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Home My WebLink AboutNon-MicrobialRiskAssessmentForm--Rev-11-25-2019- Summary of Evaluation Permit Number of Site (if applicable): WI_______________________ Name(s) of Additives/Product(s)* to be reviewed: ______________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________ Please provide a brief overview of the referenced additive(s), the targeted contaminates, and the remediation process:_________________________________________________________________________________ _______________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________ FOR THE BELOW, provide direct responses to each of the following items. Failure to do so may result in an automatic denial of approval from North Carolina Department of Health and Human Services (DHHS) Required General Information Division of Water Resources (DWR) UIC Program contact person and phone number. Current or future use of site with site contact person, address (including physical address of site, if applicable), email address, and phone number. Contractor applying product, contact person, address, email address, and phone number. Distance and likelihood of impact to public or private wells used for drinking, industrial processes, cooling, agriculture, etc. Is area served by public water supply? If the request is not site-specific, provide evidence showing the potential extent of impacts from injection of this product. Verification must be provided by the appropriate Regional Office of the Public Water Supply Section. General description of the contaminants if present in the soil and/or groundwater at the site. If products are unknown, list the contaminants for which the product is intended to remediate. Name, approximate distance, and likelihood of impact to the nearest body of surface water to the site. Approximate distance to nearest residence(s) and workplace. Required Product/Process-Specific Information Product manufacturer name, address, phone number, and contact person’s phone and email address. Identity of specific ingredients* (including CAS#) and concentrations of ingredients contained in the product and purpose of each. Documentation from authoritative technical references on the contaminants or class of contaminants the product can remediate. Provide a brief summary of the mechanism in which the product will remediate these contaminants, listing degradation products and byproducts of remediation. Approximate concentration of each ingredient following release into groundwater or soil. Approximate groundwater concentration of each ingredient after pumping or recovery (if applicable). If the product is expected to discharge to a nearby surface water, approximate concentrations of product in the water. Documentation from authoritative technical references on what additional injectants are anticipated to be injected with this product. Please provide specific ingredients of these injectants. Documentation from authoritative technical references of specific degradation products, other injectants (if applicable), and byproducts of remediation expected (provide a brief summary of the referenced material as well as a copy of the referenced material.). If degradation products are unknown, list the degradation products for the contaminants for which the injectant is intended to remediate. Documentation from authoritative technical references of expected migratory potential of specific ingredients, other injectants (if applicable), byproducts of remediation, and degradation products in soil and groundwater. Be specific to the conditions in which migration will occur (provide a brief summary of the referenced material as well as a copy of the referenced material). Documentation from authoritative technical references of expected half-lives of specific ingredients, other injectants (if applicable), byproducts of remediation, and degradation products in soil and groundwater. Be specific to the conditions in which these half-lives occur. Complete description of the use of the product at the site. Mail two copies of the risk assessment package (with attached CD or flash drive) along with any relevant documentation including MSDS sheets and product information to the UIC Program contact person at the following address: DIVISION OF WATER RESOURCES UIC PROGRAM 1636 MAIL SERVICE CENTER RALEIGH, NC 27699-1636 TELEPHONE (919) 707-9000 *If the composition of the proposed injected fluid is considered a trade secret and needs to be treated as confidential, please submit the confidential information clearly labeled as confidential. In addition, include a letter identifying the confidential information and stating why the information should be processed as confidential. All information warranting protection as a trade secret will be kept from public disclosure in accordance with G.S. 132-1.2. and 15A NCAC 2C .0211(g).