WQ0028785_Monitoring (Report)_20120925

(VYATC
ATC ASSOCIATES OF NORTH CAROLINA, P.C.
Engineering Individual Solutions
September 25, 2012
Mr. Thomas Slusser
State of North Carolina
Department of Environment and Natural Resources
Division of Water Quality
Aquifer Protection Section-UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
RE: Interim Injection Report
Injection Permit WI0400175
Circle K Store #4358 (RM&R #4109)
2121 W. Clemmonsville Road
Winston-Salem, Forsyth County, North Carolina
ATC Project No. 45.75118.4109
Dear Mr. Slusser:
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcassociates.com
N.C. Engineering License No. C-1598
ATC Associates of North Carolina, P.C. (ATC) is pleased to submit this Interim Injection Evaluation
Report to document the results of remediation injection activities completed at the above referenced site.
The following sections document background information, injection activities, pre -injection and post -
injection groundwater analytical data, and ATC's conclusions. ATC is also enclosing a Groundwater
Monitoring Report which further documents sampling events conducted on May 29, June 26 and July 26,
2012.
1.0 BACKGROUND
Circle K Store #4358 (Facility ID No. 0-05075) is a convenience store and retail gasoline sales facility.
The site is located at 2121 West Clemmonsville Road in Winston-Salem, North Carolina. A site map has
been provided as Figure 1. The site consists of a single -concrete building/convenience store and an
underground storage tank (UST) system. The UST system consists of one 8,000-gallon gasoline UST,
two 10,000-gallon unleaded gasoline USTs, two dispensers, and associated piping and vent lines.
On February 4, 2004, ATC collected soil and groundwater samples for a Due Diligence Investigation for
Couche Tard/Circle K. The soil samples were analyzed for Total Petroleum Hydrocarbons (TPH)
gasoline range organics (GRO) and TPH diesel range organics (DRO) by EPA Method 8015. The soil
analytical results indicated elevated concentration levels of TPH-GRO and TPH-DRO. Groundwater
concentrations of methyl tertiary butyl ether (MTBE) were also detected above laboratory detection
limits. The North Carolina Department of Environment and Natural Resources (NCDENR) issued a
Notice of Regulatory Requirements (NORR) on March 25, 2004, requesting the preparation of a Site
Check Report based on the results of the Due Diligence Investigation.
In April 2004, ATC collected additional soil samples around the UST system as part of the Site Check. A
total of fourteen soil borings were collected and submitted for laboratory analysis for TPH GRO and TPH
DRO to a certified laboratory. According to the laboratory analytical data, TPH was detected in the soil

Interim Injection Report September 25, 2012
Circle K Store #4358 (RM #4109) ATC Project No. 45.75118.4109
borings above NCDENR Action Levels. Based upon the Site Check findings, NCDENR requested
additional soil borings in closer proximity to the UST system.
A Site Check Addendum Report dated August 20, 2004, was submitted to NCDENR documenting the
results of the additional soil sampling activities. The soil analytical results indicated TPH DRO was
detected in one boring above NCDENR TPH Action levels. NCDENR authorized ATC to perform a
Limited Site Assessment (LSA) to delineate the extent of impacted soil and groundwater at the site.
ATC submitted an LSA on September 22, 2005. During the assessment, ATC identified fourteen water
supply wells within the site vicinity; however, all of the properties were connected to a municipal water
supply. Soil analytical results indicated no chemicals exceeded Soil -to -Groundwater Maximum Soil
Contaminant Concentrations (MSCCs) but groundwater exceeded NCAC 2L Groundwater Quality
Standards (2L Standard).
In 2007 ConocoPhillips retained Delta Environmental Consultants of NC, Inc. (Delta) to continue
environmental services at the site. Delta submitted a Groundwater Monitoring Report with updated
supply well surveys on November 7, 2007. In the report, Delta identified 14 water supply wells located
within 1,000 feet of the site (five water supply wells were located within 250 feet of the site). Of the 14
water supply wells only one well (Frye residence) was still active and used for irrigation purposes. On
July 15, 2008, NCDENR issued a NORR requesting the preparation of a Comprehensive Site Assessment
(CSA).
During CSA activities, Delta conducted soil and groundwater sampling. Based on laboratory results soil
contamination appeared to be horizontally and vertically defined and groundwater contamination
appeared to be vertically defined. The horizontal groundwater plume is not defined up gradient of the
site. It should be noted that up gradient of the site is former Cardinal 76 Service Center which had a
confirmed release in the past (NCDENR Incident #16468). Delta recommended researching the Cardinal
76 Service Center release to determine if it had impacted the site. Delta also recommended evaluating for
natural attenuation processes at the site. Delta submitted a CSA on March 19, 2009, and a CSA
Addendum on July 24, 2009.
On December 30, 2009, and July 26, 2010, Delta submitted groundwater monitoring reports documenting
field activities and groundwater sampling results. On August 6, 2010, NCDENR issued a NORR
requesting the preparation of a Corrective Action Plan (CAP). Delta reviewed remedial options for the
site and subsequently submitted a UIC Injection Permit Application on February 3, 2011, for the injection
of a magnesium sulfate solution to enhance biodegradation. In response to the application, Injection
Permit W10400175 was issued on April 21, 2011.
In April 2011, ATC was awarded the ConocoPhillips (now Phillips 66 Company) contract to perform
environmental consulting services at the site. This report documents two injection events at the site (June
2011 and April 2012) and a summary of the groundwater sampling events and laboratory analytical
results from sampling events conducted in May, July, August, September, and December 2011, and May,
June, and July 2012.
2.0 FIELD ACTIVITIES
2.1 Injection Well Installation
From May 23 through 25, 2011, ATC installed six permanent monitoring injection wells (IW-1 through
IW-6). Well locations are shown on the site map, Figure 1. Boring logs and well construction records
are attached in Appendix A.

Interim Injection Report September 25, 2012
Circle K Store #4358 (RM #4109) ATC Project No. 45.75118.4109
2.2 Pre -Injection Sampling
The approved monitoring schedule of injection permit WI0400175 requires sampling of wells MW-1
through MW-4, MW-5D, MW-6 through MW-8, and MW-9D before the initial injection event. Per this
approved schedule, ATC collected groundwater samples from monitoring wells MW-1 through MW-4,
MW-5D, MW-6 through MW-8, and MW-913 on May 18, 2011. The samples were collected using
laboratory provided sample containers and placed in ice -filled coolers for shipment to Accutest
Laboratories, Inc. (Accutest) under chain -of -custody protocol. The samples were analyzed for volatile
organic compounds by EPA Method 6200B and for volatile petroleum hydrocarbons (VPH) by the
Massachusetts Department of Environmental Protection (MADEP) Method, sulfate via ASTM D516-90,
total sulfide by Standard Method SM4500, ferrous iron by Standard Method SM3500, and nitrate by SM
4500. Dissolved oxygen, oxidation-reduction potential, pH, temperature, and specific conductance were
measured in the field utilizing calibrated field equipment. A summary of groundwater analytical data
specifically related to the injection permit requirements is presented in Table 1. Monitoring well
locations are shown on Figure 1.
2.3 Injection Activities
On June 2, 2011, ATC supervised Redox Tech, LLC during the initial injection event at the site. A total
of 660 gallons of magnesium sulfate solution (20 weight percent) was injected at the site. Gravity feed
was used to introduce injectate to wells IW-1 through IW-6. Wells IW-5 and IW-6 were injected
simultaneously, as were wells IW-2 and IW-3. Wells IW-1 and IW-4 were injected individually. A
volume of 110 gallons of injectate was introduced into each of the six wells utilized during this injection
event. An Injection Event Record was submitted to NCDENR on June 27, 2011, documenting the
injection activities. Injection well locations are shown on Figure 1.
On April 25, 2012, ATC supervised Redox Tech, LLC during the second injection event at the site. A
total of 678 gallons of magnesium sulfate solution (20 weight percent) was injected at the site. Initially,
injectate was introduced to wells IW-4 through IW-6 as a group via gravity feed. Because this yielded
low flow rates, the solution was introduced by a pump operating at a pressure of 15 pounds per square
inch (psi). This yielded favorable flow rates and continued to inject 113 gallons of solution into each
well. Similarly, wells IW-1 through IW-3 were initially gravity fed before switching to the introduction
of solution by pump, also operating at 15 psi. A total of 112 gallons were injected into wells IW-1
through IW-3. An Injection Event Record was submitted to NCDENR on May 1, 2012, documenting the
injection activities.
2.4 Post -Injection Sampling
In accordance with the approved monitoring schedule, ATC sampled wells MW-1 through MW-4, MW-
5D, MW-6 through MW-8, and MW-9D on a monthly basis for the first quarter after the first injection
event followed by a quarterly sampling event. Per the approved schedule, ATC performed post -injection
sampling events on July 7, 2011, August 8, 2011, September 13, 2011 and December 28, 2011.
After the second injection event in April 2012, ATC sampled wells MW-1 through MW-4, MW-5D, MW-6
through MW-8, and MW-9D on May 29, 2012, June 26, 2012, and July 26, 2012.
During each sampling event, field measurements of temperature, dissolved oxygen, ORP, pH and specific
conductivity were collected using a calibrated water quality meter to assure sampling of representative
formation water. The laboratory samples from the July 7, 2011, and the August 8, 2011, sampling events
were entered into chain -of -custody, placed in an ice filled cooler, and shipped to Accutest. The laboratory
samples from the September 13, 2011, December 28, 2011, May 29, 2012, June 26, 2012, and July 26, 2012,
were entered into chain -of -custody, placed in an ice filled cooler, and shipped to Lancaster Laboratories. The

Interim Injection Report September 25, 2012
Circle K Store #4358 (RM #4109) ATC Project No. 45.75118.4109
groundwater samples were analyzed for VOCs by EPA Method 6200B, VPH by the MADEP Method.
sulfate via ASTM D516-90, total sulfide by Standard Method SM4500, ferrous iron by Standard Method
SM3500, and nitrate by SM 4500. A summary of groundwater analytical data specifically related to the
injection permit requirements is presented in Table 1. Monitoring well locations are shown on Figure 1.
A summary of the sampling results is provided as Table 1. Full analytical data tables, groundwater
elevation contour maps, isoconcentration contour maps (benzene, MTBE, and additional chemicals of
concern), and complete analytical laboratory reports are provided in the enclosed Groundwater
Monitoring Report.
3.0 INJECTION EFFECTIVENESS EVALUATION
Injections at the site have generally shown to be effective in reducing concentrations of chemicals of
concern in most monitoring wells. The additional of magnesium sulfate has enhanced the natural
degradation of the petroleum hydrocarbon compounds. Elevated sulfate concentrations are evident in the
majority of monitoring wells following an injection event, indicative of injectate material moving through
the water bearing formation. Increased dissolved oxygen levels further indicate the effectiveness of the
injection events at promoting natural attenuation at the site.
This discussion is representative of analytical data from samples collected prior to and following the June
2011 injection event and following the April 2012 injection event. Further discussion of the monitoring
events is provided in the enclosed Groundwater Monitoring Report. The third injection event is currently
postponed pending evaluation of the site risk by the NCDENR UST Section. ATC will inform the UIC
Group if the third injection is performed.
If you have any questions or require any additional information, please do not hesitate to contact us at
[phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Corey . cheip Gabriel Araos, P.E. e 0�f
�� rre�o�e;y�
'Z
Staff Scientist Senior Project Manager
Attachments: Table 1 — Summary of Analytical Data for Groundwater
Figure 1 — Site Map
Appendix A — Boring Logs and Well Construction Records
cc: Mr. Ed Kuhn, contact for Phillips 66 Company
G
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F � 022569i
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TABLES

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NOTES: TITLE FIGURE 1
SITE MAP
CIRCLE K STORE #4358 (RM&R 4109) (:V?ATC
2121 WEST CLEMMONSVILLE ROAD AMS&sh>idtelstff*0 CarbINcGP.C.
WINSTON-SALEM, NORTH CAROLINA Raleigh, North Carolina 27604 [phone] FAX [phone]
CAD FILE TYPE CODE PREP. BY REV. BY SCALE DATE PROJECT NO.
1253730.DWG AW GA 1" = 40' k-18-20121 45.75118.4109

APPENDIX A
BORING LOGS AND WELL CONSTRUCTION RECORDS

North Carolina Department of Environment and Natural Resources-Divisionv[
WELL CONTRACTOR CERTIFICATION # 2345
1.WELL CONTRACTOR:
MARKGBTY
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
Street Address
City or Town State Zip Code
04 872-7686
Area code Phone number
o.WELL INFORMATION:
WELL CONSTRUCTION PERM| N/A
OTHER ASSOCIATED PERm|T#Vonpl/oam
|N�1
m�EvvELLm#�avm/com
3.WELL USE (Check One Box) Monitoring Municipal/Public O
Industrial/Commercial O Agricultural O Recovery OInjection O
|mgoUnnO Other O(list use)
DATE DRILLED
4. WELL LOCATION:
2121 VVE8TCLEMNYONGV|LLE ROAD 27127
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: VV|NGT0N8ALEM COUNTY P]RaYT*
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
00opo Ovaoev ORat OpxuQa OOmo
LATITUDE ^��oMomR oo
uows|TuoE ^'"oMaOm oo
LaUmue0ongnodesounm: [3GPG []Topographic map
(location vfwell must bwshown onaUoG8umomap ondauachedm
this form ifnot using GnS)
5.FACILITY (Name ovthe business where the well io|uoomd.)
Facility Name
Facility ID# (if
applicable)
2121 WEST CLEMMONSVILLE ROAD
Street Address
City or Town
State
Zip Code
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
City or Town
State
Zip Code
Area code Phone number
6.WELL DETAILS:
a. TOTAL
b.DOES WELL REPLACE EXISTING WELL? YEeo NO
c. WATER LEVEL Below Top of Casing: 32.0 —FT,
(Use"+" if Above Top of Casing)
�d. TOP OF CASING IS 0.0 FT. Above Lonuaumaca
� ot/o( below land oudama may require
� ov�o��mo�omun���,o*muxC 2Cu/m
. '.
�e.YIELD (gpm): N/A' METHOD OF TEST _N/A
�f. ommrEcnoN: xmmnun
�
�e WATER ZONES (depth):
�n,prvn____-_'
Bottom
!Top______ Tvv___-__'
�TvnTop______
� Bottom -
Thickness/
' Diameter Vwygo Material
Top Depth�,gn
�Tvp_0.0Bottom _32.0-Ft. 4 INCH L -SC±40L _-PVC-__
�Top
oouvm____-Ft._____
Top Bottorrk_ Ft._
' �um�o Method
�uGROUT Depthmu��o
�Top_-QJ0 _avuvn-29.0_Ft. 'm'mw000NTO*ITE �SLURRY
__--
�Tvp_____avuom____- Ft.
9.SCREEN: Depth Diameter Slot Size Material
Top _32.0L'Bottom �3[7.0'Ft. 4.0Lin. _.010-in. -PVC
�_-__
Tnp_____anuvn�____m`___Jn.____in.
_________
Tvp_____Bvuvm_____rY`____in. _____ in.
________�
1uaANumomAVELPACK:
Depth
Size Material
Top 31.0
Bottom 37.0
Ft`2l-40FINE SILICA SAND
Top
Bottom
Ft._
Top
ommm____m`____
11.DRILLING LOG
Top
Bottom
Formation Description
ORANGE SANDY SILT
12. REMARKS:
BENTONITE SEAL FROM 29.0 TO 31.0 FEET
BY A�CTIFYCT
C WATHIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
: %RE E TO TH 05/26/11
SIGNATURE OF CERTIFIED WET CONTRACTOR DATE
�PRINTED NAME OFPERSON CONSTRUCTING THE WELL
Form Gvv-1u

co
Nib
North Carolina Department nfEnvironment and NaturalDesomces-DivisionnYWaterVuality
WELL CONTRACTOR CERTIFICATION # 2345
-- .
1.WELL CONTRACTOR: d. TOP OF CASING IS 0.0 FT. Above Land ounamr
MARKGETTYG *Top of casing terminated land surface may require
Well Contractor ''
Name evon�ac
cordance
GEOLOGIC EXPLORATION, INC e.YIELD (gpm): ., N/A METHOD OF TEST NIA
Well -Contractor Company —Name �f. DISINFECTION: Amount N/A
Street Address
City or Town State Zip Code
04 872-7686
Area code Phone number
2. WELL INFORMATION:
WELL CONSTRUCTION PERMN/A
OTHER ASSOCIATED PsnMn#(if
SITE WELL m#(ifapplicable) KN-
u.WELL USE (Check One Box) Monitoring 4 Mumdpai/publicO
Industrial/Commercial U Agricultural FmooveryO Injection
|nigobonO 0tha,O (list use)
DATE DRILLED
4.WELL LOCATION:
2121WEST CLEK8K0ONGV|LLEROAD 27127
(Street Name, Numbers, Community, Subdivision, Lot wu.Parcel, Zip Code)
CITY- WINSTON GALEM COUNTY FOnSYTH
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
0SIope OVolley ORm OpUdge OOthe
urnTuos ~'^oMaOwDID
u)me|Tuor ~'^omamm oo
Latituuaxnngitudaxounm: []BP8 []nopvgnepmomop
(location ofwell must boshown unauoG3topnmap enmattachmum
this form ifnot using GrS)
5.FACILITY (Name ofthe business where the well io|ncoteu.)
Facility Name
Facility ID# (if
applicable)
2121 WEST CLEMMONSVILLE ROAD
Street Address
City or Town
State
Zip Code
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
City or Town
State
Zip Code
Area code Phone number
aWELL DETAILS:
a TOTAL DEPTH:—
u`DOES WELL REPLACE EXISTING WELL? vsao woG/
c. WATER LEVEL Below Top of Casing: 32.0
(Use"+" if Above Top of Casing)
g. WATER ZONES (deptn
Top____
Bottom
TopBottom
___
Tun______.Bottom
�_____
mn___'
Bottom
Top
Top __Bottom
-
Thickness/
:7.cxmINo: Depth Diameter Weight Material
�Top _I.L_Bottom �l2.D_Ft. 4 INCH � -SC±40 _-PVC___
�TvnL____Bottom m`_____
Top Bottom— Ft.
�8.GROUT Depth Material Method
�Top.0.0 Bottom _2G.0L_Ft. PORTLAND emn»°ITE _SL1DRY�__'
�Top Bottom Ft.
Top Bottom— Ft.—
�9.ecmEEm: Depth Diameter Slot Size Material
�Top
Bottom _____pt__m.
____�,�________-
:Ton_____�oounm_____pt___�n
____ in.
'1uoumommxVsLPACK:
�
Depth
Size Material
�
m.2D-4{L_ FINE SILICA SAND
�
pL_____.
Top
Bottom
Ft-_
�11.DRILLING LOG
� Top
�
anuum
�
�
�
� 10.0
�
' ------------
' -----'--------'
'
Formation Description
ORANGE SANDY SILT
TAN/ORANGE SANDY SILT
TAN SANDY SILT
TAN/GRAY SANDY SILT
12. REMARKS:
BENTONITE SEAL FROM 29.0 TO 31.0 FEET
usm�vrxm�m�su�mo��nm��wxccox�wo�rD j&BPROV�DTOTH Ow
_�l W
�MARK GETTYS
PRINTED NAME OFPERSON CONSTRUCTING THE WELL
Form Gvv4u

NONRESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department uYEnvironment and Natural Resources- Division ofWater Quality
WELL CONTRACTOR CERTIFICATION # 2345
1.WELL CONTRACTOR:
MARK GBTY
Well Contractor VndividuaVName
GEOLOGIC EXPLORATION, INC
Welt Contractor Company Name
Street Address
City or Town State Zip Code
Area code Phone number
2.mELL INFORMATION:
WELL CONSTRUCTION PERMIT# mm
OTHER ASSOCIATED Psnm[T#K:
SITE WELL 0w(if /W-3
uWELL USE (Check One Box) Monitoring W MunicipomzublicO
Industrial/Commercial 0 Agricultural 0 Recovery OInjection O
|nigebonO Other O(list use)
DATE DRILLED D
4.WELL LOCATION:
2121WEST CLE/N/NONGV|LLEROAD 27127
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: VY|NSTON8ALEM COUNTY poRSYTH
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
08|pmo OVaxny Ormt Omugo Omhe
un/Tuos �^oMamRoo
LowonnoE �'�omSou oo
bmdudexonOimueuvunm: []GPS []ropuQmpmcmop
(location of well must boshown onaU3eotopmmap amdattacho to
this form ifnot using Gpz)
5.FACILITY (Name mthe business where the well io|ouatem.)
Facility Name
Facility ID# (if applicable)
2121 WEST CLEMMONSVILLE ROAD
Street Address
City or Town
State
Zip Code
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL
b.DOES WELL REPLACE EXIonmoxELL? YES woG/
c. WATER LEVEL Below Top of Casing: 32.0 -FT
�m. TOP OF CASING IS 0.0 FT. Above Land Surface*
� *Top of land surface may require
� nvmiance inaccordance With 1sANCmCuCln1K
e.YIELD (gpm): METHOD OF TEST N/A
I. DISINFECTION: Amount N/A
9. WATER ZONES Wwpth
Top___
Bottom
Top
Top Bottom
�_____
Top___
Bottom
ToP___'
Bottom
Top
Bottom
rx/"k""==/
.
�7. CASING:
.
Depth
.�'-----
Diameter Weight
Material
�nqp__U.O
Bottom 32.l-Ft.
4 INCHL _SCHL40L
PlC�_-_
�n,x_____Bottom
pt._____
�Top
a000nc_____Ft.______
�8. GROUT:
Depth
Material
Method
�Top _0.0
Bottom l_29.{L'Ft.
PORTLAND BENTONITE _81l}RFY.___
Top
Bottom—
Ft.
�Tvp_____ovoom__--_'
Ft.
�
�aooREEm:
Depth
Diameter Slot Size
Material
:Top _32.0_
Bottom �-3[.0_Ft.
4J0_in. _.01g_in.
_PVC
�_—__�
�vvp_____oounm�____pt____in.
____ in.
TOP
Bottom
Ft. in. in.
'10SAND/GRAVEL PACK:
� Depth Size
Top Bottom- Ft.
Top Bottom Ft.
Material
RNEG|LICA8AND
11.DRILLING LOG
Top Bottom Formation Description
�0.0 5.0 ORANGE SANDY SILT
5.0 10.0 TAN/ORANGE SANDY SILT
�
�
� _..~=0 TAN SANDY SILT
30.0 37.0 TAN/GRAY SANDY SILT
�___
�
' ------------�
�
' ------------'
�
^
' ------------
12. REMARKS:
BENTONITE SEAL FROM 29.0 TO 31.0 FEET
�
�
I BY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
BY .�WECRON\ S&�CTIIIDN ST%ARDS, AND THAT A COPY OF THIS
0 N
R E �C%A 0 THE
05/26/11
_LL CO
SIGNATURE OF CERTIFIED WELL CONTRACT- DATE
MARK GETTYS
: PRINTED NAME orPERSON CONSTRUCTING THE WELL
Form GVVAu

NONRESIDENTL4L WELL CONSTRUCTION RECORD
North Carolina Department of Environment and Natural Resources- Division of Water Quality
WELL CONTRACTOR CERTIFICATION # 2345
1. WELL CONTRACTOR:
MARK GETTYS
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
176 COMMERCE BLVD
Street Address
STATESVILLE NC 28625
City or Town State Zip Code
(704. 872-7686
Area code Phone number
2. WELL INFORMATION:
d. TOP OF CASING IS 0.0 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): N/A METHOD OF TEST N/A
f. DISINFECTION: TypeN/A Amount N/A
g. WATER ZONES (depth):
Top_ Bottom Top_ Bottom
Top_ Bottom Top Bottom
Top_ Bottom Top Bottom
Thickness/
:7. CASING: Depth Diameter Weight Material
WELL CONSTRUCTION PERMIT# N/A
Top 0.0
Bottom 32.0
Ft. 4 INCH SCH 40 PVC
OTHER ASSOCIATED PERMIT#(if applicable)
TOP
Bottom
Ft.
SITE WELL ID #(If applicable) IW-4
Top
Bottom
Ft.
3. WELL USE (Check One Box) Monitoring #f Municipal/Public E]
:8. GROUT:
Depth
Material Method
Industrial/Commercial El Agricultural r-i Recovery F1 Injection 0
Top 0.0
Bottom 29.0
Ft.- PORTLAND BEMONITE SLURRY
IrrigationEl OtherE] (list use)
DATE DRILLED 05/23/11 - 05/25/11
4. WELL LOCATION:
2121 WEST CLEMMONSVILLE ROAD 27127
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: WINSTON SALEM COUNTY FORSYTH
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
E]Slope oValley 0FIat oRidge E]Other
LATITUDE o " DMS OR DD
LONGITUDE . . I "DMS OR DD
Latitude/longitude source: BPS Dropographic map
(location of well must be shown on a USGS topo map andattached to
this form if not using GPS)
5. FACILITY (Name of the business where the well is located.)
RMR - 4109
N/A
Facility Name
Facility ID# (if applicable)
2121 WEST CLEMMONSVILLE ROAD
Street Address
WINSTON SALEM
NC
27127
City or Town
State
Zip Code
CONOCO PHILLIPS
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
BARTLESVILLE
OK
74006
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL DEPTH: 37.0 FEET
b. DOES WELL REPLACE EXISTING WELL? YES 0 NO G/
c. WATER LEVEL Below Top of Casing: 32.0
(Use"+" if Above Top of Casing)
Top Bottom- Ft.
Top_ Bottom- Ft.
9. SCREEN: Depth Diameter Slot Size Material
:Top 32.0 Bottom 37.0 Ft. 4.0 in. .010 in. PVC
Top Bottom Ft. in.
TOP Bottom Ft. in.
10. SAND/GRAVEL PACK:
Depth Size
Top-.q1.0 Bottom 37.0 Ft.- 20-40
Top Bottom Ft.
Top Bottom Ft.
11. DRILLING LOG
Top Bottom
0.0 5.0
5.0
10.0
10.0
30.0
30.0
37.0
in.
in.
Material
FINE SILICA SAND
Formation Description
ORANGE SANDY SILT
TAN/ORANGE SANDY SILT
TAN SANDY SILT
TAN/GRAY SANDY SILT
12. REMARKS:
BENTONITE SEAL FROM 29.0 TO 31.0 FEET
. I
_*O EREBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
2C,WKLLCONST UCTION.JTANIDARDS, AND THAT A COPY OF THIS
B PRD
3K TO THT LOW
05/26/11
SIGNATURE OF CERTIFIED WELL CONTRAC11OR DATE
MARK GETTYS
- PRINTED NAME OF PERSON CONSTRUCTING THE WELL
Form GIN-1 b
Rev. 2/09

'NONRESIDENTL4L WELL CONSTRUCTION RECORD
1.WELL CONTRACTOR:
MARKGETTYG
Well Contractor (Individual) Name
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
Street Address
City or Town State Zip Code
704 872-7686
Area code Phone number
2.WELL INFORMATION:
WELL CONSTRUCTION PERM|r# N/A
OTHER ASGOCNTEopERMIT#(n
SITE WELL m#(if IW-5
n.WELL USE (Check One Box) Monitoring O1Municipal/Public O
mdumhaUCommonjo|O Agricultural Recovery )njeoVu^O
|m0000no Other o(list use)
DATE DRILLED
4.WELL LOCATION:
2121WEST CLEYN(NDNGV|LLEROAD 27127
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
C|nr VV|NGTONSALEM COUNTY FORoYTH
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
OS|ope Ove||ey ORat []Ridge OOme
uT|Tuoe ^'"oMamn oo
uuwa|Tuos ��"oMamR oo
Latituda0ongimd000urcm: OGpS []nopogoophiomop
(location ofwell must »oshown onoU3G3mpomap evdauamedm
this fonnifnot using apS/
*. FACILITY (Name mythe business where the well is|uoomu.)
Facility Name
Facility ID# (if applicable)
2121 WEST CLEMMONSVILLE ROAD
Street Address
City or Town
State
Zip Code
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL
b.DOES WELL RspuucE EXISTING WELL? YES woG/
c. WATER LEVEL Below Top of Casing: 32.0 —FT
(Use"+" if Above Top of Casing)
�m. TOP OF CASING IS 0.0 FT. Ab�ve Land Surface*
� *Top of casing terminated 6tlor below land surface may require
� evariance maccordance with 1sAwCAC2Cln1&
�e. YIELD (gvm):N/A METHOD OF TEST. N/A
�� DISINFECTION: Amount bK8____
. ' �
�9. WATER ZONES (devm):
�TopBottom TvpBottom
______�
�TonBottom TvpBottom
______
�TnpBottom Tvn_-____'
Bottom
� Thickness/
:7.c4oINa: Depth Diameter Weight Material
:Top _-U.0L-Bottom �-32.l_Ft`4JNCU- SCH 40 _JPVC
__-
�Top Bottom Ft.
______
Top- Bottom— Ft—
:uGnouT Depth Material momvu
�Top 0.IL_Bottom 29.0L_Ft. PORTLAND oENn0141TE _SLURRY�___
�Top
Bottom Ft.
Top Bottom— Ft.
9.aoRsem: Depth Diameter Slot Size Material
Top _82.0_Bottom _37.l_Ft. 4.0 in. -.0L10_ in. _tVC�__-_
Top Bottom pt.____In.-in.
________
Top Bottom n`___Jn.____in.
________
�1uSAND/GRAVEL PACK:
�
�
Depth
size Material
�Top 31.0
Bottom 37.0
pt_2l-40FINE SILICA SAND
�Top
Bottom
Ft.______
Top
Bottom__
Ft.—
�11.onILLNGLOG
� Top
Bottom
Formation Description
�0.0
5.0
ORANGE SANDY SILT
5.0
10.0
TAN/ORANGE SANDY SILT
�
. _~~~0
�___
TAN SANDY SILT
30.0
37.0
TAN/GRAY SANDY SILT
�
�
�
�
�
:12.mEMAmwa
BENTONITE SEAL FROM 29.0 TO 31.0 FEET
.
'O REBY CERTIFY THAT THIS WELL WAS CONSTRUCTED IN ACCORDANCE WITH
CC
05/26/11
SIGNATURE OF CERTIFIED WE DATE
MARK GETTYS
PRINTED NAME OF PERSON CONSTRUCTING THE WELL
ponnGW-1u

'
NONRESIDENTLIL WELL CONSTRUCTION RECORD
North Carolina Department ofEnvironment and Natural Resoumes-DivisionofWatezOu ality
WELL CONTRACTOR CERTIFICATION # 2345
1.WELL CONTRACTOR:
MARKGETTY8
Well Contractor ynUwiduoVName
GEOLOGIC EXPLORATION, INC
Well Contractor Company Name
Street Address
City or Town State Zip Code
704 872-7686
Area code Phone number
�WELL INFORMATION:
WELL COwSTRUCTIOwpERMN/A
OTHER ASSOCIATED peeMIT#*applicable)
SITE WELL 0#(ifapplicable) |VV-6
u.WELL USE (Check One Box) Monitoring Municipuupub|ioO
Industrial/Commercial O Agricultural Recovery OInjection O
|mgauvno Other o(list use)
DATE DRILLED
4.WELL LOCATION:
2121WEST CLEK0K0DN8V|LLEROAD 27127
(Street Name, Numbers, Community, Subdivision, Lot No., Parcel, Zip Code)
CITY: VY|NGTONSALEK4 COUNTY pORGYTH
TOPOGRAPHIC / LAND SETTING: (check appropriate box)
OG|opmOva||evOFlau ORidge Ogthe
u«|Tuos __^___I^oMooe oo
uowo|roos __~'"oMaon oo
���Ue�ongimuaonunm: [ISpa []ropognophiomep
(location mwell must boshown uneuoGOuopumap undaxoc»edm
this form vnot using SPS)
5.FACILITY (Name ovthe business where the well ix|onatem>
Facility Name
Facility ID# (if applicable)
2121 WEST CLEMMONSVILLE ROAD
Street Address
City or Town
State
Zip Code
Contact Name
420 SOUTH KEELER AVENUE
Mailing Address
City or Town
State
Zip Code
Area code Phone number
6. WELL DETAILS:
a. TOTAL
b. DOES WELL REPLACE EXISTING WELL? vEeo woG/
c. WATER LEVEL Below Top of Casing: 32.0 -FT
(Use "+"if Above Top of Casing)
: d. TOP OF CASING IS 0.0 FT.'Above Land Surface*
� *Top of casing terminated at/or below land surface may require
� avohunoe�ocoo�anoe��15ANC/��2C.m1n.
. '
�e. YIELo(gpm):
METHOD OF TEST. NIA
�� DISINFECTION:
�xm��n0�L--__
WATER,ZONES (depth):
�TvnBottom
TnpBottom
_______
�TunBottom
TvoBottom
�Top_______ Bottom
Tnp_______ Bottom
:zoAeINmc oppm
�
Diameter Weight Material
�Tnn_Q.O_Bottom z_32.l
pt.4 INCH -SCHi40L _PVIL___
�Top_____ovnnn�____m`_____
�ropovxnn�____Ft`______
�u.onOUT Depth
Material momoU
�Top _0.0Bottom L28.0_Ft.
PORTLAND aano*ITE _SLURRY�___
�Top Bottom
Ft.
�Tvp_____nnuon�____
Ft.
�eeonssw oenm
Diameter Slot Size Material
�Top_,�2.0_Bottom l_37.l�Ft.
£'0_in. _lU{L in. _PVC
�Top avxvn�____n`___in
____ in. ________
'1ao/wmmoFmvELPACK:
�
Deptx
Size Material
:Top 31.0
Bottom 37.0
Ft.— 20-40 FINE SILICA SAND
�
rt-_____
TOP
Bottom
FL-
�11.oRUJNouzG
� Top
Bottom
Formation Description
�0.0
5.0
ORANGE SANDY SILT
5.0
10.0
TAN/ORANGE SANDY SILT
�
�
. _==�
30.030.0
�
37.0
�
' ------------
�
�
�
�
'12.msMoRno
� BENTONITE SEAL FROM 29.0
TO 31.0 FEET
.
11 Y CERTIfY THAT THIS WELL'JVAS CONSTRUCTED IN ACCORDANCE WITH
R% -hROCTION ST DS, THAT A COPY OF THIS
,WEL DNS
05/26/11
SIGNATURE OF CERTIFIED WELL CONTRACTOR DATE
MARK GETTYS
: PRINTED NAME OFPERSON CONSTRUCTING THE WELL
Form GvV-1h

%TC
INJECTION WELL LOG: IW-1
A S S O C, A F E S I N c.
(Page 1 of1)
Circle K Store #4358 (RM&R # 4109)
Date(s) Drilled : 5/23-25/11 Boring Diameter : 12 Inches
2121 W. Clemmonsville Road
Drilling Conractor : GEX Sampling Method : NA
Winston-Salem, North Carolina
Drilling Method : Hollow Stem Augers Sampling Interval : NA
ATC Project No. 45.75118.4109
Logged By : Aaron Leff
Client: ConocoPhillips Company
aa)
LL
U_
Well:
IW-1
.r-
0
U)
Z)
2
a-
DESCRIPTION
Cover
Orangish tan sandy SILT
ML
5
Tan sandy SILT
10
Grout
15
ML
2" Diameter Casing
20
25
— — — — — — — — — — — — — — — — — — — —
Grayish tan SILT
ML
Bentonite
30
— — — — — — — — — — — — — —
Grayish tan SILT, moist
ML
Sand
35
Grayish tan SILT, wet
Screen
ML
Boring terminated at 37 feet below ground surface.

%TC
INJECTION WELL LOG: IW-2
A 5 S O C 1 A T E S I N C.
(Page 1 of 1)
Circle K Store #4358 (RM&R # 4109)
Date(s) Drilled : 5/23-25/11 Boring Diameter : 12 Inches
2121 W. Clemmonsville Road
Drilling Conractor : GEX Sampling Method : NA
Winston-Salem, North Carolina
Drilling Method : Hollow Stem Augers Sampling Interval : NA
ATC Project No. 45.75118.4109
Logged By : Aaron Leff
Client: ConocoPhillips Company
LL
U_
Well:
I
W-2
.r-
�
0
U
Z)
2
a-
DESCRIPTION
Cover
Orangish tan sandy SILT
5
ML
10
Tan SILT
Grout
15
2" Diameter Casing
20
ML
25
Bentonite
30
— — — — — — — — — — — — — — — —
Tan SILT, moist
ML
Tan SILT, wet
Sand
35
ML
Screen
Boring terminated at 37 feet below ground surface.

%TC
INJECTION WELL LOG: IW-3
A S S O C, A F E S I N c.
(Page 1 of1)
Circle K Store #4358 (RM&R # 4109)
Date(s) Drilled : 5/23-25/11 Boring Diameter : 12 Inches
2121 W. Clemmonsville Road
Drilling Conractor : GEX Sampling Method : NA
Winston-Salem, North Carolina
Drilling Method : Hollow Stem Augers Sampling Interval : NA
ATC Project No. 45.75118.4109
Logged By : Aaron Leff
Client: ConocoPhillips Company
LL
U_
Well:
I
W-3
.r-
�
0
U
Z)
2
a-
DESCRIPTION
Cover
Orangish tan SILT
ML
5
— — — — — — — — — — — — — — — — — — — —
Orangish tan sandy SILT
ML
Tan sandy SILT
10
Grout
15
2" Diameter Casing
20
ML
25
Bentonite
30
Sand
35
Screen
Boring terminated at 37 feet below ground surface.

%TC
INJECTION WELL LOG: IW-4
A S S O C, A F E S I N c.
(Page 1 of1)
Circle K Store #4358 (RM&R # 4109)
Date(s) Drilled : 5/23-25/11 Boring Diameter : 12 Inches
2121 W. Clemmonsville Road
Drilling Conractor : GEX Sampling Method : NA
Winston-Salem, North Carolina
Drilling Method : Hollow Stem Augers Sampling Interval : NA
ATC Project No. 45.75118.4109
Logged By : Aaron Leff
Client: ConocoPhillips Company
LL
U_
Well:
I
W-4
.r-
�
0
U
Z)
2
a-
DESCRIPTION
Cover
Orangish tan sandy SILT
ML
5
Tan sandy SILT
10
ML
Grout
15
2" Diameter Casing
20
Tan sandy SILT, moist
25
ML
Bentonite
30
Tan sandy SILT, wet
Sand
35
ML
Screen
Boring terminated at 37 feet below ground surface.

%TC
INJECTION WELL LOG: IW-5
A S S O C, A F E S I N c.
(Page 1 of1)
Circle K Store #4358 (RM&R # 4109)
Date(s) Drilled : 5/23-25/11 Boring Diameter : 12 Inches
2121 W. Clemmonsville Road
Drilling Conractor : GEX Sampling Method : NA
Winston-Salem, North Carolina
Drilling Method : Hollow Stem Augers Sampling Interval : NA
ATC Project No. 45.75118.4109
Logged By : Aaron Leff
Client: ConocoPhillips Company
LL
U_
Well:
I
W-5
.r-
�
0
U
Z)
2
a-
DESCRIPTION
Cover
Reddish orange SILT
ML
5
Tan sandy SILT
ML
10
Grayish tan sandy SILT
Grout
15
2" Diameter Casing
20
ML
25
Light brown sandy SILT
ML
Bentonite
30
Light brown sandy SILT, moist
ML
_ _ _ _ _ _ _ _ _ _ _ _
Light brown sandy SILT, wet
Sand
35
ML
Screen
Boring terminated at 37 feet below ground surface.

%TC
INJECTION WELL LOG: IW-6
A S S O C, A F E S I N c.
(Page 1 of1)
Circle K Store #4358 (RM&R # 4109)
Date(s) Drilled : 5/23-25/11 Boring Diameter : 12 Inches
2121 W. Clemmonsville Road
Drilling Conractor : GEX Sampling Method : NA
Winston-Salem, North Carolina
Drilling Method : Hollow Stem Augers Sampling Interval : NA
ATC Project No. 45.75118.4109
Logged By : Aaron Leff
Client: ConocoPhillips Company
LL
U_
Well:
I
W-5
.r-
�
0
U
Z)
2
a-
DESCRIPTION
Cover
Reddish orange SILT
ML
5
Tan sandy SILT
ML
10
Grayish tan SILT
Grout
15
2" Diameter Casing
20
ML
25
Bentonite
30
— — — — — — — — — — — — — —
Grayish tan SILT, moist
ML
Grayish tan SILT, wet
Sand
35
ML
Screen
Boring terminated at 37 feet below ground surface.