%)
Explosive limit - upper (%)
Vapor pressure
Vapor density
Relative density
Not available.
Not available.
Not available.
Not available.
Not applicable.
Not applicable.
2.76±0.16 (25°C)
Oxygen Biochem (OBC)TM
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Solubility(ies)
Solubility (water)
Partition coefficient
(n-octanol/water)
Auto -ignition temperature
Decomposition temperature
Viscosity
Other information
Oxidizing properties
10. Stability and reactivity
Reactivity
Chemical stability
Possibility of hazardous
reactions
Conditions to avoid
Incompatible materials
Hazardous decomposition
products
Soluble in water.
Not available.
Not available.
Not available.
Not available.
Oxidizing.
The product is stable and non -reactive under normal conditions of use, storage and transport.
Material is stable under normal conditions.
No dangerous reaction known under conditions of normal use.
Contact with combustibles.
Combustible material. Oxidizing material. Reducing agents.
No hazardous decomposition products are known.
11. Toxicological information
Information on likely routes of exposure
Ingestion
Inhalation
Skin contact
Eye contact
Symptoms related to the
physical, chemical and
toxicological characteristics
Information on toxicological effects
Acute toxicity
Skin corrosion/irritation
Serious eye damage/eye
irritation
Respiratory or skin sensitization
Respiratory sensitization
Skin sensitization
Germ cell mutagenicity
Carcinogenicity
Reproductive toxicity
Specific target organ toxicity -
single exposure
Specific target organ toxicity -
repeated exposure
Aspiration hazard
Chronic effects
Further information
12. Ecological information
Ecotoxicity
Persistence and degradability
Bioaccumulative potential
Harmful if swallowed.
May cause irritation to the respiratory system.
Causes skin irritation.
Causes serious eye irritation.
May cause redness and pain. Exposed individuals may experience eye tearing, redness, and
discomfort. Symptoms may include coughing, difficulty breathing and shortness of breath.
Harmful if swallowed.
Causes skin irritation.
Causes serious eye irritation.
May cause allergy or asthma symptoms or breathing difficulties if inhaled.
May cause an allergic skin reaction.
No data available.
This product is not considered to be a carcinogen by IARC, ACGIH, NTP, or OSHA.
No data available.
May cause respiratory irritation.
No data available.
Not applicable.
Prolonged exposure may cause chronic effects.
No data available.
This product's components are not classified as environmentally hazardous. However, this does
not exclude the possibility that large or frequent spills can have a harmful or damaging effect on
the environment.
No data is available on the degradability of this product.
No data available for this product.
Oxygen Biochem (OBC)TM
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Mobility in soil
Other adverse effects
Not available.
No data available.
13. Disposal considerations
Disposal instructions Consult authorities before disposal. Dispose in accordance with all applicable regulations.
Hazardous waste code The Waste code should be assigned in discussion between the user, the producer and the waste
disposal company.
Waste from residues / unused Dispose of in accordance with local regulations.
products
Contaminated packaging Empty containers should be taken to an approved waste handling site for recycling or disposal.
14. Transport information
DOT
UN number UN1479
UN proper shipping name Oxidizing solid, n.o.s. (Sodium persulfate)
Transport hazard class(es)
Class 5.1
Subsidiary risk -
Packing group II
Environmental hazards
Marine pollutant No
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
Special provisions 62, IB5, IP1
Packaging exceptions None
Packaging non bulk 211
Packaging bulk 242
IATA
UN number UN1479
UN proper shipping name Oxidizing solid, n.o.s. (Sodium persulfate, Calcium peroxide)
Transport hazard class(es)
Class 5.1
Subsidiary risk -
Label(s) 5.1
Packing group II
Environmental hazards No
ERG Code 5L
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
IMDG
UN number UN1479
UN proper shipping name OXIDIZING SOLID, N.O.S. (Sodium persulfate, Calcium peroxide)
Transport hazard class(es)
Class 5.1
Subsidiary risk -
Label(s) 5.1
Packing group II
Environmental hazards
Marine pollutant No
EmS F-A, S-Q
Special precautions for user Read safety instructions, SDS and emergency procedures before handling.
Transport in bulk according to This product is not intended to be transported in bulk.
Annex II of MARPOL 73/78 and
the IBC Code
15. Regulatory information
US federal regulations This product is a "Hazardous Chemical' as defined by the OSHA Hazard Communication
Standard, 29 CFR 1910.1200.
All components are on the U.S. EPA TSCA Inventory List.
TSCA Section 12(b) Export Notification (40 CFR 707, Subpt. D)
Not regulated.
Oxygen Biochem (OBC)TM
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US. OSHA Specifically Regulated Substances (29 CFR 1910.1001-1050)
Not listed.
CERCLA Hazardous Substance List (40 CFR 302.4)
Not listed.
Superfund Amendments and Reauthorization Act of 1986 (SARA)
Hazard categories Immediate Hazard - Yes
Delayed Hazard - Yes
Fire Hazard - Yes
Pressure Hazard - No
Reactivity Hazard - No
SARA 302 Extremely hazardous substance
Not listed.
SARA 311/312 Hazardous Yes
chemical
SARA 313 (TRI reporting)
Not regulated.
Other federal regulations
Clean Air Act (CAA) Section 112 Hazardous Air Pollutants (HAPs) List
Not regulated.
Clean Air Act (CAA) Section 112(r) Accidental Release Prevention (40 CFR 68.130)
Not regulated.
Safe Drinking Water Act Not regulated.
(SDWA)
US state regulations This product does not contain a chemical known to the State of California to cause cancer, birth
defects or other reproductive harm.
US. Massachusetts RTK - Substance List
Not regulated.
US. New Jersey Worker and Community Right -to -Know Act
Calcium peroxide (CAS 1305-79-9)
Sodium persulfate (CAS 7775-27-1)
US. Pennsylvania Worker and Community Right -to -Know Law
Not listed.
US. Rhode Island RTK
Not regulated.
US. California Proposition 65
US - California Proposition 65 - Carcinogens & Reproductive Toxicity (CRT): Listed substance
Not listed.
International Inventories
Country(s) or region Inventory name On inventory (yes/no)*
Australia Australian Inventory of Chemical Substances (AICS) Yes
Canada Domestic Substances List (DSL) Yes
Canada Non -Domestic Substances List (NDSL) No
China Inventory of Existing Chemical Substances in China (IECSC) Yes
Europe European Inventory of Existing Commercial Chemical Yes
Substances (EINECS)
Europe European List of Notified Chemical Substances (ELINCS) No
Japan Inventory of Existing and New Chemical Substances (ENCS) Yes
Korea Existing Chemicals List (ECL) Yes
New Zealand New Zealand Inventory Yes
Philippines Philippine Inventory of Chemicals and Chemical Substances Yes
(PICCS)
United States & Puerto Rico Toxic Substances Control Act (TSCA) Inventory Yes
"A "Yes" indicates this product complies with the inventory requirements administered by the governing country(s).
A "No" indicates that one or more components of the product are not listed or exempt from listing on the inventory administered by the governing
country(s).
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16. Other information, including date of preparation or last revision
Issue date 09-May-2014
Revision date
Version # 01
Further information
NFPA Ratings
HMIS® is a registered trade and service mark of the NPCA.
List of abbreviations NFPA: National Fire Protection Association.
References
Disclaimer
Registry of Toxic Effects of Chemical Substances (RTECS)
HSDB® - Hazardous Substances Data Bank
The information contained herein is accurate to the best of our knowledge. However, data, safety
standards and government regulations are subject to change and, therefore, holders and users
should satisfy themselves that they are aware of all current data and regulations relevant to their
particular use of product. CARUS CORPORATION DISCLAIMS ALL LIABILITY FOR RELIANCE
ON THE COMPLETENESS OR ACCURACY OR THE INFORMATION INCLUDED HEREIN.
CARUS CORPORATION MAKES NO WARRANTY, EITHER EXPRESS OR IMPLIED,
INCLUDING, BUT NOT LIMITED TO, ANY WARRANTIES OF MERCHANTIABILITY OR FITNESS
FOR PARTICULAR USE OR PURPOSE OF THE PRODUCT DESCRIBED HEREIN. All conditions
relating to storage, handling, and use of the product are beyond the control of Carus Corporation,
and shall be the sole responsibility of the holder or user of the product.
(Carus and design) is a registered service mark of Carus Corporation.
Oxygen Biochem (OBC)TM
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