WI0300502_Notification of Intent (NOI) – GW Remediation_20231002

MECEWD
OCT 0 2 2 93140 lailuaD
(1liaib3a QM
NC DEQ/D."? a 0100
Central Off
NC Department of Environmental Quality (DEQ)—Division of Water Resources � VR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule"and do not require an application to be submitted and an individual permit
be issued when constructed in accordance with the rules of I5A NCAC 02C.0200(NOTE: This form must be
received at least 14 DAYS prior to infection)
GROUNDWATER(GW)REMEDIATION INJECTION PERMIT TYPES:
(1)IN-SITU GW REMEDIATION PERMIT TYPE(15A NCAC 02C.0225)
• In-Situ 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).
• In-Situ Small-Scale Injection Operations—Injection wells located within a land surface area not to exceed 10,000
square feet(SF)for the purpose of soil or groundwater remediation or tracer tests. If area to be treated exceeds 10,000
SF do not use this NOI;an injection Permit application shall be submitted,and a Permit issued per 15A NCAC
02C.0225(f).
• In-Situ Pilot Tests-Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy 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. Also,if pilot test is going to be conducted on separate groundwater
contaminant plumes do not use this NOI;a Permit application shall be submitted,and a Permit issued as per
15A NCAC 02C .0225(f).
• In-Situ Thermal(IST)—IST wells 'heat'contaminated groundwater in-situ to enhance remediation.
(2)AIR INJECTION PERMIT TYPE(15A NCAC 02C.0225)
These permit types are used to inject ambient air to enhance treatment of soil or groundwater.
(3)TRACER WELL PERMIT TYPE(15A NCAC 02C.0229)
These permit types are used to inject substances for determining hydrogeologic properties of aquifers.
(4)AQUIFER TEST PERMIT TYPE(15A NCAC 02C.0220)
These permit types are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
DATE: September 29 2023 NOI TRACKING NO. (To be filled in by DWR)
DIRECTIONS- Submit this NOI only for(1)New deemed `permitted by rule' injection project or(2)If there is going
to be a different permit type(listed above)used for a previously issued NOI.
NOTE-After this NOI is processed and acknowledged,any supplemental or additional injections still meeting the
criteria referenced in Section G below shall be reported using Injection Event Records(IERs)and using the NOI
tracking number provided by DWR.
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) Passive Injection System...............................Complete sections B through F,H-M
(4) X 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
Deemed Permitted GW Remediation NOl Rev.3-1-2023 Page 1

,
B. STATUS OF WELL OWNER: State Government
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): North Carolina Department of Environmental Quality—Underground Storage Tank/State Lead
Mailing Address: 3800 Barrett Dr.
City: Raleigh State: NC Zip Code: 27609 County:Wake
Day Tele No.: 919-707-8166 Cell No.: 919-280-8900
EMAIL Address: Sharon.ghioldrn.deq.nc.gov Fax No.:
D. PROPERTY OWNER(S)(if different than well owner/applicant)
Name and Title: Mr.Richard Bronson
Company Name Not Applicable-Residence
Mailing Address: 7918 Royal Court
City: Waxhaw State:NC Zip Code: 28173 County:Union
Day Tele No.: 704-843-3769 Cell No.: Unknown
EMAIL Address:Unknown Fax No.:
E. PROJECT CONTACT(Typically Environmental Consulting/Engineering Firm)
Name and Title: Sean O'Neil,PE Contract Manager
Company Name CATLIN Engineers and Scientists
Mailing Address: 1044 Washington Street
City: Raleigh State: NC Zip Code: 27605 County:Wake
Day Tele No.: 984-222-1214 Cell No.: 919-539-4403
EMAIL Address:sean.oneil`catlinusa.com Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name&Address: McCain Grocery
10018 Lancaster Highway
(2) City:Waxhaw County:Union Zip Code: 28173
(3) Geographic Coordinates: Latitude": 0 "or 34 0.83603
Longitude": 0
If
or -80 1.72821
Reference Datum:NAD83 Accuracy: +/-5 feet
Method of Collection: Gooele Earth
"FOR AIR INJECTION AND AQUIFER TEST WELLS ONLY: A FACILITY SITE MAP WITH PROPERTY
BOUNDARIES MAY BE SUBMITTED IN LIEU OF GEOGRAPHIC COORDINATES.
G. TREATMENT AREA
Land surface area of contaminant plume: 34,075 square feet
Land surface area of inj.well network: 4,650 square feet(< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 14% (must be<5%of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev.3-1-2023 Page 2

r
H. INJECTION ZONE MAPS—Attach the following to the notification.
(1) Contaminant plume map(s) with isoconcentration lines that show the horizontal extent of the
contaminant plume in soil and groundwater, existing and proposed monitoring wells, and existing and
proposed injection wells;and
(2) Cross-section(s)to the known or projected depth of contamination that show the horizontal and vertical
extent of the contaminant plume in soil and groundwater, changes in lithology, existing and proposed
monitoring wells,and existing and proposed injection wells.
(3) Potentiometric surface map(s)indicating the rate and direction of groundwater movement,plus existing
and proposed wells.
I. 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:
BOS 200+injection to treat residual LNAPL and dissolved phase concentrations associated with the former UST
system. Injection consists of 55 temporary DPT injection points injecting between 30 and 50 feet below eround
surface. TwoAdditional points were installed but hit refusal prior to infection depth.
J. WELL CONSTRUCTION DATA
(1) No.of injection wells: 57 Proposed Existing(provide NC Well
Construction Record(GW-1)for each well)
(2) Appx. injection depths(BLS): 30 to 50 feet BLS
(3) For Proposed wells or Existing wells not having GW-ls,provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following(indicate if construction is proposed or as-built):
(a) Well type as permanent,Geoprobe/DPT,or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth,screen,and sand pack
(c) Well contractor name and certification number
K. INJECTION SUMMARY
NOTE: Onh,iniectants approved br the epidemiology•section ofthe NC Division ofPublic Health.Department
of Health and Human Services can be infected. &J-7roved iniectants can be found online at
http://d2g.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/k;round-water-approved-injectants. All other substances must be reviewed br the DHHS prior to use.
Contact the UIC Program for more info if you wish to get approval for a dill Brent additive. However,please
note it mai take 3 months or longer. If no iniectants are to be used use N/A.
Injectant: BOS 200 Total Amt.to be injected(gal)/event: 25.300 lbs
Injectant: Gypsum Total Amt.to be injected(gal)/event: 8,450 lbs
Injectant: Magnesium Sulfate Total Amt. to be injected(gal)/event: 8,450 lbs
Injectant:Starch Total Amt. to be injected(gal)/event: 4,249.50 lbs
Injectant:Yeast Extract Total Amt. to be injected(gal)/event: 165 lbs
Deemed Permitted GW Remediation NOI Rev.3-I-2023 Page 3

Total Amt.to be injected(gal/event): 12.600 gallons
No.of separate injection events:I Total Amt.to be injected(gal): 12,600 gallons
Source of Water(if applicable): Delivered to site from water transporter located in Charlotte.NC
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.
Post iniection groundwater monitoring will be conducted on a quarterly basis followingthe he injection.Provided
results are over GCL standards specified in Subchapter 02L the agency will be notified immediately.
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 15A NCAC 02C 0200 Rules."
J-^--' ©& Sean O'Neil.PE/CATLIN Engineers Project Manager(On Behalf ofNCDEQ)
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 wells)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.02001-"
"Owner"means any person who holds the fee or other property rights in the well being constructed.A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
See Access Agreement
Signature*of Property Owner(if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant andproperty 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 NO[Rev.3-1-2023 Page 4

ATTACHMENT H
INJECTION ZONE DETAILS

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Elevation (Feet)
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Groundwater Contour ( ) .'*` r► ' "`
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Water Supply Well "f T
Approximate Location
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a
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MaxarR- ,rt sta�,Ge •ra
NOTES:
1.Well and tank locations were obtained from previous reports 40 20 0 40 80
prepared by other consultants and are approximate. MONEMENid 2.The groundwater elevation contour interval is 0.50 feet. Feet
PROJECT TITLE
MCCAIN GROCERY FIGURE
ATLII� 10018 GROUNDWATER ELEVATION —
LANCASTER HWY MARCH 22, 2023
WAXHAW, NC
Engineers and Scientists
INCIDENT N0. JOB N0. DATE SCALE DRAWN BYICHECKED BY
27981 I 223071 1 MAY 2023 1 AS SHOWN KMC/BJA

SUMMARY OF GROUNDWATER LABORATORY RESULTS-STANDARD METHOD 6200B
Incident Name and No.: McCain Grocery-27981
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Date c Q on° NESample M
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ID m N C LU W N N V O �_ Z C F F H F
MW-1 R 03/22/23 8,100 J 9,300 5,300 48 J <32 1 <35 1,100 430 2,400 2,000 60 J <32 f 340 Ll 160 22,000 1,800 540 13,900
MW-2 03/22/23 <20 130 <17 20 3.9 J 14 <1.6 f <2.0 160 <12 52 11 190 L 75 7.4 810 280 1,543 1
MW-3 03/22/23 7.3 J 10 <1.7 5.0 2.1 4.3 <0.161 <0.20 0.75 <1.2 2.1 1.3 0.65 L 6.0 <0.22 4.9 4.3 <1.34"
MW-5 03/22/23 <2.0 <0.18 <1.7 <0.15 <0.13 <0.14 <0.161 <0.20 <0.22 <1.2 <0.15 <0.13 <0.38 <0.12 <0.22 <0.20 <0.15 <0.73
MW-6 03/22/23 1,400 J 4,200 910 810 110 180 <8.01 130 3,000 <601 250 74 460 L 1,100 5,100 6,900 2,600 14,800
MW-10 03/22/23 5.2 J <0.18 <1.7 <0.15 <0.13 <0.14 <0.161 <0.20 <0.22 <1.2 <0.15 <0.13 <0.38 <0.12 <0.22 <0.20 <0.15 <0,73
GCL(pg/L)6,000,000 5,000 4,000,000 5,900 8,800 14,750 50 7g000 80,000 40,000 30,500 11,700 6,000 26,105 260,000 28,500 24,100 1 50,000 `
2L GWQS(N /L 6,000 1 4,000 70 70 70 0.02 70 600 40 70 25 6 70 600 400 400 500 r�
A 11 results in micro grams per liter(pg/L). Bold results are above 2L GWQS. Shaded results are above GCL. Referto Table 4 for all other results and notes.
MW-10
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.l� ESTIMATED HORIZONTAL
EXTENT OF 2L GWQS
'1Asw - EXCEEDANCES
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` EXTENT OF GCL
J_* , EXCEEDANCES
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LEGEND 1 1
Sampled Monitoring
Well (Type II)
© Active Potable
Water Supply Well
aApproximate Location %��
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NOTE: Well and tank locations were obtained from previous
reports prepared by other consultants and are approximate. 50 25 0 50 100
Feet
PROJECT TITLE
MCCAIN GROCERY MONITORING WELL FIGURE
ATLIN
10018 GROUNDWATER SAMPLE
LANCASTER HWY ANALYTICAL RESULTS-
WAXHAW, NC
Engineers and Scientists MARCH 22, 2023
INCIDENT NO. I JOB NO. DATE SCALE I DRAWN BYICHECKED BY
27981 223071 MAY 2023 AS SHOVVN KMC/BJA

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ATTACHMENT J
CONSTRUCTION RECORDS

WELL CONSTRUCTION RECORD(GW-1? For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM TO I DESCRIPTION
A. n.
A - 2581
n. rt.
NC Well Contractor Certification Number 15.OUTER CASING for mutti-eased wells OR LINER if livable
GEOLOGIC EXPLORATION FROM TO DIAMETER THICKNESS MATERIAL
rt. rL In.
Company Name 16.INNER CASINO OR TUBING Thermal closed-two)
2.Well Construction Permit kh FROM TO ILVIAMETER THICKNESS MATERIAL
r.i..i all applicable urll conxbVction pernritr(i.e.(11C.County,Scare.Variance,etc) ft. fr. in,
3.Well Use(check well use): it, ft. in.
Water Supply Well: 17.SCREEN
FROM TO I DIAMETER I SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. rt. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
Dirrieation ❑Wel)s> 100,000GPD FROM TO MATERIAL EMPLACEMENPMEfHOD&AMOUNT
_
Non-Water Supply Well: n n'
❑Monitoring QRecovery
Injection Well:
rt. rt.
❑Aquifer Recharge 15Ground%vater Remediation
19.SAND/CRAVELPACK Ifa livable
OAquifer Storage and Recovery ❑Salinity Barrier FROM i TO MATERIAL EMPLACEMENrMEFHOD
❑Aquifer Test ❑SlormuraterDrainage rt' I n•
❑Experimental Technology ❑Subsidence Control ft, I n.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheen if necessary)
❑Geothermal(Heat in `Coolin Return) 00ther(explain under f121 Remarks) FROM TO DESCRIPTION eelor.hnriftim soillmis min size.etc.
0.0 n• 49.0 ft. DIRECT PUSH
o6M/23-Ob/2t/23 SEE REMARKS ft. ft.
4.Date Wells)Completed: Well 1 Dli
5s.Well Location:
MCCAIN GROCERY
Facility/Owner Name Facility 1134(ifappbcable) n. ft.
10018 LANCASTER HIGHWAY WAXHAW 28173
Physical Address.City,and Zip fL ft.
UNION 21.REMARKS
County Parcel Identification No(PIN) AA A-3,A-5,A-7,A-9,A-11,A-13,A•15,A-17,A-19,A-21,A-23,A-25
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(ifwell ficld.one lodlong is sufficient) 22.Certification:
34° 50' 10.46" N 800 43' 42.21" W ON,,_.
09/15/23
6.Is(are)the well(s): ❑Permanent or OTemporary signature ol'Cenified well Contractor Date
Hysilming th6fitrin.1 hereby certify Char the rreli{s)tras Arere)caturructedin accordance inch
7.Is this a repair to an existing well: ❑Yes or MNo 15A N AC 02( 0100 ar ISA NL AC 02C.02(N1 Weli Consrnrc+la»Srmtdonlr utrd dery a rrgir
If ihli is a repair.Jill our kiwi ten well refufniclion n farmattrnt and explain fire rarture aj"die ofthis record has been prrn•ided to the well ostwer
repair tartkr-21 renrarkt seedoa or on die back of this farm.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional sell construction info
construction,only 1 GW-I is needed Indicate TOTAL NUMBER of istclls (add'See Over'in Remarks Box).You may also attach additional pages if necessary
drilled: 11 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 49.0 (n.)
1•irr mrdttple wells list all depdrs fdpirerrt(example-3 200'wid 2-01W) Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR).
10.Static water level below top of casing: (fL) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1 6 1 7
lfuaterlereiisaborecasing.use" "
11.Borehole diameter: 2.25 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(111C,
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: DPT RODS
24c.For Water 5u pIv and O cn-Loo Geothermal Return Neils:Copv_ to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departmenl o i e county w.ere Installs
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producinL,over 100 000 GPD:Copy to DWR.C CPCUA
Permit Program,1611 MSC,Raleigh,INC 276- ,1
13a.Yield(gpm) Method of test: 6I
13b.Disinfection type: Amount:
Form G W-1 North Carolina Depanment of Environmental Quality-Division of Water Re_at.:ces Re%ised i;4 1073

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
!.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Name FROM To DESCRIPTION -
ft. R
A - 2581
R. R.
NC Well Contractor Centrreation Number 15.OUTER CASING for multi-cased wells OR LINER if a Rcable
GEOLOGIC EXPLORATION FROM To DIAMETER TH1cKNE3S MATERIAL
fl. R. in.
Company Name
I'L INNER CASING OR TUDING fleotheramil closed400
2,Well Construction Permit H: FROM TO I DIAMETER I THICKNESS I MATERIAL
4W all applicable twit canstracriao peraritr(i.e.UIr•.County,,late,Variance,etc) ff. R. I in.
3.Well Use(check well use): fr. rt. in.
Water Supply Well: 17.SCREEN
FROM i TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) R• R. in.
[)Industrial/Commercial OResidential Water Supply(shared) I&GROUT
01rrl.i,tion O Wells>100,000 GPD FROM . TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. rt.
❑Monitoring ❑Recovery ft. ft.
Injection Well:
R. R.
OAqu i ler Recharge OGroundwatcrRemediation 19.SANDIGRAVEL PAC K ifs (cable
❑Aquifer Storage and Recovery OSelinity Barrier FROM TO I MATERIAL I EMPIACEMENTMETHOO
OAquifer Test OStormwaler Drainage
OExperimental Technology ❑Subsidence Control R. ft.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILL[NG LOG taftch additional sheets if necesfa
OGeothermal(Heatin Coolin Return) OOther(explain under#21 Remarks) FRO'`t TO DESCRIPTION color,hardomsolurorknpgynln tizt,He,
0.0 It. 50.0 fl. DIRECT PUSH
06/ow23-06/Zt/23 4.Date Well(s)Completed: Well IDH SEE REMARKS R. ft
Sm.Well Location: ft. ft.
MCCAIN GROCERY R ft
Faciliry/Owner Name Facility IDH(if applicable)
10018 LANCASTER HIGHWAY WAXHAW 28173 fl. ft.
Physical Addrass,City,and Zip R. ff.
UNION 21.REMARKS
County Parcel Identification No.(PIN)
A-2,A-4,A-6,A-8,A-10,A-12,A-14,A-16,A-18,A-20,A-22,A-24
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(jfwell field,one fat/long is sufficient) 22.Certification:
340 50' 10.46" N 80"43' 42.21" W !z/ fiz-1010--• 09/15/23
6.Is(are)the well(s): ❑Permanent or ifflTemporary signature ofCertified Well Contractor Date
By signing this farm,I hereby certify that the irell(s)rros(irere)comirueted in accortknnce n•ith
7.Is this a repair to an existing well: ❑Yes or RlNo 15A NCAC 02('.0lW or 15A NCAC 02C.0200 Well Consiruclimr Standards and that:a ca/n
lfdns is a repoir.fill out 4noun trell construction information and explain the mature of the of this recard has been provided to the,yell ouwer.
repair under 921 reotarks section or on the back ofihis form.
23,Site diagram or additional well derails:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages If necessary
drilled: 12 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50.0 (ft.)
Hat muluple trells lin all depths ifdperent(example-3 a 00'atid 2tt 100') Submit this GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (ft.) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
lfirater level is above casing use'•.'
11.Borehole diameter: 2.25 (in.) 24b. For Injection Wells:Copy to DWR,Underground Injection Control(JUC)
Program,1636 MSC,Raleigh,NC 27699.1636
12,Well construction method: APT RODS
----- 24c,For Water Su li and O en-Loo Geothermal Return Wells:Copy to the
G a auger,rotary,cable,direct push,etc.) county environmental health department of the county Ahere installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roducin over f00,000 GPD;Copy to DWR,CCPCUA
Permit Program,1611 M- :,Rale
13a.field(gpm) Method of test: tgn NC 27699-1 61 1
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality•Division of Water Resources Revised 6-6-2019

WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
I.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
FROM TO DESCRIPTION
Well COMMOor Name R• R.
A - 2581 ft. p.
NC Well Contractor Certification Number I&OUTER CASING Ifor multi-cased wells)OR LINER if■ lieable
GEOLOGIC EXPLORATION _ FROM ft. To DtAMEr¢R1� 'THICKNESS MATERIAL
I IL
Company Name Id.INNER CASING OR TUBING tteothermal closed-loo
2,Well Construction Permit N: FROM TO DIAMLri'ER THICtWI:SS MATERIAL
Lista!l opplicahle well catstrnednn pernrits(i.e.UH•.Countjt Siate.Variance,etc) ft. ft. in.
3.Well Use(check well use): fL a, in.
Water Supply Well: 17.SCREEN
PPY FROM To DIAMETER SLOT SIZE THtCKNF.SS MATERIAL
❑Agricultural ❑Municipal/Public h. ft. In.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft. is
[]Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
Olm ation ❑Wells>100,000GPD PSAND/GIRAVEL
TO MATERIAL EMPLACEMENT MErHOD&AMOUNT
Non-Water Supply Well: fr'
[]Monitoring []Recovery u.
Injection Well: h
❑Aquifer Recharge []Groundwater Remediation
PAC Kftfa Ncable
•Aquifer Storage and Recovery ❑Salinity Barrier TO MATERIALEMPLAC•Aquifer Test ❑Stormwater Drainage❑Experimental Technology OSubsidence Control R.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG attach additional sheets irnecessa
❑Geothermal(Heatin-'Coolin Return) ❑Other(explain under N21 Remarks) FROM To DESCRIPTION Icolor.hardam tOnli—it iypr.irain sire.etc.
0.0 rL 49.0 u• DIRECT PUSH
4.Date Well(s)Completed: 06M/23-06/21/23 Well IDN SEE REMARKS ft. tr.
ft. rL
52.Well Location:
MCCAIN GROCERY n a.
FaeilitylOwner Name Facility tD#(i£applicable) ft. h.
10018 LANCASTER HIGHWAY WAXHAW 28173 f. ry
Physical Address.City,and Zip ft. ft.
UNION 21.REMARKS
County Parcel Identification No.(PIN) C-1,C-3,C-5,C-7,C-9,C-11,C-13,C-15,C-17,
51b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: C-19,C-21,C-23,C-25,C-27,C-29,C-31
(if well field•one lat/long is sufficient) 22,Certification:
34o 50' 10.46" N 80"43' 42.21" W � — ow— 09/15/23
6.Is(are)the w•ell(s): ❑Permanent or DTemporary Signature ofCenified Well Contractor Date
by signing this farm,1 h.reby certify lfsN the well(s)nbs(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or ®No 15A NCAC 02C.0100 or 15A NCAC 02C.02001ye1J Comiruction Sta+alarrls and that a copy
lfihis Is a reiWr,fill out known well construction information aril explain the nature afthe afthis record har been provided to the welf owner_
repair under e21 reworks section or on the back ofthis farm.
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Over'to Remarks Box).You may also attach additional pages if necessary
drilled: i6 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 49.0 (ft.)
Idrr multiple wells list all depths fdi&reni(example-1 n 2(X1'and 2« 00) Submit This GW-1 within 30 days of well completion per the following:
24a. For All Wells: Original form to Division of Water Resources (DWR),
10.Static water level below top of casing: (Ft') Information Processing Unit,1617 MSC,Raleigh,NC 27699.1617
!J walrr iere!is a^rn�rasJnr'.urn"
11.Borehole diameter- 2,25 (in.) 24b. For Iniection Wells:Copy to DWR,Underground Injection Control(1UC)
Program, 1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: DPT RODS
24c.For Water 5u I."in
and O en-Loo Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc) county environmental health epanment of the county where instal led
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells roduein over 100 0 GP).Copy to DWR,CCPCUA
Permit Program,Ibl I MSC,Ra etgh,NC 276 -161 1
13s.Yield(gpm) Method of test: GENE®
RE
13b.Disinfection type: Amount: 2 23
Form GW-I North Carolina Department ofEn me vironmal Quality-Division of Water Resources [YL O"ReOea 2 6-oo01a
GeDEa office

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
BRIAN THOMAS 14.WATER ZONES
Well Contractor Neme
FROM TO DESCRIPTION
h. fr.
A - 2581
R. R.
NC Well Contractor Certification Number 1S.OUTER CASING for multi-cooed wens OR LINER iFa Iteablt
GEOLOGIC EXPLORATION FROM To DIAMETER THICKNESS MATERIAL
h. in.
Company Name
16.INNER CASING OR TUBING eothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER THICKNESS i MATERIAL
List all applicable eel/construction permim(.e UK.County.State.Variance,etc.) ft. ff. In.
3.Well Use(check well use): R. ft.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER I SLOTSIZE I THICKNESS I MATERIAL
OAgriculttual ❑Municipal.Pubiic h, h, in.
OGcothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft R in,
Olndustrial/Commercial OResidential Water Supply(sham) I&GROUT
❑)rri ation ❑Wells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNr
Non-Water Supply Well: ft. ft.
OMonitoring ❑Recovery h. R.
Injection Well:
R, ft.
❑Aquifer Recharge OGroundwater Remediation
I9.SAND/GRAVEL PACK if applicable)
_
❑Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL__ EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft It.
❑Experimental Technology ❑Subsidence Control ft. h.
❑Geothermal(Closed Loop) ❑Tracer 20.DRILLING LOG ialffftaeIt addkiond aheeb if necessan
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION Icobn hardnem tollfrock r rain■ve,eir.I
0,0 /1. 50.0 h' DIRECT PUSH
4.Date Well(s)Completed: 06/a6R3-OWI/23 Well ID# SEE REMARKS h. R.
5a Well Location:
ft. IL.
MCCAIN GROCERY h
Facility/Owner Name Facility ID#(ifapplicable) fL It.
10018 LANCASTER HIGHWAY WAXHAW 28173 ft. ft.
Physical Address,City,and Zip R, ft.
UNION 21.REMARKS
County Parcel Identification No.(PIN) C-2,C-4,C-6,C»8,C 10,C-12,C-14,C-16,C-18,
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
C-20,C-22,Cc24,C-26,C,28,C-30,C-32
(if well field,one ladlong is sufficient) 22.Certification:
34° 50' 10.46" N 800 43' 42.21" W 09/15/23
6.Is(are)the well(s): ❑Permanent or ElTemporary Signature ofCertifted Well Contractor Date T
By.signing thisfarm.I hereby eertefy that the ssellfs)seas(is-ere)constructed in accordant.Irult
7.is this a repair to an existing well: OYes or ®No 1 SA NCA(.'02C.0100 or MA NCAC 01C 0200 Wei/Consirucann Standards and that a cop)
rfthis is a repair,fill out known n-eff construction information and explain the nature of dte of ihis record lies been provided to the well owner.
repair tinder 021 remarks section or on the back ofthis lbrin.
23.Site diagram or additional well derails:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells (add'See Ovee in Remarks Box),You may also attach additional pages if necessary
drilled: Is 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 50•0 (ft.
Far mufriple wells fiOall dlepths ifdAerrerr(examrple-3 ne200'arul2dr IIID') ) Submit this GW-1 within 30 days of well completion per the following:
10.Static water level below top otcasing: (ft.) 24a. For All Wells: Original form to Division of Water Resources (DWR),
Information Processing Unit,1617 MSC,Raleigh,NC 27699-)617
lfwaier level is above coshig nxe•' ••
U.Borehole diameter: 2.25 (in.) 24b.For Iniection Wells:Copy to DWR,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh.,NC 27699-I636
12.Well construction method: DPT RODS
24c.For Water Su I and O n-Lino Geothermal Return Wells:Copy to the
(i.e.auger,rotary.cable,direct push,etc.) county environmental tealth epartmenI o.the county re installed
FOR WATER SUPPLY WELLS ONLY: 24d,For Water Wttls roducin over 100000 GPD: Copy to DWR,CCPCUA
Permit Program,1611 MS27699-1 61 1
13a.Yield(gpm) Method of test:_
13b.Disinfection type: Amount:
Fond G W-I North Carolina Depanment of Enviromnentai Quality-Division of Water Resources Revised 6.6-;1413

ATTACHMENT M
ACCESS AGREEMENT
Gen

dY' f
ROY COOPER NORTH CAROLINA
Governor Environmental Quality
MICHAEL S.REGAN
Secretary
MICHAEL SCOTT
Director
February 14, 2019
Kyle Norwood
7105 Tirzah Church Road
Waxhaw,NC 28173
Re: Supply Well Sample Request
Related to McCain Grocery Site,FTF 427981
10018 Lancaster Highway
Waxhaw,Union County,NC-MRU
Dear Mr.Norwood:
A petroleum release occurred near your property from a former underground storage tank system at the
referenced site,which used to sell gasoline. The tanks were removed in 2005,but residual petroleum
compounds remain in the soil and groundwater at the site. The incident was recommended to the State-Lead
Cleanup Program in 2006 because there was no Responsible Party to address the release, and we have been
assessing the extent of contamination and monitoring groundwater quality since then.
For the past two years,the Trust Fund has been providing bottled water to your home for drinking and cooking
purposes. We need to sample your well to check the water quality.
As part of our groundwater monitoring program, we will be sampling area supply wells to make sure the water
meets drinking water standards. In order to sample your well, please sign and return the attached form
granting permission for a sample to be collected. We will provide you with the test results after we receive
them.
If you have any questions,please contact me at(919) 707-8166 or sharon.gWold.a.ncdenr.►:ov.
Thank you,
Sharon Ghiold, Hydrogeologist
Division of Waste Management,NCDEQ
E QIN
�
:North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 1 1646 Mail Service Center I Raleigh,North Carolina 27699-1646
919.707.8200

Water Supply Well Sampling Agreement
I, K!r, Nor-,,00a . owner of the property at 7105 Tirzah Church Road
hereby grant permission to North Carolina Division of Waste Management personnel or
its agent to sample the drinking water supply well located at the property. The water
samples collected from the supply well will be submitted for laboratory analysis of
volatile organic compounds using an EPA approved method, and the test results will be
sent to you upon receipt. If the test results show that your well contains detectable
concentrations of volatile organic compounds,the DWM will complete a health risk
evaluation on the test results and the health risk evaluation will be sent to you upon
completion. I understand that the cost of the well sampling and analytical services will
be borne by the DWM and this agreement remains in effect until you no longer own the
property.
Owners Name Owr!ers Signature
7)0 5 C-A"'4 R4 IAAx -w j�/ -IVG 2 %7
Owners Address City,State and Zip Code
'q �/p -3 (3-027 � 2-2.1 -(l
Phone Number (Home/Work) Date
Email(Optional)
Related to STF 27981,McCain Grocery