WI0501143_Well Construction Record(s) (GW-1)_20240924

Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 1
NC Department of Environmental Quality – Division of Water Resources (DWR)

Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.

DATE: 8/7, 20_24___ PERMIT NO. (to be filled in by DWR)

NOTE- If this NOI is being submitted as notification of a modification of a previously issued NOI for this site (e.g.,
different injection wells, plume, additives, etc.) and still meets the deemed permitted by rule criteria, provide the
previously assigned permit tracking number and any needed relevant information to assess and approve injection:

Permit No. WI Issued Date:

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

B. STATUS OF WELL OWNER: Single Family Residence

NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS

The following are “permitted by rule” and do not require an individual permit when constructed in accordance
with the rules of 15A NCAC 02C .0200 (NOTE: This form must be received at least 14 DAYS prior to injection)

AQUIFER TEST WELLS (15A NCAC 02C .0220)
These wells are used to inject uncontaminated fluid into an aquifer to determine aquifer hydraulic characteristics.

IN SITU REMEDIATION (15A NCAC 02C .0225) or TRACER WELLS (15A NCAC 02C .0229):
1) 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).

2) Small-Scale Injection Operations – Injection wells located within a land surface area not to exceed 10,000
square feet for the purpose of soil or groundwater remediation or tracer tests. An individual permit shall be required
for test or treatment areas exceeding 10,000 square feet.

3) Pilot Tests - Preliminary studies conducted for the purpose of evaluating the technical feasibility of a
remediation strategy in order 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. An individual permit shall be required to conduct more
than one pilot test on any separate groundwater contaminant plume.

4) Air Injection Wells - Used to inject ambient air to enhance in-situ treatment of soil or groundwater.

5) In-Situ Thermal Wells (IST) – Used to ‘heat’ contaminated groundwater to enhance remediation.

WI0501143
0501143 09/24/2024
Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 2

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): Betty Holthouser
Mailing Address: 307 W Walker Rd
City: Elkin State: __NC__ Zip Code: 28621 County: Surry
Day Tele No.: 919-636-0952 Cell No.:
EMAIL Address: Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Chloe and Michael Del Signore
Company Name
Mailing Address: 4811 Dodsons Crossroads
City: Hillsborough State: _NC___ Zip Code: 27278 County: Orange
Day Tele No.: 301-613-5905 Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Ryan Kerins
Company Name Terraquest Environmental Consultants, P.C.
Mailing Address: 100 E Ruffin St
City: Mebane State: __NC__ Zip Code: 27302 County: Alamance
Day Tele No.: 919-563-9091 Cell No.: 919-906-0960
EMAIL Address: [e-mail] Fax No.: 919-563-9095
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Betty Holthouser Property, 4811 Dodson’s Crossroads

(2) City: Hillsborough State: _NC___ Zip Code: 27278 County: Orange
(3) Geographic Coordinates: Latitude**: o ′ ″ or 36 o. 010099
Longitude**: o ′ ″ or -79 o. 164066
Reference Datum: WGS-84 Accuracy:39.7 meters RMSE
Method of Collection: Google
**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: 4,950 square feet
Land surface area of inj. well network: 7x 315 ft2 = 2,205 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 45% (must be < 5% of plume for pilot test injections)

Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 3

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: An Oxygen Biochem slurry will be gravity poured into seven monitoring wells: MW1, MW2A,
MW3, MW4, MW5, MW8A, and MW11A.

J. WELL CONSTRUCTION DATA

(1) No. of injection wells: Proposed 7 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 6-10 feet below ground surface depending on water table elevation___
(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

K. INJECTION SUMMARY

NOTE: Only injectants approved by the epidemiology section of the NC Division of Public Health, Department
of Health and Human Services can be injected. Approved injectants can be found online at
http://deq.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 if you wish to get approval for a different additive. However, please
note it may take 3 months or longer. If no injectants are to be used use N/A.

Injectant: Oxygen Biochem Total Amt. to be injected (gal)/event: 20 gal/well x 7 = 140 gal

Injectant: Total Amt. to be injected (gal)/event:

Injectant: Total Amt. to be injected (gal)/event:

Injectant: Total Amt. to be injected (gal)/event:

Deemed Permitted GW Remediation NOI Rev. 2-17-2020 Page 4
Injectant: Total Amt. to be injected (gal)/event:

Total Amt. to be injected (gal/event): 140

No. of separate injection events: 6 Total Amt. to be injected (gal): 840

Source of Water (if applicable): municipal

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.

Site is monitored under a semi-annual VOC monitoring well sampling plan.

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.”

Ryan D. Kerins, Project Manager – see attached signature authorization form
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 well(s) 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
(15A NCAC 02C .0200).”

“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 and property 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]
Michael Pascal Del Signore

AGREEMENT FOR SERVICES

This Agreement is made and entered into this 4th day of January 2016, by and between Terraquest
Environmental Consultants, P.C. (hereinafter called “Terraquest”), and Betty Holthouser (hereinafter called
“CLIENT”), to provide for Terraquest to perform the services described herein, in accordance with the terms and
conditions set forth below and in the attached Schedules A and B, which are incorporated and made a part hereof
by reference.
RECITALS

CLIENT hereby engages Terraquest to conduct environmental investigations (“Services”) for “Betty
Holthouser property” located at 4811 Dodsons Crossroads in Hillsborough, NC (the “Property”). The Property is
either owned or leased by Client or Client has a written permit or authorization of the Property Owner to allow
Terraquest to entry upon and about the Property to perform its Services for the benefit of Client. The client
hereby authorizes Terraquest to sign environmental documents on behalf of client. The purpose of this
agreement is to set forth the procedures for and conditions under which Terraquest will provide services to
CLIENT.

PROJECT DESCRIPTION

The scope of Services to be provided include: Environmental assessment and treatment

PROJECT SITE & CONDITIONS

Upon execution of this Agreement, CLIENT shall provide Terraquest with all site information in the possession of
CLIENT as applicable to the subject work.

GENERAL TERMS & CONDITIONS

A. Terraquest is an independent consultant and agrees to provide to CLIENT, for its sole benefit and
exclusive use, the consulting services set forth in this Agreement. This Agreement shall not be assigned by CLIENT
without the prior written consent of Terraquest. All reports, information, analysis, and data submitted by
Terraquest to CLIENT shall remain confidential and shall not be disclosed to third parties without the prior written
consent of Terraquest; notwithstanding anything contrary herein, Terraquest reserves the right to report or
disclose to any governmental or regulatory authorities its findings if required by applicable regulation, code, law
or court order.

B. Either party may terminate this Agreement without cause upon three (3) days’ written notice to the
other party. In the event that CLIENT requests termination prior to completion of Services by Terraquest, CLIENT
agrees to timely pay Terraquest for all incurred costs and services that Terraquest has rendered prior to such
notice upon invoice delivery by Terraquest.

C. Terraquest will perform its Services using the degree of skill and care that is ordinarily exercised under
similar conditions by comparably situated environmental consulting professionals. NO OTHER WARRANTY,
EXPRESS OR IMPLIED, IS MADE OR INTENDED TO BE MADE BY THIS AGREEMENT, EITHER BY ORAL OR WRITTEN
STATEMENTS. CLIENT agrees that Terraquest’s liability to CLIENT or to any third party due to any negligent
professional acts or omissions shall not exceed and be limited to the amount of Terraquest’s professional fees.

D. CLIENT agrees to indemnify and hold harmless Terraquest from all claims, suits, losses, personal
injuries, death, and property liability resulting from damage or injury to subterranean structures (including, but
not limited to, pipes, tanks, telephone cables, etc.) arising from the performance of Terraquest’s services, when

the existence of known objects or structures are not called to the attention of Terraquest or when the location
of such objects or structures is not correctly shown in information furnished to Terraquest, including any activity
on property adjacent to or nearby the primary property that is taken in connection with this project.

E. ARBITRATION. CLIENT and Terraquest agree that any and all disputes, claims, or controversies arising
out of this Agreement shall be subject to binding arbitration. If CLIENT does not agree to arbitration within 10
days of being notified then Terraquest will proceed with court action. Arbitration shall be by and in accordance
with the commercial Arbitration Rules of the American Arbitration Association at a site located in Alamance
County, North Carolina, or as near thereto as possible. The Arbitrator shall be randomly assigned by the Duke
Private Adjudication Center; or if that Center is unable or unwilling to do so, then by the Arbitrator selected by
the Chief District Court Judge in Alamance County, North Carolina, or from the roll of the American Arbitration
Association (Charlotte, North Carolina office) in accordance with its procedures. Absent fraud, collusion, or
willful misconduct by the arbitrator(s) shown by clear and convincing evidence (not simply a preponderance of
the evidence), judgment rendered by the arbitrator(s) shall be final. The arbitrator(s) shall be empowered to
make a fair and equitable ruling regarding the specific matters in controversy, but shall have no power to
adjudicate any dispute that is not related to said matter, unless both Parties specifically agree to expand the
scope of arbitration, agree to the terms of expanded scope, and reduce that agreement to a writing. The
arbitrator(s) may reward injunctive relief as well as any other remedy available from a judge, including
reimbursement of expenses, should such relief be necessary, but shall not have the power to award punitive or
exemplary damages. The fee and expenses of the arbitrator(s) shall be shared and paid equally by the Parties to
this Agreement. The Parties confirm that by agreeing to this alternative dispute resolution process they intend
to give up and do hereby waive their right to have any factual dispute or finding of fault, breach of contract, or
negligence under this Agreement decided in civil court by a judge or jury.

In the event that, notwithstanding the agreement outlined above regarding binding arbitration, a claim
is made that results in litigation, and the claimant fails to prevail, then the claimant shall pay all costs incurred in
defending the claim, including reasonable attorneys’ fees, expert witness expenses, and all other reasonable
costs and expenses arising in the action. The claimant will be considered to have prevailed if the judgement
obtained and retained through any applicable appeal is at least ten percent greater than the sum offered to
resolve the matter prior to the commencement of Arbitration or trial, as the case may be.

F. Should Terraquest be called or asked to provide testimony or other evidence by CLIENT, in relation
to any services provided under this Agreement, and Terraquest is not a party in the dispute, CLIENT shall fully
compensate for such reasonable expenses and labor at appropriate unit rates to the extent that the party
compelling or requesting the testimony does not provide such compensation.

G. CLIENT shall indemnify Terraquest and hold it harmless from and against any loss, damage, claim or
injury which Terraquest or its subcontractor shall suffer or incur as a result of any breach of this Agreement by
CLIENT. CLIENT shall be responsible for and shall pay to Terraquest for all actual, general, and special
consequential damages, including attorneys’ fees, costs of suits, costs of arbitration, costs of appeal, which may
be awarded in any arbitration or litigation instituted by or against CLIENT to recover any of the foregoing items
indemnified or to obtain injunctive relief from CLIENT’S failure to perform as specified in this Agreement.
Provided that Terraquest is performing its professional duties in accordance with the terms of this Agreement
and based upon information to the best of its knowledge and skills, any and all consequential damages incurred
or arising from the performance of Terraquest or its subcontractor’s performance of this Agreement are hereby
waived by the CLIENT. In addition to the foregoing and not in limitation thereof, CLIENT shall indemnify and hold
harmless Terraquest from any and all claims, liabilities, losses, damages and expenses, incurred or arising from
the performance of or resulting from acts of Terraquest performed in the course and within the scope of its
engagement herewith provided such are done in good faith. This indemnification shall survive the termination
of employment and engagement of Terraquest.
N
1. Identification
Product identifier Oxygen Biochem (OBC)™
Other means of identification Not available.
Recommended use Oxygen Biochem (OBC)™ is used to promote chemical oxidation and aerobic bioremediation of
petroleum compounds in groundwater.
Recommended restrictions Use in accordance with supplier's recommendations.
Manufacturer/Importer/Supplier/Distributor information
Manufacturer/Supplier Redox Tech, LLC
Address 200 Quade Drive Cary
NC 2751
Telephone [phone]
E-mail [e-mail]
Contact person Dr. John Haselowi
Emergency Telephone For Hazardous Materials [or Dangerous Goods] Incidents ONLY
(spill, leak, fire, exposure or accident), call CHEMTREC at
CHEMTREC®, USA: 001 [phone]
CHEMTREC®, Mexico (Toll-Free - must be dialed from within country):
01-800-681-9531
CHEMTREC®, Other countries: 001 [phone]
2. Hazard(s) identification
Category 3Oxidizing solidsPhysical hazards
Category 4Acute toxicity, oralHealth hazards
Category 2Skin corrosion/irritation
Category 2Serious eye damage/eye irritation
Category 1Sensitization, respiratory
Category 1Sensitization, skin
Category 3 respiratory tract irritationSpecific target organ toxicity, single exposure
Not classified.OSHA defined hazards
Label elements
Signal word Danger
Hazard statement May intensify fire; oxidizer. Harmful if swallowed. Causes skin irritation. Causes serious eye
irritation. May cause allergy or asthma symptoms or breathing difficulties if inhaled. May cause an
allergic skin reaction. May cause respiratory irritation.
Precautionary statement
Prevention Keep away from heat. Keep/Store away from clothing and other combustible materials. Take any
precaution to avoid mixing with combustibles. Wear protective gloves/eye protection/face
protection. Wash thoroughly after handling. Do not eat, drink or smoke when using this product.
Avoid breathing dust/fume. In case of inadequate ventilation wear respiratory protection.
Contaminated work clothing must not be allowed out of the workplace. Use only outdoors or in a
well-ventilated area.
Response In case of fire: Use foam, carbon dioxide, dry powder or water fog for extinction. If swallowed: Call
a poison center/doctor if you feel unwell. Rinse mouth. If on skin: Wash with plenty of water. If
skin irritation or rash occurs: Get medical advice/attention. Take off contaminated clothing and
wash before reuse. If in eyes: Rinse cautiously with water for several minutes. Remove contact
lenses, if present and easy to do. Continue rinsing. If eye irritation persists: Get medical
advice/attention. If inhaled: If breathing is difficult, remove person to fresh air and keep
comfortable for breathing. If experiencing respiratory symptoms: Call a poison center/doctor.
Oxygen Biochem (OBC)™SDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 1 / 7
Material Safety Data Sheet – Oxygen BioChem
Storage Store in a well-ventilated place. Keep container tightly closed. Store locked up.
Disposal Dispose of contents/container in accordance with local/regional/national/international regulations.
Hazard(s) not otherwise
classified (HNOC)
None known.
3. Composition/information on ingredients
Mixtures
7775-27-1 70 - 90Sodium persulfate
CAS number %Chemical name
1305-79-9 10 - 20Calcium peroxide
Composition comments All concentrations are in percent by weight unless ingredient is a gas. Gas concentrations are in
percent by volume.
4. First-aid measures
Inhalation Move to fresh air. Do not use mouth-to-mouth method if victim inhaled the substance. For
breathing difficulties, oxygen may be necessary. Call a physician or poison control center
immediately.
Skin contact Remove and isolate contaminated clothing and shoes. For minor skin contact, avoid spreading
material on unaffected skin. Wash clothing separately before reuse. If skin irritation or an allergic
skin reaction develops, get medical attention.
Eye contact Immediately flush eyes with plenty of water for at least 15 minutes. Remove contact lenses, if
present and easy to do. Continue rinsing. Get medical attention if irritation develops and persists.
Ingestion Rinse mouth. Do not induce vomiting without advice from poison control center. If vomiting occurs,
keep head low so that stomach content doesn't get into the lungs. Do not use mouth-to-mouth
method if victim ingested the substance. Induce artificial respiration with the aid of a pocket mask
equipped with a one-way valve or other proper respiratory medical device. Get medical attention if
any discomfort continues.
Most important
symptoms/effects, acute and
delayed
May cause redness and pain. Symptoms may include coughing, difficulty breathing and shortness
of breath.
Indication of immediate
medical attention and special
treatment needed
Provide general supportive measures and treat symptomatically.
General information Ensure that medical personnel are aware of the material(s) involved, and take precautions to
protect themselves.
5. Fire-fighting measures
Suitable extinguishing media Water fog. Foam. Dry chemical powder. Carbon dioxide (CO2).
Unsuitable extinguishing
media
None known.
Specific hazards arising from
the chemical
Contact with combustible material may cause fire.
Special protective equipment
and precautions for firefighters
Self-contained breathing apparatus and full protective clothing must be worn in case of fire.
Fire-fighting
equipment/instructions
In the event of fire, cool tanks with water spray.
General fire hazards May intensify fire; oxidizer.
6. Accidental release measures
Personal precautions,
protective equipment and
emergency procedures
Keep unnecessary personnel away. Keep people away from and upwind of spill/leak. Wear
appropriate protective equipment and clothing during clean-up. Do not touch damaged containers
or spilled material unless wearing appropriate protective clothing. Avoid skin contact and inhalation
of vapors during disposal of spills. Ventilate closed spaces before entering them. Local authorities
should be advised if significant spillages cannot be contained. For personal protection, see Section
8 of the SDS.
Methods and materials for
containment and cleaning up
Stop the flow of material, if this is without risk. Prevent entry into waterways, sewer, basements or
confined areas. Following product recovery, flush area with water. For waste disposal, see Section
13 of the SDS.
Environmental precautions Avoid discharge into drains, water courses or onto the ground.
Oxygen Biochem (OBC)™SDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 2 / 7
7. Handling and storage
Precautions for safe handling Avoid inhalation of vapors/dust and contact with skin and eyes. Wash thoroughly after handling.
Keep away from clothing and other combustible materials. Use only with adequate ventilation. Do
not taste or swallow. Wear appropriate personal protective equipment (See Section 8). Observe
good industrial hygiene practices.
Conditions for safe storage,
including any incompatibilities
Store in original tightly closed container. Store away from incompatible materials (See Section 10).
Keep locked up.
8. Exposure controls/personal protection
Occupational exposure limits
US. ACGIH Threshold Limit Values
ValueTypeComponents
TWA 0.1 mg/m3Sodium persulfate (CAS
7775-27-1)
Biological limit values No biological exposure limits noted for the ingredient(s).
Appropriate engineering
controls
Observe occupational exposure limits and minimize the risk of exposure. Ensure adequate
ventilation, especially in confined areas.
Individual protection measures, such as personal protective equipment
Eye/face protection Wear safety glasses with side shields (or goggles).
Skin protection
Hand protection Wear protective gloves.
Other Neoprene or rubber gloves are recommended. Apron and long sleeves are recommended.
Respiratory protection In the case of respirable dust, use self-contained breathing apparatus. Wear positive pressure
self-contained breathing apparatus (SCBA).
Thermal hazards Wear appropriate thermal protective clothing, when necessary.
General hygiene
considerations
Always observe good personal hygiene measures, such as washing after handling the material
and before eating, drinking, and/or smoking. Routinely wash work clothing and protective
equipment to remove contaminants.
9. Physical and chemical properties
Appearance Off-white, granular solid.
Physical state Solid.
Form Solid.
Color Off-white.
Odor Odorless.
Odor threshold Not available.
pH 11.7±0.4 (1-40% solution, slurry)
Melting point/freezing point Not available.
Initial boiling point and boiling
range
Not applicable.
Flash point Not available.
Evaporation rate Not available.
Flammability (solid, gas)Not available.
Upper/lower flammability or explosive limits
Flammability limit - lower
(%)
Not available.
Flammability limit - upper
(%)
Not available.
Explosive limit - lower (%)Not available.
Explosive limit - upper (%)Not available.
Vapor pressure Not applicable.
Vapor density Not applicable.
Relative density 2.76±0.16 (25°C)
Oxygen Biochem (OBC)™SDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 3 / 7
Solubility(ies)
Solubility (water)Soluble in water.
Partition coefficient
(n-octanol/water)
Not available.
Auto-ignition temperature Not available.
Decomposition temperature Not available.
Viscosity Not available.
Other information
Oxidizing properties Oxidizing.
10. Stability and reactivity
Reactivity The product is stable and non-reactive under normal conditions of use, storage and transport.
Chemical stability Material is stable under normal conditions.
Possibility of hazardous
reactions
No dangerous reaction known under conditions of normal use.
Conditions to avoid Contact with combustibles.
Incompatible materials Combustible material. Oxidizing material. Reducing agents.
Hazardous decomposition
products
No hazardous decomposition products are known.
11. Toxicological information
Information on likely routes of exposure
Ingestion Harmful if swallowed.
Inhalation May cause irritation to the respiratory system.
Skin contact Causes skin irritation.
Eye contact Causes serious eye irritation.
Symptoms related to the
physical, chemical and
toxicological characteristics
May cause redness and pain. Exposed individuals may experience eye tearing, redness, and
discomfort. Symptoms may include coughing, difficulty breathing and shortness of breath.
Information on toxicological effects
Acute toxicity Harmful if swallowed.
Skin corrosion/irritation Causes skin irritation.
Serious eye damage/eye
irritation
Causes serious eye irritation.
Respiratory or skin sensitization
Respiratory sensitization May cause allergy or asthma symptoms or breathing difficulties if inhaled.
Skin sensitization May cause an allergic skin reaction.
Germ cell mutagenicity No data available.
Carcinogenicity This product is not considered to be a carcinogen by IARC, ACGIH, NTP, or OSHA.
Reproductive toxicity No data available.
Specific target organ toxicity -
single exposure
May cause respiratory irritation.
Specific target organ toxicity -
repeated exposure
No data available.
Aspiration hazard Not applicable.
Chronic effects Prolonged exposure may cause chronic effects.
Further information No data available.
12. Ecological information
Ecotoxicity This product’s components are not classified as environmentally hazardous. However, this does
not exclude the possibility that large or frequent spills can have a harmful or damaging effect on
the environment.
Persistence and degradability No data is available on the degradability of this product.
Bioaccumulative potential No data available for this product.
Oxygen Biochem (OBC)™SDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 4 / 7
Mobility in soil Not available.
Other adverse effects No data available.
13. Disposal considerations
Disposal instructions Consult authorities before disposal. Dispose in accordance with all applicable regulations.
Hazardous waste code The Waste code should be assigned in discussion between the user, the producer and the waste
disposal company.
Waste from residues / unused
products
Dispose of in accordance with local regulations.
Contaminated packaging Empty containers should be taken to an approved waste handling site for recycling or disposal.
14. Transport information
DOT
UN1479UN number
Oxidizing solid, n.o.s. (Sodium persulfate)UN proper shipping name
5.1Class
Transport hazard class(es)
-Subsidiary risk
IIPacking group
NoMarine pollutant
Environmental hazards
Read safety instructions, SDS and emergency procedures before handling.Special precautions for user
62, IB5, IP1Special provisions
NonePackaging exceptions
211Packaging non bulk
242Packaging bulk
IATA
UN1479UN number
Oxidizing solid, n.o.s. (Sodium persulfate, Calcium peroxide)UN proper shipping name
5.1Class
Transport hazard class(es)
-Subsidiary risk
5.1Label(s)
IIPacking group
NoEnvironmental hazards
5LERG Code
Read safety instructions, SDS and emergency procedures before handling.Special precautions for user
IMDG
UN1479UN number
OXIDIZING SOLID, N.O.S. (Sodium persulfate, Calcium peroxide)UN proper shipping name
5.1Class
Transport hazard class(es)
-Subsidiary risk
5.1Label(s)
IIPacking group
NoMarine pollutant
Environmental hazards
F-A, S-QEmS
Read safety instructions, SDS and emergency procedures before handling.Special precautions for user
This product is not intended to be transported in bulk.Transport in bulk according to
Annex II of MARPOL 73/78 and
the IBC Code
15. Regulatory information
US federal regulations This product is a "Hazardous Chemical" as defined by the OSHA Hazard Communication
Standard, 29 CFR 1910.1200.
All components are on the U.S. EPA TSCA Inventory List.
TSCA Section 12(b) Export Notification (40 CFR 707, Subpt. D)
Not regulated.
Oxygen Biochem (OBC)™SDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 5 / 7
US. OSHA Specifically Regulated Substances (29 CFR 1910.1001-1050)
Not listed.
CERCLA Hazardous Substance List (40 CFR 302.4)
Not listed.
Superfund Amendments and Reauthorization Act of 1986 (SARA)
Hazard categories Immediate Hazard - Yes
Delayed Hazard - Yes
Fire Hazard - Yes
Pressure Hazard - No
Reactivity Hazard - No
SARA 302 Extremely hazardous substance
Not listed.
SARA 311/312 Hazardous
chemical
Yes
SARA 313 (TRI reporting)
Not regulated.
Other federal regulations
Clean Air Act (CAA) Section 112 Hazardous Air Pollutants (HAPs) List
Not regulated.
Clean Air Act (CAA) Section 112(r) Accidental Release Prevention (40 CFR 68.130)
Not regulated.
Safe Drinking Water Act
(SDWA)
Not regulated.
US state regulations This product does not contain a chemical known to the State of California to cause cancer, birth
defects or other reproductive harm.
US. Massachusetts RTK - Substance List
Not regulated.
US. New Jersey Worker and Community Right-to-Know Act
Calcium peroxide (CAS 1305-79-9)
Sodium persulfate (CAS 7775-27-1)
US. Pennsylvania Worker and Community Right-to-Know Law
Not listed.
US. Rhode Island RTK
Not regulated.
US. California Proposition 65
US - California Proposition 65 - Carcinogens & Reproductive Toxicity (CRT): Listed substance
Not listed.
International Inventories
Country(s) or region Inventory name On inventory (yes/no)*
Australian Inventory of Chemical Substances (AICS) YesAustralia
Domestic Substances List (DSL) YesCanada
Non-Domestic Substances List (NDSL) NoCanada
Inventory of Existing Chemical Substances in China (IECSC) YesChina
European Inventory of Existing Commercial Chemical
Substances (EINECS)
YesEurope
European List of Notified Chemical Substances (ELINCS) NoEurope
Inventory of Existing and New Chemical Substances (ENCS) YesJapan
Existing Chemicals List (ECL) YesKorea
New Zealand Inventory YesNew Zealand
Philippine Inventory of Chemicals and Chemical Substances
(PICCS)
YesPhilippines
*A "Yes" indicates this product complies with the inventory requirements administered by the governing country(s).
A "No" indicates that one or more components of the product are not listed or exempt from listing on the inventory administered by the governing
country(s).
Toxic Substances Control Act (TSCA) Inventory YesUnited States & Puerto Rico
Oxygen Biochem (OBC)™SDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 6 / 7
16. Other information, including date of preparation or last revision
Issue date 09-May-2014
Revision date -
Version #01
Further information HMIS® is a registered trade and service mark of the NPCA.
NFPA Ratings
0
1
2
OX
List of abbreviations NFPA: National Fire Protection Association.
References Registry of Toxic Effects of Chemical Substances (RTECS)
HSDB® - Hazardous Substances Data Bank
Disclaimer The information contained herein is accurate to the best of our knowledge. However, data, safety
standards and government regulations are subject to change and, therefore, holders and users
should satisfy themselves that they are aware of all current data and regulations relevant to their
particular use of product. CARUS CORPORATION DISCLAIMS ALL LIABILITY FOR RELIANCE
ON THE COMPLETENESS OR ACCURACY OR THE INFORMATION INCLUDED HEREIN.
CARUS CORPORATION MAKES NO WARRANTY, EITHER EXPRESS OR IMPLIED,
INCLUDING, BUT NOT LIMITED TO, ANY WARRANTIES OF MERCHANTIABILITY OR FITNESS
FOR PARTICULAR USE OR PURPOSE OF THE PRODUCT DESCRIBED HEREIN. All conditions
relating to storage, handling, and use of the product are beyond the control of Carus Corporation,
and shall be the sole responsibility of the holder or user of the product.
(Carus and design) is a registered service mark of Carus Corporation.
Oxygen Biochem (OBC)™SDS US
920293 Version #: 01 Revision date: - Issue date: 09-May-2014 7 / 7
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 1XPEHURIZHOOVFRQVWUXFWHG 
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By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
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_______________
Wesley J. Sorrells
3577
Terraquest Environmental Consultants, P.C.
✔
4/11/17 MW1
Betty Holthouser Prop.
4811 Dodsons Crossroads
Orange
36.010099 -79.164066
✔
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Digitally signed by Wesley Sorrells
DN: cn=Wesley Sorrells, o, ou, email=[e-mail], c=US
Date: 2017.08.04 09:30:18 -04'00'
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
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 #21 Remarks)
4. Date Well(s) Completed: Well ID#
5a. Well Location:

Facility/Owner Name Facility ID# (if applicable)

Physical Address, City, and Zip

County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft.ft.
ft.ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.ft.
ft.ft.
ft.ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft.ft.
ft.ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
21. REMARKS
22. Certification:

Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection 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 construction to the county health department of the county
where constructed.
Certification:
ature of Certifieiefieiiefifiefiefifieiefieiefiefiefiefiefiieiefiefieieeeddddd Wdddddddddell Contractor
Wesley J. Sorrells
3577
Terraquest Environmental Consultants
2
5/24/23 MW2A,MW11A
Betty Holthouser Prop.
4811 Dodsons Crossroads
Orange
36.010099 -79.164066
15
4.25
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5/25/23
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3152 10Slot Schd.40 PVC
0.5
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15
Portland
Bentonite
No. 2 Sand Pour
Pour
0
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11
15
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Saprolite
Print Form
Pour
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_______________
Wesley J. Sorrells
3577
Terraquest Environmental Consultants, P.C.
✔
4/11/17 MW3 & MW4
Betty Holthouser Prop.
4811 Dodsons Crossroads
Orange
36.010099 -79.164066
✔
✔
2
20
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4.25
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5 20 2 .010 Sch. 40 PVC
0 1 Portland Pour
1 3 Bentonite Pour
3 20 No. 2 Sand Pour
0 15 Lean Clay(CL)
15 20 Lean Clay(CL)
Digitally signed by Wesley Sorrells
DN: cn=Wesley Sorrells, o, ou, email=[e-mail], c=US
Date: 2017.05.22 10:26:36 -04'00'
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copy of this record has been provided to the well owner.
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_______________
Wesley J. Sorrells
3577
Terraquest Environmental Consultants, P.C.
✔
4/2/18 MW5 & MW6
Betty Holthouser Prop.
4811 Dodsons Crossroads
Orange
36.010099 -79.164066
✔
✔
2
15
3.94,8.80
4.25
Solid Stem Auger
2 15 2 .010 Sch. 40 PVC
0 0.5 Portland Pour
0.5 1 Bentonite Pour
1 15 No. 2 Sand Pour
0 15 Lean Clay(CL)
Digitally signed by Wesley Sorrells
DN: cn=Wesley Sorrells, o, ou, email=[e-mail],
c=US
Date: 2018.04.27 09:49:08 -04'00'
WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only:
Form GW-1 North Carolina Department of Environmental Quality - Division of Water Resources Revised 2-22-2016
1. Well Contractor Information:
Well Contractor Name
NC Well Contractor Certification Number
Company Name
2. Well Construction Permit #:
List all applicable well construction permits (i.e. UIC, County, State, Variance, etc.)
3. Well Use (check well use):
Water Supply Well:
□Agricultural □Municipal/Public
□Geothermal (Heating/Cooling Supply) □Residential Water Supply (single)
□Industrial/Commercial □Residential Water Supply (shared)
□Irrigation
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 #21 Remarks)
4. Date Well(s) Completed: Well ID#
5a. Well Location:

Facility/Owner Name Facility ID# (if applicable)

Physical Address, City, and Zip

County Parcel Identification No. (PIN)
5b. Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field, one lat/long is sufficient)
N W
6. Is(are) the well(s): □Permanent or □Temporary
7. Is this a repair to an existing well: □Yes or □No
If this is a repair, fill out known well construction information and explain the nature of the
repair under #21 remarks section or on the back of this form.
8. For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction, only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells
drilled:
9. Total well depth below land surface: (ft.)
For multiple wells list all depths if different (example- 3@200’ and 2@100′)
10. Static water level below top of casing: (ft.)
If water level is above casing, use “+”
11. Borehole diameter: (in.)
12. Well construction method:
(i.e. auger, rotary, cable, direct push, etc.)
FOR WATER SUPPLY WELLS ONLY:
13a. Yield (gpm) Method of test:
13b. Disinfection type: Amount:
14. WATER ZONES
FROM TO DESCRIPTION
ft.ft.
ft.ft.
15. OUTER CASING (for multi-cased wells) OR LINER (if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
16. INNER CASING OR TUBING (geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
17. SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft.ft.in.
ft.ft.in.
18. GROUT
FROM TO MATERIAL EMPLACEMENT METHOD & AMOUNT
ft.ft.
ft.ft.
ft.ft.
19. SAND/GRAVEL PACK (if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
ft.ft.
ft.ft.
20. DRILLING LOG (attach additional sheets if necessary)
FROM TO DESCRIPTION (color, hardness, soil/rock type, grain size, etc.)
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
ft.ft.
21. REMARKS
22. Certification:

Signature of Certified Well Contractor Date
By signing this form, I hereby certify that the well(s) was (were) constructed in accordance
with 15A NCAC 02C .0100 or 15A NCAC 02C .0200 Well Construction Standards and that a
copy of this record has been provided to the well owner.
23. Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
SUBMITTAL INSTRUCTIONS
24a. For All Wells: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information Processing Unit,
1617 Mail Service Center, Raleigh, NC 27699-1617
24b. For Injection Wells: In addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24c. For Water Supply & Injection 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 construction to the county health department of the county
where constructed.
tification:
e of Certified WWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWWell Contractor
Wesley J. Sorrells
3577
Terraquest Environmental Consultants
1
5/24/23 MW8A
Betty Holthouser Prop.
4811 Dodsons Crossroads
Orange
36.010099 -79.164066
14.5
6.25
Solid Stem Auger
5/25/23
0 2.5 2 Schd.40 PVC
2.5 14.5 2 10Slot Schd.40 PVC
0.5
1
1.5
1
1.5
14.5
Portland
Bentonite
No. 2 Sand Pour
Pour
0
10
10
15
Backfill
Saprolite
Print Form
Pour