WI0400508_DEEMED FILES_20181221

Permit Number
Program Category
Deemed Ground Water
Permit Type
WI0400508
Injection Deemed In-situ Groundwater Remediation Well
Primary Reviewer
shristi.shrestha
Coastal SWRule
Permitted Flow
Facility
Facility Name
Former Kimball Autoglass
Location Address
748 N Main St
High Point
Owner
Owner Name
Ncdeq Us! Section
Dates/Events
NC
Orig Issue
12/20/2018
App Received
12/11/2018
Regulated Activities
Groundwater remediation
Outfall
Waterbody Name
27262
Draft Initiated
Scheduled
Issuance Public Notice
Central Files : APS SWP
12/21/2018
Permit Tracking Slip
Status
Active
Version
1.00
Project Type
New Project
Permit Classification
Individual
Permit Contact Affiliation
Major/Minor
Minor
Region
Winston-Salem
Facility Contact Affiliation
Sharon Ghiold
1637 Mail Service Ctr
Raleigh
Owner Type
Government -State
Owner Affiliation
Sharon Ghiold
1637 Mail Service Ctr
Raleigh
County
Guilford
NC
NC
Issue
12/20/2018
Effective
12/20/2018
27699
27699
Expiration
Requested /Received Events
Streamlndex Number Current Class Subbasin
VV1-D 'f-00508
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
ENVIRONMENTAL • GEDTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
----------------------------------~-
January 7, 2019
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality-Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Injection Event Record -WI0400508
Former Kimball Autoglass
748 North Main Street
High Point, Guilford County, North Carolina
NCDEQ Incident No. 45049
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Kimball Auto glass Property on behalf of the North Carolina Department of Environmental Quality
State Lead Program. The record documents the placement ofEnviro-BAC in one monitoring well
(MW-I) associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Sharon Ghiold, Hydrogeologist for NCDEQ
Attachments
RECEM;hAI,,,.._ ___ _
--•~tiMJWR
JAN l ~2019
R Water Quality
eglonaf Operauo nssect1011
Injection Event Record
Kimball AutoFass, Hide Point, North Carolina
INJECTION EVENT RECORD
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North Carolina Department of Environmental Quality -Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400508
1. Permit Information
NCDE Q
Permittee
Kimball Autog lass
Facility Name
748 N. Main Street, Hi gh Point. Guilford County
Facility Address (include County)
2. Injection Contractor Information
ATC Associates of NC. P.C .
Injection Contractor/ Company Name
Street Address 2725 E. Millbrook Road, Ste 121
Ralei NC 27604
City State Zip Code
[phone]
Area code -Phone number
3. Well Information
Number of wells used for injection.--=1 ____ _
Well IDs MW-I
Were any new wells installed during this injection
event?
D Yes ~ No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells -------
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please i11clude a copy oftl,e GW-1 fo rm/or eacl,
well installed.
Were any wells abandoned during this injection
event?
D Yes [81 No
If yes, please provide the following information:
Number of Monitoring Wells _____ _
Number of Injection Wells -------
Please include a copy of t/,e GW-30 for eacll well
abandoned.
4. Injectant Information
Enviro-BAC
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration -=-3---=5_,_o/c=--o _________ _
If the injectant is diluted please indicate the source
dilution fluid. City of Ralei gh Municipal Water
Total Volume Injected (gal)----=-92=6,._c=m=3 ____ _
Volume Injected per well (gal) 926 cm3
5. Injection History
Injection date(s) Janua1y 3 , 2019
Injection number ( e.g. 3 of 5)____,,1:...=of""'l=--------
1s this the last injection at this site?
[81 Yes D No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON nns FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT.
Cc______ l Jj
SIGNATURE OF INJECTION CONTRACTOR
ATC Associates ofNorth Carolina, P.C.
DATE
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcg rou pservi ces.co rn
N-C_ Engineering License No. C-1598
January 7, 2019
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, TJIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Injection Event Record — WI0400508
Former Kimball Autoglass
748 North Main Street
High Point, Guilford County, North Carolina
NCDEQ Incident No, 45049
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) is submitting an Injection Event Record for the
Kimball Autoglass Property on behalf of the North Carolina Department of Environmental Quality
State Lead Program. The record documents the placement of Enviro-BAC in one monitoring well
(MW-1) associated with the above referenced site.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
cf
Ashley M. Winkelman, P.G.
Senior Project Manager
cc: Sharon Ghiold, Hydrogeologist for NCDEQ
Attachments
AN
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Injection Event Record
Kimball Autoelass. Hiu,h Point. North Carolina
INJECTION EVENT RECORD
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North Carolina Department of Environmental Quality-Division of Water Resources
INJECTION EVENT RECORD (IER)
Permit Number WI0400508
1. Permit Information
NCDEQ
Permittee
Kimball Auto glass
Facility Name
748 N. Main Street. High Point. Guilford County
Facility Address (include County)
2. Injection Contractor Information
ATC Associates of NC. P.C.
Injection Contractor I Company Name
Street Address 2725 E. Millbrook Road. Ste 121
Ralei ) NC 27604
City State Zip Code
(919 ) 871-0999
Area code -Phone number
3. Well Information
Number of wells used for injection~l ____ _
Well IDs_~MW~~-1~----------
Were any new wells installed during this injection
event?
D Yes !ZI No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number of Injection Wells _______ _
Type of Well Installed (Check applicable type):
D Bored D Drilled D Direct-Push
D Hand-Augured D Other (specify) __ _
Please include a copy of the GW-1 form for each
well installed.
Were any wells abandoned during this injection
event?
D Yes !ZI No
If yes, please provide the following information:
Number of Monitoring Wells ______ _
Number of Injection Wells _______ _
Please include a copy of the GW-30 for each well
abandoned.
4 . Injectant Information
Enviro-BAC
Injectant(s) Type (can use separate additional sheets
if necessary
Concentration -~3~-5~o/c~o~----------
If the injectant is diluted please indicate the source
dilution fluid. Ci tv of Ralei gh Munici pal Water
Total Volume Injected (gal).---"9-==2=6---"i=n3 _____ _
Volume Injected per well (gal)_~9=2--=-6 -=in=-3 ___ _
5. Injection History
Injection date(s) January 3 . 2019
Injection number ( e.g. 3 of 5) .~l ~o=f~l _____ _
Is this the last injection at this site?
!ZI Yes D No
I DO HEREBY CERTIFY THAT ALL THE
INFORMATION ON THIS FORM IS CORRECT TO
THE BEST OF MY KNOWLEDGE AND THAT THE
INJECTION WAS PERFORMED WITHIN THE
STANDARDS LAID OUT IN THE PERMIT . c-z__ ___ ___. 1 /7 b I '1
SIGNATURE OF INJECTION CONTRACTOR ATE
ATC Associates ofNorth Carolina. P.C.
PRINT NAME OF PERSON PERFORMING THE INJECTION
Submit the original of this form to the Division of Water Resources within 30 days of injection.
Attn: UIC Program, 1636 Mail Service Center, Raleigh, NC 27699-1636, Phone No. 919-807-6464
Form UIC-IER
Rev. 3-1-2016
ATC
ENVIRONMENTAL• GERTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Milibrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www. atcg roupse rvices. corn
N.C. Engineering License No. C-1598
December 4, 2018
Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Reference: Notice of Intent to Construct or Operate Injection Wells
Former Kimball Autoglass
748 North Main Street
High Point, Guilford County, North Carolina
NCDEQ Incident No. 45049
Dear Ms. Shrestha:
ATC Associates of North Carolina, P.C. (ATC) has prepared the WoLe71 lice of Intent to
Construct or Operate Injection Wells on behalf of the North', Carolina Department of
Environmental Quality State Lead Program. The permit applR f h covers the performance of
passive remediation in one monitoring well associated with the above referenced she.
If you have questions or require additional information, please contact our office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Elizabeth Allyn
Project Manager
cc: Sharon Ghiold, Hydrogeologist for NCDEQ
Attachments
Ashley M. Winkelman, P.G.
Senior Project Manager

Notice of Intent to Construct or Operate Injection Wells
Former Kimball Auto !?lass, Hi gh Point. North Carolina
NOTICE OF INTENT FORM
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IUILIIIIIISCIEIICU•IIAtEIIAUIDTIIII
North Carolina Department of Environmental Quality-Division of Water Resources
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. This fo rm shall be submitted at least 2 WEEKS prior to in iection.
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 In jection Sv stems -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 In jection O perations -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 are 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 In jection Wells -Used to inject ambient air to enhance in-situ treatment of soil or groundwater.
Print Clearly or Type Information. Illegible Submittals Will Be Returned As Incomplete.
DATE: December 4, 20 18 PERMIT NO. /.✓ J..O 9-0 0 >{)~ (to be filled in by DWR)
A. WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1)
(2)
(3)
(4)
(5)
(6)
--~Air Injection Well ...................................... Complete sections B through F, K, N
--~Aquifer Test Well ....................................... Complete sections B through F, K, N
--~Passive Injection System ............................... Complete sections B through F, H-N
X Small-Scale Injection Operation ...................... Complete sections B through N
___ Pilot Test. ................................................ Complete sections B through N
___ Tracer Injection Well .................................. Complete sections B through N
B. STATUS OF WELL OWNER: State Government
C. WELL OWNER(S) -State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:
Name(s): ___ S~h_ar_o~n~G~h_io~l~d _-~H=y~d=r~o=g~eo=l~o=gi=· s=t.~N~o=rt~h~C=ar~o=li=n=a~D~e'""p~a=rtm=e=n~t ~o ~f =E=nv~ir=onm=~en=t=a~l ~O~u=al=it'-'y __
Mailing Address: ___ 1_6_4_6 _M_a_i_l _S_erv_ic_e_C_e_n_t_er ____________________ _
City: Raleigh State: NC Zip Code: 27699-1646 County:_W_ak_e ___ _
Day Tele No.: 919-707-8166 Cell No.: --~No..c..=.o=t Ac=...c.v=a1=·1a=b=l-=-e ___ _
EMAIL Address: sharon.ghiold@ ncdenr.gov Fax No.: --~N~o~t -=-A=v~a=il=ab-=-l=e ___ _
Deemed Permitted GW Remediation NOi Rev. 8-28-2017 Page 1

2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598

December 4, 2018

Ms. Shristi Shrestha
North Carolina Department of Environmental Quality
Division of Water Quality - Aquifer Protection Section, UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636

Reference: Notice of Intent to Construct or Operate Injection Wells
Former Kimball Autoglass
748 North Main Street
High Point, Guilford County, North Carolina
NCDEQ Incident No. 45049

Dear Ms. Shrestha:

ATC Associates of North Carolina, P.C. (ATC) has prepared the enclosed Notice of Intent to
Construct or Operate Injection Wells on behalf of the North Carolina Department of
Environmental Quality State Lead Program. The permit application covers the performance of
passive remediation in one monitoring well associated with the above referenced site.

If you have questions or require additional information, please contact our office at [phone].

Sincerely,
ATC Associates of North Carolina, P.C.

Elizabeth Allyn Ashley M. Winkelman, P.G.
Project Manager Senior Project Manager

cc: Sharon Ghiold, Hydrogeologist for NCDEQ

Attachments
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ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
Notice of Intent to Construct or Operate Injection Wells
Former Kimball Autoglass, High Point, North Carolina

NOTICE OF INTENT FORM
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Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 1
North Carolina Department of Environmental Quality – Division of Water Resources

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

DATE: December 4, 20__18__ PERMIT NO. (to be filled in by DWR)

A. WELL TYPE TO BE CONSTRUCTED OR OPERATED

(1) Air Injection Well……………………………..…Complete sections B through F, K, N
(2) Aquifer Test Well……………………….………..Complete sections B through F, K, N
(3) Passive Injection System…………………..……..Complete sections B through F, H-N
(4) X Small-Scale Injection Operation………………….Complete sections B through N
(5) Pilot Test………………………………………….Complete sections B through N
(6) Tracer Injection Well………………………….….Complete sections B through N

B. STATUS OF WELL OWNER: State Government

C. WELL OWNER(S) – State name of Business/Agency, and Name and Title of person delegated authority to
sign on behalf of the business or agency:

Name(s): Sharon Ghiold – Hydrogeologist, North Carolina Department of Environmental Quality
Mailing Address: 1646 Mail Service Center
City: Raleigh State: _NC_ Zip Code: 27699-1646 County: Wake
Day Tele No.: 919-707-8166 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: Not Available
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. This form shall be submitted at least 2 WEEKS 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 are 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.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 2
D. PROPERTY OWNER(S) (if different than well owner)
Name and Title: Spencer Moon, Brenda Moon, and Brandon Moon
Company Name Not Applicable
Mailing Address: 2632 Mapine Drive
City: High Point State: _NC__ Zip Code: 27265 County: Guilford
Day Tele No.: 336-501-4800 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: Not Available

E. PROJECT CONTACT (Typically Environmental Engineering Firm)

Name and Title: Ashley M. Winkelman, Senior Project Manager
Company Name ATC Associates of North Carolina, P.C.
Mailing Address: 2725 E. Millbrook Road, Suite 121
City: Raleigh State: _NC_ Zip Code: 27604 County: Wake
Day Tele No.: 919-871-0999 Cell No.: 919-830-3576
EMAIL Address: [e-mail] Fax No.: 737-207-8261

F. PHYSICAL LOCATION OF WELL SITE

(1) Facility Name & Address: Former Kimball Autoglass
748 N. Main Street
City: High Point County: Guilford Zip Code: 27262
(2) Geographic Coordinates: Latitude**: o ′ ″ or 35 o. 96377
Longitude**: o ′ ″ or -80 o. 01034
Reference Datum: WGS84 Accuracy: 10-meter
Method of Collection: DOQ-Acme Mapper 2.2
**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: 5,306 square feet
Land surface area of inj. well network: 5,306 square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: 100 (must be < 5% of plume for pilot test injections)

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. –Cross-sections were not identified in
previous reports submitted for the site.
(3) Potentiometric surface map(s) indicating the rate and direction of groundwater movement, plus existing
and proposed wells.

Deemed Permitted GW Remediation NOI Rev. 8-28-2017 Page 3
The following figures are included with this NOI package:
Figure 1 – USGS Topographic Map
Figure 2 – Site Map with soil analytical results
Figure 3 – Receptor Survey Map
Figure 4 – Potentiometric Surface Map with hydraulic gradient
Figure 5 – Benzene Isoconcentration Map
Figure 6 – Total BTEX Isoconcentration Map
Figure 7 – EDB Isoconcentration Map
Figure 8 – Naphthalene Isoconcentration Map

I. DESCRIPTION OF PROPOSED INJECTION ACTIVITIES – Provide a brief narrative regarding the
purpose, scope, and goals of the proposed injection activity. This should include the rate, volume, and duration
of injection over time.
ATC will gravity feed two kilograms of Enviro-BAC into monitoring well MW-1 in order to aide in natural
attenuation and reduce compound concentrations to below the North Carolina Gross Contaminant Levels
(GCLs). Based on the most recent sampling event performed in June 2018, the following compounds exceeded
GCLs in MW-1: benzene at 7,750 micrograms per liter (g/L) and 1,2-dibromoethane at 54.4 g/L. The
injectate, followed by 5 to 10 gallons of municipal water, will be poured into MW-1 over up to a 3 hour time
period.

J. APPROVED INJECTANTS – Provide a MSDS for each injectant. Attach additional sheets if necessary.

NOTE: Only injectants approved by 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 (919-
807-6496).

Injectant: Enviro-BAC
Volume of injectant: 926 cm3
Concentration at point of injection: 100%
Percent if in a mixture with other injectants: 3-5% (includes approximately 7.5 gallons of
municipal water to be poured in well following Enviro-BAC)

See Appendix A for MSDS information.

K. WELL CONSTRUCTION DATA

(1) Number of injection wells: Proposed 1 Existing (provide GW-1s)
(2) 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
See Appendix B for well construction details. Note that a GW-1 form is not available for MW-1.
L. SCHEDULES -Briefly describe the schedule for well construction and injection activities.
Approximately two weeks after submitting the NOi, ATC will gravity feed Enviro-BAC into monitoring well
MW-1.
M. 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.
A TC will collect one sample approximately 6 months after the injection event (sampling to occur in June 2019).
During the sampling event, A TC will collect a sample from monitoring well MW-1 for analysis of volatile
organic compounds by EPA Method 6200B. The sample will be shipped to SGS Accustest in Scott, Louisiana.
A TC will also measure dissolved oxygen, conductivity, temperature, pH, and oxygen reduction potential in MW-
1 during the June 2019 sampling event.
N. SIGNATURE OF APPLICANT AND PROPERTY OWNER
APPLICANT: "I h ereby certify, under penalty of law, that I am familiar with th e information submitted in this
document and all attachm ents th ereto and that, based on my inquiry of those individuals immediately responsible
for obtaining said information, I believe that th e information is true, accurate and complete. I am aware that
there are significant p enalties, including the possibility of fines and imprisonm ent, for submitting fals e
information. I agree to construct, operate, maintain, repair, and if applicable, abandon the injection w e ll and
all related appurtenances in accordance with the 15A NCAC 02C 0200 Rules."
~ Ashley Winkelman, Senior Project Manager, on behalf of Sharon Ghiold, NCDEO
Signature of Applicant
(see Authorization to sign on next page)
Print or Type Full Name and Title
PROPERTY OWNER (if the property is not owned by the permit applicant):
"As owner of th e property on which the injection w ell(s) are to be constructed and operated, I hereby consent to
allaw the applicant to construct each injection w ell as outlined in this application and agree that it shall be th e
responsibility of th e applicant to ensure that the injection well(s) conform to th e Well Construction Standards
(J 5A 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.
See Appendix C Brandon Moon
Signature* of Property Owner (if different from applicant) Print or Type Full Name and Title
*An access agreem ent betwe en the applicant and property owner may be submitted in li eu of a signature on this form .
Submit TWO hard copies of the completed application package with an electronic version in CD or
USB Flash Drive to:
Deemed Permitted GW Remediation NOI Rev . 8-28-2017
DWR -UIC Program
1636 Mail Service Center
Raleigh, NC 27699-1636
Telephone: [phone]
Page 4
1
Ashley Winkelman
From:Ghiold, Sharon <[e-mail]>
Sent:Tuesday, December 04, 2018 9:39 AM
To:Rogers, Michael; Ashley Winkelman
Cc:Shrestha, Shristi R
Subject:[EXTERNAL] RE: STF #45049 Kimball Autoglass NOI Authorization

[External Email] This email originated from outside of the ATC mail system. Please use caution when
opening attachments.

Hi Shristi,

I am authorizing Ashley Winkelman of ATC to sign as our (NCDEQ/DWM/UST Trust Fund Branch) agent for NOIs. If you
have any questions, please let me know.

Thanks,

From: Rogers, Michael
Sent: Tuesday, December 4, 2018 9:12 AM
To: Ghiold, Sharon <[e-mail]>; Ashley Winkelman <[e-mail]>
Cc: Shrestha, Shristi R <[e-mail]>
Subject: RE: STF #45049 Kimball Autoglass NOI Authorization

Please send any info on NOIs to Shristi.

Thanks

From: Ghiold, Sharon
Sent: Tuesday, December 4, 2018 8:20 AM
To: Ashley Winkelman <[e-mail]>
baron Ohiold
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Ema.t corr~ to artJ from tlllS a<:Jo~ess is subject lo llil3
1\Jo<th Cercx.re A.it:lic P.eaxds l.ir11 arc fflfJ'/ be <:Jisdosed tot o part~
2
Cc: Rogers, Michael <[e-mail]>
Subject: STF #45049 Kimball Autoglass NOI Authorization

Hi Michael,

Ashley Winkelman with ATC is preparing a NOI for Kimball’s Autoglass on our behalf. I am authorizing Ashley Winkelman
to sign as our agent. If you have any questions, please let me know.

Thanks for your help,

h.aron Ghio d
Hytfrogeologist, ndergrourui Storage Tm1 S c1ion
orth Carolina Dcpamnc:n of Ed,. ·rorune.o , Quali
919.~,07.8166
Sh _ _ n.Ohlo dencdem.go
Ernttl COtrespot'tie(x;e to and from tJts addtess JS subject o the
/olth ~ Put:f,c P.eco«Js 1.8-11 af)(J may be disdosed to t/'wd parties
Notice of Intent to Construct or Operate Injection Wells
Former Kimball Autoglass, High Point, North Carolina

FIGURES

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SITE:
748 N. MAIN STREET
LOCATION:
HIGH POINT, NORTH CAROLINA
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USGS IDENTIFICATION
USGS 7.5
MINUTE MAP
ORIGINAL DATE:
PHOTOREYISION
DATE:
.c
r
0
0
HIGH POINT WEST, NC
1950
2016
PRIMARY HIGHWAY, HARD SURFACE
SECONDARY HIGHWAY, HARD SURFACE
LIGHT -DUTY ROAD HARD OR
IMPROVED SURFACE
UNIMPROVED ROAD
STATE ROAD
U.S. ROUTE
INTERSTATE ROUTE
SCALES
NOTES: OP- TDPOGRAP HICAL CONTOUR INTERVAL = 10 FEET
P. PHOTOREVISIDNS DENOTED IN PURPLE
MAGNETIC
NORTH
COUNTY MAP OF: ���.-■■ � �L�"
NORTH CAROLINA0arabbif A11014
ISEVILIIISV
4Likier
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COUNTY: G U I LFO R D
APPROXIMATE SITE LOCATION
PYRAMID
ENVIRONMENTAL & ENGINEERING, P.G.
``'SPENCER MOON
—FORMER KIMBLE AUTO GLASS
67* HIGH POINT
STATE NORTH CAROLINA
TLTOPOGRAPHIC MAP
SCAM
1"=2000'
6/29/18
COMIC NINE
USGSTOPO
TRwM " KAM I
Iaeih: TDL
Los NO: 2Oi8-700
ITS ASSESSMENT j
/IGIR MAW:
NOTES
TOPOGRAPHIC MVP IAED IN THIS
GRAPHIC 6 MAPPED, LOTTED, MO
PUBLISHED Re THE UNREO STATES
GEOLOGIC STR7YEY, DEPARTMENT Or
THE *MDR. RESTON W &
'MIS IMP COUPLES KM wpm.
Mw ACCURACY STANCAROS.

~ MW-2
'
~ 7 ~ .... ~ '-l
:,.,
;.s'Pw,J,t
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ff z MW-3 ~ ~ -~
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AnalytlC<!I An•l)'\._.I Sample Nun,ber and Laboratory RHuli. {mg/kg)
TW-2 Para motor Uo\hod MW -1 MW-1 MW-2 MW-.l MW-.l
$ S.1 mdG1 Data: 412Y2018 41w201a 412Y2018 412Y2018 412Y2018
Siam dlll 0Gipttl (NQt.l: 61:>tleel 11b13fee1 13 t:, 1b feel 31:>bleel 131:> 1Sfee1
I
CVA Re..i,rg
Re(Ol1oro u~1, ....,.0 ....,.0 ....,.0 ....,.0 ...,,.0
I MADEi" VPH RNuli.
t,1a1roo 50l5/&)1 S (;RO GRO ND 440 ND ND 2!..b
t,\>lroo 3SSCl'&)1b ORO DRO ND 172 63.2 234} 414 0 ~ MA DEi" VPH RNult. ~ CS-C8 ;.,, Oha11G1 VP~ ND 200 NA NA NA
:,., ~12 AIIPl'l811c1 VP~ ND 373 NA NA NA
~I ~ 10 A,oma1,c1 VP~ ND 220 NA NA NA
~I EPA Method &2fiO RNult.
0 ~ kelore 8l00 ND ND NA NA NA
8et\2ere 8~ ND ND NA NA NA
B,omofo,m 8~ ND ND NA NA NA
1>-61J1arore fMEK> 8~ ND ND NA NA NA
rr-BLll\'lbet\2ere 8~ ND 5.172 NA NA NA I ,ec,-61J1.i1>er.zene 8~ ND ND NA NA NA
I TW-4 ~n-Bt.11-vlt:et\2ete 8~ ND ND NA NA NA
$ 1,2-D, brom0e1 toe re IED 6) 8~ ND ND NA NA NA
Eur,,11>er.zere 8~ O.C"7 13.2 NA NA NA
2•Hexarore 8l00 ND ND NA NA NA
h ............ -.1 tel'\Zere 8l00 Nn ND NA NA NA
~l1O0,om,11O1u?re 8l00 ND ND NA NA NA
t,\>lh\4-1e ~-blJ1'1-e1hel fMT6E) 8l00 ND ND NA NA NA
LEGEND Neot11tlalere 8l00 ND 0 .7$ NA NA NA
I I MONIITORING WELL
r,-ProP\llber.zel"e 8~ ND 7.47 NA NA NA
~ TOiuene 8~ 0.032 18.4 NA NA NA
1,2,4-T ome11Mller.zere ND 53.3 NA NA NA
I I TE MPORARY WELL.
8~
$ 1.3.~T nme1r11-11>er.zere 8~ ND 16.1 NA NA NA
Tors X.iere, 8~ 0.037 74.4 NA NA NA
I I AII01tlwUSOl'.:r.:rnoiQn. 8~ ND ND NA NA NA
I
I [!JI SPENCER MOON IOOl6/28/1a Ill KAM I GRAPHIC SCALE IN FEET
!IDIFORMER KIMBLE AUTO GLASS 1~1 11§11 TDL I ~ 1~ 31°
[rulHIGH IIIDINORTH CAROLINA l~I PYRAMID POINT KIMBLE SITE MAP I 1•~30'
ENVlRONMENTAL & ENGINEERING, P.C. ~!SITE MAP !112018-10 Ifill 2
•
TW-2
NG
•
124 •
a •
TEMP WELL
GW CONTOURS
TW--4
NG
LEGEND
oo
M▪ 2I
84,97 r/
•
•
•
•
•
•
•
•
•
•
h
op
185.142
1 /
OVERHAN
•
•
' Y
T•3.
Y
NG
MONIITORING WELL
TEMPORARY WELL
/
1
/
/
/
/
/87.58
BUILDING
38.50' TO
MAIN ST.
PYRAMID
SPENCER MOON
6/28/18
KAM
FORMER KIMBLE AUTO GLASS
HIGH POINT
kT
NORTH CAROLINA
PS1A042515
TDL
KIMBLE SITE MAP
GRAPHIC SCALE IH FEET
1 30
1'=30'
ENVIRONMENTAL & ENGINEERING, P.C.
POTENTIOMETRIC SURFACE MAF (4/25/18)
2018-100
4

LEGEND
9
413,
PROPERTY LINE
MW-2
ND
/
00 (M ND p1 1
V RHA G
TW-2
17.5
TW-4
10.4
ca
LJ
1.65
MONIITORING WELL
TEMPORARY WELL
MW-3
ND9
BUILDING
ND — NOT DETECTED
38.50' TO
MAIN ST.
PYRAMID
SPENCER MOON
6/28/18
KAM
u
FORMER KIMBLE AUTO GLASS
HIGH POINT
NORTH CAROLINA
jewZD4u1a
m8
TDL
KIMBLE SITE MAP
GRAPHIC SCALE IN FEET
1 3D
1'=30'
NVIRONMENTAL & ENGINEERING, P,C,
BENZENE ISOCONCENTRATION MAP (4/25/18)
418-100 � 5

,B IUILDING�
1
46.5
LEGEND
9
PROPERTY LINE
60/
TW-4
40
xsp
1
1
OV RHANG
MW-2
ND
MW-1
*28,950
3.3
MONIITORING WELL
TEMPORARY WELL
PYRAMID
NVIRONMENTAL & ENGINEERING, P.C.
1 h
z
BUILDING
MW-3
ND*
ND — NOT DETECTED
* DATA FROM 5/14/18
SPENCER MOON
FORMER KIMBLE AUTO GLASS
HIGH POINT
11,
In
NORTH CAROLINA
kl
TOTAL BTEX ISOCONCENTRATION MAP (4/25/18)
6/28/18
TDL
KIMBLE SITE MAP
12018-10a
1
38.50' TO
MAIN ST.
GRAPHIC SCALE IN FEET
1 30
1'=3D'

,BUILD
PROPERTY LINE
LEGEND
TW-2
<0.5
TW-4
<0.5
M 2
ND
de4.
/ 50
�r
w
w
OVE'HANG
TW-3
0-
<0.5
MONIITORING WELL
TEMPORARY WELL
a
BUILDING
MW-3
ND •
ND -- NOT DETECTED
* DATA FROM 5/14/18
PROPERTY LI
38.50' TO
MAIN ST.
PYRAMID
ENVIRONMENTAL & ENGINEERING, P.G.
SPENCER MOON
6/28/18
n
FORMER KIMBLE AUTO GLASS
HIGH POINT
NORTH CAROLINA
LaJ KAM
EDBDM2515
TDL
EDB ISOCONCENTRATION MAP (4/25/181
KIMBLE SITE MAP
2018-100 1 I
GRAPHIC SCALE IN FEET
1 0
1'=30'

�B IULDING/
LEGEND
I
I
1
PROPERTY LINE
1W-2
•
0.95
TW-4
<0.5
MW-2
ND
(<2.0)
ps so\ P
1 1
MW 1( 1
*1020
8b0 f
TW-3
0.75
MONIITORING WELL
TEMPORARY WELL
VERHAN
ND - NOT DETECTED
* DATA FROM 5/14/18
38.50' TO
MAIN ST.
PYRAMID
SPENCER MOON
FORMER KIMBLE AUTO GLASS
HIGH POINT
NORTH CAROLINA
5/28/18
KAM
rkl.1i042575
TDL
KIMBLE SITE MAP
GRAPHIC SCALE IN FEET
15
30
'=30'
NVIRONMENTAL & ENGINEERING, P.C.
NAPHTHALENE ISOCONCENTRATION MAP (4/25/18)
2018-100

Notice of Intent to Construct or Operate Injection Wells
Former Kimball Autoglass, High Point, North Carolina

APPENDIX A

MSDS FORM

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Page 1 of 3

Safety Data Sheet

Form: Powder (SZE)
Section 1: Identification
Product Identifier: EnviroBac
Other Identifier: NONE
Recommended Use: See Product Literature
Supplier Information: 689 Canterbury Rd
Shakopee, MN 55379
(p)952-445-4251 (f) 952-445-7233 [e-mail]
Emergency Phone: [phone] 8am – 4pm EST
Section 2: Hazard Identification
Hazard Classification:
Eye Damage/Irritation Category 2B
Skin Corrosion/Irritation Category 2
Signal Word: Warning
Hazard Statements:
H315 Causes skin irritation.
H320 Causes eye irritation.
Pictogram(s):
Precautionary Statement(s):
P264 Wash face and hands thoroughly after handling.
P280 Wear protective gloves/protective clothing/eye protection/face protection.
Response Statement(s):
P302/352 IF ON SKIN: Wash with plenty of water.
P305/351/338 IF IN EYES: Rinse cautiously with water for several minutes. Remove contact
lenses, if present and easy to do. Continue rinsing. Immediately call a poison center/doctor.
P308/311 IF exposed or concerned: call a poison center/doctor.
P332/313 If irritation occurs: get medical advice/attention.
P337/313 If eye irritation persists: get medical advice/attention.
P362/364 Take off contaminated clothing and wash it before reuse.
Hazards Not Otherwise Categorized:
Moderate Respiratory Irritant
Section 3: Composition/ Information on Ingredients
Name:Proprietary bacterial blend CAS Number: N/A % by weight: 3.5-6%
Name:Maltodextrin CAS Number: 9050-36-3 % by weight: 2-3.5%
Name:Sodium chloride CAS Number: 7647-14-5 % by weight: Remainder %
Section 4: First-Aid Measures
Inhalation: If inhaled remove from contaminated area to fresh air. Report the situation. Seek
medical attention if allergic response is exhibited.
BIO-CAT
Microb ials

Page 2 of 3

Eye Contact: In case of contact with eyes, flush eyes with low pressure water for at least 15 minutes.
If irritation develops, seek medical attention.
Skin Contact: In case of contact with skin, wash skin with soap and cold water. Remove
contaminated clothing and wash.
Ingestion: If swallowed, rinse mouth and throat thoroughly with tap water. Drink water.
Section 5: Fire-Fighting Measures
Suitable Extinguishing Media: Standard procedure for chemical fires. Foam. Water.
Non-Suitable Extinguishing Media: None
Specific Exposure Hazards: None
Protective Equipment: No special requirements
Section 6: Accidental Release Measures
Personal precautions, Use only with adequate ventilation/personal protection. Avoid breathing
Emergency Procedures: dust or spray mist. Avoid formation of dust and aerosols. (See section 8).
Containment methods: Prevent further leakage or spillage if safe to do so.
Cleanup Procedures: Contain and remove spilled product by mechanical means or with a
vacuum cleaner equipped with a high efficiency filter. Avoid formation
of aerosol.
Section 7: Handling and Storage
Safe Handling: Never handle powder without appropriate personal protective
equipment in accordance with Section 8. Avoid formation of dust.
Avoid splashing and high pressure washing. Ensure good ventilation of
the room when handling this product.
Storage: Keep container tightly closed in a cool, dry, well ventilated place.
Section 8: Exposure Controls/Personal Protection
Appropriate engineering controls: Adequate ventilation required for dusty conditions
Eye/face protection: Wear protective glasses or eye shield
Skin protection: Impermeable gloves recommended
Respiratory Protection: Use NIOSH approved respiratory protection such as full face mask
Section 9: Physical and Chemical Properties
Appearance: Light to dark tan colored powder
Odor: Characteristic fermentation odor
Odor Threshold: Not available
pH: Not available
Melting point/freezing point: Not available
Initial boiling point and boiling range: Not available
Flash point: Not available
Evaporation rate: Not available
Flammability (solid, gas): Not available
Upper/lower flammability or explosive limits: Not available
Vapor Pressure: Not available
Vapor Density: Not available
Relative Density: Not available
Solubility: Soluble
Partition coefficient: n-octonol/water: Not available
Auto-ignition temperature: Not available
Decomposition temperature: Not available
Viscosity: Not available
BIO-CAT
Microb ials

Page 3 of 3

Section 10: Stability and Reactivity
Reactivity: Not available
Chemical Stability: Stable under normal storage conditions
Hazardous reactions: Not available
Conditions to avoid: Not available
Incompatible materials: Not available
Hazardous Decomposition Products: Not available
Section 11: Toxicological Information
Routes of Exposure: Eye contact, skin contact, ingestion, inhalation
Symptoms:
Immediate: May cause irritation to the eyes, skin, mucus membranes, and the
upper respiratory tract
Delayed: Not available
Acute toxicity: Not available
Eye Irritation: May cause minor irritation
Skin Irritation: May cause minor irritation
Respiratory Irritation: May cause minor irritation
Sensitization towards product: There is no evidence of sensitizing potential
Germ cell mutagenicity: Not available
Reproductive toxicity: Not expected to produce reproductive toxicity
Carcinogenicity: Not classified as a carcinogen by IARC, OSHA, or NTP
Section 12: Ecological Information
Ecotoxicity: Not available
Persistence and degradability: Product is readily biodegradable
Bioaccumulative potential: Not available
Mobility in soil: Not available
Other adverse effects: Not available
Section 13: Disposal Considerations
No special disposal method required, except that in accordance to all applicable federal, state, and
local regulations.
Section 14: Transport Information
Harmonized Tariff Code: 3002.90.10 (for Microbials)
UN Number: Not classified
UN Proper Shipping Name: Not classified
Transportation Hazard Class: Not classified
Packing Group: Not classified
Transport Environmental Hazard: Not classified
Transport Special Precautions: Not classified
MARPOL: Not classified
Section 15: Regulatory Information
All components of this product are listed or exempt from listing on the TSCA Inventory.
Section 16: Other Information
Revision History: Effective Date: 04/25/17 Supersedes: First Issue GHS 2015 FORMAT

The information contained in this Safety Data Sheet, as of the issue date, is believed to be true and correct. However, the
accuracy or completeness of this information and any recommendations or suggestions are made without warranty or
guarantee. Since the conditions of use are beyond the control of the company, it is the responsibility of the user to determine
the conditions of safe use of this product. The information does not represent analytical specifications. END OF SDS
BIO-CAT
Microb ials
Notice of Intent to Construct or Operate Injection Wells
Former Kimball Autoglass, High Point, North Carolina

APPENDIX B

MONITORING WELL CONSTRUCTION DETAILS

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Pyramid Environmental & Engineering, P.C.
FIELD DRILLING RECORD
PROJECT NAME: Spencer Moon Estate
BORING/WELL NO: MW-1
PROJECT NUMBER: 2018-100
SITE LOCATION: 748 N. Main St.
BORING/WELL Near North corner of bldg. High Point, NC
LOCATION:
START DATE: 4/23/18
COMPLETED: 4/23/18
GEOLOGIST: Higgins DRILLER: REDI
DRILL METHOD: Auger
SAMPLE METHOD: Macro-Core
BORING DIA: 6 inch CASING DIA: 2-inch
TOTAL DEPTH: 30 feet
CASING DEPTH: 30 feet
VISUAL MANUAL SOIL CLASSIFICATION OVA RESULTS
DEPTH COLOR, TEXTURE, STRUCTURE, CONSISTENCY, ODOR, ETC. PERCENT RECOVERY
(ft.) BLOW COUNTS
0-4" Asphalt and ABC Stone
2-8' Mottled medium brown orange-red-tan, firm silty clay, no obvious odor 2-3"PID: 3.5 PPM
3-S'PID: 3.0 PPM
6-8'PID: 9.8 PPM
8-10' Light Brown, tan with gray-white, silty-clay 8-10'PID:113.5 PPM
11-13' Mottled medium brown and tan with black grains, silty clay, 11-13'PID:2753 PPM
Strong gas odor
13-20 Tan with medium brown-black, silty clay, strong gasoline odor 13-15'PID: 1809 PPM
15-17'PID:315.5 PPM
18-20"PID:387.5 PPM
MONITORING·WELL INFORMATION (IF APPLICABLE)
RISER LENGTH (ft)1Q_ DEPTH (ft) 0-10
SCREEN LENGTH (ft)~ DEPTH (ft) 10-30
DIAMETER (in)~
DIAMETER (in)~
BAGS OF SAND3 . DEPTH TO TOP OF SAND 8 ft
DEPTH TO TOP SEAL 6 ft -BENTONITE USED 1/2 bag ~
MATERIAL PVC .
MATERIAL PVC .
BAGS OF CEMENT USED -·
Notice of Intent to Construct or Operate Injection Wells
Former Kimball Autoglass, High Point, North Carolina

APPENDIX C

ACCESS AGREEMENT FROM SITE PROPERTY OWNER

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Sharon Ghiold
DWM UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Ms. Ghiold:
RE: Site Access Agreement
Former Kimball Autoglass
748 N. Main Street
High Point, Guilford County, NC (WSRO)
STF Incident Number 45049
Risk/Rank: Intermediate, 1170D
I am/We are the owner( s) of a parcel of property, located at or near the incident in question,
and hereby permit the Department of Environmental Quality (Department) or its contractor to enter
upon said property for the purpose of conducting an investigation of the groundwaters under the
authority of G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the
Department or its contractor. The Department or its contractor shall protect and prevent damage
to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the
shortest feasible route to the nearest public road. The Department or its contractor may enter
upon the land at reasonable times and have full right of access during the period of the
investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article
31 of Chapter 143 of the North Carolina General Statutes, Tort Claims Against State
Departments and Agencies, and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.
6. The activities to be carried out by the Department or its contractor are for the primary benefit
of the Department and of the State of North Carolina. Any benefits accruing to the owner are
incidental. The Department or its contractor is not and shall not be construed to be an agent,
employee, or contractor of the land owner.
Kimball Autoglass
STF #45049
Page 2
If We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Signature
61 -1,61.7 717e7et
Type/Print Name of Owner or Agent
;t- 5o/ - yboca
Phone Number
Address
lb) h PSIl e 7" /'C- 272-‘i'
City/State/Zip Code
Ilta7 hy
Date
6.7 6 i+e-cf*A-4m 5ei-v:4tf , (ors
Email