WI0400579_Permit (Issuance)_20211028

ATC
ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
2725 East Millbrook Road
Suite 121
Raleigh, NC 27604
Tel: [phone]
Fax: [phone]
www.atcgroupservices.com
N.C. Engineering License No. C-1598
October 8, 2021
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
Amos Grocery
5378 NC Highway 704 East
Sandy Ridge, Stokes County, North Carolina
NCDEQ Incident No. 12530
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 installation and
use of two air sparge injection wells at 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: Herb Berger, P.G., Hydrogeologist for NCDEQ
Attachments

Notice of Intent to Construct or Operate Injection Wells
Amos Grocery, Sandy Ridge, North Carolina
NOTICE OF INTENT FORM
ATC
EYTIRON•EN1AL • OEOREnlEAI
NII10Is6iCIENLCi• 4.I1EN11[i TE6HN6

NC Department of Environmental Quality — Division of Water Resources (DWR)
NOTIFICATION OF INTENT (NOI) TO CONSTRUCT OR OPERATE INJECTION WELLS
The following are `permitted by rule" and do not require an 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
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: October 8 , 20 21
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:
A.
B.
Permit No. WI
Issued Date:
WELL TYPE TO BE CONSTRUCTED OR OPERATED
(1) X Air Injection Well Complete sections B through F, J, M
(2) Aquifer Test Well .Complete sections B through F, J, M
(3) Passive Injection System Complete sections B through F, H-M
(4) Small -Scale Injection Operation Complete sections B through M
(5) Pilot Test Complete sections B through M
(6) In -Situ Thermal (IST) Well Complete all sections except K
STATUS OF WELL OWNER: State Government
Deemed Permitted GW Remediation NOI Rev. 2-14-2020
Page 1

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: Herb Berger, P.G. — 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.: 919-707-8170 Cell No.: Not Available
EMAIL Address: [e-mail] Fax No.: Not Available
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: Katie Amos
Company Name Not Applicable
Mailing Address: 5438 NC Highway 704 East
City: Sandy Ridge State: NC Zip Code: 27046 County: Stokes
Day Tele No.: 336-871-2126 Cell No.: Not Available
EMAIL Address: Not Available Fax No.: Not Available
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name: Ashley M. Winkelman — 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: Amos Grocery
5378 NC Highway 704 East
City: Sandy Ridge County: Stokes Zip Code: 27046
(2) Geographic Coordinates: Latitude**: 0' " or 36 °. 48889
Longitude**: 0 " or -80 °. 09375
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: square feet
Land surface area of inj. well network: square feet (< 10,000 ft2 for small-scale injections)
Percent of contaminant plume area to be treated: (must be < 5% of plume for pilot test injections)
Deemed Permitted GW Remediation NOI Rev. 2-14-2020 Page 2

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:
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: 2 Proposed Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 40-45'
(3) For Proposed wells or Existing wells not having GW-1 s, provide well construction details for each
injection well in a diagram or table format. A single diagram or line in a table can be used for
multiple wells with the same construction details. Well construction details shall include the
following (indicate if construction is proposed or as -built):
(a) Well type as permanent, Geoprobe/DPT, or subsurface distribution infiltration gallery
(b) Depth below land surface of casing, each grout type and depth, screen, and sand pack
(c) Well contractor name and certification number
Well
Name
Well Type
Depth BLS
Casing
Interval BLS
Screen
Interval BLS
Grout Type
BLS Depth
Sand Pack
Interval BLS
Well Contractor
AS-1
Proposed
Permanent
Air Sparge
45'
0'-40'
40'-45'
Portland
Bentonite —
0'-35'
38' - 45'
Geologic
Exploration -
A3552
AS2
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of the NC Division ofPublic 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.
Injectant: Total Amt. to be injected (gal)/event:
Amt. Water to be injected (gal/event):
Deemed Permitted GW Remediation NOI Rev. 2-14-2020
Page 3

Total Amt. to be injected (gal/event):
No. of separate injection events: Est. Total Amt. to be injected (gal):
Source of Water (if applicable):
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.
M. SIGNATURE OF APPLICANT AND PROPERTY OWNER
Well Owner/Applicant: "1 hereby certjy, under penalty of late, that 1 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. 1 am aware that there are significant penalties, including the possibility offrnes and imprisonment,
for submilling false information. nation. 1 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."
Ashley Winkelman on behalf of Herbert Berger, NCDEQ
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 10 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.
See Appendix A Katie Amos
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]
Deemed Permitted GW Remediation NO1 Rev. 2-14-2020 Page 4

Ashley Winkelman
From: Berger, Herb <[e-mail]>
Sent: Friday, October 08, 2021 2:04 PM
To: Ashley Winkelman
Subject: RE: [External] Notice of Intent for Amos Grocery (#12530)
Hi Ashley:
ATC Associates is granted/approved a permission to act as an agent for NCDEQ to sign a notification for UIC.
Thanks
Herb Berger, LG
J .'drogeologist
j North Carolina Department of Environmental Qua€ity
919.?1Y?.8170 (Office)
Herbert.BerReranedenr.zov
anduicomponrkirceito art evn adeire 8 JJ dpirke AbliP?CanAm Rie#c FOYxods Leei7 am"
From: Ashley Winkelman <[e-mail]>
Sent: Friday, October 8, 2021 1:46 PM
To: Berger, Herb <[e-mail]>
Subject: [External] Notice of Intent for Amos Grocery (#12530)
CAUTION: External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
Report Spam.
Hey Herb,
I'm preparing a Notice of Intent for the upcoming AS -enhanced MMPE at Amos Grocery. For the NOI I can either sign on
your behalf (since NCDEQ is the applicant) or I can send to you for signature. If you'd like me to sign on your behalf, can
you send me a quick email saying so for me to include with the application? I've included an example for your
reference.
Ashley M. Winkelman PGI SENIOR PROJECT MANAGER I ATC Group Services LLC
Direct [phone] I Cell [phone]
ATC
2725 E. Millbrook Road, Suite 121 I Raleigh, NC 27604
Fax [phone] I [e-mail] I www.atcgroupservices.com
1

Notice of Intent to Construct or Operate Injection Wells
Amos Grocery, Sandy Ridge, North Carolina
APPENDIX A
ACCESS AGREEMENT FROM SITE PROPERTY OWNER
ATC
EYTIRON•EN1AL • OEOREnlEAI
NII10Is6iCIENLCi• k11EN14iTE6HN6

Jul 09 14 09:55p Total Real Estate
3368873335 p.2
Herb Berger
Hydrogeologist
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
RE: Site Access Agreement
Former Amos Grocery
5438 Highway 704 East
Sandy Ridge, NC
Incident Number 12530
Dear Mr. Berger
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 Environment and Natural Resources (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 home 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 North Carolina G.S. 132-1.

Jul 09 1409:55p Total Real Estate 3368873335 p.3
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.
1/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,
Sincerely,
e/Pri ' Na rr# of Owner or
2.3, -WO or 234 - °dj' =��Z
Phone Number
Add ess
City/State/Zip Code
Date