WM0501625_Well Permit Application_20240228

North Carolina Department of Environmental Quality Division of Water Resources
512 North Salisbury Street 1611 Mail Service Center Raleigh, North Carolina 27699-1611
919.707.9000

February 28, 2024 Mr. Anthony Bell Circle K Stores, Incorporated 1100 Situs Court, Suite 100 Raleigh, North Carolina 27605 Sent Via Email Subject: Monitoring Well Construction Permit #WM0501625 Circle K Store #2723781 (UST Incident #48914) 106 East NC Highway 64 (PIN #0718-96-42-8092) Durham, North Carolina 27704 – Durham County Mr. Bell: In accordance with the application received on February 26, 2024, we are forwarding herewith Monitoring Well Construction Permit No. WM0501625 dated February 28, 2024, issued for the construction of a monitoring well system (installation of two 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 Michael Hall at [phone] or via email at [e-mail]. Sincerely,
Michael Hall, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ Enclosure -Permit -Application Package Ec: Maureen Jackson, ATC Associates of North Carolina, P.C. Laserfiche

DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
North Carolina Department of Environmental Quality Division of Water Resources
512 North Salisbury Street 1611 Mail Service Center Raleigh, North Carolina 27699-1611
919.707.9000
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, Incorporated FOR THE CONSTRUCTION OF A MONITORING WELL SYSTEM consisting of two wells owned by Circle K Stores, Incorporated, at mailing address 1100 Situs Court, Suite 100, Raleigh, North Carolina 27604. The wells will be located on the property owned by Waffle House Incorporated located at 112 East NC Highway 64 (PIN #0718-96-61-7457), Durham, NC 27704. This Permit is issued in accordance with the application received on February 26, 2024, 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.

____________________________________
Michael Hall, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission

Permit Number: WM0501625
Permit Issued: February 28, 2024
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina 27604
Tel: [phone]
Fax: [phone]
www.oneatlas.com
N.C. Engineering License No. C-1598

February 26, 2024

Mr. Mike Hall
North Carolina Department of Environmental Quality
Raleigh Regional Office
Division of Water Quality, Aquifer Protection Section
1628 Mail Service Center
Raleigh, North Carolina 27699

RE: Application for Permit to Construct a Monitoring Well System
Waffle House
112 East N.C. Highway 64 (PIN #0718-96-61-7457)
Durham, Durham County, North Carolina
NCDEQ Incident No. 48914

Dear Mr. Hall:

On behalf of Circle K Stores Inc., ATC Associates of North Carolina, P.C. (ATC) has been directed by
the NCDEQ-DWM-UST Section to perform assessment activities at the above property. Circle K has
obtained an access agreement for the adjoining property (Waffle House). ATC will be installing two
shallow monitoring wells on the property as part of the CSA activities. I have attached the well
construction permit application to this cover letter. Drilling is currently being scheduled.

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,
ATC ASSOCIATES OF NORTH CAROLINA, P.C.

Maureen Jackson, P.G.
Senior Project Manager

cc: Mr. Anthony Bell, Circle K Stores Inc. ([e-mail])
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
FOR OFFICE USE ONLY

PERMIT NO. ISSUED DATE
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:

2. County:

3. What type of well are you applying for? (monitoring or recovery):

4. Applicant: Telephone:

Applicant’s Mailing Address:

Applicant’s Email Address (if available):

5. Contact Person (if different than Applicant): Telephone:

Contact Person’s Mailing Address:

Contact Person’s Email Address (if available):

6. Property Owner (if different than Applicant): Telephone:

Property Owner’s Mailing Address:

Property Owner’s Email Address (if available):

7. Property Physical Address (Including PIN Number)
City County Zip Code

8. Reason for Well(s):
(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:
(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 in cident no(s).

11. Type of contaminants being monitored or recovered:
(ex: organics, nutrients, heavy metals, etc.)

12. Are there any existing wells associated with the proposed well(s)? If yes, how many?

Existing Monitoring or Recovery Well Construction Permit No(s).:

13. Distance from proposed well(s) to nearest known waste or pollution source (in feet):

14. Are there any water supply wells located less than 500 feet from the proposed well(s)?

If yes, give distance(s):

15. Well Contractor: Certification No.:

Well Contractor Address:

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 e. Type of casing material and thickness
b. Estimated well depth f. Grout horizons
c. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse
[phone]
[e-mail]
P.O. Box 6450 Norcross, Georgia 30091
Waffle House, Inc.
N/A
132 Gurney Road Olin, North Carolina 28660
2579Carolina Soil Investigations, Inc.
N/A
No
Approx. 50 to 80 feet
Yes - 1
petroleum
UST incident #48914
UST
petroleum release assessment for Circle K Store #2723781 (UST incident #48914)
27704DurhamDurham
112 East N.C. Highway 64 (PIN #0718-96-61-7457)
[e-mail]
2725 E. Millbrook Road, Suite 121 Raleigh, North Carolina 27604
[phone]Maureen Jackson
[e-mail]
1100 Situs Court, Suite 100 Raleigh, North Carolina 27605
[phone]Circle K Stores, Inc.
Monitoring
Durham
February 26, 2024
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)

2. Number of wells to be constructed in unconsolidated
material:

3. Number of wells to be constructed in bedrock:

4. Total Number of wells to be constructed:
(add answers from 2 and 3)
5. How will the well(s) be secured?

6. Estimated beginning construction date:

7. Estimated construction completion date:

ADDITIONAL INFORMATION

1. As required by 15A NCAC 02C .0105(f)(5), attach a scaled map of the site showing the locations of the following:

a. 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.
b. All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
c. The proposed well or well system.
d. Any test borings within 500 feet of proposed well or well system.
e. 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. 143-215.10B(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 speci fications 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 Title of Applicant or *Agent

* If signing as Agent, attach authorization agreement stating
Printed name of Applicant or *Agent 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 co nstruct
wells as outlined in this Well Construction Permit application and that it sh all 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).

Signature of Property Owner (if different than Applicant) 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
GW-22M (Rev. 5/11)
Signed Access Agreement attached Waffle House, Inc.
Sr. Project Manager for ATC
Maureen Jackson ATC on behalf of Circle K Stores
April/May 2024
April/May 2024
Steel traffic bearing cover, sealing and locking cap
2
0
2
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
From:                                         Cubberley, Alan
Sent:                                           Wednesday, February 17, 2021 8:11 AM
To:                                               Maureen Jackson
Subject:                                     [EXTERNAL] RE: Permits

  [External Email]  This email originated from 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 Cub berley
Senior Manager – Risk Control
Fuel and Environmental – North America

e:[e-mail]
t: (330) 634­2101
m: (330) 814­4032
Circle K Stores Inc.
1100 Situs Court, Suite 100
Raleigh, NC 27606
http://corpo.couche­tard.com/en/business­units/

Part of Alimentation Couche­Tard
CONFIDENTIALITY NOTE: This e­mail message, including any attachment(s), contains information
that may be confidential, protected by the attorney­client or other legal privileges, and/or proprietary
non­public 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

DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
This Message originated outside your organization.
Good morning.  I have an email from Brent from 2016 stating that he gives me permission
to sign permits on behalf of Circle K (NPDES, well permits for off‐site wells, UST (DEQ)
forms).  Can you please send me over an email stating the same?  Sometimes I have to
include this email to DEQ with my submittals.

Thanks
Maureen

Maureen Jackson | SENIOR PROJECT MANAGER | ATC Group Services LLC 
Direct [phone] 
609A Piner Road Suite 1 15  | Wilmington, NC  28409
[e-mail] | www.atcgroupservices.com
This email and its attachments may contain confidential and/or privileged inf ormation for the sole use of
the intended recipient(s). If you are not the intended recipient, any use, distribution or copying of the
information contained in this email and its attachments is strictly prohibited. If you have received this
email in error, please notify the sender by replying to this message and immediately delete and destroy
any copies of this email and any attachments. The views or opinions expressed are the author's own and
may not reflect the views or opinions of ATC.

DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
Alan J. Cubberley, Sr. Mgr Risk cntrol
330-814-4032
[e-mail]
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
Alan J. Cubberley, Sr. Mgr Risk Control
2-26-24
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
N.C.
H
I
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H
W
A
Y

5
4
CIRCLE K
#2723781
FA
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O
A
D
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B
A
S
I
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OW-4
OW-3
OW-2
OW-1
DIE
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A
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PLU
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PRE
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SB-1
SMW-1/MW-1
SMW-2/MW-2
ABANDONED
= SOIL BORING
= OBSERVAION WELL
~50 ft
~80 ft
~60 ft
A
Only if location A cannot be installed
No wells in
this area
due to
utilities
LNAPL
LNAPL
LNAPL
Proposed Monitoring Well Location
SS denotes soil samples will be collected
SS
GW flow appears to be toward the east
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4
MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP PROTECTIVE CASING AND CONCRETE PAD
L1 CASING MATERIAL steel
CASING DIAMETER 8 inches
CASING LENGTH 20 inches
PAD DIMENSIONS 2 feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 5 feet
L2 BACKFILL AROUND CASING
MATERIAL cement grout
THICKNESS 1 feet
SEAL
TYPE OF SEAL bentonite
L4 THICKNESS 1 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 1 feet
TOTAL FILTER PACK FOOTAGE 3 feet
WELL SCREEN
L3 SCREEN MATERIAL sch 40 PVC
DIAMETER 2 inches
LENGTH 20 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
WELL 25 feet
DEPTH TO BOTTOM OF
BOREHOLE 25 feet
L1 =FT.
L2 =FT.DIAMETER OF BOREHOLE 6 inches
L3 =FT.
L4 =FT.DRILLING SUBCONTRACTOR:Geologic Exploration, Inc.
DRILLER ADDRESS:176 Commerce Blvd, Statesville, NC 28625
DRILLER CERTIFICATION #:2581
TITLE
2725 East Millbrook Road, Suite 121
Raleigh, North Carolina 27604
FILE PREP. BY REV. BY DATE
MJ MJ 1/18/2024
North Carolina
Durham, Durham County
106 East N.C. Hwy 64
Circle K Store #2723781
Well Information
25
20
5
0
DocuSign Envelope ID: DC822100-8CC8-4269-BC23-42C6F04D75C4