19016_G&BOil_RS_20150911

A"v North Carolina Page 1 of 4
1 Department of Environment
NCOENR and Natural Resources
BROWNFIELDS AREA RECONNAISSANCE AND RECEPTOR SURVEY GUIDANCE FORM
This form was created to clarify and simplify preparing a receptor survey for a brownfield site. The form was designed to
minimize unnecessary delays in processing brownfield applications. This is a guidance document only and Potential
Developers may complete and submit their own receptor survey, if they desire.
General Instructions
if
1.) Complete Property Characteristics" Section and all portions of other sections where an "X" has been placed
in the far left column under "Applicable to Site," as determined by the DENR Brownfields Project Manager
on a site specific basis.
2.) The search -radius distances to potential receptors from the Property boundary will be determined by the
DENR Brownfields Project Manager on a site by site basis.
3.) Search -radius distances are measured from the site Property Boundary unless otherwise indicated by the
Site:
Address:
City:
County:
DENR Brownfield's Project Manager.
Former G & B Oil &Appalachian Energy
208 Poplar Grove Road
Boone
Wata
Property Characteristics
Provide btfortttatiott for the following potential receptors
Cttrrettt Usage
Proposed Usage
Size
of Property (acres)
2.747
2.747
%
of
property that is wooded
25
20
%
of
property that is scrub/shrub
5
6
%
of
property that is open land
0
0
%
of
property that is grass area
0
5
%
of
property that is agricultural crops
0
0
%
of
property that is barren
0
0
% of property that is used for commercial or industrial usage
including paved areas
1 70
69
Surrounding Properties
n�far�nvie ro sire.
Surrounding Properties
Current Usage
Proposed Usage
(DENR Use Oaiy)
Zoning/Land Use
Downtown
°mm'
Downtown
X
North
13-1
Business
ercial
B-1
Business
Commercial
ar
ar
X
South
R-1
Residential
Residential
R4
Residential
Residential
Downtown
°-
Downtown
X
East
BA
Business
ercial
B-1
Business
Commercial
Downtown
o
Downtown
X
West
B-1
Business
ercial
B-1
I Business
Commercial
Rev.06/05/02

�w North Carolina
t" Department of Environment
WDEHR and Natural Resources
Page 2 of 4
Potential Receptors - include depth to top, construction material and diameter of the utilities, if available
n
Applicable to Site
(DENR use only)
Provide Information for the
following potential receptors
y�
Field
Verified
Date
Verified
Distance
Direction
D th
Com lete and attach n:a as
p P
appropriate
Is a basement or subsurface
X
foundation within 500/1000 ft of
Y
Yes
9/2/15
277'
north
10'
the Property boundary?
Is a school or daycare center
X
within 1000 ft of the Property
N
Yes
8/7/15
boundary?
Is a storm sewer within 100/1000
X
ft of the Property boundary?
Y
Yes
8/7/15
0'
south east
314'
Is a sanitary sewer within
X
100/1000 ft of the Property
Y
Yes
8/7/15
0'
north
3'4'
boundary?
X
Is a septic system leach field
within 500/1000 ft of the Property
boundary?
N
Verified
by Town
9/9/15
Is a water line main within
X
100/1000 ft of Property
Y
Yes
8/7/15
15'
southwest
3'-4'
boundary?
Is a natural gas line main within
X
100/1000 ft of the Property
Y
Yes
8/7/15
0'
southwest
3'-41
,boundary?
Is a buried telephone/ cable main
X
within 100/1000 ft of the Property
Y
Yes
9/9/15
232'
north
4'-5'
boundary?
Is a buried electrical cable main
X
within 100/1000 ft of Property
Y
Yes
9/9/15
10'
west
boundary?
Local Water Supply
Public: Yes
Potable Water Supplier Name:
Potable Water Supply Source:
Distance: 2.9 miles / 2.2 miles
Potable Water Source Intake:
Distance: 2.9 miles / 2.2 miles
Private:
Town of Boone
Intakes on Winkler Creek and Middle Fork of New River
Direction: south /east
Winkler Creek &Middle Fork of New River
Direction: south /east
Rev.06/05/02

North Carolina
©a Department of Environment
MCDENR and Natural Resources
Water Supply Wells
Page 3 of 4
Applicable toSite
WENRU
Provide Information for the
followingpotential receptors
YINseOuty)
Field
Verified
Date
Verified
Distance
I Direction
I e th
Complete and attachvza p as
appropriate
Is a public water supply well
X
within 1 mile of the Property
N
No
9/9/15
bounda ?
Is a private water supply well
X
within 1/2 mile of the Property
Y
Yes
9/9/15
0.42 miles
west
unknown
boundary?
Is a irrigation supply well within
X
1/2 mile of the Property
Unknown
,boundary?
Is a monitoring well within 1500
X
ft of the Property boundary?
Unknown
Water Bodies on Property
ApplicnGle to Site
Provide Izzforznation for the
Cozzznzents
WENR use Only)
following potential receptors
Is water body naturally
X
developed or man made?
Natural
List the uses of the water body
X
Drainage
What is the source of the water
X
for the water body
Tributaries
What is the nature of the bottom
of the water body (e.g., rocky or
X
concrete bottom, drainage ways
Rocky
or impoundments)
Are there any wetlands present
X
on the property?
No
Rev.06/05/02

A�A North Carolina
0 Department of Environment
NCDMR and Natural Resources
Surface Water Body
Page 4 of 4
A to Site
Applicable Use
(DENR use only)
Provide Information for the
followingpotential receptors
y/nT
Name
Jp
Type
Distance
Direction
Depth
Complete and attacli ilia as
p P
appropriate
X
Are there surface waters located
within 500/1000 ft of the Property
boundar ?
Yes
Boone
Creek
Creek
On
Property
On Property
V2'
Additional looter bodies, if needed
Additional Requests/ Observations
AypiirnLle to Site
(DENR use only)
Provide Isiforination for the
following potential receptors
Comments
Rev.06/05/02