WI0400592_Notification of Intent (NOI) – GW Remediation_20230214

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: 2/14 , 20_23_ 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)
Air Injection Well .......................................
Complete sections B through F, J, M
(2)
Aquifer Test Well .......................................
Complete sections B through F, J, M
(3) X
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: Business/Organization
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): Beroth Oil Company
Mailing Address:
City: Pfafftown State: _NC_ Zip Code: 27040-0439 County: Forsyth
Day Tele No.:
EMAIL Address: kevin(a)berothoil.com
D. PROPERTY OWNER(S) (if different than well owner/applicant)
E.
F.
G.
Name and Title:
Company Name _
Mailing Address:
City:
Day Tele No.: _
EMAIL Address:
Cell No.:
Fax No.:
State: Zip Code: County:
Cell No.:
Fax No.:
PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Ryan D. Kerins, Project Manager
Company Name Terraquest Environmental Consultants, P.C.
Mailing Address: 100 E Ruffin St
City: Mebane State: NC_ Zip Code: 27302 County: Alamance
Day Tele No.: 9195639091
EMAIL Address: rdkerins(a,terraquestpc.com
PHYSICAL LOCATION OF WELL SITE
Cell No.: 9199060960
Fax No.: 9195639095
(1) Facility Name & Address: Four Brothers Food Store No. 208
4975 REYNOLDA ROAD
City: Winston-Salem County: Forsyth Zip Code: 27106
(2) Geographic Coordinates: Latitude": ° " or 36 0. 167540
Longitude": if or -80 0. 335961
Reference Datum: North American Datum of 1927 Accuracy: 1/2 of
a contour interval from actual elevation. and/or more than 1/40 of an inch
(0.6 mm) horizontally from actual position
Method of Collection: USGS 7.5 minute topo
TREATMENT AREA
Land surface area of contaminant plume: square feet
Land surface area of inj. well network: square feet (< 10,000 W for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 2

H.
I.
J.
K.
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:
This site has a gasoline UST release incident. It is regulated by the NCDWM-UST who has approved
the operation of an air sparge and SVE remediation system that has been active since April of 2015. Recently,
the NCDWM-UST has approved the use of Oxygen Biochem as a passive pour of the injectant into recovery
wells RW3 and RW4 that are not remediating as quick as desired. Semi-annual groundwater monitoring for
VOCs is ongoing. Terraquest will pour a 40 pound OBC to 20 gallon water mixture into each of RW3 and RW4
on a monthly basis for four months or as needed.
WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 2 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 29-50 feet BGS based on recent groundwater location
(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
INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division ofPublic Health, Department
of Health and Human Services can be injected. Approved injectants can be found online at
http:Hdeg.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 iyou wish to het 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: Oxygen Biochem Total Amt. to be injected (gal)/event: 40 gallons
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 (gal)/event:
Injectant_
Total Amt. to be injected (gal/event):
Total Amt. to be injected (gal)/event_
No. of separate injection events:4 Total Amt. to be injected (gal): 160
Source of Water (if applicable): munici
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.
Semi-annual ,groundwater monitoring for VOCs is currently in place and will continue.
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. "
Rvan D. Kerins
Signature of Applicant Print or Type Full Name and Title
Property Owner (if the property is not owned by the Well Owner/Applicant):
"As owner of the property on which the injection well(s) are to be constructed and operated, I hereby consent to
allow the applicant to construct each injection well as outlined in this application and agree that it shall be the
responsibility of the applicant to ensure that the injection wells) conform to the Well Construction Standards
(15A 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.
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

Subject: Delegation of Signature Authority
Four Brothers #208
Incident No. 30576
To Whom It May Concern:
This document serves to designate Terraquest Environmental Consultants, P.C. as an
authorized representative of Beroth Oil Company (Kevin Beroth) in the capacity of
signing necessary documents pertaining to the construction of the Corrective Action
Plan requested by the NCDWM-UST Section in an NORR dated November 29, 2011.
If you have any questions regarding this letter, please feel free to contact Ryan Kerins at
919-563-9091.
Sincerely,
���11112-
7Kevin Beroth Date(
Beroth Oil Company
Responsible Party

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SITE LOCATION MAP
FOUR BROTHERS ROOD
4975 REYNOLDA ROAD
WINSTON-SALEM, INC
BEROTH OIL COMPANY INC. WINSTON-SALEM, NC
PROJECT NO. 01205
DRAWN BY: RDK
DATE: 1/20/23
ENVIRONMENTAL CONSULTANTS, P.C.
SCALE: 1" = 2,000'
CHECKED BY: JRG
FIGURE NO. 1

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SITE VICINITY MAP
FOUR BROTHERS #208
4975 REYNOLDA ROAD
WINSTON-SALEM, NC
BEROTH OIL COMPANY INC.
WINSTON-SALEM, NC
PROJECT NO. 01205
DRAWN BY: JRc
DATE: 1/20/23
ENVIRONMENTAL CONSULTANTS, P.C.
SCALE: 1" - 400'
CHECKED BY: MUB
FIGURE NO. 2

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LEGEND
TYPE II MONITORING WELL
TYPE III MONITORING WELL
AIR SPARGE WELL
ABANDONED WELL LOCATION
® RECOVERY WELL
SVE WELL
O VACUUM WELL LOCATION
FORMER UST LEGEND
(all tanks removed)
T1 4,000 GAL. DIESEL
T2 2,000 GAL. KEROSENE
T3 10,000 GAL. GASOLINE
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GRAPHIC SCALE
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TYPE II MONITORING WELL
TYPE III MONITORING WELL
(11 ABANDONED WELL LOCATION
® RECOVERY WELL
The groundwater elevation as measured on
1/9/23 is listed in feet.
Data from the Type III monitoring wells MW5
and MW16 was not used in the construction
of this map.
The groundwater flow direction is indicated by
the arrows placed perpendicular to the
contour lines.
'Groun lwati� r
Well ID
Elevation (ft.)
1 r%q 1
66.54
MW4
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64.23
MW11
65.02
MW12
56.38
MW13
65.76
h4W14
65.42
MW15
67.60
N4W17
64.32
MW23
63.62
MW25
59.89
RW1
66.24
RW2
65.7'6
RW3
67.34
RW4
66.22
FORMER UST LEGEND
(all tanks removed)
T1 4,000 GAL. DIESEL
T2 2,000 GAL. KEROSENE
T3 10,000 GAL. GASOLINE
T4 10,000 GAL. GASOLINE
T5 10,000 GAL. GASOLINE
GRAPHIC SCALE
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SCALE: 1 " = 60'
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PRE SVE
ESTMATED EXTENT
OF STG MSCC
VIOLATION MW107
32AL MW�31
Y AL I FOUR BROTHERS
MW2 FOOD STORE
MW13 O
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RW2 -B24 B30 ® # 208 AC
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LEGEND
TYPE II MONITORING WELL
TYPE III MONITORING WELL
PHASE II ESA BORINGS
SITE CHECK BORINGS
- CSA BORINGS
NO STG MSCC OR TPH
ACTION LIMIT VIOLATIONS
STG MSCC OR TPH
ACTION LIMIT VIOLATIONS
Soil borings D1 and B1—B18 were
collected as part of a Phase II
Environmental Site Assessment.
Borings B1A, 38A, and 39A were
collected as part of site check
activities.
Soil samples from borings B19 —
B32 were collected as part of the
CSA. The CSA contains an
analytical summary Table 4 and the
full analytical report in Appendix D.
UST LEGEND
T1
4,000
GAL.
DIESEL
T2
2,000
GAL.
KEROSENE
T3
10,000
GAL.
GASOLINE
T4
10,000
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GASOLINE
T5
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GASOLINE
GRAPHIC SCALE
0' 10' 20' 40'
SCALE: 1 " = 20'
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LEGEND
D30 Soil sample location
UST LEGEND
T1 4,000 GAL. DIESEL
T2 2,000 GAL. KEROSENE
T3 10,000 GAL. GASOLINE
T4 10,000 GAL. GASOLINE
T5 10,000 GAL. GASOLINE
GRAPHIC SCALE
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SCALE: 1 " = 20'
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oil free
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MW2*
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ESTIMATED
EXTENT OF 2L
STANDARD -
VIOLATION
MW*
C-ontami nant of Concern
L L L C
o o _
C 9
Date
N O L Q N N N T a `
Sam Ie ID Collected m F z z
MW1 1/9/2023 17.5 1,110 586 3,840 44.7 <3.80 1,070 559 842 117
MW4 1/9/2023 <0.130 <0.410 <0.500 <1.60 <0.230 <0.190 <0.820 <1.40 <3.00 <0.690
MW5 1/9/2023 <0.130 <0.410 <0.500 <1.60 <0.230 <0.190 <0.820 <1.40 <3.00 <0.690
MW11 1/9/2023 <0.130 <0.410 <0.500 <1.60 <0.230 <0.190 <0.920 <1.40 <3.00 <0.690
MW12 1/9/2023 1,340 11,000 1,340 6,700 <23.0 <19.0 987 <140 838 154
MW13 1/9/2023 585 199 96.3 734 38.2 <0.950 270 59.9 150 24.1
MW14 1/9/2023 <0.130 <0.410 <0.500 <1.60 <0.230 <0.190 <0.920 <1.40 <3.00 <0.690
MW15 1/9/2023 638 3,920 1,400 7,280 19.8 <4.75 985 116 690 119
MW17 1/9/2023 0.897 <0.410 <0.500 2.35 <0.230 <0.190 3.38 <1.40 <3.00 1.33
MW23 HEATI NG OIL FREE PRODUCT NOT SAMPLED
MW25 1/9/2023 160 <0.410 <0.500 <1.60 <0.230 9.9 <0.920 <1.40 23 <0.690
RWl 1/9/2023 1,160 1,860 1,010 3,220 <2.30 <1.90 341 20.1 379 94.2
RW2 1/9/2023 0.235 <0.410 <0.500 <1.60 <0.230 <0.190 <0.920 <1.40 <3.00 <0.690
RW3 1/9/2023 891 2,290 537 3,210 50.3 <1.90 597 175 319 67.1
RW4 1/9/2023 4,310 2,090 286 2,040 103 < 3.80 361 68 282 21.9
PW3 1/9/2023 <0.130 <0.410 <0.500 <1.60 <0.230 <0.190 <0.920 <1.40 <3.00 <0.690
PW15 1/9/2023 <0.130 <0.410 <0.500 <1.60 <0.230 <0.190 <0.920 <1.40 <3.00 <0.690
21LStandard 1 600 600 500 0.02 0.40 400 40 6 70
Gross Contaminafion Levels 5,000 260,000 84,500 85,500 50 400 28,500 40,000 6,000 30,000
MW26�
Mw170 \MW16 />.WO�7111P"'o
WY
\MW1 A5 MW*
M 1�51 WM
W2 W eS3
ESTIMATED Mw
EXTENT OF
GCL VIOLATION
�9
� �90
\.
au��aarbt
LEGEND
TYPE II MONITORING WELL
TYPE III MONITORING WELL
AIR SPARGE WELL
ABANDONED WELL LOCATION
® RECOVERY WELL
Select groundwater analytical results for the
1/9/23 sampling event are listed in ug/L.
A complete summary of groundwater
analytical results is provided in Table 8 and
the full analytical report is provided in
Appendix D of the 1/2023 CAPR.
O 2L violations
O no 2L violations
O heating oil free product
GCL VIOLATION AS
i EDB AT RW3 AND
RW4 ONLY
FORMER UST LEGEND
(all tanks removed)
T1 4,000 GAL. DIESEL
T2 2,000 GAL. KEROSENE
T3 10,000 GAL. GASOLINE
T4 10,000 GAL. GASOLINE
T5 10,000 GAL. GASOLINE
GRAPHIC SCALE
0' 30' 60' 120'
SCALE: 1 " = 60'
U
z
w
J
00
O
(N
Q
(n
\
z
O
z
o
(�
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W
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w
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m
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\
\
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CC O J
m
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0 Z W
m
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)
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m
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iZ
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=
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w
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3II�

A
MW11 MW16 MW2 38A/MW1 MW15 MW7 9
DMW10 MW3 38A/MW1 MW12 REYNOLDA
9
MW8 D
LEGEND
SILTY CLAY (ML/CL)
�\ �\ medium stiff, red/orange clay
with little silt
SILT (ML)
soft to medium stiff orange/brown silt
z
O
v
Q
o
o
w
�
``
with some to little fine sand.
Few
U
00
mica present
w
oN O z
SAPROLITE
Ln
cn w
D
Q
white/yellowish brown, few gold
mica, few medium
V
w
coarse grained sand and trace
quartz gravel
O
� o Ca
�
o�
O
z
m�
m
O
r
EXTENT OF SOIL CONTAMINATION
O
(~n
m
ABOVE SOIL TO GROUNDWATER
r Z
Y
Z
MAXIMUM SOIL CONCENTRATION
O
U
CONCENTRATION
WELL ID DISPENSER
_
POTENTIOMETRIC SURFACE 1 MWGROUND SURFACE
MW52
O
U
0
�
TYLLJ
PE II MONITORING WELL
O
z
L
CASING
Q
d
LnZ
O
O
V7
O
Q
GRAPHIC SCALE
OUTER CASING-----
ASING 40'
HORIZONTAL: 1" =
J
0
O
z
-TYPE III MONITORING WELL
T
VERTICAL: 1 = 20
=
U
SCREEN 20'
0
Li
w
VERTICAL
o
Q
EXAGERATION X 2
m
a
15'
A
�MWI]
K-i
0' 20' 40'
T2�
it �B3 M
B6� �
B
Mwl4 B4�
B3i M gy' ICI I
z
AB30
B2B � -B29 •B18
81] •
W1/B W23 •
9q
28-
i4 i3 Bi 6 •Jy,�
B2 -9 B10 ett�1111 Al
Bl 14 15 MW6T i. waE
\ M y IS 13
�Y> � III'
��IIIIIII� III
.a

Table 7 MONITORING WELL CONSTRUCTION INFORMATION
Date: 1/30/23 Incident Name: Four Brothers 208 Incident No.: 30576 Facility ID No. 0-021926
Well ID
Date Installed
Date Water
Level
Measured
Well Casing
Depth (ft.
BGS)
Screened
Interval (x
toyft.
BGS)
Bottom of
Well (ft.
BGS)
Top of
Casing
Elevation
(ft.)
Depth to
Waterfrom
Top of
Casing (ft.)
Free
Product
Thickness
(ft.)
Groundwater
Elevation (ft.)
Comments AM-
MWI
8/25/2008
1/9/2023
15
15-40
40
96.07
29.53
0
66.54
2"-diameterType llmonitoring well
MW2
3/5/2009
15
15-40
40
95.20
2"-diameterType llmonitoring well
MW3
3/5/2009
15
15-40
40
95.87
2"-diameterType llmonitoring well
MW4
3/5/2009
1/9/2023
15
15-40
40
96.90
29.30
0
67.60
2"-diameter Type llmonitoringwell
MW5
8/23-24/10
1/9/2023
OC:50IC: 60
60-65
65
94.23
30.00
0
64.23
2"-diameter Type III monitoring well
MW6
8/23/2010
15
15-40
40
97.60
2"-diameterType llmonitoring well
MW7
8/24/2010
15
15-40
40
97.43
2"-diameterType llmonitoring well
MW8
8/24/2010
15
15-40
40
93.73
-
2"-diameterType llmonitoring well
MW9
8/24/2010
15
15-40
40
94.92
2"-diameterType llmonitoring well
MW10
8/24/2010
15
15-40
40
95.63
2"-diameterType llmonitoring well
MW11
8/24/2010
1/9/2023
15
15-40
40
94.12
29.10
0
65.02
2"-diameterType llmonitoring well
MW12
1/5/2011
1/9/2023
20
20-40
40
95.81
29.43
0
66.38
2"-diameterType llmonitoring well
MW13
1/5/2011
1/9/2023
20
20-40
40
94.01
28.25
0
65.76
2"-diameterType llmonitoring well
MW14
1/5/2011
1/9/2023
20
20-40
40
95.15
29.73
0
65.42
2"-diameterType llmonitoring well
MW15
1/5/2011
1/9/2023
20
20-40
40
96.50
28.90
0
67.60
2"-diameterType llmonitoring well
MW16
1/19/2011
OC:70IC: 80
80-85
85
94.39
2"-diameter Type III monitoring well
MW17
9/26/2011
1/9/2023
15
15-35
35
84.80
20.48
0
64.32
2"-diameterType llmonitoring well
MW18
9/26/2011
15
15-35
35
85.38
well destroyed
2"-diameter Type II monitoring well
MW19
9/26/2011
20
20-35
35
84.25
-
2"-diameterType llmonitoring well
MW20
9/26/2011
20
20-35
35
84.00
2"-diameterType llmonitoring well
MW21
3/22/2012
20
20-40
40
85.78
-
2"-diameterType llmonitoring well
MW22
3/22/2012
20
20-40
40
89.31
2"-diameterType llmonitoring well
MW23
8/27/2012
1/9/2023
15
15-35
35
83.77
22.20
2.8
63.62
2"-diameterType llmonitoring well
MW24
8/27/2012
15
15-35
35
83.88
2"-diameterType llmonitoring well
MW25
8/27/2012
1/9/2023
15
15-35
35
81.39
21.50
0
59.89
2"-diameterType llmonitoring well
MW26
8/27/2012
15
15-35
35
82.65
2"-diameterType llmonitoring well
MW27
8/28/2012
3
3-23
23
60.94
2"-diameterType llmonitoring well
MW28
8/28/2012
5
5-25
25
63.90
2"-diameterType llmonitoring well
RW1
1/21/2013
1/9/2023
20
20-50
50
95.28
29.04
0
66.24
4"-diameter groundwater recovery well
RW2
1/21/2013
1/9/2023
20
20-50
50
95.06
29.30
0
65.76
4"-diameter groundwater recovery well
RW3
1/21/2013
1/9/2023
20
20-50
50
96.29
28.95
0
67.34
4"-diameter groundwater recovery well
RW4
3/19/2014
1/9/2023
20
20-50
50
95.84
29.62
0
66.22
4"-diameter groundwater recovery well
RW5
3/19/2014
20
20-50
50
96.09
4"-diameter groundwater recovery well
AS1
1/22/2013
50
50-55
55
96.67
1"-diameter air sparge well
AS2
1/13/2015
48
48-53
53
95.16
-
-
-
1"-diameter air sparge well
AS3
1/13/2015
48
48-53
53
94.82
1"-diameter air sparge well
AS4
1/15/2015
48
48-53
53
95.92
-
-
-
1"-diameter air sparge well
AS5
1/15/2015
48
48-53
53
96.42
1"-diameter air sparge well
AS6
1/15/2015
48
48-53
53
96.82
-
-
-
1"-diameter air sparge well
AS7
7/23/2020
50
50-55
55
1"-diameter air sparge well
AS8
4/11/2022
40
40-45
45
96.21
-
-
-
1"-diameter air sparge well
AS9
4/11/2022
40
40-45
45
94.22
1"-diameter air sparge well
SVE1
1/22/2013
5
5-30
30
95.52
-
-
-
2"-diameter soil vapor extraction well
SVE2
1/22/2013
5
5-30
30
95.66
2"-diameter soil vapor extraction well
SVE3
1/14/2015
5
5-30
30
96.08
-
-
-
2"-diameter soil vapor extraction well
SVE4
1/14/2015
5
5-30
30
96.12
2"-diameter soil vapor extraction well
SVES
1/14/2015
5
5-30
30
95.88
-
-
-
2"-diameter soil vapor extraction well
SVE6
1/16/2015
5
5-30
30
96.38
2"-diameter soil vapor extraction well
SVE7
1/16/2015
5
5-30
30
96.38
-
-
-
2"-diameter soil vapor extraction well
SVE8
1/16/2015
5
5-30
30
96.28
2"-diameter soil vapor extraction well
SVE9
1/16/2015
5
5-30
30
96.56
-
-
-
2"-diameter soil vapor extraction well
SVE10
1/16/2015
5
5-30
30
96.52
2"-diameter soil vapor extraction well
SVE11
1/16/2015
5
5-30
30
96.50
-
-
-
2"-diameter soil vapor extraction well
SVE12
1/16/2015
5
5-30
30
96.58
2"-diameter soil vapor extraction well
SVE13
1/19/2015
5
5-30
30
97.04
-
-
-
2"-diameter soil vapor extraction well
SVE14
1/19/2015
5
5-30
30
96.86
2"-diameter soil vapor extraction well
SVE15
1/19/2015
5
5-30
30
96.76
-
-
-
2"-diameter soil vapor extraction well
SVE16
1/19/2015
5
5-30
30
96.62
2"-diameter soil vapor extraction well
SVE17
1/19/2015
5
5-30
30
96.84
-
-
-
2"-diameter soil vapor extraction well
SVE18
1/19/2015
5
5-30
30
96.46
2"-diameter soil vapor extraction well
SVE19
1/19/2015
5
5-30
30
96.40
-
-
-
2"-diameter soil vapor extraction well
Notes:
1. All units in feet.
2. IC and OC refer to the inner and outercasings of the Type III well.
3. Existing well elevations were surveyed on September 17, 2012 by William Franklin Tatum of McAnally Land Surveying. Subsequent surveying by Terraquest.
4. Groundwater elevation for wells containing free product corrected as follows: groundwater elevation + 0.7305 *product thickness).

a
NONRESIDENTIAL ON ESIDE*NTIAL WELL CONSTRUCTION RECORD
North Carolina Department of Enviromnent and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION g 3329
1. WELL CONTRACTOR:
Nick Perry
Well Contractor (Individual) Name
TerraQuest Environmental Cons
Well Contractor Company Name
100 E Ruffin St.
Street Address
Mebane NC 27302
City or Town State Zip Code
9t 19 ) 563-9091
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMIT#
OTHER ASSOCIATED PERMIT#(if applicable)
SITE WELL ID #(if applicable) RW3
3. WELL USE (Check One Box) Monitoring L/ Municlpal(Public ❑
IndustriallCommercial ❑ Agricultural ❑ Recovery 6(Injection ❑
Irrigationo Other ❑ (list use)
DATE DRILLED 1 /21 113
4. WELL LOCATION:
7975 Revnclda Rd.
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: Winston-Salem COUNTY Forsvth
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
❑Slope ❑Valley ❑Flat ❑Ridge ❑Other
LATITUDE 36 "DMS OR 36.1674 DO
LONGITUDE 75 " DMS OR 80.3360 DO
Latitude/longitude source: ❑GPS (6Topographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
S. FACILITY (Name of the business where the well is located.)
FR#208
Facility Name Facility ID# (if applicable)
7A75 RPynnidn Rd
Street Address
Winston-SaIPm NC In
City or Town State Zip Code
Kevin 6aroth
Contact Name
P O RDx 4089
Mailing Address
Winston-Salem NC In 97115
Cityor Town State Zip Code
(336.8 757-7600
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 50'
b. DOES WELL REPLACE EXISTING WELL? YES ❑ NO G(
c. WATER LEVEL Below Top of Casing: 30.16' FT.
(Use "+" If Above Top of Casing)
d. TOP OF CASING IS 0' FT. Above Land Surface'
*Top of casing terminated atlor below land surface may require
a variance in accordance
with I6A NCAC 2C .0118.
e. YIELD (gpm):
METHOD OF TEST
I. DISINFECTION: Type
Amount
: g. WATER ZONES (depth):
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom
Top Bottom -
Thickness/
7. CASING: Depth
Diameter Weight Material
Top 0 Bottom 20'
Ft. 4 in. sch 40 PVC
Top Bottom
Ft.
Top Bottom
Ft.
8. GROUT: Depth
Material Method
Top 0 Bottom 16'
Ft. Portland Pour
Top 16 Bottom 18'
Ft. Bentonite Pour
Top Bottom
Ft.
9. SCREEN: Depth
Diameter Slot Size Material
Top 20' Bottom 60' Ft. 41n in
Top
Bottom
Ft.
In.
Top
Bottom
Ft.
—In.
10. SAND/GRAVEL PACK:
Depth
Size
Top 18
Bottom 50'
Ft.
coarse
Top
Bottom
Ft.
Top
Bottom
Ft.
11. DRILLING LOG
.010 In. PVC
in.
_ In.
Material
Sand
Top Bottom Formation Description
0 / 50,
/
: 12. REMARKS
SILT
IDtl - �ERTIFYTHATTHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
15A2 NELL CONSTRUCT ION STANDARDS, AND THAT A COPY OF THIS
REH ZE
VIDEDTO THE WELL OWNER.
RTIFIED WELL CONTRACTOR DATE
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Submit within 30 days of completion to: Division of Water Quality Information Processing, Form /09
y p tY " 9 Rev. 2/09
1617 Mail Service Center, Raleigh, NC 27699.161, Phone : [phone]

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This foot can be used for single or multiple wells
1. Well Contractor Information:
NICK PERRY
14. 9ATER ZONES
FROM
TO
DESCRIPTION
Well Contractor Name
R.
ft.
3329
ft.
I ft.
NC Well Contractor Certification Number
15. OUTER CASING fornmlti-cased wells OR LINER ifa licable
FROST TO nIASIETER FTHICKNESS SATERIAL
Terraquest Environmental Consultants, P.C.
ft.
rt. in.
Company Nance
'16. INNER CASING OR I Zenthcrnirs
dosed -loot
FROST
Fro
DIAMETER
THICKNESS
I MATERIAL
2. Well Construction Permit #:
ft.
R.
in.
List all applicable yell pararils p.e. County, Slate, Parlance, LJecHon, eleJ
ft.
ff.
rn
3. Well Use (check well use):
17. SCREEN
Water Supply Well:
FROM
TO
DLIMETER
SLOTSIZE
THICKNESS
MATERIAL
DAgricullural ❑Municipal/Public
1T R-
47' R-
4in in'
0.010
SCh40
PVC
OGeothermal (HeatinglCooling Supply) DResidentiaRVater Supply sm le
ft. I
ft.
In.
OlndustriaVCommercial DResidentiaRVater Supply (shared)
-18. GROUT
FROM I TO I MATERIAL EMPLACEMENT METHOD k AMOUNT
❑Irrigation
0' R'
13' R-
Portland
Pour
Non -Water Supply Well:
13' IT-
15' R•
Bentonite
Pour
VINonitoring ORecovery,
Injection Well:
R.
ft.
DAquifer Recharge OGroundwnter Remediadon
19. SAND/GRAVE
ifa licable
OAquifer Storage and Recovery []Salinity Barrier
FROST
TO
MATERIAL
ESIPIACCSIENTMETHOT,LPACR
15' f`•
47' fL
No.2 Sand
Pour
OAquifer Test OStormwuter Drainage
tr
H
OExperimental Technology ❑Subsidence Control
20. DRILLING
LOG ostoselissulditionatsheetsifine,essa
OGeothennal(Closed Loop) OT'racer
FROSI
TO
DESCRIPTIOYcolor,kardness, soiVruck type,golinsize, etc
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)
0' ft.
0.5, ft.
CONCRETE
3/19/14 RW4
4. Date
0.5' FT-
47' D.
SILT
Well(s) Completed: Well ID#
ft.
R.
5a. Well Location:
ft.
ft.
FB #208 0-021926
R.
11.
Facility/Owner Name Facility Ing(ifappiicable)
ft
ft.
4975 Reynolda Road, Winston-Salem 27106
R.
D.
Physical Address, City. and Zip
21. REMARKS
Forsyth 6808-52-7509
County Parcel Identification No. (PIN)
SIT. Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22. C
iB
tion:
(ifivell field, one latnong is sufficient)
36.2163 80.4960
3120(14
N W
Signam. ofCerf tad } Contractor Date
6. Is (are) the n'ell(s): lZPermanent or OTemporary
By sign Ing list, hereby cerq&Thal file rrelf(s) mar (mere) constructed In accordance
isillt /5A NCAC 01C.0100 or l5A NCAC 02C.0200 I4ell Casfrnmtio,,Standards and llmf o
7. Is this a repair to An existing well: Dyes or ONo
ropy ofihis record hers been procidedta the mell mvner.
If this is a repair,fill otit iiimrn ice// cotulraction information mid e.vplahi the moire oflite
repair raider 921 remarks section or on the bacAoflhis form.
23. Site diagram or additional well details:
1
You may use the back of this page to provide additional well site details or well
S. Number of wells constructed:
construction details. You may also attach additional pages if necessary.
Formalople fnecdas or nosn-irabersap,4, cells ON1.Ymith the sense construction, )va curt
submit rate form
SUBMITTAL INSTUCTIONS
r
9. Total well depth below land surface: 7 (ft)
24a. For All Wells: Submit this form within 30 days of completion of well
For andfiplenellslist all depths ifdierenf(eranrple- 3rCi200'anl2rQi100)
construction to the following:
10. Static water level below top of casing: 28.85' (ft.)
Division of Water Resources, Information Processing Unit,
Ifireau lerel is above casing sae "+"
1617 \Mail Service Center, Raleigh, NC 27699-1617
11. Borehole diameter: S (in.)
24b. For Infection Wells ONLY: In addition to sending the form to the address in
Solid -Stem Au 9 (?r
24a above, also submit a copy of this form within 30 days of completion of well
12. Well construction method:
constmclion to the following:
(l.e. auger, rotary, cable, direct push, etc.)
Division of Water Resources, Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Nall Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection Wells:
13a. ]'field (gam) Method of test:
Also submit one copy of this form within 30 days of completion of
13b. Disinfection type: Amount:
well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Departrnent ofEmvonnxnt and
Natural Resources -Division of Water Resources Revised August 2013

REDOX TECH, LLC 06
"Providing Innovative In Situ Soil and Groundwater Treatment"
Material Safety Data Sheet — Oxygen BioChem
1. Identification
Product identifier Oxygen Biochem (OBC)TM
Other means of identification Not available.
Recommended use Oxygen Biochem (OBC)TM is used to promote chemical oxidation and aerobic bioremediation of
petroleum compounds in groundwater.
Recommended restrictions 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
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
Category 4
Skin corrosion/irritation
Category 2
Serious eye damage/eye irritation
Category 2
Sensitization, respiratory
Category 1
Sensitization, skin
Category 1
Specific target organ toxicity, single exposure Category 3 respiratory tract irritation
Not classified.
� r
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.
Prevention 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.
Response 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.
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Storage
Store in a well -ventilated place. Keep container tightly closed. Store locked up.
Disposal
Dispose of contents/container in accordance with local/regional/national/international regulations.
Hazard(s) not otherwise
None known.
classified (HNOC)
3. Composition/information
on ingredients
Mixtures
Chemical name
CAS number %
Sodium persulfate
7775-27-1 70 - 90
Calcium peroxide
1305-79-9 10 - 20
Composition comments
All concentrations are in percent by weight unless ingredient is a gas. Gas concentrations are in
percent by volume.
4. First -aid measures
Inhalation
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.
Skin contact
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.
Eye contact
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.
Ingestion
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.
Most important
May cause redness and pain. Symptoms may include coughing, difficulty breathing and shortness
symptoms/effects, acute and
of breath.
delayed
Indication of immediate
Provide general supportive measures and treat symptomatically.
medical attention and special
treatment needed
General information
Ensure that medical personnel are aware of the material(s) involved, and take precautions to
protect themselves.
5. Fire -fighting measures
Suitable extinguishing media
Water fog. Foam. Dry chemical powder. Carbon dioxide (CO2).
Unsuitable extinguishing None known.
media
Specific hazards arising from Contact with combustible material may cause fire.
the chemical
Special protective equipment Self-contained breathing apparatus and full protective clothing must be worn in case of fire.
and precautions for firefighters
Fire -fighting In the event of fire, cool tanks with water spray.
equipment/instructions
General fire hazards May intensify fire; oxidizer
6. Accidental release measures
Personal precautions, Keep unnecessary personnel away. Keep people away from and upwind of spill/leak. Wear
protective equipment and appropriate protective equipment and clothing during clean-up. Do not touch damaged containers
emergency procedures 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.
Methods and materials for Stop the flow of material, if this is without risk. Prevent entry into waterways, sewer, basements or
containment and cleaning up confined areas. Following product recovery, flush area with water. For waste disposal, see Section
13 of the SDS.
Environmental precautions Avoid discharge into drains, water courses or onto the ground.
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7. Handling and storage
Precautions for safe handling 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.
Conditions for safe storage, Store in original tightly closed container. Store away from incompatible materials (See Section 10).
including any incompatibilities Keep locked up.
8. Exposure controls/personal protection
Occupational exposure limits
US. ACGIH Threshold Limit Values
Components
Type
Value
Sodium persulfate (CAS TWA 0.1 mg/m3
7775-27-1)
Biological limit values No biological exposure limits noted for the ingredient(s).
Appropriate engineering Observe occupational exposure limits and minimize the risk of exposure. Ensure adequate
controls ventilation, especially in confined areas.
Individual protection measures, such as personal protective equipment
Eye/face protection Wear safety glasses with side shields (or goggles).
Skin protection
Hand protection Wear protective gloves.
Other
Neoprene or rubber gloves are recommended. Apron and long sleeves are recommended.
Respiratory protection
In the case of respirable dust, use self-contained breathing apparatus. Wear positive pressure
self-contained breathing apparatus (SCBA).
Thermal hazards
Wear appropriate thermal protective clothing, when necessary.
General hygiene
Always observe good personal hygiene measures, such as washing after handling the material
considerations
and before eating, drinking, and/or smoking. Routinely wash work clothing and protective
equipment to remove contaminants.
9. Physical and chemical properties
Appearance
Off-white, granular solid.
Physical state
Solid.
Form
Solid.
Color
Off-white.
Odor
Odorless.
Odor threshold
Not available.
pH
Melting point/freezing point
Initial boiling point and boiling
range
Flash point
Evaporation rate
11.7±0.4 (1-40% solution, slurry)
Not available.
Not applicable.
Not available.
Not available.
Flammability (solid, gas) Not available.
Upper/lower flammability or explosive limits
Flammability limit - lower Not available.
(%)
Flammability limit - upper Not available.
(%)
Explosive limit - lower (%) Not available.
Explosive limit - upper (%) Not available.
Vapor pressure
Vapor density
Relative density
Not applicable.
Not applicable.
2.76±0.16 (25°C)
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Solubility(ies)
Solubility (water)
Soluble in water.
Partition coefficient
Not available.
(n-octanol/water)
Auto -ignition temperature
Not available.
Decomposition temperature
Not available.
Viscosity
Not available.
Other information
Oxidizing properties
Oxidizing.
10. Stability and reactivity
Reactivity The product is stable and non -reactive under normal conditions of use, storage and transport.
Chemical stability Material is stable under normal conditions.
Possibility of hazardous No dangerous reaction known under conditions of normal use.
reactions
Conditions to avoid Contact with combustibles.
Incompatible materials Combustible material. Oxidizing material. Reducing agents.
Hazardous decomposition No hazardous decomposition products are known.
products
11. Toxicological information
Information on likely routes of exposure
Ingestion
Harmful if swallowed.
Inhalation
May cause irritation to the respiratory system.
Skin contact
Causes skin irritation.
Eye contact
Causes serious eye irritation.
Symptoms related to the
May cause redness and pain. Exposed individuals may experience eye tearing, redness, and
physical, chemical and
discomfort. Symptoms may include coughing, difficulty breathing and shortness of breath.
toxicological characteristics
Information on toxicological effects
Acute toxicity
Harmful if swallowed.
Skin corrosion/irritation
Causes skin irritation.
Serious eye damage/eye
Causes serious eye irritation.
irritation
Respiratory or skin sensitization
Respiratory sensitization
May cause allergy or asthma symptoms or breathing difficulties if inhaled.
Skin sensitization
May cause an allergic skin reaction.
Germ cell mutagenicity
No data available.
Carcinogenicity
This product is not considered to be a carcinogen by IARC, ACGIH, NTP, or OSHA.
Reproductive toxicity
No data available.
Specific target organ toxicity -
May cause respiratory irritation.
single exposure
Specific target organ toxicity -
No data available.
repeated exposure
Aspiration hazard
Not applicable.
Chronic effects
Prolonged exposure may cause chronic effects.
Further information
No data available.
12. Ecological information
Ecotoxicity 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.
Persistence and degradability No data is available on the degradability of this product.
Bioaccumulative potential No data available for this product.
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Mobility in soil Not available.
Other adverse effects 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, I135, 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.
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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
Revision date
Version #
Further information
NFPA Ratings
09-May-2014
01
HMIS® is a registered trade and service mark of the NPCA.
List of abbreviations NFPA: National Fire Protection Association.
References Registry of Toxic Effects of Chemical Substances (RTECS)
HSDB® - Hazardous Substances Data Bank
Disclaimer 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 SIDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 7/7