WM0501512_Final Permit_20221011

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
ROY COOPER
Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR.
Director
NORTH CAROLINA
Environmental Quality
October 11, 2022
Circle K Stores, Inc.
c/o Maureen A. Jackson
1100 Situs Court, Suite 100
Raleigh, NC 27606
Subj ect: Monitoring Well Construction
Permit # WM0501512
Circle K Store #2724660
1523 E. 11 Street
Siler City, NC 27344 — Chatham County
Ms. Jackson:
In accordance with the application received on August 29, 2022, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501512 dated October 11, 2022, issued for the construction
of a monitor well system (installation of three wells). Please be aware that some counties have well
construction programs, and you may be required to obtain a well construction permit before
installation.
This Permit will be effective from the date of its issuance and shall be subject to the conditions and
limitations as specified therein. Please note the addition of stipulation #3 to the permit enclosed. If you have
any questions about this permit, please contact Tyler Clark at [phone].
Enclosure
cc: RRO Files/Laserfiche
NORTH CAROLINA
Department M Environmental Quality
Sincerely,
DocuSigned by:
LI
oft uit,setn,
BCDA9D825D4A46D...
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919.707.9000

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable Laws,
Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
Circle K Stores, Inc.
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM (Circle K Store #2724660) consisting of
three monitoring wells owned by Circle K Stores, Inc. at mailing address 1100 Situs Court, Suite 100
Raleigh, NC 27606. The wells will be located on the properties owned by Incommercial Net Lease DST
4, 117 N. Jefferson Street, Suite 303, Chicago, IL 60661 . This Permit is issued in accordance with the
application received on August 29, 2022, in conformity with specifications and supporting data, all
of which are filed with the Department of Environmental Quality and are considered integral parts
of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of any other applicable law or
regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina Well
Construction Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and regulations pertaining
to well construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing upon
written request within 30 days of receipt of this Permit. The request must be in the form of a written petition conforming
to Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail
Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions,
limitations, or exceptions as follows:
1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are being
installed as part of an investigation for contamination from an underground storage tank or dry cleaner
incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by another
agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the Permit
application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC 02C
.0113 and a well abandonment record (GW-30) shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet of the
well shall be grouted within one day after the casing is set or the well abandoned.
Permit issued the 11th of October 2022
FOR THE NORTH CAROLINA EAR®bNiFaT1 4L MANAGEMENT COMMISSION
SitoScott VinNun, e_iona spervisor
Divisio`nEif liet2N16kiiRs.
By Authority of the Environmental Management Commission
Permit No. WM0501512
D_E
NORTH CAROLINA
Department of Environmental Duel
North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 11611 Mail Service Center I Raleigh, North Carolina 27699-1611
919.707.9000

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina 27604
Tel: [phone]
Fax: [phone]
www.oneatlas.com
N.C. Engineering License No. C-1598
August 29, 2022
Mr. Scott Vinson
North Carolina Depai tiuent of Environmental Quality
Raleigh Regional Office
Division of Water Quality, Aquifer Protection Section
3800 Barrett Drive
Raleigh, North Carolina 27609
RE: Application for Permit to Construct a Monitoring Well System
Former Circle K Store #2724660
1513 E. 11th Street
Siler City, Chatham County, North Carolina
NCDEQ Incident No. 47762
Dear Mr. Vinson:
On behalf of Circle K Stores, Inc., ATC Associates of North Carolina, P.C. (ATC) has obtained a Right
of Entry permission for the installation of three groundwater monitoring wells on property located at 1523
E. 1 1th Street Siler City, North Carolina. I have attached the well construction permit application to this
cover letter. Drilling will be scheduled upon receipt of the approved permit to construct a monitoring
well system.
We greatly appreciate your assistance in this matter. If you have any questions or concerns, please feel
free to contact me at [phone] or via email at [e-mail].
Sincerely,
TC ASSOCIAT OF NORTH CAROLINA, P.C.
aureen iacxson, .
Senior Project Manager

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
In accordance with the provisions of Article 7, Chapter 87, General Statutes of North Carolina and regulations pursuant thereto,
application is hereby made for a permit to construct monitoring or recovery wells
1 Date: August 29, 2022
2 County: Chatham
3.
4 Applicant: Circle K Stores, Inc.
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 1 100 Situs Court, Suite 100 Raleigh, North Carolina 27606
Applicant's Email Address (if available): [e-mail]
Contact Person (if different than Applicant): Maureen Jackson
Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook Road, Suite 121 Raleigh, North Carolina 27604
Contact Person's Email Address (if available): [e-mail]
6 Property Owner (if different than Applicant): Incommercial Net Lease DST 4 Telephone:
Property Owner's Mailing Address: 117 N. Jefferson St, Suite 303 Chicago, IL 60661-2300
Property Owner's Email Address (if available):
7 Property Physical Address (Including PIN Number) 1523 E. I lth St (PIN #8762-20-82-8288)
City Siler City County Chatham
Zip Code 27344
Reason for Well(s): petroleum release assessment for Circle K Store #2724660 (UST incident #47762)
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc )
9 Type of facility or site for which the well(s) is(are) needed UST
(ex: non -discharge facility, waste disposal site, landfill, UST, etc )
10. Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s)
UST incident #47762
11 Type of contaminants being monitored or recovered: petroleum
(ex: organics, nutrients, heavy metals, etc.)
12 Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes - 16
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13 Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 300 to 400 feet
14 Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15 Well Contractor: Geologic Exploration
Certification No.: 1 176
Well Contractor Address: 176 Commerce Blvd. Statesville, North Carolina 28625
PROPOSED WELL CONSTRUCTION INFORMATION
1 As required by 15A NCAC 02C 0105(f)(7), attach a well construction diagram of each well showing the following
a. Borehole and well diameter
b Estimated well depth
c Screen intervals
d Sand/gravel pack intervals
e. Type of casing material and thickness
f Grout horizons
g Well head completion details
Continued on Reverse

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2 Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured?
material: 3 Steel traffic bearing cover. sealing and locking cap
3 Number of wells to be constructed in bedrock: 0 Estimated beginning construction date: Sept/Oct 2022
4 Total Number of wells to be constructed:
(add answers from 2 and 3)
1.
7 Estimated construction completion date: Sept/Oct 2022
ADDITIONAL INFORMATION
As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:
a.
b
c.
d
e.
All property boundaries, at least one of which is referenced to a minimum of two landmarks such as identified roads,
intersections, streams, or lakes within 500 feet of the proposed well or well system.
All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
The proposed well or well system.
Any test borings within 500 feet of proposed well or well system
All sources of known or potential groundwater contamination (such as septic tank systems, pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.S. 143-215.106(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
Signature of Applicant or *Agent
Maureen A. Jackson, PG on behalf of Circle K Stores, Inc.
Printed name of Applicant or *Agent
Senior Project Manager ATC Associates of NC
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
that you have the authority to act as the Agent.
If the property is owned by someone other than the applicant, the property owner hereby consents to allow the applicant to construct
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C)
Fxeciitecl and signed ROE attached
Signature of Property Owner (if different than Applicant)
Incommercial Net Lease DST 4
Printed name of Property Owner (if different than Applicant)
DIRECTIONS
Please send the completed application to the appropriate Division of Water Resources' Regional Office
Asheville Regional Office
2090 U S Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
From: Cubberley, Alan
Sent: Wednesday, February 17, 2021 8:11 AM
To: Maureen Jackson
Subject: [EXTERNAL] RE: Permits
]External Email] This email originated ti•om outside of the Atlas mail system.
Please use caution when opening attachments.
I give Maureen Jackson permission to sign permits on behalf of Circle K (NPDES, well
permits for off -site wells, UST (DEQ) forms).
Alan Cubberley
Senior Manager — Risk Control
Fuel and Environmental — North America
e:acubberleyCcdcirclek.com
t: [phone]
m: [phone]
Circle K Stores Inc.
1100 Situs Court, Suite 100
Raleigh, NC 27606
http://corpo.couche-tard.com/en/business-units/
Part of Alimentation Couche-Tard
CONFIDENTIALITY NOTE: This e-mail message, including any attachment(s), contains information
that may be confidential, protected by the attorney -client or other legal privileges, and/or proprietary
non-public information. if you are not an intended recipient of this message or an authorized assistant
to an intended recipient, please notify the sender by replying to this message so that we can correct
our records to avoid the mistake in the future and then delete it from your system. Use, dissemination,
distribution, or reproduction of this message and/or any of its attachments (if any) by unintended
recipients is not authorized and may be unlawful. Your cooperation with this request is appreciated.
From: Maureen Jackson <[e-mail]>
Sent: Wednesday, February 17, 2021 7:47 AM
To: Cubberley, Alan <[e-mail]>
Subject: [EXTERNAL] Permits
Importance: High

onouSignEnvelope ID: 0o8uA4FC-540o-40oE-8rs0-C9Asuo80ozo4
|
PROPOSED MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TC)SCALE)
LOCKABLE WELL CAP PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL steel
8 inches
L4\
/
i
L2
B
u = o FT,
m~ 10 ft rr
m~ 15 ft rr
1-4~ 25 ft pr
CASING DIAMETER
CASING LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND Flush
12\noheo
2x2feet
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
—
----BACKF|LLAROUNDCAS\NG
MATERIAL
THICKNESS
SEAL
TYPE OFSEAL
THICKNESS
FILTER PACK
TYPE 0FFILTER
DISTANCE ABOVE SCREEN
— WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
__--DEPTH TOBOTTOM OF
MONITORING WELL
*-- -- DEPTH TO BOTTOM OF
BOREHOLE
DIAMETER OF BOREHOLE
2inobey
flush threaded
cement -sand grout
bentonite
2fpet.
#2 silica sand
2inchns
15 feet
0.010innhes
125feet
_
'25feet
6 inches
_
TITLE FIGURE
Proposed Monitoring Well
Circle KStore #272460O
1513E. 11UlSt.
Siler City, NC
�
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|
2725 E.KoU|bronkRoad, Suite 121
Raleigh, North Carolina 27604
FILE PREP BY
MAJ
REV. BY
PROJECT NO.

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
SITE ACCESS AGREEMENT
THIS SITE ACCESS AGREEMENT ("Agreement") is entered into by and between
CIRCLE K STORES INC., a Texas Corporation ("Circle K"), and Incommercial Net Lease
DST 4 (hereinafter referred to in the singular as "Owner").
RECITALS
The foregoing recitals are hereby incorporated by reference.
A. Owner holds record title to certain real property located at 1523 E. 11th Street (PIN
#8762-20-82-8288) in the City of Siler City, Chatham County, State of North Carolina, as
depicted in Exhibit "A" attached hereto and incorporated herein (the "Property");
B. Circle K has assumed responsibility for the management and performance of Work (as
defined in Paragraph 1 [Rights Granted]) on the Property;
C. Circle K and its agents seek Owner's authorization to access the Property to conduct the
Work (as defined in Paragraph 1 [Rights Granted]);
D. Owner is willing to grant Circle K access to the Property for the above -described
purposes.
TERMS 'AND CONDITIONS
NOW, THERETOFORE, in consideration of the mutual covenants and promises
herein, the parties herby agree as follows:
1. RIGHTS GRANTED
Owner hereby grants to Circle K, its employees, agents, representatives, consultants and
contractors (collectively, for purposes of this Agreement, "Circle K Parties"), a license over,
under and across the Property for the purpose of performing certain work under government
agency oversight or direction, relating to release [NCDEQ Incident No. 47762] or otherwise
required to meet the obligations of applicable laws (the "Work"). The NCDEQ is requesting
Circle K to install three groundwater monitoring wells on the Property. Owner agrees to fully
cooperate with Circle K, including the execution of additional documents, if necessary, in
order to obtain permits or other documents from a government agency required to install,
abandon or remove Circle K's equipment used in connection with the Work.
2. PERFORMANCE OF THE WORK
Circle K agrees, at its sole cost and expense, to conduct and perform the Work in a
prompt, safe, efficient and workmanlike manner and in compliance with all applicable federal,
state or local laws, regulations or ordinances.
14390031 2/010609.0074

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
3. TERM
This Agreement shall terminate upon completion of the Work. Completion of the Work
typically involves issuance of a "no further action" or similar closure letter by the government
agency with oversight authority regarding environmental matters.
4. RESTORATION
If entry onto the Property by Circle K, or the exercise by Circle K of any of its rights or
obligations under this Agreement, result in any material physical damage to the Property, Circle
K shall promptly repair and restore as ,needed the portions of the Property damaged to
substantially the same condition as existed prior to the damage or exercise of such right or
obligation. Circle K shall also be responsible for the repair of (and reimburse Owner or any third
party for) any out-of-pocket expenses arising from damage to personal property or person
resulting directly from the Work.
5. INDEMNITY
Circle K agrees to indemnify, defend and hold Owner, its agents, successors, and assigns,
harmless from and against any claims, causes of action, or lawsuits brought by a third party
arising directly from the performance of the Work. Circle K shall perform all Work conducted
under this Agreement at its sole cost and expense.
6. INSURANCE
Circle K shall maintain, or cause its "consultants or contractors who perform the Work
under this Agreement to maintain industry -standard insurance for the type of Work being
performed at the Property and for the entire time the Work is being performed.
7. LIENS
Circle K shall discharge any bond or otherwise secure against all liens and attachments
that are filed in connection with the Work, and shall indemnify and save Owner and the Property
harmless from and against any and all loss, damage, injury, liability and claims made by any
third party resulting directly from such liens and attachments.
8. NOTICES
Any notices required to be made under this Agreement shall be made in writing to the
address of the appropriate party as set forth below. All such notices shall be deemed to have
been duly given and received upon mailing, delivery by courier, personal delivery service, or
electronic mail. Parties may alter or modify their notice address by delivery of written notice
pursuant to the terms of this Agreement.
To Owner(s):
14390031.2/010609.0074

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
To Circle K:
9. REPORTS
Circle K Stores Inc.
1100 Situs Court, Suite 100
Raleigh, NC 27606
Attn: Alan Cubberley
Phone: [phone] x1823
Email: [e-mail]
Upon request, Circle K shall provide Owner with copies of all final reports upon written
request, laboratory test results, and other communications submitted to a government agency
regarding the Work performed on the Property. In the event Owner performs any environmental
investigations at the Property during the time the Work is being performed, Owner shall provide
Circle K with a copy of any final report(s) and laboratory results created as a result of such work.
10. APPLICABLE LAW
This Agreement shall be interpreted, and any dispute arising hereunder shall be resolved,
in accordance with the substantive laws of the State of Arizona, without reference to choice of
law rules.
11. ALTERNATIVE DISPUTE RESOLUTION (ADR)
If a dispute arises between the parties relating to this Agreement, the parties agree to use
the following procedure prior to pursuing other legal remedies:
(a) A meeting among the parties shall promptly be held in , attended
by individuals with decision -making authority regarding the dispute, who will
attempt in good faith to negotiate a resolution of the dispute.
(b) If within fifteen (15) days after the meeting, the parties have not succeeded in
negotiating a resolution of the dispute, they agree to submit the dispute to
mediation using a mediator who is mutually acceptable, and to bear equally the
costs of the mediation.
(c) The parties agree to participate in good faith in the mediation process related to
their dispute for a period of thirty (30) days from the commencement of the
mediation. If the parties are not successful in resolving the dispute through
mediation, then:
(1) If both parties agree, they may submit the matter to a binding arbitration or
a private adjudicator which has been mutually agreed upon; or
(2) Either party may initiate litigation upon ten (10) days advance written
notice to the other party.
14390031.2/010609 0074

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
12. COUNTERPARTS
This Agreement may be executed in counterparts, all of which together shall constitute
one and the same Agreement.
13. INTEGRATION
This document represents the entire Agreement between the parties. The parties
acknowledge that this Agreement supersedes and replaces any and all prior agreements between
the parties regarding the subject matter herein. No modification of the terms hereof shall be
effective unless in writing and duly executed by the authorized representatives of the respective
parties.
14. NO ADMISSION OF LIABILITY
The parties acknowledge and agree that neither this Agreement, the act of entering into it,
nor an actor or omission pursuant hereto shall be construed as an admission of any nature.
15. BINDING EFFECT
This Agreement shall be binding upon and inure to the benefit of the parties hereto and
their respective heirs, successors and assigns. The Owner shall promptly notify Circle K within
five (5) days of any transfer of its interest in the Property and shall provide a copy of this
Agreement to any and all transferees.
IN WITNESS WHEREOF, the parties have caused this Agreement to be executed and
effective as of the last date set forth below,
■
Yr! ro`w► 014
IriorceAt
r leAS.a DST 4
By:
Name: eictlr— Covve44,0
Name:
Date: - d4 ao?-i}
CIRCLE K STORES INC.,
a Texas Corporation
By:
Name:
Name:
Date:
14390031.2/010609.0074

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
1523 E. 11th Street Siler City, NC
Proposed Monitoring Well Location

DocuSign Envelope ID: 6D82A4FC-546B-40DE-8FB6-C9AE2D86B2B4
500-Foot Radius Map
NC DWM Site Locator Tool • Proposed Monitoring Well Location (approx)
8/29/2022, 10:00:41 AM
J UST Incidents
Land Use Restriction and/or Notices
County Boundary
1:2,257
0 0.01 0.03
0.06 mi
1 ti 1 II I I
0 0.03 0.05
0.1 km
NCDOT GIS Unit, Esri Community Maps Contributors, Town of Cary, State of
North Carolina DOT, © OpenStreetMap, Microsoft, Esri, HERE, Garmin,
Notice and Restriction
NC Division of Waste Management
Esri Community Maps Contributors, Town of Cary, State of North Carolina DOT, © OpenStreetMap, Microsoft, Esri, HERE, Garmin, SafeGraph, GeoTechnologies, Inc, METI/NASA, USGS, EPA, NPS, US Census Bureau, USDA I Copyright:© 2013 National Geographic