Attach 2- Report Formats.pdf

DHEC 0653 (10/2020)

SCDHEC, UST Management Division, 2600 Bull Street, Columbia, SC 29201, PHONE (803)898-7957 FAX (803) 896-6245 www.scdhec.gov

SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL

To: ______________________________________________________________________(SCDHEC Project Manager) From: ___________________________________________________________________(Contractor Project Manager) Contractor: _______________________________ UST Contractor Certification Number: ________________________

Facility Name: ___________________________________________________ UST Permit #: ____________________ Facility Address: __________________________________________________________________________________ Responsible Party: _________________________________________________Phone: _________________________ RP Address: _____________________________________________________________________________________ Property Owner (if different): ________________________________________________________________________ Property Owner Address: ___________________________________________________________________________ Current Use of Property: ___________________________________________________________________________

Scope of Work (Please check all that apply)

Analyses (Please check all that apply) Groundwater/Surface Water:

Drinking Water Supply Wells:

Soil:

Air:

o BTEXN

Sample Collection (Estimate the number of samples of each matrix that are expected to be collected.)

________ Soil ________ Water Supply Wells ________ Air ________ Field Blank ________ Monitoring Wells ________ Surface Water ________ Duplicate ________ Trip Blank

Field Screening Methodology Estimate number and total completed depth for each point, and include their proposed locations on the attached map.

# of shallow points proposed: ______________________ Estimated Footage: ___________________ feet per point # of deep points proposed: ________________________ Estimated Footage: ____________________ feet per point Field Screening Methodology: _______________________________________________________________________

Permanent Monitoring Wells Estimate number and total completed depth for each well, and include their proposed locations on the attached map.

# of shallow wells: __________________________ Estimated Footage: __________________________ feet per point # of deep wells: ____________________________ Estimated Footage: __________________________ feet per point # of recovery wells: _________________________ Estimated Footage: __________________________ feet per point Comments, if warranted:

Site-Specific Work Plan for Approved ACQAP Underground Storage Tank Management Division

UST Permit #: ___________________ Facility Name: ____________________________________________________

Implementation Schedule (Number of calendar days from approval) Field Work Start-Up: _____________________________ Field Work Completion: ______________________________ Report Submittal: _______________________________ # of Copies Provided to Property Owners: ________________

Aquifer Characterization Pump Test: o Slug Test: o (Check one and provide explanation below for choice)

Investigation Derived Waste Disposal Soil: _____________________________ Tons Purge Water: ________________________________ Gallons Drilling Fluids: _____________________ Gallons Free-Phase Product: ___________________________ Gallons

Additional Details For This Scope of Work For example, list wells to be sampled, wells to be abandoned/repaired, well pads/bolts/caps to replace, details of AFVR event, etc.

Compliance With Annual Contractor Quality Assurance Plan (ACQAP) ____ Laboratory as indicated in ACQAP? (Yes/No) If no, indicate laboratory information below.

Name of Laboratory: __________________________________________________________________________ SCDHEC Certification Number: _________________________________________________________________ Name of Laboratory Director: ___________________________________________________________________

____ Well Driller as indicated in ACQAP? (Yes/No) If no, indicate driller information below.

Name of Well Driller: _________________________________________________________________________ SCLLR Certification Number: ___________________________________________________________________

____ Other variations from ACQAP. Please describe below.

Attachments

1. Attach a copy of the relevant portion of the USGS topographic map showing the site location.

2. Prepare a site base map. This map must be accurately scaled, but does not need to be surveyed. The map must include the following:

North Arrow Proposed monitoring well locations Location of property lines Legend with facility name and address, UST permit number, and bar scale Location of buildings Streets or highways (indicate names and numbers) Previous soil sampling locations Location of all present and former ASTs and USTs Previous monitoring well locations Location of all potential receptors Proposed soil boring locations

3. Assessment Component Cost Agreement, SCDHEC Form D-3664

SOUTH CAROLINA DEPARTMENT OF

HEALTH AND ENVIRONMENTAL CONTROL

DHEC FORM D-0653

Instructions for Completing

• Form’s title – Site Specific Work Plan

• Form’s purpose – The purpose of this form is for the South Carolina certified site rehabilitation contractor to identify all specific components of the work scope to be conducted.

• Who will complete the form (audience) – The South Carolina certified site rehabilitation contractor.

• Enough instruction to guide the person completing the form.

o Fill in all UST facility information.

o Address all boxes with correct information that pertain to the specified scope of work.

o Include all required attachments as listed at the bottom of page 2 of this form document.

• Form is scanned and saved electronically - Record Group Number 169, Retention Schedule 13300

TIER I REPORT FORMAT

I. INTRODUCTION

A. Owner/Operator Information

Facility name UST Permit #

Name

Address

Telephone Number (include area code)

B. Property Owner Information

Name (if different from above)

Address

Telephone Number (include area code)

C. Contractor Information

Name

DHEC Certification #

Address

Telephone Number (include area code)

D. Facility Information

Address

Description of Adjacent Land Use (Commercial, residential, rural, etc.) Include documentation (e.g. zoning regulations) as appropriate.

Predicted Future Land Use (include site and adjacent area)

E. Facility History

Date Release Reported to DHEC

Estimated Quantity of Product Released

Cause of Release

UST # Product Date Installed Currently in Use

(yes or no) If not in use, Date

Removed

Other Releases at this site? Yes ____________ No ____________

If yes, Date Release Reported to DHEC

Status of Release

No Further Action Date

II. SITE CHARACTERISTICS

A. Site Geography

Describe the topography of the site and surrounding area (slope, vegetation, bodies of water, major land features, etc.)

Mean Elevation of Site

Additional Comments

Exposure Analysis

Describe all potential receptors and preferential pathways within a 1000-foot radius of the site.

Description of Receptor Distance/Direction from Site

Provide any additional comments necessary to complete the exposure analysis

C. Utilities Survey

List the utilities on site, and adjacent to the site within a 1000 foot radius, that could serve as exposure points or as preferential pathways.

Utility On-site or Distance/Direction from site Depth to Utility Material and Size

D. Site Geology

Provide a brief description of the regional geology and hydrogeology

Provide a brief description of the site-specific geology and stratigraphy

E. Soil Boring Data

Drilling Dates

Provide a brief justification for the location of the soil borings

SB-1

SB-2

SB-3

SB-4

SB-5

SB-6

SB-7

SB-8

Standard Operating Procedure for Field-screening:

Complete the table below for each soil boring.

UST Area Borings –

Borehole SB-1 Sampling Date- Sample Depth-

Split Spoon Interval (ft.) Field-screening Results (mg/kg) Lithology (soil type, color, rocks/ minerals present)

Soil Conditions (dry, moist, etc;

petroleum odor)

Borehole SB-2 Sampling Date- Sample Depth-

Split Spoon Interval (ft.) Field-screening Results (mg/kg) Lithology (soil type, color, rocks/ minerals present)

Borehole SB-3 Sampling Date- Sample Depth-color, rocks/ minerals present)

Borehole SB-4 Sampling Date- Sample Depth-color, rocks/ minerals present)

Borehole SB-5 Sampling Date- Sample Depth-color, rocks/ minerals present)

Borehole SB-6 Sampling Date- Sample Depth-color, rocks/ minerals present)

Borehole SB-7 Sampling Date- Sample Depth-color, rocks/ minerals present)

Borehole SB-8 Sampling Date- Sample Depth-color, rocks/ minerals present)

Background Boring

Borehole SB- Sampling Date- Sample Depth-

Split Spoon Interval (ft.) Field-screening Results (mg/kg) Lithology (soil type, color, rocks/ minerals present)

Enter the soil analytical data for each soil boring for all COC in the table below and on the following page. Enter the appropriate RBSL for the soil type from Tables 4 through 8 in DHEC Risk-Based Corrective Action (RBCA) for Petroleum Releases Guidance Document.

CoC RBSL SB-1 SB-2 SB-3 SB-4 SB-5 SB-6 SB-7 SB-8

Benzene

Toluene

Ethylbenzene

Xylenes

Total BTEX

MTBE

Naphthalene

Benzo(a)anthracene

Benzo(b)flouranthene

Benzo(k)flouranthene

Chrysene

Dibenz(a,h)anthracene

Total Lead

TOC (Background boring)

TPH -DRO

Discuss the horizontal and vertical extent of COC in the soil

F. Chemicals of Concern - Groundwater

Provide well installation information in the table below.

MW # Installation Date Development Date Sampling Date

Enter the soil analytical data for each monitoring well for all CoC in the table below.

CoC RBSL MW- MW - MW - MW-

Depth of sample

Benzene

Toluene

Ethyl benzene

Xylenes

Total BTEX

MTBE

Naphthalene

Benzo(a)anthracene

Benzo(b)flouranthene

Benzo(k)flouranthene

Chrysene

Dibenz(a,h)anthracene

Total Lead

TOC (Background boring)

TPH-DRO

Summarize the monitoring well and groundwater data in the table below.

MW # TOC Elevation (ft) Screened Interval (ft) Depth to Water (ft) Water Table Elev. (ft)

Enter field data measurements (temperature, pH, conductivity, turbidity, and dissolved oxygen) taken during well purging on the Field Data Information Sheet for Groundwater Sampling form. Complete one for each well.

Enter the groundwater analytical data for each monitoring well for all CoC in the table below. If free product is present, indicate the measured thickness to the nearest 0.01 feet.

CoC RBSL/Action Level (μg/l)

MW- MW- MW - MW -

Free Product Thickness None

Benzene 5

Toluene 1,000

Ethylbenzene 700

Xylenes 10,000

Total BTEX N/A

MTBE 40

Naphthalene 25

1,2-DCA 5

EDB 0.05

Benzo(a)anthracene 10

Benzo(b)flouranthene 10

Benzo(k)flouranthene 10

Chrysene 10

Dibenz(a,h)anthracene 10

Ethanol 10,000

EtBE (ethyl tert-butyl ether) 47 tAME (tert-amyl ethyl ether) 128

DIPE (diisopropyl ether) 150 tBA (tert-butyl alcohol) 1400 tAA (Tert-amyl alcohol) 240

Total Lead 15

G. Aquifer Characteristics

Hydraulic Conductivity

Hydraulic Gradient

Porosity

Estimated Seepage Velocity

Complete the slug test form and include in Appendix F of the report. Include all data, graphs, and equations used to derive the aquifer characteristics and hydrologic parameters (hydraulic conductivity, seepage velocity, hydraulic gradient, etc.) in Appendix F.

III. Tier I Evaluation

A. CURRENT LAND USE - Identify any potential receptors or human exposure pathways (e.g. basements, contaminated soils from UST closures, etc.) within a 1000-foot radius for current land use. Complete the table below. Additional sheets may be attached if necessary.

Media

(for exposure)

Exposure Route Pathway Selected for Evaluation?

(Yes or No)

Exposure point or

Reason for

Non-Selection

Data Requirements

(IF pathway selected)

Air Inhalation

Explosion Hazard

Yes No

Groundwater Ingestion

Dermal Contact

Inhalation

Surface Water Ingestion

Dermal contact

Surficial Soil Ingestion

Leaching to Ground-Water

Subsurface Soil Ingestion Yes No

Volatile Inhalation

B. FUTURE LAND USE - Identify any potential receptors or human exposure pathways (e.g. basements, contaminated soils from UST closures, etc.) within a 1000-foot radius for projected future land use. Complete the table below. Additional sheets may be attached if necessary

Media

(for exposure)

Exposure Route Pathway Selected for Evaluation?

(Yes or No)

Exposure point or

Reason for

Non-Selection

Data Requirements

(IF pathway selected)

Air Inhalation

Explosion Hazard

Groundwater Ingestion

Dermal Contact

Inhalation

Yes No

Surface Water Ingestion

Inhalation

Yes No

Surficial Soil Ingestion

Inhalation

Leaching to Ground-Water

Yes No

Subsurface Soil Ingestion

Volatile Inhalation

Yes No

Yes No

Recommendations for further action

IGWA REPORT FORMAT

Facility Name

Facility Address

Facility Telephone Number

UST Permit Number

UST Owner and Operator's Name

Address

Phone Number

Property Owner's Name

Address Phone Number

Contractor’s Name Cert. #

Address Phone Number

Well Driller’s Name Cert. #

Address Phone Number

Receptor and Site Data

Current Site Name if different: ____________________________________________________________________

Please place a check in the appropriate answer block for each question:

Receptor Survey Questions No Yes *

Are any drinking water supply wells (public or private) or surface water supply intakes within 1000 feet of the UST?

Are irrigation or other non-drinking water wells located within 1000 feet of the UST?

Are other potential receptors (i.e., utilities, surface waters, wetlands) less than 1000 feet from the UST?

*If “yes” provide additional information below:

Were any water supply wells or surface waters within 250 ft. sampled?

Yes No (Show on site base map)

Is a public water supply line in the area? Yes No (Show on site base map)

Is the current use of the facility and surrounding properties commercial, residential, agricultural or industrial?

Adjacent Properties:

North:

East:

South:

West:

Soil and Boring/Monitoring Well Data

Primary Soil Type:

Well Installation Method and Date:

Development Method and Date:

Soil Sample obtained from feet.

SOIL ANALYTICAL DATA

Benzene

(μg/kg)

Toluene

(μg/kg)

Ethylbenzene

(μg/kg)

Xylenes

(μg/kg)

Naphthalene

(μg/kg)

MTBE

(μg/kg)

Benzo (a)-anthracene

(μg/kg)

Benzo (b)-fluoranthen e

(μg/kg)

Benzo (k)-fluoranthene

(μg/kg)

Chrysene

(μg/kg)

Dibenz(a,h)an thracene

(μg/kg)

Total PAH (μg/kg)

Total Lead

*For waste oil UST releases only:

Chromium*

(μg/kg)

Mercury*

(μg/kg)

Selenium*

(μg/kg)

Silver*

(μg/kg)

Arsenic*

(μg/kg)

Barium* (μg/kg)

Cadmium*

Include Laboratory Data and Chain of Custody Form in Appendix B.

Groundwater Data

Depth to Groundwater: Depth to FP, if present:

Free Product Thickness:

Well Purging/Sampling Method:

Date of Well Installation_____________________________________

Date Well Developed________________________________________

Date Sampled:

Equilibrated values: Temperature: pH: Turbidity:

Specific Conductivity: Dissolved Oxygen:

Soil/Water Disposal Method (Include in Appendix G. Costs for work cannot be compensated without manifest):

GROUNDWATER ANALYTICAL DATA

Benzene

(μg/L)

Toluene

(μg/L)

Ethylbenzene

(μg/L)

Xylenes

(μg/L)

MTBE

(μg/L)

Naphthalene

(μg/L)

1,2-DCA

(μg/L)

EDB

(1,2- Dichloroeth ane)

(μg/L)

Benzo (a)-anthracene

(μg/L)

Benzo (b)-fluoranthene

(μg/L)

Benzo (k)-fluoranthene

(μg/L)

Chrysene

(μg/L)

Dibenz(a,h) anthracene

(μg/L)

Total PAH

Ethanol

EtBE

(Ethyl tert-butyl ether)

(μg/L) tAME

(tert-amyl ethyl ether)

(μg/L)

DIPE

(Diispopropyl ether)

(μg/L) tBA

(tert-butyl alcohol)

(μg/L) tAA

(tert-amyl alcohol)

(μg/L)

Total Lead

*For waste oil UST releases only:

Chromium*

Mercury*

(μg/L)

Selenium*

(μg/L)

Silver*

(μg/L)

Arsenic*

(μg/L)

Barium* (μg/L)

Cadmium*

Include Laboratory Data and Chain of Custody Form in Appendix B.

Report Completed By (Print Name):

Signature:

DHEC Contractor Certification # Date: