WQ0028785_More Information (Received)_20161207

;ETC
ENVIRONMENTAL - GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
December 7, 2016
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax:[phone]
www.atcassociates.com
N.C. Engineering License No. C-1598
Mr. Thomas Moore
North Carolina Department of Environmental Quality
Winston-Salem Regional Office
Division of Waste Management - Underground Storage Tank Section
450 West Hanes Mill Road, Suite 300
Winston-Salem, North. Carolina 27105
Re: Site Closure Report
Circle K Store #4358 (RM 94109)
2121 West Clemmonsville Road
Winston-Salem, Forsyth County, North Carolina
NCDEQ Incident No. 30360
ATC Project No. 45.75118.4109
Dear Mr. Moore:
ATC Associates of North Carolina, P.C. (ATC), on behalf of Phillips 66 Company, is submitting
this Site Closure Report documenting water supply well abandonment activities performed in
November 2016.
If you have any questions or require additional information, please contact our office at (919)
871-0999.
Sincerely,
ATC Associates of North Carolina, P.C.
o.
Ashley M. Winkelman, P.G. Gabriel Araos, P.E.
Project Manager Senior Project Manager
cc: Mr. Ed Kuhn, Contract Program Manager for Phillips 66 Company

Site Closure Report
Circle K Store #4358 (RM #4109)
2121 West Clemmonsville Road
Winston-Salem, Forsyth County, North Carolina
NCDEQ Incident No. 30360
ATC Project No. 45.75118.4109

Site Identification
A. Site Information
1. Site Identification
Date of Report: 12/7/16
Facility I.D.: 0-05075 UST Incident Number (if known): 30360
Site Name: Circle K Store #4358 (RM #4109)
Site Street Address: 2121 West Clemmonsville Road
City/Town: Winston-Salem Zip Code: 27127 County: Forsyth
Description of Geographical Data Point: Canopy
Location Method: Aerial Man
Latitude (decimal degrees): 36.027417° Longitude (decimal degrees): 80.292739°
2. Information about Contacts Associated with the Leaking UST System
UST Owner: RI CS2. LLC
Address: P.O. Box 460069, Escondido, CA 92046 Tel.: [phone]
UST Operator: R1 CS2, LLC
Address: P.O. Box 460069, Escondido, CA 92046 Tel.: [phone]
Property Owner: RI CS2, LLC
Address: P.O. Box 460069, Escondido, CA 92046 Tel.: [phone]
Property Occupant: Circle K Store #4358
Address: 2121 W Clemmonsville Rd, Winston-Salem, NC 27127 Tel.: [phone]
Consultant/Contractor: ATC Associates of North Carolina, P.C.
Address: 2725 E. Millbrook Road, Suite 121, Raleigh NC 27604 Tel.: [phone]
Analytical Laboratory: Lancaster Laboratories State Certification No.: 521
Address: _ 2425 New Holland Pike, P.O. Box 12425, Lancaster PA 17605 Tel: [phone]
3. Information about Release
Date Discovered: February 2004
Estimated Quantity of Release: Unknown
Cause of Release: Unknown
Source of Release (Dispenser/Piping/UST): Unknown
Sizes and contents of UST system(s) from which the release occurred:
One 8,000-gallon and two 10,000- alg lon gasoline USTs
4. Certification
I, Gabriel Araos Irofessional Enginee icensed Geologist (circle one) for
ATC Associates of North Carolina, P.C. , do certify t at the information contained in this report is
correct and accurate to the best of my knowledge.
ATC Associates of North Carolina, P.C. is licensed to practic
in North Carolina. The certification number of the company or
B•. 6v,q or both)
a fi SEAL o
' a
022569
r o ce!
�°°..�YGI{vE�Q. ..

TABLE OF CONTENTS
1.0 SITE DESCRIPTION..................................................................................................I
2.0 BACKGROUND..........................................................................................................1
3.0 SOIL AND GROUNDWATER QUALITY...............................................................4
3.1 Site Geology........................................................................................................4
3.2 Historical Soil Assessment..................................................................................4
3.3 Site Hydrogeology...............................................................................................5
3.4 Groundwater Assessment.....................................................................................5
4.0 WATER SUPPLY WELL ABANDONMENT ACTIVITIES.................................6
5.0 CONCLUSIONS..........................................................................................................7
TABLES
Table 1 Historical Soil Analytical Results
Table 2 Monitoring Well Construction Details and Historical Groundwater Elevations
Table 3 Historical Groundwater Analytical Results
Table 4 Monitored Natural Attenuation Parameters
Table 5 Water Supply Well Information
FIGURES
Figure 1
Site Topographic Map
Figure 2
Site Map
Figure 3
Soil Analytical Map
Figure 4
Groundwater Elevation Contour Map
Figure 5
Dissolved Benzene Isoconcentration Contour Map
Figure 6
Dissolved MTBE Isoconcentration Contour Map
Figure 7
Chemicals of Concern In Groundwater
Figure 8
Water Supply Well Location Map
APPENDICES
Appendix A Well Abandonment Record

Site Closure Report December 7, 2016
NCDEQ Incident No. 30360 ATC Project No. 45.75118.4109
1.0 SITE DESCRIPTION
ATC Associates of North Carolina, P.C. (ATC) was retained by Phillips 66 Company to conduct site
investigations at the Circle K Store #4358. The project site is located at 2121 West Clemmonsville
Road in Winston-Salem, Forsyth County, North Carolina. Figure 1 represents a site topographic
map depicting topography in the area and Figure 2 represents a site map indicating site layout and
pertinent features. This report documents historical soil and groundwater analytical results for the
site as well as water supply well abandonment activities performed in November 2016.
2.0 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. 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 Environmental Quality
(NCDEQ) 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 borings above NCDEQ Action Levels. Based upon the Site Check findings,
NCDEQ requested additional soil borings in closer proximity to the UST system.
Page 1

Site Closure Report December 7, 2016
NCDEQ Incident No. 30360 ATC Project No. 45.75118.4109
A Site Check Addendum Report dated August 20, 2004, was submitted to NCDEQ documenting the
results of the additional soil sampling activities. The soil analytical results indicated TPH DRO was
detected in one boring above NCDEQ TPH Action levels. NCDEQ authorized ATC to perform a
Limited Site Assessment (LSA) to delineate the extent of 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 (now Phillips 66 Company) 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 Survey 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. There was also an inactive water supply well identified
at the site. On July 15, 2008, NCDEQ issued a Notice of Regulatory Requirements (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
upgradient of the site. It should be noted upgradient of the site is former Cardinal 76 Service Center
which had a confirmed release in the past (NCDEQ 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.
Page 2

Site Closure Report December 7, 2016
NCDEQ Incident No. 30360 ATC Project No. 45.75118.4109
On December 30, 2009, and July 26, 2010, Delta submitted groundwater monitoring reports
documenting field activities and groundwater sampling results. On August 6, 2010, NCDEQ 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 WI040017 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. In June 2011 and April 2012, ATC
conducted magnesium sulfate injection events at the site to enhance biodegradation of the
petroleum hydrocarbons at the site. An Interim Injection Report was submitted on September 25,
2012, documenting the injection activities and post -injection sampling events.
In an attempt to reduce the site's risk classification, Phillips 66 negotiated with the site property
owner to abandon the inactive on -site water supply well (WSW-1). ATC supervised Geologic
Exploration, Inc. on June 12, 2014, during the abandonment of the onsite water supply well.
ATC submitted a Site Closure Report on July 31, 2015, to document an updated receptor survey
and groundwater sampling event. The receptor survey determined that five inactive water supply
wells (WSW-1 through WSW-5) located within 250 feet of the site had been driving the site's
"High" risk. As noted above, water supply well WSW-1 has been abandoned. ATC received
correspondence in February 2012 from Mr. Lanier Williams indicating that the water supply well
on his property (WSW-2) is no longer in use. ATC received correspondence in April 2015 from
Red FDS, LLC, the property owner of water supply wells WSW-3 and WSW-4, indicating that
these water supply wells no longer exist. Ms. Linda Dillard (WSW-5) indicated in
correspondence received by ATC in June 2014 that there is no well on her property. Therefore,
it was determined one inactive water supply well (WSW-2) was driving the site's "High" risk
classification.
A Groundwater Monitoring Report was submitted on May 17, 2016 documenting a February 2016
sampling event. The groundwater analytical data indicated that dissolved petroleum constituents
Page 3

Site Closure Report December 7, 2016
NCDEQ Incident No. 30360 ATC Project No. 45.75118.4109
exceeded the corresponding applicable 2L Standards. Based on the results of the February 2016
sampling event and the updated receptor survey performed for the July 2015 Site Closure Report,
ATC recommended abandoning inactive water supply well WSW-2. Following abandonment of
WSW-2 the site risk's classification would be reduced to "Low".
This report presents historical soil and groundwater data as well as the abandonment of water supply
well WSW-2 in November 2016.
3.0 SOIL AND GROUNDWATER QUALITY
3.1 Site Geology
Based on previous investigations, the on -site geology consists of tan, orange, brown, and grey
silt to sandy silt from the ground surface to the termination of the logged borings. Based on the
United States Department of Agriculture Web Soil Survey, the site lies within the Toast -
Devotion complex which is characterized with 6 to 10 percent slopes, is well drained with a
medium range for runoff, and originates from saprolite derived from granite and gneiss.
3.2 Historical Soil Assessment
On February 4, 2004, ATC collected soil samples GP-2, GP-6, and GP-7. The analytical results
indicated TPH GRO and TPH DRO above NCDEQ Action Levels in GP-6 and GP-7. In addition,
GP-7 contained toluene, ethylbenzene, total xylenes, and naphthalene above Soil -to -Groundwater
MSCCs. As a result, soil samples SB-1 through SB-14 were collected for analysis of TPH GRO and
TPH DRO in April 2004. Samples SB-2 and SB-8 indicated an exceedence of the NCDEQ Action
Level for TPH DRO. A LSA submitted in September 2005 documented soil samples collected from
monitoring wells MW-1 and MW-2. No compounds exceeded laboratory detection limits in either
of the monitoring wells. During CSA activities in June 2009, soil samples were collected from
borings GP-6A, GP-7A, SB-2A, and SB-8A. Sample GP-7A indicated MTBE exceeding Soil -to -
Groundwater MSCCs. No other compounds exceeded laboratory detection limits. Historical
laboratory results indicate petroleum compounds have not exceeded Residential or
Industrial/Commercial MSCCs. Historical soil sampling results are included as Table 1. Historical
soil sampling locations are shown on Figure 3.
Page 4

Site Closure Report December 7, 2016
NCDEQ Incident No. 30360 ATC Project No. 45.75118.4109
3.3 Site Hydrogeology
During the most recent sampling event performed at the site on February 9, 2016, groundwater
levels were measured in monitoring wells MW-1 through MW-4, MW-51), MW-6 through MW-8,
and MW-9D. An oil/water interface probe was used to measure the depths to water and free -phase
product. Free product was not detected during the sampling event. Depths were measured from the
top of the well casings and recorded to the nearest 0.01 feet. Monitoring well construction details
and the historical groundwater elevation data is summarized in Table 2 and a groundwater elevation
contour map is included in Figure 4. Based on the February 9, 2016 data, groundwater flow at the
site is generally towards the east, which is consistent with historical data.
Slug tests were performed on monitoring wells MW-51), MW-7, and MW-8, during CSA activities.
Based on the tests, hydraulic conductivity is measured at 3.95 feet/day and a seepage velocity of
0.84 feet/day was calculated. Based on February 2016 groundwater level measurement data,
horizontal hydraulic gradient at the site is measured at 0.041 feet/feet using monitoring wells MW-2
and MW-8. Vertical hydraulic gradient is measured at 0.034 feet/feet with an upward flow using
monitoring wells MW-2 and MW-5D.
3.4 Groundwater Assessment
On February 9, 2016, groundwater samples were collected from monitoring wells MW-1 through
MW-4, MW-5D, MW-6 through MW-8, and MW-9D. The groundwater samples were packed in
ice -filled coolers and transported under chain of custody to Lancaster Laboratories in Lancaster,
Pennsylvania. The samples were analyzed for volatile organic compounds by EPA Method 6200B.
Groundwater samples that exceeded the 2L Standards are summarized as follows:
Benzene: MW-3 and MW-6
Toluene: MW-6
Ethylbenzene: MW-6
Total Xylenes: MW-3 and MW-6
MTBE: MW-2, MW-3, MW-51), MW-6, and MW-91)
Naphthalene: MW-3, MW-5D, and MW-6
1,2-Dibromoethane: MW-3 and MW-6
Page 5

Site Closure Report December 7, 2016
NCDEQ Incident No. 30360 ATC Project No. 45.75118.4109
n-Propylbenzene: MW-6
1,2,4-Trimethylbenzene: MW-6
1,3,5-Trimethylbenzene: MW-6
p-Isopropyltoluene: MW-6
Carbon Tetrachloride: MW-1
1,2-Dichloroethane: MW-2, MW-3 and MW-6
Tetrachloroethene: MW-8
Methylene Chloride: MW-51) and MW-6
Bromodichloromethane: MW-1, MW-2, and MW-4
None of the groundwater samples indicated contaminant concentrations that exceeded the
corresponding Gross Contamination Levels (GCLs). Table 3 presents the historical groundwater
analytical results. The presence of carbon tetrachloride and tetrachloroethylene (PCE) are most
likely attributed to an off -site source and are not associated with the petroleum release at the site.
Historical monitored natural attenuation parameters are included as Table 4. Isoconcentration
contour maps for benzene and MTBE are included as Figures 5 and 6, respectively. Additional
chemicals of concern are shown in Figure 7.
4.0 WATER SUPPLY WELL ABANDONMENT ACTIVITIES
On September 16, 2016, Phillips 66 received approval from Mr. Lanier Williams to abandon
water supply well WSW-2. Water supply well WSW-2 is located at 2111 Clemmonsville Road
which is adjacent and east of the site property. On November 2, 2016, ATC supervised Geologic
Exploration, Inc. during the abandonment of the well. Prior to the abandonment, the required
notifications were made to the Forsyth County Health Department. During the abandonment, an
inspector from the Forsyth County Health Department observed the field activities. The water
supply well was 43 feet deep and 20 inches in diameter. The well was abandoned with a
Portland bentonite slurry emplaced via a tremie pipe. Water supply well information is included
as Table 5 and depicted in Figure 8. A well abandonment record for WSW-2 is included as
Appendix A.
Page 6

Site Closure Report December 7, 2016
NCDEQ Incident No. 30360 ATC Project No. 45.75118.4109
5.0 CONCLUSIONS
ATC is submitting this Site Closure Report for the Circle K Store #4358 in Winston-Salem, North
Carolina to document historical soil and groundwater analytical data as well as the abandonment of
WSW-2. A summary of field activities and relevant historical information is as follows:
• Water supply well WSW-2 was abandoned on November 2, 2016. There are now no active
water supply wells within 1,000 feet of the site and no existing water supply wells within 250
feet of the site;
• Historical soil analytical results indicate soil concentrations do not exceed Residential MSCCs;
and
• Recent groundwater analytical data indicated that dissolved petroleum constituents exceeded the
corresponding applicable 2L Standards but not the GCLs.
Based on the results of this report, the site's risk classification should be reduced to "Low" and site
closure activities should commence for the site.
Page 7

TABLES

TABLE 1
HISTORICAL SOIL ANALYTICAL RESULTS
RM #4109 (CIRCLE K STORE #4358)
2121 CLEMMONSVILLE ROAD
WINSTON-SALEM, NC
ATC PROJECT NO.45.75118.4109
Analytical Method:
8015
8260B
MADEP VPH
W
O
00
ti
N
N
GP-2
9-10
2/4/2004
<0.2
<5
<0.005
0.022
0.006
0.027
<0.005
<0.005
<0.005
GP-6
9-10
2/4/2004
17.6
28
<0.005
0.757
0.065
3
0.083
<0.005
0.054
GP-6A
9-10
6/16/2009
<5.3
<0.0077
<0.0077
<0.0077
<0.0077
<0.0077
<0.0077
<0.0077
<4
<1.3
<4.6
GP-7
5-6
2/4/2004
93
766
<0.45
9.57
9.74
71.4
<0.45
<0.45
26.9
GP-7A
5-6
6/16/2009
<6.2
<0.0066
<0.0066
<0.0066
<0.0066
0.1
<0.0066
<0.0066
<3.7
1.8
<4.3
SB-1
2
4/15/2004
<0.2
<5
SB-2
2
4/15/2004
<0.2
29
SB-2A
2-3
6/16/2009
<6.6
<0.0061
<0.0061
<0.0061
<0.0061
<0.0061
<0.0061
<0.0061
<4
<1.3
<4.6
SB-3
6
4/15/2004
<0.2
<5.1
SB-4
2
4/15/2004
<0.2
7.9
SB-5
2
4/15/2004
<0.2
<4.7
SV-6
14
4/15/2004
<0.2
<4.9
SB-7
12
4/15/2004
<0.2
<4.5
SB-8
8
4/15/2004
<0.3
25
SB-8A
8-9
6/16/2009
<5.9
<0.0058
<0.0058
<0.0058
<0.0058
<0.0058
<0.0058
<0.0058
<3.6
<1.2
<4.2
SB-9
2
4/15/2004
<0.2
8
SB-10
6
4/15/2004
<0.2
<4.7
SB-11
10
4/15/2004
<0.2
<4.7
SB-12
6
4/15/2004
<0.2
4.8
SB-13
2
4/15/2004
<0.2
<4.7
SB-14
2
4/15/2004
<0.3
<4.7
5-7
3/23/2005
<0.0005
<0.001
<0.001
<0.001
<0.0005
<0.001
<0.001
<3.07
<3.07
<3.07
9-11
3/23/2005
<0.0006
<0.001
<0.001
<0.001
<0.0006
<0.001
<0.001
<2.95
<2.95
<2.95
MW-1
14-16
3/23/2005
<0.0006
<0.001
<0.001
<0.001
<0.0006
<0.001
<0.001
<2.94
<2.94
<2.94
19-21
3/23/2005
<0.0006
<0.001
<0.001
<0.001
<0.0006
<0.001
<0.001
<2.93
<2.93
<2.93
24-26
3/23/2005
<0.0005
<0.001
<0.001
<0.001
<0.0005
<0.001
<0.001
<2.81
<2.81
<2.81
5-7
3/23/2005
<0.0004
<0.0008
<0.0008
<0.0008
<0.0004
<0.0008
<0.0008
<2.91
<2.91
<2.91
9-11
3/23/2005
<0.0006
<0.001
<0.001
<0.001
<0.0006
<0.001
<0.001
<3.5
<3.5
<3.5
MW-2
14-16
3/23/2005
<0.0006
<0.001
<0.001
<0.001
<0.0006
<0.001
<0.001
<3.1
<3.1
<3.1
19-21
3/23/2005
<0.0006
<0.001
<0.001
<0.001
<0.0006
<0.001
<0.001
<2.98
<2.98
<2.98
24-26
3/23/2005
<0.0006
<0.001
<0.001
<0.001
<0.0006
<0.001
<0.001
<2.9
<2.9
<2.9
NCDENR Action Level
10
10
NE
NE
NE
NE
NE
NE
NE
NE
NE
NE
Soil -to -Groundwater MSCCs
NE
NE
0.0056
4.3
4.9
4.6
0.091
0.37
0.16
68
540
31
Residential MSCCs
NE
NE
18
1,200
1,560
3,129
350
156
313
939
1,500
469
Industrial/Commercial MSCCs
NE
NE
164
32,000
40,000
81,760
3,100
4,088
8,176
24,528
40,000
12,264
Notes:
1. "<" or ND = Not detected at or above the Laboratory Reporting Limit.
2. Concentrations are reported in micrograms per liter (ug/1) = parts per billion.
3. Concentrations in bold equal or exceed the NCDENR 15A NCAC 02L. 0202 Groundwater Quality Standards (2L Standard) in effect at time of sampling.
4. GCL = Gross Contamination Level
Page 1 of 1

TABLE2
MONITORING WELL CONSTRUCTION DETAILS AND HISTORICAL GROUNDWTER ELEVATIONS
CIRCLE K STORE #4358 (RM #4109)
2121 WEST CLEMMONSVILLE ROAD
WINSTON-SALEM, NC
ATC PROJECT NO. P664109503
Monitoring
Well
Installation
Date
Well
Diameter
inches
Screen
Slot Size
inches
Total Well
Depth
feet b s
Screen
Interval
feet b s
TOC
Elevation
feet
Date
Measured
Depth to
Water
feet
Groundwater
Elevation
fee[
MW-1
3/23/2005
2
0.01
40
10-40
854.61
8/4/2005
31.28
823.33
10/17/2007
33.23
821.38
1/21/2009
35.56
819.05
6/24/2009
34.11
820.50
12/11/2009
33.76
820.85
6/23/2010
31.28
823.33
10/7/2010
30.36
824.25
5/18/2011
32.07
822.54
7/7/2011
32.35
822.26
8/8/2011
32.47
822.14
9/13/2011
32.80
821.81
12/28/2011
33.56
821.05
5/29/2012
33.47
821.14
6/26/2012
33.50
821.11
7/26/2012
33.71
820.90
2/20/2013
35.40
819.21
9/23/2013
34.01
820.60
4/8/2014
33.30
821.31
3/18/2015
34.32
820.29
2/9/2016
34.11
820.50
MW-2
3/23/2005
2
0.01
40
10-40
854.48
8/4/2005
31.1
823.38
10/17/2007
33.52
820.96
1/22/2009
35.33
819.15
6/25/2009
33.91
820.57
12/11/2009
33.53
820.95
6/23/2010
30.47
824.01
10/7/2010
30.52
823.96
5/18/2011
32.24
822.24
7/7/2011
32.50
821.98
8/8/2011
32.83
821.65
9/13/2011
32.96
821.52
12/28/2011
33.76
820.72
5/29/2012
33.66
820.82
6/26/2012
33.67
820.81
7/26/2012
33.93
820.55
2/20/2013
35.58
818.90
9/23/2013
34.21
820.27
4/8/2014
33.54
820.94
3/18/2015
34.45
820.03
2/9/2016
34.34
820.14
MW-3
7/27/2005
2
0.01
40
10-40
856.18
8/4/2005
32.72
823.46
10/17/2007
35.14
821.04
1/23/2009
36.94
819.24
6/24/2009
35.51
820.67
12/11/2009
35.17
821.01
6/23/2010
31.63
824.55
10/7/2010
31.74
824.44
5/18/2011
34.43
821.75
7/7/2011
33.74
822.44
8/8/2011
33.87
822.31
9/13/2011
34.21
821.97
12/28/2011
34.95
821.23
5/29/2012
34.88
821.30
6/26/2012
34.9
821.28
7/26/2012
35.12
821.06
2/20/2013
36.77
819.41
9/23/2013
36.48
819.70
4/8/2018
34.77
821.41
3/18/2015
35.69
820.49
2/9/2016
35.50
820.68
MW-4
7/26/2005
2
0.01
40
10-40
855.54
8/4/2005
32.29
823.25
10/17/2007
36.78
818.76
1/21/2009
36.47
819.07
6/24/2009
35.08
820.46
12/11/2009
34.69
820.85
6/23/2010
31.27
824.27
10/7/2010
31.28
824.26
5/18/2011
33.00
822.54
7/7/2011
33.31
822.23
8/8/2011
33.39
822.15
9/13/2011
33.73
821.81
12/28/2011
34.50
821.04
5/29/2012
34.42
821.12
6/26/2012
34.45
821.09
7/26/2012
35.65
819.89
2/20/2013
36.29
819.25
9/23/2013
34.97
820.57
4/8/2014
34.27
821.27
3/18/2015
35.24
820.30
2/9/2016
35.04
820.50
Note:
bgs = below ground surface
Page 1 of 2

TABLE2
MONITORING WELL CONSTRUCTION DETAILS AND HISTORICAL GROUNDWTER ELEVATIONS
CIRCLE K STORE #4358 (RM #4109)
2121 WEST CLEMMONSVILLE ROAD
WINSTON-SALEM, NC
ATC PROJECT NO. P664109503
Monitoring
Well
Insta llation
Date
Well
Diameter
inches
Screen
Slot Size
inches
Total Well
Depth
feet b s
Screen
Interval
feet b s
TOC
Elevation
(feet)
Date
Measured
Depth to
Water
feet
Groundwater
Elevation
fee[
MW-5D
7/27/2005
Outer casing
6
Inner casing
2
0.01
50
45-50
854.87
8/4/2005
31.48
823.39
10/17/2007
33.98
820.89
1/22/2009
35.71
819.16
6/25/2009
34.29
820.58
12/11/2009
33.94
820.93
6/23/2010
30.46
824.41
10/7/2010
30.55
824.32
5/18/2011
32.22
822.65
7/7/2011
32.52
822.35
8/8/2011
32.68
822.19
9/13/2011
32.98
821.89
12/28/2011
33.77
821.10
5/29/2012
33.67
821.20
6/26/2012
33.69
821.18
7/26/2012
33.89
820.98
2/20/2013
35.56
819.31
9/23/2013
34.22
820.65
4/8/2014
33.55
821.32
3/18/2015
34.49
820.38
2/9/2016
34.39
820.48
MW-6
7/26/2005
2
0.01
40
10-40
854.78
8/4/2005
31.46
823.32
10/17/2007
33.87
820.91
1/22/2009
35.66
819.12
6/24/2009
34.22
820.56
12/11/2009
34.85
819.93
6/23/2010
29.43
825.35
10/7/2010
30.46
824.32
5/18/2011
32.16
822.62
7/7/2011
32.46
822.32
8/8/2011
32.60
822.18
9/13/2011
32.91
821.87
12/28/2011
33.66
821.12
5/29/2012
33.58
821.2
6/26/2012
33.65
821.13
7/26/2012
33.85
820.93
2/20/2013
35.47
819.31
9/23/2013
34.15
820.63
4/8/2014
33.48
821.30
3/18/2015
34.40
820.38
2/9/2016
34.20
820.58
MW-7
1/15/2009
2
0.01
44
24-44
854.93
1/22/2009
35.72
819.21
6/24/2009
34.28
820.65
12/11/2009
33.95
820.98
6/23/2010
30.47
824.46
10/7/2010
30.61
824.32
5/18/2011
32.18
822.75
7/7/2011
32.51
822.42
8/8/2011
32.71
822.22
9/13/2011
32.98
821.95
12/28/2011
33.74
821.19
5/29/2012
33.68
821.25
6/26/2012
33.75
821.18
7/26/2012
33.97
820.96
2/20/2013
35.53
819.4
9/23/2013
34.27
820.66
4/8/2014
33.52
821.41
3/18/2015
34.45
820.48
2/9/2016
38.24
816.69
MW-8
1/15/2009
2
0.01
49
29-49
854.07
1/22/2009
41.46
812.61
6/24/2009
39.63
814.44
12/11/2009
39.81
814.26
6/23/2010
36.55
817.52
10/7/2010
38.03
816.04
5/18/2011
38.57
815.5
7/7/2011
39.30
814.77
8/8/2011
39.45
814.62
9/13/2011
40.88
813.19
12/28/2011
40.11
813.96
5/29/2012
39.51
814.56
6/26/2012
39.87
814.2
7/26/2012
40.48
813.59
2/20/2013
41.34
812.73
9/23/2013
40.40
813.67
4/8/2014
38.95
815.12
3/18/2015
40.92
813.15
2/9/2016
39.98
814.09
MW-9D
1/16/2009
Outer casing
6
Inner casing
2
0.01
70
65-70
855.08
1/22/2009
35.99
819.09
6/25/2009
34.52
820.56
12/11/2009
34.1
820.98
6/23/2010
30.69
824.39
10/7/2010
30.77
824.31
5/18/2011
32.48
822.6
7/7/2011
32.77
822.31
8/8/2011
32.92
822.16
9/13/2011
33.13
821.95
12/28/2011
34.00
821.08
5/29/2012
33.96
821.12
6/26/2012
33.89
821.19
7/26/2012
34.15
820.93
2/20/2013
35.60
819.48
9/23/2013
34.37
820.71
4/8/2014
33.63
821.45
3/18/2015
34.58
820.50
2/9/2016
1 34.55
820.53
Note:
bgs = below ground surfacc
Page 2 of 2

TABLES
HISTORICAL GROUNDWATER ANALYTICAL RESULTS
CIRCLE K STORE #4358 (RM #4109)
2121 WEST CLEMMONSVILLE ROAD
WINSTON-SALEM, NC
ATC PROJECT NO. P664109503
Monitoring
Date
Ethyl-
Total
Total
Isopropyl
Well
Sampled
Benzene
Toluene
benzene
Rylenes
BTEX
MTBE
ether
Naphthalene
EDB
6/9/2005
<0.5
<0.7
<0.8
<0.8
ND
40
<0.8
<I
<1
10/17/2007
<0.2
<0.5
<0.5
<1.6
ND
170
<0.5
<1
0.0053J
1/21/2009
<0.1
<0.1
<0.1
<0.1
ND
100
<0.1
<0.2
<0.021
6/24/2009
<0.1
<0.1
<0.1
<0.2
ND
120
<0.1
<0.1
<0.022
12/11/2009
<0.1
<0.1
<0.1
<0.1
ND
160
<0.1
<0.1
<0.1
6/23/2010
<0.1
<0.1
<0.1
<0.2
ND
220
0.79
<0.1
<0.1
5/18/2011
<0.1
<0.1
<0.2
<0.2
ND
130
<0.1
<0.1
<0.1
7/7/2011
<0.1
<0.1
<0.1
<0.1
ND
110
<0.1
<0.1
<0.1
8/8/2011
<0.1
0.21
<0.1
<0.1
0.21
180
0.4
0.14
<0.1
MW-1
9/13/2011
<0.5
<0.5
<0.5
<0.5
ND
94
<0.5
<0.5
<0.5
12/28/2011
<0.5
<0.5
<0.5
<0.5
ND
61
<0.5
<0.5
<0.5
5/29/2012
<0.5
<0.5
<0.5
<0.5
ND
53
<0.5
<0.5
<0.5
6/26/2012
<0.5
<0.5
<0.5
<0.5
ND
37
<0.5
<0.5
<0.5
7/26/2012
<0.5
<0.5
<0.5
<0.5
ND
30
<0.5
<0.5
<0.5
2/20/2013
<0.1
<0.1
<0.1
<0.2
ND
22
<0.1
<0.1
<0.1
9/23/2013
<0.5
<0.5
<0.5
<0.5
ND
18
<0.5
<0.5
<0.5
4/8/2014
<0.5
<0.5
<0.5
<0.5
ND
94
0.5J
<0.5
<0.5
3/18/2015
<0.5
<0.5
<0.5
<0.5
ND
12
<0.5
<0.5
<0.5
2/9/2016
<0.1
<0.1
<0.1
<0.1
ND
7.6
<0.1
<0.1
<0.1
6/9/2005
5
<0.7
<0.8
3
8
870
17
<l
<1
10/17/2007
6.6
<2.5
<2.5
<8
6.6
950
12J
<5
<0.0051
1/22/2009
2.8
<0.1
0.17
<0.1
2.97
360
4.2
<0.2
<0.021
6/25/2009
1.1
<0.1
<0.1
<0.2
1.1
180
3.5
<0.1
<0.023
12/11/2009
4.4
0.1
1.7
1.38
3.28
500
8.8
0.75
<0.1
6/23/2010
11
1.7
14
37.1
63.8
1,200
23
9
<0.1
5/18/2011
10
<1
5.5
<2
15.5
360
5.7
29
<1
7/7/2011
2.5
0.12
6.9
4.8
14.32
610
12
5.4
<0.1
8/8/2011
2.1
0.24
7.5
6.75
16.59
570
10
6.4
<0.1
MW-2
9/13/2011
1.6.1
<2.5
4.7
3.2
9.5
560
11
3.8
<2.5
12/28/2011
1.7.1
<2.5
7.3
1.6J
10.6
400
7.1
4.9
<2.5
5/29/2012
1.6.1
<2.5
6.8
1.2J
9.6
490
9.5
3.2
<2.5
6/26/2012
0.6J
<1
1.3
0.7J
2.6
250
3.6
0.6J
<1
7/26/2012
1J
<2.5
3.8
1.91
6.7
250
4.8
1.91
<2.5
2/20/2013
1.2.1
<0.1
3.2
<0.2
4.4
200
4.4
1.3J
<0.1
9/23/2013
1.5
<0.5
3.9
1.8J
7.2
160
2.6
2.4
<0.5
4/8/2014
0.6
<0.5
1.2
0.11
1.9
90
1.5
0.5
<0.5
3/18/2015
IAJ
<2.5
5.8
<2.5
7.2
140
3.4
1.91
<2.5
2/9/2016
0.3J
<0.1
0.7
<0.1
LO
39
0.5
<0.1
<0.1
8/4/2005
580
4,400
880
5,300
11,160
1,700
31
380
28
10/17/2007
310
4,300
980
6,500
12,090
1,400
41J
550
33
1/23/2009
190
1,700
630
3,500
6,020
1,800
57
250
22
6/24/2009
150
1,900
640
3,900
6,590
1,900
41
280
25
12/11/2009
130
2,200
570
4,000
6900
1,500
49
270
35
6/23/2010
89
2,000
390
3,300
5,779
1,200
40
280
43
5/18/2011
88
2,500
760
4,500
7,848
580
19
420
<1
7/7/2011
77
1,900
500
4,200
6,677
600
23
380
35
8/8/2011
95
3,100
800
6,000
9,995
740
20
530
38
MW-3
9/13/2011
80
2,900
760
5,800
9,540
680
21
470
29
12/28/2011
72
2,200
660
4,300
7,232
690
27
480
33
5/29/2012
38
1,800
570
4,100
6,508
770
30
390
32
6/26/2012
40
1,700
540
4,100
6,380
550
18
320
24
7/26/2012
32
1,500
430
3,100
5,062
580
26
310
33
2/20/2013
32
1,600
480
3,100
5,212
590
26
300
33
9/23/2013
19
1,000
310
2,300
3,629
660
21
200
35
4/8/2014
18
1,200
420
2,900
3,538
630
24
240
34
3/18/2015
15
1,300
600
3,200
5,115
330
15
380
25
2/9/2016
6.4
540
280
1620
2,446.4
370
14
190
21
8/4/2005
<0.5
<0.7
<0.8
<0.8
ND
66
<0.8
<I
<1
10/17/2007
<0.2
<0.5
<0.5
<1.6
ND
7.5
<0.5
<1
<0.0051
1/21/2009
<0.1
<0.1
<0.1
<0.1
ND
17
<0.1
<0.2
<0.021
6/24/2009
<0.1
<0.1
<0.1
<0.2
ND
14
<0.1
<0.1
<0.022
12/11/2009
<0.1
<0.1
<0.1
<0.1
ND
6.7
<0.1
<0.1
<0.1
6/23/2010
<0.1
<0.1
<0.1
<0.2
ND
16
<0.1
<0.1
<0.1
5/18/2011
<0.1
<0.1
<0.2
<0.2
ND
4.8
<0.1
<0.1
<0.1
7/7/2011
<0.1
<0.1
<0.1
<0.1
ND
6.2
<0.1
<0.1
<0.1
8/8/2011
<0.1
<0.1
<0.1
<0.1
ND
3.6
<0.1
<0.1
<0.1
MW-4
9/13/2011
<0.5
<0.5
<0.5
<0.5
ND
2.6
<0.5
<0.5
<0.5
12/28/2011
<0.5
<0.5
<0.5
<0.5
ND
2.3
<0.5
<0.5
<0.5
5/29/2012
<0.5
<0.5
<0.5
<0.5
ND
3.6
<0.5
0.1J
<0.5
6/26/2012
<0.5
<0.5
<0.5
<0.5
ND
4
<0.5
<0.5
<0.5
7/26/2012
<0.5
<0.5
<0.5
<0.5
ND
2.3
<0.5
<0.5
<0.5
2/20/2013
<0.1
<0.1
<0.1
<0.2
ND
7.7
<0.1
<0.1
<0.1
9/23/2013
<0.5
<0.5
<0.5
<0.5
ND
2.6
<0.5
<0.5
<0.5
4/8/2014
<0.5
<0.5
<0.5
<0.5
ND
2.6
<0.5
<0.5
<0.5
3/18/2015
<0.5
<0.5
<0.5
<0.5
ND
1
<0.5
<0.5
<0.5
2/9/2016
<0.1
<0.1
<0.1
<0.1
ND
1.l
<0.1
<0.1
<0.1
2L Standard
1
600
600
500
NE
20
70
6
0.02
GCL
5,000
260,000
84,500
85,500
NE
20,000
70,000
6,000
50
Notes:
1. "<' or ND = Not detected at or above the Laboratory Reporting Limit and/or laboratory method detection limit
2. Concentrations are reported in micrograms per liter (ug/1) = parts per billion
3. Concentrations in bold equal or exceed the NCDEQ 15A NCAC 02L. 0202 Groundwater Quality Standards (2L Standard)
4. GCL=Gross Contamination Level
5. EDB =Ethylene dibromide (1,2-Dibromoethane)
6. BTEX = Benzene, Toluene, Ethylbenzene, and Total Xylenes
7. MTBE = Methyl Tertiary Butyl Ether
8. NE = Not Established Page 1 of 3

TABLES
HISTORICAL GROUNDWATER ANALYTICAL RESULTS
CIRCLE K STORE #4358 (RM #4109)
2121 WEST CLEMMONSVILLE ROAD
WINSTON-SALEM, NC
ATC PROJECT NO. P664109503
Monitoring
Date
Ethyl-
Total
Total
Isopropyl
Benzene
Toluene
MTBE
Naphthalene
EDB
Well
Sampled
P
benzene
Xylenes
BTEX
ether
8/4/2005
<0.5
<0.7
<0.8
<0.8
ND
120
<0.8
<I
<1
10/17/2007
47
101
<10
64J
121
3,900
25J
<20
0.25
1/22/2009
100
290
180
1,170
1,740
2,900
36
140
0.83
6/25/2009
73
160
97
890
1,220
1,700
21
130
0.35
12/11/2009
65
2.1
120
442
629.1
980
17
190
<0.1
6/23/2010
17
<0.1
9.2
102.5
128.7
450
4
63
<0.1
5/18/2011
5.8
<0.1
3.8
18.4
28
140
1.3
43
<0.1
7/7/2011
3.2
0.12
1.5
19
23.82
110
0.9
34
<0.1
8/8/2011
3.2
<0.1
3.8
35.6
42.6
110
0.93
35
<0.1
MW-5D
9/13/2011
3
<0.5
3.3
36.3
42.6
120
1.3
23
<0.5
12/28/2011
3.9
<2.5
5
46
54.9
370
2.8
55
<2.5
5/29/2012
1.6.1
<2.5
1.8J
18
21.4
540
3.4
36
<2.5
6/26/2012
1.3.1
<2.5
IAJ
18.51
21.2
420
2.4J
34
<2.5
7/26/2012
1.81
<5
1.8J
18
21.6
500
3.8J
41
<5
2/20/2013
<0.1
<0.1
<0.1
2.6J
2.6
1,100
8.5J
28
<0.1
9/23/2013
<5
<5
<5
<5
ND
1,100
7.6
2.4J
<5
4/8/2014
<0.5
<0.5
<0.5
<0.5
ND
2,100
14
<0.5
<0.5
3/18/2015
<25
<25
<25
<25
ND
1,800
16J
<25
<25
2/9/2016
<5.0
<5.0
9.3J
26
35.3
2100
15J
13J
<5.0
8/4/2005
470
760
110
540
1,880
4,400
130
45
14
10/17/2007
670
5,300
800
3,100
9,870
4,900
120J
310
33
1/22/2009
1,300
11,000
1,700
6,700
20,700
5,400
270
740
87
6/24/2009
750
6,700
1,200
4,600
13,250
3,700
140
530
49
12/11/2009
1,500
16,000
2,200
9,400
29,100
3,800
190
690
72
6/23/2010
490
6,900
1,400
5,000
13,790
3,200
110
500
36
5/18/2011
160
2,600
960
1,670
5,390
2,200
57
290
<0.1
7/7/2011
140
1,500
770
1,470
3,880
2,300
40
240
12
8/8/2011
150
1,700
760
1,440
4,050
2,100
41
270
16
MW-6
9/13/2011
120
1,300
650
1,110
3,180
1,900
39
210
10
12/28/2011
110
1,100
540
1,010
2,760
1,800
30
180
6.9
5/29/2012
65
1,000
410
900
2,375
1,700
25
120
4.2.1
6/26/2012
150
2,800
720
2,500
6,170
2,300
40
280
12
7/26/2012
68
1,100
370
1,050
2,588
1,200
23
150
6.14
2/20/2013
160
3,200
680
2,700
6,740
1,700
43
260
181
9/23/2013
110
3,200
600
2,490
6,400
900
20
230
13
4/8/2014
150
5,000
940
3,600
9,690
1,200
36
280
18J
3/18/2015
51
1,600
280
1,310
3,241
330
11
110
8.7
2/9/2016
140
5,700
1,200
4,900
11,940
1,700
46
360
26
1/22/2009
<0.1
1
<0.1
0.43
1.43
360
1.9
l
<0.021
6/24/2009
<0.1
<0.1
<0.1
<0.2
ND
310
1.6
<0.1
<0.023
12/11/2009
<0.1
<0.1
<0.1
<0.1
ND
280
1
<0.1
<0.1
6/23/2010
<0.1
<0.1
<0.1
<0.2
ND
220
0.46
<0.1
<0.1
5/18/2011
<0.1
<0.1
<0.2
<0.2
ND
180
1.1
<0.1
<0.1
7/7/2011
<0.1
0.34
<0.1
<0.1
0.34
280
0.75
<0.1
<0.1
8/8/2011
<0.5
<0.5
<0.5
<0.5
ND
250
0.61
<2.5
<0.5
9/13/2011
<0.5
2.2
<0.5
<0.5
2.2
190
<0.8
<0.5
<0.5
MW-7
12/28/2011
<0.5
<0.5
<0.5
<0.5
ND
120
0.4J
<0.5
<0.5
5/29/2012
<0.5
<0.5
<0.5
<0.5
ND
83
0.3J
<0.5
<0.5
6/26/2012
<0.5
<0.5
<0.5
<0.5
ND
74
0.2J
<0.5
<0.5
7/26/2012
<0.5
<0.5
<0.5
<0.5
ND
54
0.2J
<0.5
<0.5
2/20/2013
<0.1
<0.1
<0.1
<0.2
ND
30
0.2J
<0.1
<0.1
9/23/2013
<0.5
<0.5
<0.5
<0.5
ND
64
0.11
<0.5
<0.5
4/8/2014
<0.5
<0.5
<0.5
<0.5
ND
220
<0.5
<0.5
<0.5
3/18/2015
<0.5
<0.5
<0.5
<0.5
ND
75
<0.5
<0.5
<0.5
2/9/2016
<0.1
<0.1
<0.1
<0.1
ND
12
<0.1
<0.1
<0.1
1/22/2009
<0.1
0.14
<0.1
<0.1
0.14
100
0.63
<0.2
<0.021
6/24/2009
<0.1
<0.1
<0.1
<0.2
ND
7.8
<0.1
<0.1
<0.023
12/11/2009
<0.1
<0.1
<0.1
<0.1
ND
15
<0.1
<0.1
<0.1
6/23/2010
<0.1
<0.1
<0.1
<0.2
ND
0.43
<0.1
<0.1
<0.1
5/18/2011
<0.1
<0.1
<0.2
<0.2
ND
7.5
<0.1
<0.1
<0.1
7/7/2011
<0.1
<0.1
<0.1
<0.1
ND
12
<0.1
<0.1
<0.1
8/8/2011
<0.1
<0.1
<0.1
<0.1
ND
19
<0.1
<0.1
<0.1
9/13/2011
<0.5
<0.5
<0.1
<0.5
ND
4
<0.5
<0.5
<0.5
MW-8
12/28/2011
<0.5
<0.5
<0.5
<0.5
ND
0.2J
<0.5
<0.5
<0.5
5/29/2012
<0.5
<0.5
<0.5
<0.5
ND
<0.5
<0.5
<0.5
<0.5
6/26/2012
<0.5
<0.5
<0.5
<0.5
ND
12
0.11
<0.5
<0.5
7/26/2012
<0.5
<0.5
<0.5
<0.5
ND
0.8
<0.5
<0.5
<0.5
2/20/2013
<0.1
<0.1
<0.1
<0.2
ND
20
<0.1
<0.1
<0.1
9/23/2013
<0.5
<0.5
<0.5
<0.5
ND
0.1J
<0.5
<0.5
<0.5
4/8/2014
<0.5
<0.5
<0.5
<0.5
ND
0.4J
<0.5
<0.5
<0.5
3/18/2015
<0.5
<0.5
<0.5
<0.5
ND
51
0.11
<0.5
<0.5
2/9/2016
<0.1
<0.1
<0.1
<0.1
ND
1.2
<0.1
<0.1
<0.1
2L Standard
1
600
600
500
NE
20
70
6
0.02
GCL
5,000
260,000
84,500
85,500
NE
20,000
70,000
6,000
50
Notes:
1. "<' or ND = Not detected at or above the Laboratory Reporting Limit and/or laboratory method detection limit
2. Concentrations are reported in micrograms per liter (ag/1) = parts per billion
3. Concentrations in bold equal or exceed the NCDEQ 15A NCAC 02L. 0202 Groandwater Quality Standards (2L Standard)
4. GCL=Gross Contamination Level
5. EDB =Ethylene dibromide (1,2-Dibromoethane)
6. BTEX = Benzene, Toluene, Ethylbenzene, and Total Xylenes
7. MTBE = Methyl Tertiary Butyl Ether
8. NE = Not Established
Page 2 of 3

TABLES
HISTORICAL GROUNDWATER ANALYTICAL RESULTS
CIRCLE K STORE #4358 (RM #4109)
2121 WEST CLEMMONSVILLE ROAD
WINSTON-SALEM, NC
ATC PROJECT NO. P664109503
Monitoring
Date
Ethyl-
Total
Total
Isopropyl
Benzene
Toluene
MTBE
Naphthalene
EDB
Well
Sampled
P
benzene
Xylenes
BTEX
ether
1/22/2009
<0.1
0.13
<0.1
0.27
0.40
<0.2
<0.1
<0.2
<0.021
6/25/2009
<0.1
<0.1
<0.1
<0.2
ND
0.33
<0.1
<0.1
<0.021
12/11/2009
<0.1
<0.1
<0.1
<0.1
ND
<0.2
<0.1
<0.1
<0.1
6/23/2010
<0.1
<0.1
<0.1
<0.2
ND
<0.2
<0.1
<0.1
<0.1
5/18/2011
<0.1
<0.1
<0.2
<0.2
ND
<0.2
<0.1
<0.1
<0.1
7/7/2011
<0.1
<0.1
<0.1
<0.1
ND
<0.2
<0.1
<0.1
<0.1
8/8/2011
<0.1
<0.1
<0.1
<0.1
ND
<0.2
<0.1
<0.1
<0.1
9/13/2011
<0.5
<0.5
<0.5
<0.5
ND
<0.5
<0.5
<0.5
<0.5
MW-913
12/28/2011
<0.5
<0.5
<0.5
<0.5
ND
<0.5
<0.5
<0.5
<0.5
5/29/2012
<0.5
<0.5
<0.5
<0.5
ND
<0.5
<0.5
<0.5
<0.5
6/26/2012
<0.5
<0.5
<0.5
<0.5
ND
<0.5
<0.5
<0.5
<0.5
7/26/2012
<0.5
<0.5
<0.5
<0.5
ND
<0.5
<0.5
<0.5
<0.5
2/20/2013
<0.1
<0.1
<0.1
<0.2
ND
<0.1
<0.1
<0.1
<0.1
9/23/2013
<0.5
<0.5
<0.5
<0.5
ND
43
0.3J
0.4J
<0.5
4/8/2014
<0.5
<0.5
<0.5
<0.5
ND
<0.5
<0.5
<0.5
<0.5
3/18/2015
<0.5
<0.5
<0.5
<0.5
ND
49
0.4J
<0.5
<0.5
2/9/2016
<0.1
<0.1
<0.1
<1.0
ND
240
1.5J
<0.1
<0.1
2L Standard
1
fillll
fillll
500
NE
20
70
6
0.02
GCL
5,000
260,000
84 SUU
85 500
NE
20 0001
70,000
6,000
50
Notes:
1. "<' or ND = Not detected at or above the Laboratory Reporting Limit and/or laboratory method detection limit
2. Concentrations are reported in micrograms per liter (ug/1) = parts per billion
3. Concentrations in bold equal or exceed the NCDEQ 15A NCAC 02L. 0202 Groundwater Quality Standards (2L Standard)
4. GCL=Gross Contamination Level
5. EDB =Ethylene dibromide (1,2-Dibromoethane)
6. BTEX = Benzene, Toluene, Ethylbenzene, and Total Xylenes
7. MTBE = Methyl Tertiary Butyl Ether
B. NE = Not Established
Page 3 of 3

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SCALE: SEE ABOVE I DATE: 01/20121 REVIEWED BY: GA
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SOIL ANALYTICAL MAP /
/
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2121 WEST C L E M M O N S VI L L E ROAD Raleigh, North Carolina 27604 ENVIRONMENTAL • GEOTECHNICAL
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WINSTON-SALEM, NORTH CAROLINA [phone] FAX [phone] BUILDING SCIENCES • MATERIALS TESTING
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ENVIRONMENTAL • GEOTECHNICAL
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[phone] FAX [phone]
BUILDING SCIENCES • MATERIALS TESTING
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WINSTON-SALEM, NORTH CAROLINA
CAD FILE TYPE CODE PREP. BY REV. BY
1253730-DWG AM GA
Raleigh, North Carolina 27604
[phone] FAX [phone]
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ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
SCALE DATE PROJECT NO.
1" = 60' L-02-20161 P664109503

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TITLE r Il7UKt /
1. SAMPLES COLLECTED AT EACH MONITORING WELL
ON 02/09/2016.
CHEMICALS OF CONCERN IN GROUNDWATER
kTc
2. CONCENTRATIONS ARE PRESENTED AS MICROGRAMS
CIRCLE K STORE # 43 58 (RIM 4109 )
N
PER LITER (uG/L).
2121 WEST CLEMMONSVILLE ROAD
W I N S T O N- S A L E M, NORTH C A R O L I N A
Raleigh, North Carolina 27604 ENVIRONMENTAL•GEOTECHNICAL
[phone] FAX [phone] BUILDING SCIENCES • MATERIALS TESTING
CAD FILE
TYPE CODE
PREP. BY
REV. BY
SCALE
DATE
PROJECT NO.
1253730-DWG
AM
GA
1" = 60'
03-02-2016
P664109503

— sthompson —
—12-07—
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NOTES: TITLE FIGURE 8
WATER SUPPLY WELL LOCATION MAP L
O
CIRCLE K STORE #4358 (RM 4109) O
2121 WEST CLEMMONSVILLE ROAD ENVIRONMENTAL • GEOTECHNICAL
Raleigh, North Carolina 27604
WINSTON-SALEM, NORTH CAROLINA [phone] FAX [phone] BUILDING SCIENCES• MATERIALS TESTING
CAD FILE TYPE CODE PREP. BY REV. BY SCALE DATE PROJECT NO.
1253730.DWG AW GA 1" = 300' 112-07-20161 P664109503

APPENDIX A
WELL ABANDONMENT RECORD

WELL ABANDONMENT RECORD
This form can be used for single or multiple wells
1. Well Contractor Information:
MARK IRELAND
Well Contractor Name (or well owner personally abandoning well on his/her property)
A - 4163
NC Well Contractor Certification Number
GEOLOGIC EXPLORATION, INC
Company Name
2. Well Construction Permit #:
List all applicable we// cosstruction permits ri.e. County, State, Variance, etc.) ifknotrn
3. Well use (check well use):
Water Supply Well:
❑Agricultural
❑Geothermal (Heating/Cooling Supply)
❑ Industrial/Commercial
❑Municipal/Public
OResidential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
❑Monitoring
❑Recovery
Injection Well:
❑Aquifer Recharge
❑Groundwater Remediation
❑Aquifer Storage and Recovery
❑Salinity Barrier
❑Aquifer Test
❑Stormwater Drainage
❑Experimental Technology
❑Subsidence Control
❑Geothermal (Closed Loop)
❑Tracer
❑Geothermal (Heating/Cooling Return)
❑Other (explain under 7g)
4. Date well(s) abandoned: 1 1 /02/16
5a. Well location:
RM - 4109
Facility/Owner Name Facility IDH (if applicable)
2111 WEST CLEMMONSVILLE ROAD WINSTON SALEM 27127
Physical Address, City, and Zip
FORSYTH
County
Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
36e 01' 37.87" N 800 17' 32.30"
For Internal Use ONLY:
WELL ABANDONMENT DETAILS
7a. Number of wells being abandoned: 1
For multiple injection or non -crater supply wells ONLY with the saute
construction abandonment, you can submit one fornt.
7b. Approximate volume of water remaining in well(s): 375.25 (gal.)
FOR WATER SUPPLY WELLS ONLY:
7c. Type of disinfectant used:
7d. Amount of disinfectant used:
7e. Sealing materials used (check all that apply):
ID Neat Cement Grout
❑ Bentonite Chips or Pellets
❑ Sand Cement Grout
❑ Dry Clay
❑ Concrete Grout
❑ Drill Cuttings
❑ Specialty Grout
❑ Gravel
❑ Bentonite Slurry
❑ Other (explain under 7g)
7f. For each material selected above, provide amount of materials used:
701.75 GALLONS
7g. Provide a brief description of the abandonment procedure:
WELL ABANDONED VIA TREMIE PIPE WITH
PORTLAND BENTONITE SLURRY
8. Certification:
11/16/16
S atureofCertifiedWell tororWellOwner Date
By signing this form, / hereby certify that the well(s) was (were) abandoned in
accordance with /SA NCAC 02C .0/00 or 2C .0200 Well Construction Standards
and that a copy of this record has been provided to the well owner.
9. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
W abandonment details. You may also attach additional pages if necessary.
CONSTRUCTION DETAILS OF WELL(S) BEING ABANDONED
Attach well construction record(y) if orailable. For multiple it jecoon or non -Crater supply
wells ONLY frith the same construction abandonment, you can submit one form.
6a. Well ID#: WSW-2
6b. Total well depth: 43.0 (ft.)
6c. Borehole diameter: 20.0 (in.)
6d. Water level below ground surface: 20.0
SUBMITTAL INSTRUCTIONS
10a. For All Wells: Submit this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
10b. For Iniection Wells: In addition to sending the form to the address in 10a
above, also submit one copy of this form within 30 days of completion of well
abandonment to the following:
Division of Water Quality, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
fie. Outer casing length (if known): (ft.) 10c. For Water Supply & Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
completion of well abandonment to the county health department of the county
6E Inner casing/tubing length (if known): (ft.) where abandoned.
6g. Screen length (if known): (ft.)
Form GW-30 North Carolina Department of Environment and Natural Resources — Division of Water Quality Revised March 2013