WI0400629_Notification of Intent (NOI) – GW Remediation_20240802

CDM
Smith
July 30, 2024
Blake Butcher, Geologist/Hydrogeologist
Groundwater Resources Branch— UIC Program
Division of Water Resources—Water Planning Section
North Carolina Department of Environmental Quality
1636 Mail Service Center
Raleigh, NC 27699
Subject: Notification of Intent (NOI)to Construct and Operate Injection Wells
Permit Type: (5) Pilot Test
Kitchens Operation Center, Greensboro, North Carolina
Dear Mr. Butcher:
CDM Smith has submitted an NOI to the North Carolina Department of Environmental Quality (NCDEQ)
DWR—UIC Program to perform aquifer testing at the Kitchens Operation Center site located in
Greensboro, North Carolina. We are providing you with this letter containing additional information
because you have served as the reviewer on this project previously and have requested the information
herein.
A conceptual remedial design for volatile organic compounds (VOCs) in groundwater has been
completed for this site that includes constructing a treatment barrier at the property line to treat
groundwater before it migrates offsite. Bioremediation will be used for treatment in the barrier and the
injection of bioremediation agents will require a Groundwater Remediation Permit to construct and use
wells for injection.
Aquifer testing is planned under this NOI to provide the hydrogeologic data necessary to finalize the
remedial design and prepare the Groundwater Remediation Permit.This aquifer testing NOI includes the
"Deemed Permitted GW Remediation (NO1) Form (Rev. 3-1-2023)" in Attachment A and additional
information below to address previous NCDEQ requests and compliance with 15A NCAC Subchapter 02C
Rule .0220—Aquifer Test Wells.This rule defines "Aquifer Test Wells" as "...wells used to inject
uncontaminated fluid into an aquifer to determine the aquifer characteristics."
Aquifer Test Summary
The existing and proposed well locations are shown on Figure 1 and Figure 2.The following sequence of
work will be completed to support and complete the aquifer testing.
1. Obtain well construction permits from the Guilford County Health Department.
2. Well Installation
a. Record boring logs, 6 boreholes
b. Install/develop saprolite/partially weathered rock (PWR) aquifer test wells,4 each
c. Install/develop shallow bedrock aquifer test wells,4 each
d. Install/develop shallow bedrock monitoring wells, 2 each
e. Submit GW-1 Well Construction Records
■ 5400 Glenwood Avenue,Suite 400, Raleigh, North Carolina 27612 1 tel:[phone]

CDM
Smith
Blake Butcher
July 30, 2024
Page 2
3. Collect baseline samples from all new wells for VOC analyses
4. Construct a temporary potable water line from a fire hydrant to supply aquifer test water to
the aquifer test wells
5. Complete 4.5-hour step tests on 4 saprolite/PWR aquifer test wells and 4 shallow bedrock
aquifer test wells
6. Complete 48-hour constant rate tests on 2 saprolite/PWR aquifer test wells
Subsurface Conditions
A hydrogeologic cross section through the site is shown on Figure 3 and the cross-section location is
shown on Figure 1. Groundwater flow from the site is to the south-southwest toward Buffalo Creek.The
following subsurface zones have been investigated at the site.
Overburden—Two overburden types were observed at the site: 1) an upper layer consisting of
residual soil and fill and 2) a lower layer consisting of saprolite.The site topography has been
altered by development and flat terraces have been graded along the slope leading down to
South Buffalo Creek.The upper surface includes residual soil and fill and this material does not
extend to depths below the water table.The saprolite consists of the in-place weathered
material that retains remnant bedrock structure and consists primarily of micaceous silty sand,
clayey sand, sandy clay, clay with rock fragments, and clayey silt.The water table is in the
saprolite at a depth of approximately 20 feet below land surface (bls).
PWR—The transitional zone between bedrock and saprolite originating from the partial
weathering of the parent bedrock.
Bedrock—Competent bedrock underlying the overburden consisting of metamorphosed granitic
rock.
Well Installation
All wells will be installed using sonic drilling techniques and continuous formation samples will be
collected and recorded on boring logs. Figure A-1 included with the attached NOI shows the planned
well construction materials and completion depths. The wells will be constructed by methods that will
ensure mechanical integrity.The borehole will be constructed using sonic drilling with a steel casing
open for the full depth of the boring for installation. Well materials will be installed and depths verified
before the steel casing in withdrawn.The cement/bentonite grout will be installed using the tremie pipe
method in continuous operation until the complete well annulus is filled. Grout will be allowed to cure
for a minimum of 48 hours before any injections are attempted. Visual checks will be made for
mechanical integrity as injection is initiated and the injection pressure will be increased incrementally.
Any conditions indicative a mechanical integrity problem will cause injections to cease and the next
course of action will be determined.
Aquifer Testing
Two types of aquifer performance tests will be completed.The first test is a 4.5-hour step test. Separate
step tests will be performed using the saprolite/PWR and bedrock test wells to determine well capacity
5400 Glenwood Avenue,Suite 400, Raleigh, North Carolina 27612 1 tel:[phone]

CDM
Smith
Blake Butcher
July 30, 2024
Page 3
and formation transmissivity.The second test is a 48-hour constant rate test performed for
saprolite/PWR to obtain addition aquifer parameters such as hydraulic conductivity and specific yield.
The aquifer test setup is shown on Figure 4.
The step tests will consist of injecting potable water at 3 flow rates for approximately 90 minutes at
each flow rate while recording water levels, injection pressure, and flow.The tests will be conducted
with steps at 3, 6, and 10 gallons per minute (gpm) and will not exceed 10 pounds per square inch (psi)
measured at the wellhead.The flow rates will be adjusted as required by the observed pressure
responses to flow but the maximum injection rate will not exceed 10 gpm.The anticipated test
parameters are summarized below and the total injection radii are shown on Figure 2.
Table 1:Aquifer Test Parameters
Step Test Constant Constant Total
Average Step Test Rate Test Rate Test Screen Effective Injection
Well Rate Volume Rate Volume Length Porosity Radius
INJ-1S 6.33 gpm 1,709 gal. 10 gpm 28,800 gal. 15 feet 20% 20.8 feet
INJ-2S 6.33 gpm 1,709 gal. None None 15 feet 20% 4.9 feet
INJ-3S 6.33 gpm 1,709 gal. None None 15 feet 20% 4.9 feet
INJ-4S 6.33 gpm 1,709 gal. 10 gpm 28,800 gal. 15 feet 20% 20.8 feet
INJ-11) 6.33 gpm 1,709 gal. None None 20 feet 15% 4.8 feet
INJ-213 6.33 gpm 1,709 gal. None None 20 feet 15% 4.8 feet
INJ-31) 6.33 gpm 1,709 gal. None None 20 feet 15% 4.8 feet
INJ-413 6.33 gpm 1,709 gal. None None 20 feet 15% 4.8 feet
If you have any questions or need any additional information, please contact me at your earliest
convenience at [phone] or by email at [e-mail].
Sincerely,
%&4 IVJLI--
Mathew F. Colone, P.G., PMP
Associate
CDM Smith Inc.
cc: Eddie Raynard, City of Greensboro
Virginia Spillman, City of Greensboro
Tom Duffey, CDM Smith Inc.
5400 Glenwood Avenue,Suite 400, Raleigh, North Carolina 27612 1 tel:[phone]

Figures
■ 5400 Glenwood Avenue,Suite 400, Raleigh, North Carolina 27612 1 tel:[phone]

I Scale in Feet
E. , y
0 150 300 MW 7 'ice . I �� "I I +►t
g
*"***O%IMW-30s¢, MW-29d• +`4 �:..--.
t t .
I ~ 4b , 4 MW-38s#. i 1
• �► ti .L _ �, ! �MW-34s' 4 T l T
1. ( ;";': i"-, / NJ ID MW-39s
( ) rIr M1Y49U
f -MW-42s 'I r I I
a MW-43dAil
r a 1 r w MW 45d rMW-44s —
r• •r fti r lei '� X: t'• ' --
b- i�r r L � � • � � I :.,:fi gip. �
rJ
e'��. n•'�T�t I F
MW-47 w-ass
W-s -
W-1
it I
Site Boundary
Offsite Parcels Existing Well Proposed Well cross section
__ _ - - - - Figure 1
CDMSaprolite Monitoring Well Shallow Bedrock Monitoring Well Well Location Map
DM_ �` Saprolite/PWR Monitoring Well X Shallow Bedrock Injection Well Kitchens Operation Center
Saprolite/PWR Injection Well -* Deep Bedrock Monitoring Well Greensboro, North Carolina

N
• ' Scale in Feet ♦ Cr
E ♦ �� .�^
0 60 120 ♦ (i7 r
s ♦ (-F n $1 r--�
1 r MW-32d?:-BMW-31s off-)
MW-41d IV) ' �r
,onI� 0-1
1� 1 t�� •a - , � J
or
fro ire-I
k NW
INJ-IS- INJ-1D /
MW-35s MW-48d /
NJ-2D D
IN -2
-49d MW-
1 � '�T/ rli��t , � •
rr►
WNW M1
f / MWi24s
MW 25d
1~ :;fMW-26d
Site Boundary
Existing Well Proposed Well cross section
Off site Parcels — — — — Potable Water Figure 2
CDMSaprolite Monitoring Well Shallow Bedrock Monitoring Well Injection Diameter Aquifer Test Area
Smith Saprolite/PWR Monitoring Well X Shallow Bedrock Injection Well J.Edward Kitchen Operations Center
Saprolite/PWR Injection Well Deep Bedrock Monitoring Well Greensboro, North Carolina

• "ISO •
:11 Site
:• •.
:1
Meadowview
�r
Road
City of Greensboro
BDL
26
1 1
�1
-.�/... j�.r..../i✓!�� :'//�%/lF}i/� 7/0p,wg
/��J//'L�•/I��...�.1fi%O/i/ijjil�/�n�/��/I/<-'vr/��//L/.�%/�%%1'��� ��
' / /�r� Pr/)ooiFFJI IFEN NOWN ON MENOMONEE "'Orm
�i 'G+ !/ �/�I:/ // �MIN®R,
, � fylyri//r
I ti h6G' /�0=////lf�/1��riiior�r'�1�///• /f////l��//��� �//
1 11 11 11 • 11 11 •11 11 :11 •11 111 11 11 11 �11 11 •11 11 :11 •11 111 11 11 11 �11 11
--*-2019 PCE —Site Boundary
MOM • '■■■■■■■■■■■■ ■■■■■■■■-m30
�■
1 11 11 11 � 11 11 •11 11 :11 •11 111 11 11 11 •11 11 •11 11 :11 •11 111 11 11 11 • 11

Transducer
Cable
Cable
— Gland
� Pressure
Potable Flow Gauge
Water Totalizing Control
Supply Flow Meter Valve
- = = = = = = = = = = = =--=--=--=--=--=--=--= ---=--=--=--=--=--=--- -----=--=--- ------------------------ --=--=--=--=- = ;_=________________________________ =
_________________ _______________
________ ___ __ ______ = = = = = = = _ _________ ___ ____________________ _______ ____ _____ _ --_--__-____--__-__________:
---------------=-=-==-----=-==-----=--=-=--==--=---=-------------==-----==--=--=------==--=-==-----==------=--==--=====--==--==---=----------==-=--==-------=--=--== --_______-_-___=_=====_===========____
_______ ______________________________________________________________________________________________________________________________________________________ t-:=_=____________ ____-_____;
___________________________________________________________________________________________________________________________________ ___________________________-____
_____ _ _ ____ =__-__-_ ________-__-____________.
_ _ _ _ _ _ _ _ _ _ _ = = __-___-__________________
--------- -------------------------------------------------------------------------------------------------------------------------------------- Figure 4
Aquifer Test Setup
CDM J.Edward Kitchen Operations Center
Smith Greensboro, North Carolina

I� -r- -�rrrr N
❑� MW-37s
I 771.95 M MW-36s
770.21 3
772.24
t
I .21
L 770
38
766.04 MW-34s
761.54
MW-31s
j761.82 . 760 j
MW-35s / MW-3_
3s MW-39s•
' 755.72 752.77 756.56• 1 I
T / • L . E
� ❑I
MW-42s 750 n r ❑ ❑IE
752.79 1 % MW-24s I I 1 � 750.28 a�i/ I a�
3
_. ul t
750 / I � U)
' ❑
W Meadow Rd. 74 t - - — •/� I L - 1 — -� � I— .l _ .
— . . III MW-44s - - • . — .� — . . i - � � -- - - -
739.72 t
740
i1 1
MW-46s
729.74 ' I
MW-28 I
4a/0 C, -
� —7 n
Scale in Feet
0 300 600 I '
i
Site Boundary Cross Section
Saprolite/PWR Figure 5: Saprolite/PWR
Offs ite ar Pcels Potentiometric Surface
Saprolite/PWR Monitoring Well 750 Potentiometric Surface
Shallow Bedrock Monitoring Well Contour Interval=10 Feet
SmithA Surface Water Contour Interval=2 Feet Kitchens Operation Center
PWR-Partially Weathered Rock February 2023 Greensboro, North Carolina

0 -rrrrrr N
�- •�. .LI L°j Ell o ��� ci
I 770 � �! � S
• MW-29d I
—� 768.80 '* r� i
I� MW-40d I
J 762.14
MW-32d
760.7 -
• / �E1 ❑I
MW-25d I r
M NA 6a ' j50 750.01 ❑ °❑IE
c I I
MW-43d
753.99
--
�� n 1 ��
\ J/ I� y� MW-212 II I
LKE741. 1 I
— I—
W Meadow Rd. A
740
M 5
739.4
u
730 — I
/ I I I
I \
----- M 7.16 - - - I I
__— 717.1s I
Se I -
4n`a/o C�ee / — I \ I—
— \�A -
Scale in Feet
0 300 600
i
Site Boundary Bedrock
Offsite Parcels Potentiometric Surface Figure 6: Bedrock
— . . — . Cross Section
— — — ' 750 Potentiometric Surface
Contour Interval=10 Feet
Smith Shallow Bedrock Monitoring Well Contour Interval=2 Feet Kitchens Operation Center
Greensboro, North Carolina
February2023

!—r-f—f �—�—r r _ N
Lj W-.6 '
C I MW-36s I w E
❑� I MW-37s� �1y'2.11 •
ND I NIDS 1 ` MND 3 I I S
I I 8,140
MIP-21 I
I / 21* l. — I MW-38s� � � /6.5 MW- 0 \ El
1,240
IMW-35s / 509 MW-39s -
r205 / /MINp*0 /M /IP-19. 11.21 I
/ 0 ' 872 ND* u ❑
MW-42s ' IE
ND I tMW-24s/ c I� i❑
68.9 U
_J
I �
d
I la �
L _. _ . L . _ _
W Meadow Rd. `
— ¢MW-44s —
a I �
Loy � � ro
I
MW-46s
ND*
MW-28
Se 10*1
\0io
creek
�J 1001,
\ S11.9
11.9
SW-1
ND
Scale in Feet
0 300 600
Site Boundary -(�Saprolite/PWR Monitoring Well PCE>Residential VISL, 12 ug/L
Offsite Parcels `Shallow Bedrock Monitoring Well Figure 7: Saprolite/PWR
0 Surface Water PCE-Non-Residential VISL,48�g/L
— — — — — — Tetrachloroethene (PCE)
CDM Kitchens Operation Center
Smith PWR-Partially Weathered Rock Posted values are PCE in ug/L Greensboro, North Carolina
ND-Not Detected *-Sample prior to 2023

l—r—�—rrrrr _ N
I L �LJI 1Ji E7,ciI I W E
MW-29d• I i S
. / 5,050
II / MV% I
1,450
/ MW-41d I
2,300 i
/ El . -
M 1890d I
• 11EI ❑I
I , N. . �. . �L . _ . . - . . -. I
I MW-25d °' ID i❑IE
MW-43d MW-26d 80.7
I 1.6 2,040
w = _
d ,
I I MW-27d 21.2
ElLI
W Meadow Rd. 1 `
MW-45d I I I
� 448
-LOYr--T ro
I � I
0
MW-47d83
I -
e4 I
a/o I
\•creek ,�at�
Scale in Feet
0 300 600
Site Boundary Shallow Bedrock Monitoring Well PCE>100 ug/L
Offsite Parcels Deep Bedrock Monitoring Well � � � � � - Figure 8: Bedrock
CDM _ PCE>500 ug/L _ Tetrachloroethene (PCE)
Posted values are PCE in u /L
Smith g Kitchens Operation Center
ND-Not Detected PCE>1,000 ug/L
Greensboro, North Carolina

Attachment A
Deemed Permitted GW Remediation (NOI) Form
■ 5400 Glenwood Avenue, Suite 400, Raleigh, North Carolina 27612 1 tel:[phone]

NC Department of Environmental Quality (DEQ)—Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule"and do not require an application to be submitted and an individual permit
be issued when constructed in accordance with the rules of 15A NCAC 02C.0200(NOTE: This form must be
received at least 14 DAYS prior to iniection)
GROUNDWATER(GW)REMEDIATION INJECTION PERMIT TYPES:
(1)IN-SITU GW REMEDIATION PERMIT TYPE(15A NCAC 02C.02251
• 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 05A NCAC 02C.02251
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.02201
These permit types are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.
DATE: ,20 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) Small-Scale Injection Operation...................... Complete sections B through M
(5) X 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 NOI Rev.3-1-2023 Page 1

B. STATUS OF WELL OWNER: County 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): City of Greensboro—Virginia Spillman,Assistant Director,Water Resources Department
Mailing Address: PO Box 3136
City: Greensboro State:NC Zip Code: 27402-3136 County: Guilford
Day Tele No.: 336-373-7779 Cell No.:
EMAIL Address: claudia.spillman(a)greensboro-nc.gov Fax No.:
D. PROPERTY OWNER(S)(if different than well owner/applicant)
Name and Title:
Company Name
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT(Typically Environmental Consulting/Engineering Firm)
Name and Title: Mathew Colone—Project Manager
Company Name CDM Smith Inc.
Mailing Address: 5400 Glenwood Avenue, Suite 400
City: Greensboro State:NC Zip Code: 27612 County:Wake
Day Tele No.: 919.325.3569 Cell No.: 919.609.2955
EMAIL Address: colonemf(a,cdmsmith.com Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name&Address: City of Greensboro—Kitchen Building
City: Greensboro County:Guilford Zip Code: 27406
(2) Geographic Coordinates: Latitude": 0 1 "or 36 0.0419757
Longitude": "or -79 0.7930471
Reference Datum:North American 1983
Accuracy: 0.1 Feet
Method of Collection: Calculated geographic center of property
"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: —867,800 square feet
Land surface area of inj.well network: —21,800 square feet(< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: —2.5% (must be<5%of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev.3-1-2023 Page 2

H. INJECTION ZONE MAPS—Attach the following to the notification.—Maps attached and included in cover
letter.
(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:See cover
letter.
J. WELL CONSTRUCTION DATA
(1) No.of injection wells: 8 Proposed 0 Existing(provide NC Well
Construction Record(GW-1)for each well)
(2) Appx. injection depths(BLS): Saprolite/PWR wells 20—35 ft BLS,Bedrock wells 40—60 ft BLS
(3) For Proposed wells or Existing wells not having GW-1s,provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following(indicate if construction is proposed or as-built):
(a) Well type as permanent,Geoprobe/DPT,or subsurface distribution infiltration gallery
(b) Depth below land surface of casing,each grout type and depth, screen,and sand pack
(c) Well contractor name and certification number
Well diap-ram attached.
K. INJECTION SUMMARY
NOTE: Only iniectants approved by the epidemiology section of the NC Division ofPublic Health,Department
of Health and Human Services can be injected. Approved iniectants can be found online at
http:Hdeg.nc.gov/about/divisions/water-resources/water-resources-permits/wastewater-branch/ground-water-
protection/ground-water-approved-injectants. All other substances must be reviewed by the DHHS prior to use.
Contact the UIC Program for more info iyou wish to get approval for a deferent additive. However,please
note it may take 3 months or lonzer. If no iniectants are to be used use N/A.
Injectant: NA Total Amt.to be injected(gal)/event:
Injectant: NA Total Amt.to be injected(gal)/event:
Injectant: NA Total Amt.to be injected(gal)/event:
Injectant: NA Total Amt.to be injected(gal)/event:
Injectant: NA Total Amt.to be injected(gal)/event:
Total Amt.to be injected(gal/event):
Deemed Permitted GW Remediation NOI Rev.3-1-2023 Page 3

No.of separate injection events: Total Amt.to be injected(gal):
Source of Water(if applicable): City of Greensboro municipal water
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.
Injecting_potable water to perform aquifer performance testing. Following well installation and aquifer
performance testing a comprehensive round of groundwater samples will be collected from all wells at the site.
The wells will be sampled for volatile organic compounds(VOCs)by EPA Method 8260.
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, 1 believe that the information is true, accurate and
complete. 1 am aware that there are significant penalties, including the possibility of fines and imprisonment,
.for submitting false information. I agree to construct, operate, maintain, repair, and if applicable, abandon the
injection well and all related appurtenances in accordance with the 1 SA NCAC 02C 0200 Rules."
Signaturevof 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 well(s) conform to the Well Construction Standards
(I5A NCAC 02C.0200J."
"Owner"means any person who holds the fee or other property rights in the well being constructed. A well
is real property and its construction on land shall be deemed to vest ownership in the land owner, in the
absence of contrary agreement in writing.
Signature*of Property Owner(if different from applicant) Print or Type Full Name and Title
*An access agreement between the applicant 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 NOI Rev.3-1-2023 Page 4

1
•
•
1
1
•
� ��/ UAi •rif!///i� /L/iry � //�niii ,f ,(wir�(/,7 - w/`/��s�i1�//�/V�i,J►/I��"//%�/i/�Jj/
,ram✓/_ � /O r�� , .,_ /io/` r /// /yi
NO
Me" / �
VO—
FA
ofop
�ilrii:I raj".�,10-%/ir ,Wells are to be installed by M&W Drilling,
;7,IvIuIuple NC certified drillers are employed by
nn-Mr, &r '/M&W and the selected driller for this work will
�uri
OVA
KA
110
1 o." 0 M
IN ZW
"r be iderILIfied on the GW-1 Well Construction
ias�iii�/ �/////G_1/1h!►ri���J///���iiiaaiir/���%/�/..�ii���%11s'Y/�iiiai��iiir ... „ � �.. !