DHEC Form 0653 "Site-Specific Work Plan for Approved Acqap" - South Carolina

What Is DHEC Form 0653?

This is a legal form that was released by the South Carolina Department of Health and Environmental Control - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2020;
  • The latest edition provided by the South Carolina Department of Health and Environmental Control;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DHEC Form 0653 by clicking the link below or browse more documents and templates provided by the South Carolina Department of Health and Environmental Control.

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Download DHEC Form 0653 "Site-Specific Work Plan for Approved Acqap" - South Carolina

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Site-Specific Work Plan for Approved ACQAP
Underground Storage Tank Management Division
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)
o IGWA
o Tier II
o Groundwater Sampling
o GAC
o Tier I
o Monitoring Well Installation
o Other _________________________________
Analyses (Please check all that apply)
Groundwater/Surface Water:
o BTEXNMDCA (8260D)
o Lead
o BOD
o Methane
o Oxygenates (8260D)
o 8 RCRA Metals
o Nitrate
o Ethanol
o EDB (8011)
o TPH
o Sulfate
o Dissolved Iron
o PAH (8270E)
o pH
o Other ______________________________
Drinking Water Supply Wells:
o BTEXNMDCA (524.2)
o Mecury (200.8 245.1 or 245.2)
o EDB (504.1)
o Oxygenates & Ethanol (8260D)
o RCRA Metals (200.8)
Soil:
o BTEXNM
o Lead
o RCRA Metals
o TPH-DRO (3550B/8015B)
o Grain Size
o PAH
o Oil & Grease (9071)
o TPH-GRO (5030B/8015B)
o TOC
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:
________________________________________________________________________________________________
________________________________________________________________________________________________
SCDHEC, UST Management Division, 2600 Bull Street, Columbia, SC 29201, PHONE (803)898-7957 FAX (803) 896-6245 www.scdhec.gov
DHEC 0653 (10/2020)
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Site-Specific Work Plan for Approved ACQAP
Underground Storage Tank Management Division
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)
o IGWA
o Tier II
o Groundwater Sampling
o GAC
o Tier I
o Monitoring Well Installation
o Other _________________________________
Analyses (Please check all that apply)
Groundwater/Surface Water:
o BTEXNMDCA (8260D)
o Lead
o BOD
o Methane
o Oxygenates (8260D)
o 8 RCRA Metals
o Nitrate
o Ethanol
o EDB (8011)
o TPH
o Sulfate
o Dissolved Iron
o PAH (8270E)
o pH
o Other ______________________________
Drinking Water Supply Wells:
o BTEXNMDCA (524.2)
o Mecury (200.8 245.1 or 245.2)
o EDB (504.1)
o Oxygenates & Ethanol (8260D)
o RCRA Metals (200.8)
Soil:
o BTEXNM
o Lead
o RCRA Metals
o TPH-DRO (3550B/8015B)
o Grain Size
o PAH
o Oil & Grease (9071)
o TPH-GRO (5030B/8015B)
o TOC
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:
________________________________________________________________________________________________
________________________________________________________________________________________________
SCDHEC, UST Management Division, 2600 Bull Street, Columbia, SC 29201, PHONE (803)898-7957 FAX (803) 896-6245 www.scdhec.gov
DHEC 0653 (10/2020)
SOUTH CAROLINA DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
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
DHEC 0653 (10/2020)
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
DHEC 0653 (10/2020)
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