WI0400540_Permit (Issuance)_20200225 (2)

February 7, 2020
Mr. Mike Rogers
NCDEQ
Division of Water Resources — UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Subject: Notice of Intent for Injection
Former Vitafoam / Current Innocor Facility
2222 Surrett Drive
High Point, Randolph County, North Carolina
Site ID #NONCD 0002676
Dear Mr. Rogers:
On behalf of M.5 Corporation, Blue Ridge Geological Services, Inc. (Blue Ridge) is planning to perform
additional assessment and remediation activities at the subject site. Attached is a Notice of Intent (NOI)
application form and the required attachments for performing injection activities at the site. Per our
discussion, we plan to use existing well(s) at this time but may drill / install additional wells / injection
points if this work is successful.
Please contact the undersigned if you have any questions and / or if you need any additional information.
We appreciate your review of this information.
Sincerely,
o SIN SRO yo,
i SEAL
1141
Jeffrey L. Gerlock, L.G.
NC Licensed Geologist #1141
Registered Environmental Consultant #149
Attachments NOI Form, Figures, MW-17 construction record
cc: Ms. Candace Moeller, M.5 Corporation
7356 Belmont Drive, Trinity, NC 27370 * Phone: [phone]

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 .02251 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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: February 7, , 20 20 PERMIT NO. W 10400540 (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.
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) X
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)
Tracer Injection Well...................................Complete
sections B through M
B. STATUS OF WELL OWNER: Choose an item.
Deemed Permitted GW Remediation NOI Rev. 10-14-2019 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(s): M.5 Corporation - Jeff Gerlock of Blue Ridge Geol Services auth to sign on behalf of M.5
Mailing Address: PO Box 126
City: Spencerville State: OH Zip Code: 45887 County: Allen
Day Tele No.: Cell No.: 336-382-6849 Jeff
EMAIL Address: candacestnkyahoo.com Fax No.:
D. PROPERTY OWNER(S) (if different than well owner/applicant)
Name and Title: same as above
Company Name
Mailing Address:
City: State: Zip Code: County:
Day Tele No.: Cell No.:
EMAIL Address: Fax No.:
E. PROJECT CONTACT (Typically Environmental Consulting/Engineering Firm)
Name and Title: Jeff Gerlock, President
Company Name Blue Ridge Geological Services, Inc.
Mailing Address: 7356 Belmont Drive
City: Trinity State: NC_ Zip Code: 27370 County: Randolph
Day Tele No.: Cell No.: 336-382-6849
EMAIL Address: Jeff. erg lockggmail.com Fax No.:
F. PHYSICAL LOCATION OF WELL SITE
(1) Facility Name & Address: Innocor, 2222 Surrett Drive
City: High Point County. Randolph/ Guilford Zip Code: 27263
(2) Geographic Coordinates: Latitude": " or 35 °.917
Longitude": " or 80 °.000
Reference Datum: MW-17 Accuracy:
Method of Collection: USFWS Wetlands Mapper
"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: NA 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. 10-14-2019 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.
L 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:
We Dlan to install Dotassium Dermanaanate (RemOx) cvlinders (1.35" x 18 inch) in one existine monitorin
well (MW-17) to enhance biodegradation of the chlorinated solvents (TCE and 1,4-dioxane) in the
groundwater at the site. We will install two to four cylinders in well MW-17; the cylinders will to placed in a
mesh and set to depths of approximately 20, 25, and 30 feet in the well. If successful, we would like to install
cylinders in one or more existing or proposed wells in or near the contaminant plume.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 1 to 2 Existing (provide NC Well
Construction Record (GW-1) for each well)
(2) Appx. injection depths (BLS): 15, 20, 25, and/or 30 feet
(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 iniectants avvroved by the evidemiologv section of the NC Division of Public Health
Department of Health and Human Services can be injected. Approved injectants can be found online at
hitp:Hdeq.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 avvroval for a different additive. However.
lease note it may take 3 months or longer.
Injectant: Potassium Permanganate - RemOx Total Amt. to be injected (gal)/event: 1-5 cylinders
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. 10-14-2019 Page 3

Injectant: Total Amt. to be injected (gal)/event:
Amt. Water to be injected (gal/event):
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.
We plan to collect groundwater from adjacent and downgradient wells following the injection activity. We
will analyze the samples for VOCS by Method 8260 We will provide a summarreport to the NCDEO
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 inject' n well and all related appurtenances in accordance with the I5A NCAC 02C 0200 Rules."
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 (1 SA NCAC 02C . 0200I. "
"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 rroperty 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 NOI Rev. 10-14-2019 Page 4

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NOTES:
Stratification lines approximate;
in -situ
transition may be gradual.
Blue
Ridge logged borings and installed
groundwater
monitoring wells. Geoprobed
to
B' then augered to depth.