WI0400540_Permit (Application Amendment)_20210309

Piri."44
L�LUL RIDGL
GEOLOGICAL SERVICES, INC.
February 2021
Mr. Shristi Shrestha
NCDEQ
Division of Water Resources — UIC Program
1636 Mail Service Center
Raleigh, North Carolina 27699-1636
Subject: Notice of Intent for Additional Injection
Former Vitafoam / Current Innocor Facility
2222 Surrett Drive
High Point, Randolph County, North Carolina
Site ID #NONCD 0002676
Existing Injection Permit #WI0400540
Dear Mr. Shrestha:
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 additional injection activities at the site.
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,
Jeffrey L. Gerlock, L.G.
NC Licensed Geologist #1141
Registered Environmental Consultant #149
Attachments NOI Form, Figures, construction records
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 .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.
Print Clearly or Type Information. Illegible Submittals Will Be Returned as Incomplete.
DATE: February 19, , 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:
Permit No. WI 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: [e-mail] 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.gerlock(cr�,gmail.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.
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:
We plan to install potassium permanganate (RemOx) cylinders (1.35" x 18 inch) into two existing monitoring
wells (MW-2 and DW-1) 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 each well; the cylinders will to placed in a
mesh and set to depths of approximately 20 and 60 feet, respectively in wells MW-2 and DW-1.
J. WELL CONSTRUCTION DATA
(1) No. of injection wells: Proposed 2 Existing (provide NC Well
Construction Record (GW-1) for each well)
Appx. injection depths (BLS): 20 and 60 feet
For Proposed wells or Existing wells not having GW-ls, 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
(2)
(3)
K. INJECTION SUMMARY
NOTE: Only injectants approved by the epidemiology section of 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 if you wish to get approval for a different additive. However,
please note it may take 3 months or longer.
Injectant: Potassium Permanganate - RemOx Total Amt. to be injected (gal)/event: 2-4 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:
Injectant: Total Amt. to be injected (gal)/event:
Deemed Permitted GW Remediation NOI Rev. 10-14-2019 Page 3

Amt. Water to be injected (gal/event): 0
Total Amt. to be injected (gal/event):
0
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 the existing well and adjacent and downgradient wells following the
injection activity. We will analyze the samples for VOCS by Method 8260. We will provide a summary
report to the NCDEQ.
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 injection well and al
l related apurtenances in accordance with the 15A NCAC 02C 0200 Rules."
Jeff Gerlock, BRGS, Agent for M.5 Corporation
Signature/ r plicant 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 (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.
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 NOI Rev. 10-14-2019 Page 4

SOIL
SYMBOL
SOIL BORING LOG R K
WITH MONITORING WELL CONSTRUCTION NOTES
PROJECT: Flexible Foam - Vita Foam High Point, NC
BORING NO. DW-1
BORING LOCATION: East Side of Parkinglot
METHOD OF DRILLING:HSA & Air Rotary Rig DATE: 6/16/06
WATER ELEVATION: -44.03 BTOIC (6/16/06) GROUND SURFACE ELEVATION: 99.69'
SURFACE CONDITIONS: Asphalt
RK & Associates, Inc.
2 South 631
Route 59, Suite B
Warrenvitle, Illinois 60555
DEPTH
ELEVATION
16 — -IS
-
46 — -46
50 — -50
60 — -60
65 — -65
—J
eC
SAMPLE NURSER
SOIL DESCRIPTION
ASPHALTIC CONCRETE
BROWN CLAYEY SILT(SC)
BROWN SILT (SC)
PARTIALLY WEATHERED ROCK
(PWR).
WEATHERED ROCK - GRANITE
ROCK GRANITE No signifiioarrt
fractures encountered.
IN
WELL
CONSTRUCTION
1:111 IML
NCI I
1E101 MEI
ICI
Mii MIN
CM III
= =
Its MX
COI CCM
COI CCM
M
= CCM
=
a—.
WELL
DESCRIPTION
Qn L!C
cTr
Rullim punt Qltbr
Casing
0.4br7116106
Portland I:A nbnite
6" Oui r PVC Cl rl ng
7 Inch Pvccasing
viAttr6 iaro6
E n4sntt SeaI
Sand PapH
3 Inpllo.ol alotAUC
scu*n
£:ttom of MII
screen 66.71' BGS
NOTES: Stratification lines are approximate; in -situ transition between soil types may
be gradual. BGS= Below Ground Surface. BTOIC = Below top of inner casing.
Bottom of well Screen 66.75 ' BTOIC. TOIC = 0.43' BGS.

Emit e-
Project Number: 09583-050
Client: Vitafoam
Site: High Point, NC
Well Log
Boring Number: MW-2
Sheet: 1 Of 1
Equipment: Hollow Stem Auguer
Sampling Method: Split Spoon
Depth of Boring: 22 ft
Initial Water Level: 15 ft
Project Manager: D. O'Brien
Logged: D. O'Brien
Date Started: 11/14/05
Drilling Contractor. Geologic Exploration
Driller:
Date Finished: 11/14/05
Depth
(ft)
Sample
Depth(ft)
Blow
Count
Recovery
(inches)
Moisture
PID ppm
Letter
Symbol
Classification of Material
f-fine f/m-fine to medium a. -and (35-45%)
m-medium f/c-fine to coarse s.-some (20-35%)
c-coarse m/c-medium to coarse 1.-little (10-20%)
All capital letters-50%+ t.-trace (1-10%)
Details
Manhole
1
2
3
4 _
5
6 _
7
8 _
9
10 _
11
12 _
13
14 _
15
16
17
18
19 _
20
21 _
22
4-6
6-8
8-10
14-15.5
19-20.5
19-20.5
3/4/6/6
3/6/7/17
5/7/7/12
4/5/5/8
4/4/12/7
4/4/12/7
18
14
16
16
18
14
SC
Asphalt
Brown -grey fine, sandy CLAY
Grout
0'-8'
Bentonite
8'-10'
Sand
10'-22'
0
SC
Brown -grey, stiff, fine, sandy CLAY
0
SC
Brown -red, very stiff, fine, sandy CLAY
0
SM
Grey with red mottling, very stiff, fine sandy SILT
PVC
Screen
12'-22'
0
SM
Orange to grey, stiff fine, sandy SILT with black thin stringers
(relic structure?) - moist
0
SC
Yellow to light grey, very stiff, fine -medium sandy CLAY -
moist
0
SC
Yellow to light grey, very stiff, fine -medium sandy CLAY -
moist
22' - Total Depth

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TCE ISOCONCENTRATION
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MW-18
Maintenance
r
ti
27708397712
Fiber Line (not in use)
Bun Storage
MW-2
7709307251
Cutting/Sawing
MW-23
ND
-
7708399425
Groundwater Flow Direction
16.4 1,4-Dioxane concentration (ug/L) in groundwater
in April 2020; NC2L Standard is 3 ug/L
ND - Not Detected
REF.: Randolph County GIS Aerial
Scale
1"=80feet
7709403391
77095025!
BLUE RIDGE
GEOLOGICAL SERVICES, INC.
1,4-Dioxane Isopleth - 2020
Former Vitafoam
2222 Surrett Drive
High Point, North Carolina
April 2020
Figure 3

MW-18 N D
Maintenance
•
ti
2222
Aar.
n7708397712
Fiber Line (not in use)
Bun Storage
MW,
x
N'
7709307251
Cutting/Sawing
MW-23 H
ND
7708399425
Groundwater Flow Direction
6.2
--ND MW-
MW-3 prim N Di,
ND ..
CORPoR•ATJON DR
16.4 TCE - Trichloroethene concentration (ug/L) in groundwater
in April 2020 - NC2L Standard is 3 ug/L
ND - Not Detected
REF.: Randolph County GIS Aerial
Scale
1"=80feet
7709403391
1 "
017095025
s
•�
1 J
f
BLUE RIDGE
GEOLOGICAL SERVICES, INC.
TCE Isopleth Map - 2020
Former Vitafoam
2222 Surrett Drive
High Point, North Carolina
April 2020
Figure 2

Fiber Line (not in
MW-18
Maintenance 869.12
7709307251
a)
Cutting/Sawing
+-.nr-....
mw-
MW-23
858.52
7708399425
Legend
Groundwater Flow Direction
868.83 Groundwater Elevation on Apri12, 2020
REF.: Randolph County GIS Aerial
a
0
-14
$ 864.
0
0
cn
862.18
Scale
1"=80feet
7709403391
"
.: ' .
77095025'
MW-15
862.79
858.14
t
855.55
BLUE RIDGE
GEOLOGICAL SERVICES, INC.
Groundwater Contour Map
Former Vitafoam
2222 Surrett Drive
High Point, North Carolina
April 2020
Figure 1