WI0300488_Notification of Intent (NOI) – GW Remediation_20230118

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 individualpermit 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 .02251 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: January 17, 2023 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.
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 B through M
(5)
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
B. STATUS OF WELL OWNER: State Governmcnt
Deemed Permitted GW Remediation NOI 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): NCDEQ Division of Waste Management, UST Section, State Lead Program
Mailing Address: 1636 Mail Service Center
City: Raleigh State: NC Zip Code:27699 County: Wake
Day Tele No.: 919-707-8166 Cell No.:
EMAIL Address: [e-mail] Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Jennifer Jones, Etal C/O Karen Johnson
Company Name
Mailing Address: 548 New Salem Rd.
City: Statesville State: NC Zip Code: 28625 County: Iredell
E.
F.
G.
Day Tele No.: 704-832-2399 Cell No.: 704-437-2790
EMAIL Address: kllohnson(&co.iredell.nc.us Fax No.:
PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Al Quarles, Project Manager
Company Name ATC Associates of North Carolina, PC
Mailing Address: 7606 Whitehall Executive Center Drive, Suite 800
City: Charlotte
State: NC Zip Code: 28273
Day Tele No.: 704-529-3200
EMAIL Address:William.Quarlesponeatlas.com
PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: TF#10782 Jones Grocery
1156 East Memorial Highway
Cell No.:
Fax No.:
County: Mecklenburg
City: Harmony County: Iredell Zip Code: 28625
(2) Geographic Coordinates: Latitude": 0 1" or 35.918499'
Longitude": " or-80.720954'
Reference Datum: UST Basin Accuracy:
Method of Collection: Goo,gle Earth
"FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
TREATMENT AREA
Land surface area of contaminant plume: NA square feet
Land surface area of inj. well network: NA square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: NA (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.
L 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:
Air SDarging (using air compressor) connected to MW-ID and AS-1 as air snarge wells. and using wells OW-
2, 3, 4, and 5 as air injection wells for the vadose zone, during the 96-hour Mobile -Multiphase Extraction Event
(MMPE) wells MW-1, 2, 6, 7, OW-1, and VE-lwill be used as extraction wells assuming they are accessible.
The sparging will be performed at approximately 5 cfin for up to 96 hours. The MMPE/Air Sparge event is
scheduled for January 30 through February 3, 2023.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: NA Proposed 7 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 70-75 feet
(3) For Proposed wells or Existing wells not having GW-1s, 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: Onlv iniectants avvroved by the evidemioloev section ofthe NC Division ofPublic Health. Department
of Health and Human Services can be infected. Approved iniectants can be found online at
hitp:Hdeq.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 Pro ream for more info if you wish to 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: Total Amt. to be injected (gal)/event:
Total Amt. to be injected (gal)/event:
No. of separate injection events: Total Amt. to be injected (gal):
Source of Water (if applicable
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

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.
ATC will sample selected monitoring wells, approximately two weeks after the Air Sparge event. The water
samples will be analyzedy SM 620013, during the post MMPE/AS sampling event
M. 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 1 SA NCAC 02C 0200 Rules. "
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
(I5A NCAC 02C C. 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 access agreement
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 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 GW Remediation NOI Rev. 2-17-2020 Page 4

LEGEND:
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MW-ID
WELL CONSTRUCTION RECORD
North Carolina -Department of Environment and Natural Resources - Division of Water Qudlity - Groundwater Section
WELL CONTRACTOR (1NDIVIDUAL) NAME (print). Milton (Ravl Raeera CERTIFICATION # 2428
WELL CONTRACTOR COMPANY NAME SEI Environmental Inc PHONE # [phone]
STATE WELL CONSTRUCTION PERMIT# ASSOCIATED WQ PERMIT #
(if applicable) (if applicable)
1. WELL USE (Cheek Applicable Box): Residential E 3 Municipal(Pubiic Q Industrial ❑ Agricultural
Monitoring[E Recovery f] Beat Pump Water Injection Q Other ❑ If Other, -list Use
2. WELL LOCATION;
Nearest Town: Harmony County liedell
1 156 East Memorial Highway 28634 DEPTH pRILLANG
(Street Name, Numbers, CommunhLOG
ty, or Subdivision and Lot No., Zip Code) From To Formation 19esLion
0 5 BF❑Wn red clay and silt
ADDRESS ! 156 East Memorial Highway3. Parks Jones 5.0 10 Brown red clay and silt petroleum
ADDRESS - -
(Street or Route No.) odor
Hanna v
10 - 15 Hrown red clay and silt petroleum
N 2R634
City or Town State Zip Code odor
[phone] 15 20 Brown red clay and silt petroleum
Area Code - Phone Number odor
20 25 _Brown red clay find silt, petroleum
4. DATE DRILLED 7/14-15105 odor
5. TOTAL DEPTH' 75 feet 25 - 30 Brown red clay and silt, strong
6. DOES WELL REPLACE EXISTING WELL? YES El NO d petroleum odor, sli htmaisture at
7, STATIC WATER LEVEL Below Top of Casing: 42.00 FT. 27 feet
(Use "+" if Above Top of Casing) 30 - 35 Brown red cla�and silt moist some
s. T6F OFCASING IS OA FT. Above Land Surface* _petroleum odor
'Top of casing terminated at/or below land surface requires a variance in accordance 35 - Red brown 20% fine sand 80% clay
with 15A NCAC 2C ,0118.. - and silt, moist miner pet. odor
9, YIELD (gpm): N/A METHOD OF TEST N/A 40 45 Red brawn 25%fioe-medium sand
10. WATER ZONES (depth): 75% clay end silt saturated no odor
45 50 Red brown 25%fine medium sand,
l l _ DISINFECTIOt�i: Type N/A Attiount 73%clay and silt
U. CASING:50 - 55 Red brown 25% brie -medium Land
Wall Thicknes's '. 75°!° clay and silt
Depth Diameter or WajghtlFC. Material55 75 Not Sampled. Mud rotary
FROM 0 TO 65 FT 6" Sch40. PVC Total Depth 75 Feet
'FROM 0 TO 65 FT 2" Sch40 PVC LOCATION SICETCH
FROM TO FT Show direction and distance in miles from at least two State Roads
13. GROUT: or County Roads; include the road numbers and common names.
Depth Material Method r
FROM 0 TO 65 FT Portland Slurry
FROM 0 TO 61 FT Portland Slurry
,sa
14. SCREEN: /
/ 6TnRE sF°VNi,o i i
�Mfl�j
Depth Diameter S16tSize Material
FROM 65 TO 75 FT 2 in 0.010 in PVC
FROM TO FT 'in in
O NM'-1 II
15. SAND/ORAVELPACK: c-------=-==-==p"1�tr°ReeRsowc.uera°
Depth Size Material ---=----=----- -=- ---- ti
Funr�x,,do<+n�uer `x
FROM. 63 TO 75 FT #2 Fine Silica Sand RtMRoMgcAD �
Topographic !Land setting;
❑Ridge (check
apr e p ate leybox)
ft7 Flat
_ (ehec4c appropriate box) ur
Latitude / langitude of well location: a mmeuuo nwuwnwr�, I
N 35°5Q1" WOHM43,257" ® hPe mucR mFiRaweu
(degregs/minutes/seconds)
Latitude/longitude source; 0 CPS © Topographic map
p e ,o ac FT. ,nu +:naavw�
,a.es wcanr
l� wuar�uuwauuwr,
°w6 i;,°pl]pR °ATE YI.L1
OPAWN6'n,.C�
16 REMARKS: Bmtonite I-fi feet
F
I DO HEREBY CERTIFY THAT THIS:1WWE:LL-WAS N UCT13D IN ACCORDANCE WITH 15 NCAC 2C, WELL CONSTRUCTION STANDARDS, AND
THAT A COPY OF THIS RECORD HEN PRO ED ! THE WELL OWNER
SfONATURE OF 1CONTRA TOR R AGENT DATE
Submit original to the Division of Water Quality, Groundwater Section, 1636 Mail Service Center -Raleigh, NC 27699-1636 Phane No. [phone], within 3D
days. GW-I REV, 07/2001
900 [n IaS aZZO1VH0 ... JV1NaWN02IIANH IHS VT62ZCS XVA ££ t 60 NOW 50/ZZ/90

NONRESIDENTMWELL CONSTRUCTION RECORD
.r, North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contra ondlvidual) Name
k10Gtr..c.' C& -T/1.'.�
Well Contractor Company Naiihe
STREET ADDRESS D O 81C�,1` 3 cI S
City or Town State Zip Code
�- 7 3..:Z - 0 a i_3
Area Code- Phone number
7- WELL INFORMATION:
SITE WELL ID #[dappric�{e}
WELL CONSTRUCTION PERMITkd appliahle)
OTHER ASSOCIATED PERMIT #Qf appllcable)
3_ WELL USE (Check Applicable Sox) Moniloring13 MuninipauPubticij
Industrial/CommerWIII Agricuftuy Iq Recovery❑ in)ectionO
IrrigationG Otherg' (fist use) �fttr S.�aCE5i e
DATE DRILLED % a� - 0 d;
TIME COMPLETED / : U Ci AMO PNIR
4. Wr=LL LOCATION:
CITY: )4Ccrman: COUNTY -Ct-Je-l'
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Tip Cade)
TOPOGRAPHIC / D SETTING:
❑ Slope 13 Vat Flat © Ridge 0 Other
(check appicipriate b* May be in degrees.
LATITUDE _ _ minutes, seconds or
LONGITUDE in a decimal Format
LatitudcAongitude source: 13 CPS D Topographic map
(location of xeff must be shown On a USGS topo map and
attached to this form d not using GPS)
6. FACILITY- is the name or the bww^ where vw vmm is imaw-
FACILITY ID #(if applicable)
NAME OF FACILITY TO tV e.S C rU Gc r
STREETS ADDRESS
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
City or Town State .Tip Code
f }_
Area code - Phone number
6. WELL DETAILS: r
a. TOTAL DEPTH: 7
b. DOES WELL REPLACE EXISTING WELL? YES{] NO/
C. WATER LEVEL Below Top of Casing: r / U FT.
(Use'+' ifAbove Top of Casing)
d. TOP OF CASING IS FT. Above Land Surface*
'Tap of rasing ternrinated atfor below land surface may require
a variance in accordance with 15A NCAC 2C .011 S_
e. YIELD (gpm): — METHOD OF TEST_
f. DISINFECTION: Type Amount:
9. WATER ZONES (depth):
From
To
From
To
From
To
From
To
From
TO
Fran
TO
7. CASING:
Depth
Diameter
ThiclrressMaight Material
From 0 To 7 V Ft -
From To Ft -
From To Ft.
8. GROUT: Depth Material Method
From U
Ta t o y Ft. G�avt%t` n :-v r ec
From
To Ft.
From
To Ft
9. SCREEN: Depth Diameter Slot Size Material
From _2 O
To 7_S�_ Ft Lin. in.
From
To Ft in. in.
From
To Ft. in_ in.
14. SANDIGRAVEL
PACK:
Depth
Size Material
From fo
To_ :i 5 t=t_±2 5 ext:
From
To Ft.
From
To Ft.
I1.0R1LLING LOG
From TO
Formation Description
t.7 -7 S
12-e! c So /
12. REMARKS:
Lo R S l
I DO HEREBY CERTIFYTHAT THIS WELL WAS C.ONSTRLK-7M IN ACCORDANCE WITH
15A NCAC 2C. WELL CONSTRUCTION STANDARDS. AND THAT A COPY OF THIS
RECW BEEN PROVIDED TO THE WELL OWNER.
L4 it
SIG RE OF ERTI ED WE CONTRACTOR DATE
PRftTtED NAME OF PERSON CONSTRUCTING THE WELL
Submit the original to the Division of Water Quafity within 30 days. Attn: Infolmatiorl Mgt., Form GW-1b
1617Mail Service Center- Raleigh, NC 27699-161T Phone No. [phone] ext56a. Pev.12/07

r _ N6TIEESIDENTMWELL CONSTRUCTION RECORD
North Carolina Department of Envirimment aad Nativai Resources- Division of Water Quality
`} WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR:
Well Contractor (Individual) Name
01c4d A--rjc,
Well Contractor Company NarAe
rrg7 G
STREETADDRESS `P C
l
City or Town State Zip Code
70y a --? 13
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *(if applicable).
WELL CONSTRUCTION PERMriWwokai le)
OTHER ASSOCIATED PERMIT *(if applicable)
3. WELL USE (Check Applicable Box) MonitoringIr MunicipaVPublicD
IndustriallCommercial[] AgriculturalO Recovery[] Injection❑
Inigatiora OtherG (fist use)
DATEDRRLED / /Z�'ZEE
TIME COMPLETED %% , `�U AMVPMO
4. WELL LOCATION:
CITY: 82t-MOVJ N,C, COUNTY
(Stred Nana, Numbers, ContmurKiY, 5ubdivtslon, Lot Na, Parcel, Zip Cade)
TOPOGRAPHIC I LAND SETTING:
❑ Slope 13 Valley lrtat ❑ Ridge 0 Other
(check appropriate box) May be in degrees,
LATITUDE _ minutes, seconds or
LONGITUDE in a decimal format
Latitude/longitude source: 0 GPS ❑ Topographic map
(location of welt must be shown on a USGS topo map and
attached to this form if not usiru1 GPS)
S. FACILITY- is he name of the Whines where he Well is Iorated.
FACILITY ID(if applicable)
NAME OF FACILITY1r,,UC5
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
City or Town State Zip Code
( 3-
Area code - Phone number
S. WELL DETAIN: {
a. TOTAL DEPTH: 70 ✓
b. DOES WELL REPLACE EXISTING WELL? YES❑ NOe
t. WATER LEVEL Below Top of Casing: FT.
(Use "+" if Above Top of Casing)
d. TOP OF CASING IS (Z) FT. Above Land Surface'
'Top of casing terminated at/or below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type_____::Amount
g. WATER ZONES (depth):
From — To From TO
From To From TO
From To From To
7. CASING: Depth Diameter Thickaesawesght Material
From Q_ To Ft : 7 L _ c_
From TO FL
From To FL
B. GROUT: Depth Material Method
From_ _To__Ft. Cnwf �Qb`: �cQ
From To Ft
Ftom To Ft
9. SCREEN: Depth Diameter Slot Size Material
From 10 To
60 Ft. _� I' in. r L.' i i> in. Pvlr
From To Ft_ in. in,
From To Ft in. tn.
10. SANDIGRAVEL PACK:
Depth Size Material
From�To 7© Ft. r-Fc� .5e
From To Ft
From To Ft.
I I.DRILLiNG LOG
From o formation Description
© -- 7 O c,i
12. REMARKS:
L-0 # Oct;
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC 2C, WELL CONSTRUCTION STANDARDS, AND THAT A COPY OF THIS
RECORD 1,ffiS BEEN PROVIDED TO THE WELL OWNER.
St NATURE OF ERP IED WELL D NTRACTOR'DATE
3Rrz- qz&:� O ''41e;Iy
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Subunit the original to the Division of Water Quality within 30 days. Attn: Information Mgt, Form GWAb
1617 Mail Service Center— Raleigh, NC 27699-1617 Phone No. [phone] ext 568. Rev,12107

19' ONR SLOENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Rcsources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
t. WELL CONTRACTOR:
P7 '2
Well Contractor (Ind'dual) flame
MC4 X Dc i , ,C, -.1- A,)
Well Contractor Company Na
STREET ADDRESS P 0 8 Ox 3 C g
3�7r'o&- 5+ft�',&A1�-
City or Town State Zip Code
(2oq)- '7 3a -0
Area code- Phone number
2- WELL INFORMATION:
SITE WELL ID#(rTappFrable)
WELL CONSTRUCTION PERM!rrtY-it applicable)
OTHER ASSOCIATED PERMIT #Clf applicable)
3. WELL USE (Check Applicable Sox) Monitoring Municipal/Publico
Industrial/CommerkialD AgriculturalI3 Recovery[] tniection13
IrrigationD Otherfi (list use)
DATE DRILLED11441!C
TIME COMPLETED 111 11 U AMW PMo
4. WELL LOCATION: 0/ATION: =rred e-
CITY: f'T'�Me'L'Z/ COUNTY
(Street Name, Numbers, Community, Sul dMsion, Lot No., Pafoel, Tip Code)
TOPOGRAPHIC I LAND SETTING:
o Slope 0 Valley $'rtat o Ridge 13 Other
(dredt appoprIsie b-) May be in degrees,
LATITUDE _ _ minutes, seconds or
LONGITUDE in a decimal fommr
Latitudellongitude source: [] GPS o Topographic map
(location of well must be shown on a USGS topo map and
attached to this form if not using GPS)
5_ FACILITY- is the name or the i-nk� where the weu is loratad-
FACILITY ID #(If applicable)
NAME OF FAC1LfTY-
STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
City or Town Slate Zip Code
Area code - Phone number
B. WELL DETAILS:
a. TOTAL DEPTH: ��
b. DOES WELL REPLACE EXISTING WELL? YES[] NOr—
c. WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
d. TOP OF CASING LS — FT. Above Land Surface`
'Top of casing temninated atior below land surface may require
a variance in accordance with 15A NCAC 2C .D11 B-
e. YIELD (gpm): METHOD OF TEST
f. DISINFECTION: Type
Amount
g. WATER ZONES {depth):
From To
From To
From To
From To
From To
From Toiam
7. CASING: Depth
Deter TNcknesslWerght
Material
From Q To )
Ft_
-?
fmrr Tc
Ft
From To
Ft
S. GROUT: Depth
Material
Method
From Ta—L— Ft. C P.rJt ° r.J r rV
C l3=%
From To
Ft.
From Ta
FL
9. SCREEN: Depth
Diameter Slot Size Material
FromO To 70
Ft.
r,
in. 0 y C in.
P Ll {.
From To—
Ft.
in_ In.
From To
Ft
in_ in.
10. SAND/GRAVEL PACK:
Depth
Size Material
From__5 _To__ 70
Ft.
"�' a 5aAJ C
From To
Ft.
From To
Ft.
I1.DRILLING LOG
From To
Formation Description
0 70 _ 2,a
sn 11
12. REMARKS:
I DO HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WrrH
ISA NCAC 2C. WELL CONSTRUCTION STANDARD, AND THAT A COPY OF THIS
RECORD HAS N PRO%4DED TO THE WELL OWNER.,
SIGNATME OF CE IFIK WELL CONTRACTOR DATE
fl P g"-( xis C P; rJ
PRINTED F PERSON CONSTRUCTING G THE WELL
Submit the original to the Division of Water Quality within 30 days. Attn: Information Nlgt, Form GW-tb
1617 Mail Service Center- Raleigh, NC 27699-1917 Phone Flo. [phone] ext 568. Rev.12M7

NONRESIDENTIAL QNRE*S'IDEN,IAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION #
1. WELL CONTRACTOR: }
'�� r4I? , t! ''1 1%1aiA)
Well Contractor (Ind iduaq Name
mc(f Q D t 1 ' !' 4 )C
Well Contractor Company Nwhe
STREET ADDRESS P (7 113 n r 3 S F
:�rcrl) sia:k:Inllj rV,C, DSC2F0
City or Town State Zip Code
732- 0�;- 13
Area code- Phone number
2. WELL INFORMATION:
SITE WELL ID *(If applicable)
WELL CONSTRUCTION PERMITRif appricaue)
OTHER ASSOCIATED PERMIT #(If applicable)
3. WELL USE (Check Applicable Box) MonitodPgj2 1krfcipaU bIkU
Industrial/GomrnemialD AgrimtturelO RecoveryO tnjectiorC
Irrigation(I Dtherd (list use)
DATE DRILLED i l -- 3 -- 0 5j
-nmE COMPLETED a : vv AMD Pf-
4. WELL LOCATION:
CITY: _ Wc,,rrto-xv� COUNTY -;=r-j
(Street ?lama, Numbers, Commis*. Subws!Dn, Lot No., Parcel, Zip Coda)
TOPOGRAPHIC I LAND SETTING:
0 Slope 17 Valley ,flat 0'Ridge D Other
(chaelc apprDpriate bmc) May he in dues
LATITUDE _ _ minutes, seconds or
in a decunai format
LONGITUDE
Latitude/longitude source: tl GPS 0 Topographic map
(location of welt must be shown on a USGS topo map and
attached to this loan if not using GPS)
5. FACILITY- is we new or the twxnan wt" me well is locewd.
FACILITY ID #(if applicable)
NAME OF FACILITY s.� 0,Ve5 t ^ I STREET ADDRESS
City or Town State Zip Code
CONTACT PERSON
MAILING ADDRESS
Ctty or Town State Zip Code
f Area code - Phone number
S. WELL DETAILS:
a. TOTAL DEPTH-
b. DOES WELL REPLACE EXISTING WELL? YES13 NOEr -
c- WATER LEVEL Below Top of Casing: FT.
(Use '+' if Above Top of Casing)
d. TOP OF CASING IS FT, Above Land Surface'`
"Top of casing temtinated at/or below land surface may require
a variance in aocoRdance with 15A NCAC 2C .0118.
e. YIELD (gprn): METHOD OF TEST
f. DISINFECTION: Type Amount
g. WATER ZONES (dam):
From To From To
From To From To
Fran To From To
7. CASING: Depth Diameter 1 /IMelght Material
From C I Tom Ft. �e
From--_ To Ft
From To FL
8. GROUT: Depth Material Method
From 0 To—L—Ft. LPmevru �P�?
From Tc Ft
From To Ft
9- SCREEN: Depth Diameter Slot Size Material
From 10 To k' C7 Ft a e r J,. I Ui O in, PL'C,
From TD Ft in. in_
From To FL in. M.
10. SANDIGRAVEL PACK:
Depth Size Material Fmm_,,To 7 0 Ft ' ;X $C1'� Cn�
From To Ft
From To Ft
II.DRILLING LOG
From TO Formation Description
60 "70 ar�y -�o I`
12. REMARKS:
100 HEREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED W AC=PMANCE WITH
15A NCAC 2C, WELL CONSTRI.CfIDN STANDARDS, AND THAT A COPY OF THIS
RECORD EEN PROVIDED TO THE WELL OWNER.
C1 it3D�
SIGNATURE OF C TIFI WELL N� DATE
PRINTED NAME PF PERSON GaNSTRUCTING THE WELL
Submit the original to the Division of Water Quality within 30 days. Attu: Information Mgt_, Form GW-1b
1617 Mail Service Center— Raleighr NC 27699-1617 Phone No- [phone] ext 568. Rev 12107

1. WELL CONTRA
NONRESIDENTIAL ONRESIDENTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # P vz 13 r 49
-^i�/n i/-)
/lG
wirwu,eaa ,C r CP87C�1"
City or Town State Zip Code
cam) 7./3
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMITi#
OTHER ASSOCIATED PERMITAV applicable)
SITE WELL ID *(if applicable)
d. TOP OF CASING IS FT, Above Land Surface'
"Top of casing terminated aUor below land surface may require
a variance in accordance with 15A NCAC 2C .0118.
r
a. YIELD (gpm): METHOD OF TEST—
L DISINFECTION: Type Amount
g. WATT ONES (depth):
Top Bottom
Top
Bottom
Top Bottom
Top
Bottom
Top Bottom
Top
Bottom
Thickness/
: 7. CASING: Depth
Diameter
Weight Wtqrlal
Top_ Bottom
Ft. a� J
if
Top Bottom
Ft.
Top Bottom
Ft.
3. WELL USE (Check One Box) MonitoringET'Municipal/Public ❑
Industrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
8, GROUT: Depth Material Method
: Top _ Bottom_ Ft. ' dy ,�A/
Irigation❑ Other ❑ (I' u
Top Bottom Ft.
DATE DRILLED
Top Bottom Ft.
4. WELL LOCATION:
; 9. SCREEN: Depth Diameter Slot Size Material
Top It Q Bottom Q Ft. ��r in. , Oly In, RJC-
(Street Name, Numbam, Community, Subdivision, Lot No., Parcel, Zip code)
'Top Bottom Ft. in. in.
CITY: COUNTY �' � /
/ ; Top Bottom Ft in. in.
TOPOGRAPHIC I AND SETTING: (dwck apxopriate box)
❑Slope ❑Valley,,c1flat ❑Ridge ❑Other
: 10, SANDIGRAVEL PACK:
LATITUDE °_ " DMS OR 3x.XxXXXX7VOC DID
��P 20 Ft.�—e Stm mate
:Top Bottom
LONGITUDE 75 °_' ° DMS OR 7X.xx>ncx)O= DID
: Top Bottom Ft.
Latitudellongitude source: 03PS aopographic map
; Top Bottom Ft.
(location of Ymil must be shown on a USGS topo map andattached to
this form ifnot using GPS)
: 11. DRILLING LOG
5. FACILITY (Name of the business where the well is located.)
: Tap Bottom Formation/ Desc ipti n
^
JO N tS
�Di
Facility Name Facility [DO (f applicable)
1
I
Street Address
1
City or Town State Zip Code
1
Contact Name
/
Mailing Address
1
City or Town State Zip Code
: 12. REMARKS:
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: -? 0
b. DOES WELL REPLACE EXISTING WELL? YES ❑ N&?,—�
c. WATER LEVEL Below Top of Casing: FT.
(Use "+' if Above Top of Casing)
100 HEREBY WTiPY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A NCAC LL CONSTRUCTION STANDARDS, AND THAT A COPY OF IS
RECORD SEEN PROV= TO THE JNER.
�7
MARE OF IF D WELL C OR D TE
PRINTED NAMVOF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - InformationProcessing, Processin , Form Rev. 2/09/08
1617 Mall Service Center, Raleigh, NC 27699-161, Phone: [phone]

V. SrATE4:,,
L`
NONRESIDENT'IA.L WELL CONSTRUCTION RECORD
North Carolina Department of Enviromnent and Natural Resources- Division of Water Quality
•k ""' - WELL CONTRACTOR CERTIFICATION # ��
1. WKL CONTRACTOR: y� - ' d. TOP OF CASING IS -� FT. Above Land Sullace'
rcWqI f A.) 'Top of casing tanranatad atior bakm land surface may require
mw on (in v' ual) Name _ a variance in accordance with 15A NCAC 2C .0118.
r az�— r(lG J
w Contra mpany N e a.YIELD (gpm): METHOD OF TEST
t� O ; f. DISINFECTION: Type �r Arnount
bz eet� ress z
/� /� u, C r a 8-0 yo 9WATER ZONES h)= Top Bottom
City or Town
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMrr#
OTHER ASSOCIATED PERMIT*Cd app —bie)
SITE WELL ID#(dappkcable)
3. WELL USE (Check One Box) Monitoring$ MunicipaltPublic ❑
tndustrial/Commercial ❑ Agricultural ❑ Recovery ❑ Injection ❑
Irrigation❑ Outer❑ (Ii U--Afi
DATE DRILLED
4. WELL LOCATION:
Top Bottom
Top Bottom
Top Bottom
Top Bottom-
-Thickness/
7. CASING: Depth
Diameter Weight wwrlat
r
Top_ Q_ BoWy
Ft. oZ I U
Top Botbrr
FL
Top Bottom
Ft.
S. GROUT: Depth Material Method
Top, _ Bottnm"�o Ft. 0
Top Bottom Ft.
Top Bottom Ft.
4. SCREEN: Depth DlaFrwWr Sint Sim Maorial
Top_LV Bottom 7 Ft.�r in. ��/ U in. --- I/
(Steak Noma, Numbers, Commurroty, SubdMsian. Lot No,, Pa et. Zip Code) l ' Top Bottom Ft. in.
CITY: Cv ' NCOUNTY '�'e I / : Top Bottom Ft. in.
TOPOGRAPHIC I (AND SETTING: (check appropriate box)
❑Slope ❑Valley�al ❑Ridge ❑Other ' 10. SANDIGRAVEL PACK:
LATITUDE 36 " DMS OR 3X•xla)UCXXrOc DD ; Depth Size
Top__,3 Bottom_Q Ft._
LONGCTUDE 75 ° DMS OR 7�x�W_Wt DD : Top Bottom Ft.
Lstitudetongitude source: (BPS Qropographic map : Top Bottom Ft.
(l)cation of well must be shown on a USGS topo map andattached to
this form if not using GPS)
6- FACILMY (Name air fire business where We well is located.)
Faa ty Name !i Facility ID# cif applicable)
Street Address
City or Town State Zip Code
Contact Name
Mailing Address
City or Town State Tip Code
Area code Phone number
S. WELL DETAILS:
r
a. TOTAL DEPTH:_ 7 .
b. DOES WELL REPLACE EXISTING WELLY YES ❑ N41f�
c. WATER LEVEL Below Top of Casing: FT.
(Use '+' it Above Top of Casing)
11. DRILLING LOG
Top Bottorrr
r
r
12. REMARKS: }i ,r ]
in.
in.
ftAater
Fammtkin AIV L ,/
t DO HEREBY CERTIFY THAT THIS WELL. WAS CONSTRUCTED IN ACCORDANCE WLTH
IsA NCAC4, WELL CONSTRUCTION STANDARDS, AND TPAT A COPY DF THIS
RECORW,KS BEEN PRm48 D 70 T11W NER. ♦/.._.,/�J{
S RE O RTIF C TRA fC DATE
�`l�.DOR
NAMI'OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality - Infornm lon Processing, Rev.
2/09 its
ev. 09
1817 Mail Service Center, Raleigh, NC 27899-161, Phone : [phone]

Waste Management
ENVIRONMENTAL QUALITY
July 6, 2017
Mr. Scott Ryals
Environmental Engineer
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: State -Lead Acceptance
Jones grocery
1156 E. Memorial Highway,
Harmony, Iredell County, NC
Incident Number 10787
Dear Mr. Ryals
ROY COOPER
6nve,,,..
MICHAEL REGAN
Secretary
MICHAEL SCOTT
Di.eLror
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 Environment and Natural Resources (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 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 in accordance with the acceptance of the site into the State -Lead Program, 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.
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.
Nothing Compares_�,�
Stele of North Carolina I E.h,a.,,,mat Quality I Waste Management
1646 Mail Servico Ci,=, 1217 Weat Sones Sttnat I Raleigh, NC 27699-1646
919 707 8200 T

5. 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.
[/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,
Sig ture
ka,rtn T J 0 knso )
Type/Print Name of Owner or Agent
job-- Is3a - A3gq (W)
9 +I 59. ).q go (c l
Phone Number
61K New Salerv, Rd
Address
A -I -a sw I fr C A,BbaS
City/State/Zip Code
RE: State -Lead Acceptance
Jones grocery
1156 E. Memorial Highway,
Harmony, Iredell County, NC
Incident Number 10787
LtJ �i"I ol�
IDate
Nothing Compares�-
Stain of North Carolina I8uvu'omnnntal Quality I Wasta Management
1646 Mail Service Center 1217 W estJanes Street I Raleigh, NC 27699-1646
919 707 8200 T

Ashleigh Thrash
From: Karen Johnson <[e-mail]>
Sent: Tuesday, January 17, 2023 1:25 PM
To: Ashleigh Thrash
Subject: [EXTERNAL] RE: Jones' Grocery
I[External Email] This email originated from outside of the Atlas mail system. Please use caution when opening
attachments.
Good afternoon Ms. Thrash,
Thank you for your follow up email.
Yes, I am one of the five owners of the Jones Grocery property at 1156 E. Memorial Hwy. Harmony, NC. and can sign the
access agreement.
Karen J. Johnson
704-437-2790
From: Ashleigh Thrash <[e-mail]>
Sent: Tuesday, January 17, 2023 12:55 PM
To: Karen Johnson <[e-mail]>
Subject: Jones' Grocery
Good Afternoon Ms. Johnson!
I just wanted to document our phone conversation as well as I wanted you to have my contact information in case you
had any follow up questions or concerns.
As we discussed, you are one of the owners of the Jones' Grocery property at 1156 E Memorial Highway, Harmony, NC
and therefore authorized to sign the access agreement. Please let me know if that is not an accurate reflection of our
conversation.
Thank you, and I will keep you updated of the field work activities. Have a great day!
Ashleigh Thrash, P.G. I PROJECT MANAGER I ATC Associates of North Carolina, P.C.
Registered, SC
Office 704.529.3200 1 Direct 704.972.4087 1 Cell 980.369.0425
MOM ■
.9
7606 Whitehall Executive Center Drive Suite 800 1 Charlotte, NC 28271
ashleiclh.thrash(c�oneatlas.com I www.atcgroupservices.com
1

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