WS-3741_12263_CA_RPTS_20210920

WithersRavenel
Our People. Your Success. 

115 MacKenan Drive | Cary, NC 27511 
t: 919.469.3340 | f: 919.467.6008 | www.withersravenel.com | License No. C‐0832 
Asheville | Cary | Greensboro | Pittsboro | Raleigh | Wilmington 

September 20, 2021 

State of North Carolina 
Department of Environmental Quality 
Federal & State Lead Program 
Division of Waste Management‐Underground Storage Tank Section 
1646 Mail Service Center 
Raleigh, North Carolina 27699‐1646 

Attn: Herb Berger, P.G. 

Reference:   Receptor Survey Letter Report  
Former Bodenhamer Store 
550 Bethania‐Rural Hall Road (NC Hwy 65W) 
Rural Hall, Forsyth County, North Carolina 
Groundwater Incident Number: 12263 
UST Number: WS‐3741 
Site Risk Ranking: Not Assigned 
WR Project Number:  02172214.63 

Mr. Berger: 

WithersRavenel, Inc. (WR), in association with Task Authorization‐01 (TA‐01) for the site, under 
NCDEQ Contract # N122019B, completed a site reconnaissance and receptor survey associated 
with the release at the Former Bodenhamer Store property, located in a residential area of Rural 
Hall, Forsyth County, NC (Figure 1), addressed as 550 Bethania‐Rural Hall Road.   

UST Information 
According to the Letter Report prepared by Engineering Consulting Services, Ltd. (ECS) prepared 
October 18, 1996, GeoScience and Technology, P.A., removed two 3,000‐gallon USTs and one 
550‐gallon kerosene UST from the site in May 1994. The associated dispensers and piping were 
also removed. Soil samples were obtained at the time of removal. Soil samples collected during 
the UST closure activities indicated concentrations of Total Petroleum Hydrocarbons (TPH) – 
Gasoline Range Organics (GRO) ranging from non‐detect to 15,742 milligrams per kilogram 
(mg/kg) and TPH – Diesel Range Organics ranging from non‐detect to 8,651 mg/kg. No remedial 
activities have been performed to date.  An associated UST Facility ID number was not 
identified. UST information is included in Table B‐1 and the former UST locations are shown on 
Figure 2.  An AST is currently located on the south side of the building.  The size, status, and 
contents of the AST are unknown. 

Former Bodenhamer’s Store – Inc. 12263 WR Project # 02172214.63 
Receptor Survey Letter Report September 2021 
2 

Site Characteristics 
The property is located at 550 Bethania‐Rural Hall Road in Rural Hall, Forsyth County, North 
Carolina (Figure 2). Site photographs are included in Appendix A. The property includes a single‐
story slab‐on‐grade concrete block and metal sided structure, reportedly constructed in 1955, 
and a garage at the rear of the property.  The rear of the property is enclosed by a chain link 
fence. The site was vacant during the site reconnaissance activities.  Surface coverings at the 
location include the site structure, asphalt, and gravel areas. The NC PIN for the property is 
6910‐66‐0734 and is approximately 0.38‐acres. The site is zoned by Rural Hall as “Residential 
Single Family” (RS9), defined as “primarily intended to accommodate relatively high density single 
family detached dwellings in urban areas”.   
Surface drainage through the area generally follows topography or is channeled curb inlets along 
primary and secondary roadways.  At the site location, surface drainage flows to the south and 
west.     

Site Reconnaissance 
The site is located on the western side of Bethania Rural Hall Road in a residential area within 
the corporate limits of Rural Hall, Forsyth County. Adjacent properties include residences to the 
south and to the east across Bethania Rural Hall Road, pastures to the west, and undeveloped 
wooded land to the north.  The site is shown on Figure 2, including site features, structures and 
the locations of the former UST system.  The site and adjoining parcels are depicted on Figure 3, 
and adjacent property information included in Table B‐5C.  
WR examined the U.S. Geological Survey 7.5‐minute series topographic map for the site (Figure 
1) and the surface contours for the location indicate the site has an approximate elevation of 
1,005‐ft above mean sea level (AMSL), in an area topographically higher than surrounding areas.   
The site is situated in the Piedmont Physiographic Province.  The Geologic Map of North 
Carolina depicts the site in the as being underlain by Cambrian to Late Proterozoic 
metagraywacke (biotite gneiss) interlayered and gradational with amphibolite and kyanite schist 
with minor ultramafic and granitic rock. 
Groundwater flow through the site was not determined by WR in August 2021, however, based 
on a review of the USGS Topographic Map and the observed topography, groundwater flow is 
likely to the west.   

Receptor Survey 
WR identified five (5) water supply wells within a 1,000‐foot (ft) radius. The nearest of these 
wells (WSW‐1) is situated approximately 335‐ft to the west of the source area.   

 Active water supply wells identified by WR include one water supply well within 500 feet of 
the source area (WSW‐1 at 335‐ft) and four water supply wells between 500 and 1,000 feet 
of the source area (WSW‐2 at 575‐ft, WSW‐3 at 695‐ft, WSW‐4 at 890‐ft, and WSW‐5 at 
1,000‐ft).  An additional water supply well was identified outside the 1,000‐ft radius of the 
source area (WSW‐6). 
 WR inquired with the City of Winston‐Salem Public Utilities Department via email to obtain 
information regarding the connection status of the properties within 1,000 ft of the site.  

Former Bodenhamer’s Store – Inc. 12263 WR Project # 02172214.63 
Receptor Survey Letter Report September 2021 
3 

Municipal water is available to the site and surrounding area with the exception of properties 
along Bodenhamer Farm Road. 
 Subsurface utilities were identified in the site vicinity and the depth to water at the site has 
not been determined. Therefore, it is unknown if these utilities are preferential pathways for 
contamination. 
 A tributary of Grassy Creek is located approximately 420 feet east of the source area and a 
tributary of Beaver Dam Creek is located approximately 900‐ft west of the source area. No 
additional receptors (streams or wetlands) were identified within 1,000‐ft of the source area.   
Water supply well information is provided on Table B‐5A, while locations of the wells are shown 
on Figure 4. The response from the City of Winston‐Salem Public Utilities Department and 
returned water supply well forms are included in Appendix B.  

Recommendations 
Based on a review of the available historical information for the site, WR recommends 
periodically sampling water supply wells within 1,000‐ft of the source area along Bodenhamer 
Farm Road until such time as site access is obtained.    

WithersRavenel appreciates the opportunity to be of service to the Federal & State Lead 
Program. Should you have any questions regarding the attached, please do not hesitate to 
contact Elizabeth Allyn at (919) 469‐3340. 
Sincerely, 
WithersRavenel

 Elizabeth A. Allyn, P.G. 
Senior Project Manager 

Enclosure(s): Figures, Tables, Photographs, Municipality Response, and Returned WSW surveys 

FIGURES 

CBM
LA
DRAWN BY:
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SCALE:FIGURE NO.:
PROJECT NO.:DATE:APPROVED BY:
FORMER BODENHAMER STORE
NCDEQ INCIDENT #12263
550 BETHANIA RURAL HALL ROAD
RURAL HALL, FORSYTH COUNTY, NC
GENERAL LOCATION MAP
1"=1000 '
GRAPHIC SCALE
1 inch = 1000 ft.
0 1000500 2000
WithersRavenel
Engineers | Planners | Surveyors
115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: C-0832
www.withersravenel.com
SUBJECT SITE
± 0.38 ACRES
K:\17\17-2210\172214.63-NCDEQ - BODENHAMER STORE\Enviro\CAD\Bodenhamer.dwg- August 27, 2021 - LALLYN
FORMER
GASOLINE
PUMPS
FORMER GASOLINE UST
FORMER KEROSENE UST & PUMP
SITE
1 inch = 20 ft.
2010 40
GRAPHIC SCALE
0
CBM
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DRAWN BY:
1"=20 '
08/26/21 02172214.63
2
SCALE:FIGURE NO.:
PROJECT NO.:DATE:APPROVED BY:
FORMER BODENHAMER STORE
NCDEQ INCIDENT #12263
550 BETHANIA RURAL HALL ROAD
RURAL HALL, FORSYTH COUNTY, NC
SITE MAP
WithersRavenel
Engineers | Planners | Surveyors
115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: C-0832
www.withersravenel.com
K:\17\17-2210\172214.63-NCDEQ - BODENHAMER STORE\Enviro\CAD\Bodenhamer.dwg- August 27, 2021 - LALLYN
NOTES:
1.) AERIAL AND PROPERTY BOUNDARIES OBTAINED FROM THE LOCAL
COUNTY GIS DEPARTMENT.
NC HIGHWAY 65/BETHANIA-RURAL HALL ROAD
SITE
001
004
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003
BODENHAM
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1 inch = 80 ft.
8040 160
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CBM
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DRAWN BY:
1"=80 '
08/26/21 02172214.63
3
SCALE:FIGURE NO.:
PROJECT NO.:DATE:APPROVED BY:
FORMER BODENHAMER STORE
NCDEQ INCIDENT #12263
550 BETHANIA RURAL HALL ROAD
RURAL HALL, FORSYTH COUNTY, NC
ADJACENT PROPERTIES MAP
WithersRavenel
Engineers | Planners | Surveyors
115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: C-0832
www.withersravenel.com
K:\17\17-2210\172214.63-NCDEQ - BODENHAMER STORE\Enviro\CAD\Bodenhamer.dwg- August 27, 2021 - LALLYN
LEGEND
001 ADJACENT PROPERTY IDENTIFIER
NOTES:
1.) AERIAL AND PROPERTY BOUNDARIES OBTAINED FROM THE LOCAL
COUNTY GIS DEPARTMENT.
© 2021 Microsoft Corporation © 2021 Maxar ©CNES (2021) Distribution Airbus DS NC HIGHWAY 65/BETHANIA-RURAL HALL ROAD
WSW-6
WSW-4
WSW-3 WSW-2 WSW-1
WSW-5
SITE
BODENHAM
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F
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1 inch = 400 ft.
400200 800
GRAPHIC SCALE
0
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DRAWN BY:
1"=400 '
08/26/21 02172214.63
4
SCALE:FIGURE NO.:
PROJECT NO.:DATE:APPROVED BY:
FORMER BODENHAMER STORE
NCDEQ INCIDENT #12263
550 BETHANIA RURAL HALL ROAD
RURAL HALL, FORSYTH COUNTY, NC
POTENTIAL RECEPTOR MAP
WithersRavenel
Engineers | Planners | Surveyors
115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: C-0832
www.withersravenel.com
K:\17\17-2210\172214.63-NCDEQ - BODENHAMER STORE\Enviro\CAD\Bodenhamer.dwg- August 27, 2021 - LALLYN
LEGEND
ACTIVE WATER SUPPLY WELL LOCATION
NOTES:
1.) AERIAL AND PROPERTY BOUNDARIES OBTAINED FROM THE LOCAL
COUNTY GIS DEPARTMENT.

TABLES 

UST IDNumberCapacity(in gallons)ConstructionDetailsTankDimensions (diameter x length)Description ofAssociatedPiping & PumpsDate of TankInstallationStatus ofUSTWas release associated with UST System? (Y/N)13,000 Steel 5.33' x 18' UnknownUnknownPermanently Closed By Removal (May 3,1994)Y2 3,000 Steel 5.33' x 18' Unknown UnknownPermanently Closed By Removal (May 3,1994)Y3560Steel 3.5' x 7.67' UnknownUnknownPermanently Closed By Removal (May 3,1994)YAST IDNumberCapacity(in gallons)ConstructionDetailsTankDimensions (diameter x length) (ft)Description ofAssociatedPiping & PumpsDate of TankInstallationStatus ofASTWas release associated with AST System? (Y/N)1 Unknown Steel Unknown Unknown UnknownUnknown - it is located to the south side of the site buildingUnknownIncidentNumberMaterialReleasedDateofRelease12263 PetroleumDiscovered 5/3/1994Table B‐1Site History:  UST/AST System & Other Release InformationBodenhamer's StorePetroleum-contaminated soil was discovered during the removal of the three USTs. Soil samples collected during tank closure activities identified Total Petroleum Hydrocarbons (TPH) - Gasoline Range Organics (GRO) concentrations ranging from below detection limits 15,742 ppm and TPH-Diesel Range Organics (DRO) ranging from below detection limits to 8,651 ppm (Source Written Release Confirmation Summary of UST Closure, GeoScience & Technology, P.A., May 1994).550 Bethania‐Rural Hall RoadRural Hall, Forsyth County, North CarolinaDescription of Release Incident # 12263Current/LastContentsCurrent/LastContentsGasolineGasolineUnknownKerosene
Notes: 1)615 Cook RoadRural Hall, NCForsyth Alan Mitchell5729 Haweswater RoadWinston‐Salem, NC 27105551 Bodenhamer Farm RoadRural Hall, NC551 Bodenhamer Farm RoadRural Hall, NC 27045UnknownWSW‐1 Forsyth Tyler Joseph Guynn Active Potable575 feet West‐southwestUnknown557 Bodenhamer Farm RoadRural Hall, NCForsythGregory Gaither336‐462‐9059557 Bodenhamer Farm RoadRural Hall, NC 27045Active Potable 185 UnknownUnknownWell ID Property Address County Property Owner Well UseWell Depth(feet)Well Screen Interval(feet)Well Distance from Source Area(feet)Location Relative to Groundwater FlowWSW‐2Active Potable561 Bodenhamer Farm RoadRural Hall, NC 27045Unknown Unknown335 feet West‐southwestProperty Owner AddressUnknown Unknown695 feet West‐southwestWSW‐3561 Bodenhamer Farm RoadRural Hall, NCForsyth Adan Chavez CorreaWSW‐4Active Potable Unknown UnknownWSW‐6564 Bodenhamer Farm RoadRural Hall, NCForsythMichael W. Prim336‐692‐8250875 Cook RoadRural Hall, NC 27045Active Potable Unknown UnknownWSW‐5562 Bodenhamer Farm RoadRural Hall, NCUnknown566 Bodenhamer Farm RoadRural Hall, NCForsythMichael W. Prim336‐692‐8250875 Cook RoadRural Hall, NC 27045890 feet West‐southwestUnknownForsythDebbie and Michael Prim336‐692‐8250875 Cook RoadRural Hall, NC 27045UnknownActive Potable Unknown Unknown1,000 feet NorthwestProperty owner information was obtained from Forsyth County, NC Geographic Information System on 8/27/2021.TABLE B‐5APUBLIC & PRIVATE WATER SUPPLY WELL INFORMATIONBodenhamer's Store Incident # 12263550 Bethania‐Rural Hall RoadRural Hall, Forsyth County, North CarolinaComments1,125 feet West‐southwest
550 Bethania‐Rural Hall Road Shirley and Johnny ButlerRural Hall, NC 27045 455 College StreetRural Hall, NC 27045Unaddressed lot alongKimberley Polakoff & Lisa DoughtenBethania‐Rural Hall Road 142 Rolling Dunes Dr., Unit ARural Hall, NC 27045 Santa Rosa Beach, FL 32459560 Bethania‐Rural Hall Road Deborah A. GroceRural Hall, NC 27045 560 Bethania‐Rural Hall RoadRural Hall, NC 27045554 Bodenhamer Farm Road Debbie and Michael PrimRural Hall, NC 27045 875 Cook RoadRural Hall, NC 27045551 Bethania‐Rural Hall Road Jane ReidRural Hall, NC 27045 551 Bethania‐Rural Hall RoadRural Hall, NC 270451)2)3)Town of Rural Hall Zoning Codes: RS9 = ResidentialRM12 = Multi‐Family ResidentialNotes: Property owner information from the Forsyth County GIS Service, data current as of August 26, 2021. See Figure 3 for corresponding map information.Distances shown from source area are measured from location of former UST basins and the nearest property boundary of the adjacent property004Residence RS975 ft East (across Bethania‐Rural Hall Road)UnknownUnknown003Vacant Livestock Pastures and BarnRS9 150 ft West Unknown002Residence RS9 32 ft South001Undeveloped RM12 20 ft North UnknownLocation Relative to Groundwater FlowSITEVacant RS9‐‐‐ ‐‐‐Property ID Property Address Property Owner & Address Usage ZoningDistance/Direction from Source AreaRural Hall, Forsyth County, North CarolinaTABLE B‐5CADJACENT PROPERTY INFORMATIONBodenhamer's Store Incident # 12263550 Bethania‐Rural Hall Road

APPENDIX A 

SITE PHOTOGRAPHS

Former Bodenhamer’s Store – Inc. 12263 WR Project # 02172214.63 
Receptor Survey Letter Report Photograph Date: August 5, 2021 

 PHOTO 1 
View of site facing west 

 PHOTO 2 
Water meter at site 

Former Bodenhamer’s Store – Inc. 12263 WR Project # 02172214.63 
Receptor Survey Letter Report Photograph Date: August 5, 2021 

 PHOTO 3 
View along Bethania‐Rural Hall Road facing north 

 PHOTO 4 
View along Bethania‐Rural Hall Road facing south 

Former Bodenhamer’s Store – Inc. 12263 WR Project # 02172214.63 
Receptor Survey Letter Report Photograph Date: August 5, 2021 

 PHOTO 5 
Water meter at east‐adjacent property 

 PHOTO 6 
Water meter at south‐adjacent property    

Former Bodenhamer’s Store – Inc. 12263 WR Project # 02172214.63 
Receptor Survey Letter Report Photograph Date: August 5, 2021 

 PHOTO 7 
Informational sign on front door of site building 

APPENDIX B 

RESPONSE FROM MUNICIPALITY  
AND 
RETURNED WATER SUPPLY WELL SURVEYS 

Connected to Municipal WaterProperty Address Owner Mailing Ad Mailing City, State, ZipNo (would need to be addressed) Unaddressed Parcel along Tobaccoville Road Town Of Rural Hall PO BOX 54 Rural Hall NC 27045No 531 Tobaccoville Road ‐ CemeteryTown Of Rural Hall PO BOX 54 Rural Hall NC 27045No 615 Cook Road Mitchell Alan Dale 5729 HaweWinston Salem NC 27105Yes 635 Cook RD Williams Teresa Lee 635 Cook RRural Hall NC 27045Yes 640 Cook RD Tedder William Steven 640 Cook RRural Hall NC 27045No 664 Cook Road ‐ No building at addressPRIM MICHAEL W 875 COOK RURAL HALL NC 27045Yes 690 COOK RD BLASINGAME CHASE W 690 COOK RURAL HALL NC 27045Yes 696 Cook Road PRIM MICHAEL W 875 Cook RRural Hall NC 27045Yes 700 Cook Rd Flinchum Matthew Lee 700 Cook RRural Hall NC 27045Yes 720 Cook RD Maveus Todd R 720 Cook RRural Hall NC 27045Yes 400 Heatherton Lane Rural Hill IiLlc 750 BethesWinston‐Salem NC 27103Yes 500 HEATHERTON LN HOLDER SHAYNE ANTHONY 500 HEATHRURAL HALL NC 27045Yes 501 Heatherton LN Pike Virginia MPO BOX 11 Rural Hall NC 27045Yes 504 Heatherton LN Sivon Joseph PO BOX 764Rural Hall NC 27045Yes 509 Heatherton LN Grubbs Odis A 509 HeatheRural Hall NC 27045Yes 505 Heatherton LN Oliver Garry L 505 HeatheRural Hall NC 27045Yes 508 Heatherton LN Michel Courtney 508 HeatheRural Hall NC 27045Yes 512 Heatherton Ln RICE REGINA 512 HeatheRural Hall NC 27045Yes 513 Heatherton LN Crews Tina Gelaine 513 HeatheRural Hall NC 27045Yes 516 Heatherton LN Dalton Reba D 516 HeatheRural Hall NC 27045Yes 517 Heatherton LN Prather Dianna S 517 HeatheRural Hall NC 27045Yes 520 Heatherton LN Pace Dalphne 520 HeatheRural Hall NC 27045Yes 521 Heatherton LN Mcgee Charles W 521 HeatheRural Hall NC 27045Yes 524 Heatherton LN Hairston Monica S 524 HeatheRural Hall NC 27045Yes 525 Heatherton Ln MORPHIES SHIRLEY L525 HeatheRural Hall NC 27045Yes 528 Heatherton LN Ledbetter Gregory LPO Box 129Rural Hall NC 27045Yes 529 Heatherton Ln DOUGLAS SALLY A 529 HeatheRural Hall NC 27045Yes 532 Heatherton LN Dockery Shirley P 532 HeatheRural Hall NC 27045Yes 533 HEATHERTON LN EF3R LLC 533 HEATHRURAL HALL NC 27045Yes 536 Heatherton LN Grubbs Anne W 536 HeatheRural Hall NC 27045Yes 537 Heatherton LN LEONIDES ANTUNEZ ISABEL 757 RunninRural Hall NC 27045Yes 540 Heatherton LN Young Deborah Moser 540 HeatheRural Hall NC 27045Yes 541 Heatherton LN Friend Donna MontgomeryPO BOX 55 RURAL HALL NC 27045Yes 544 Heatherton LN Saunders Properties Llc 167 WallacFRANKLINVILLE NC 27248Yes 545 Heatherton Ln Wolfe William W 545 HeatheRural Hall NC 27045Yes 548 Heatherton Lane HAWLEY SHELLIE SLADE 22 YESTER GREENSBORO NC 27455Yes 549 Heatherton LN Barton Sandra D 549 HeatheRural Hall NC 27045Yes 552 HEATHERTON LN CARLSON KAREN MARIE 552 HEATHRURAL HALL NC 27045Yes 553 Heatherton LN Garner Pamela W 553 HeatheRural Hall NC 27045Yes 556 Heatherton Ln Arnold Sonja Michele 556 HeatheRural Hall NC 27045Yes 560 Heatherton Lane RESI TL1 BORROWER LLC 3505 KOGEDULUTH GA 30096Yes 100 Woodbriar Path ANDRAOS GRACE 1430 GrindKernersville NC 27284Yes 404 Pine CTTreadwell Tawanda K 404 Pine CTRural Hall NC 27045Yes 405 Pine CTPace Christopher Matthew405 Pine CTRural Hall NC 27045Yes 409 Pine CTSavage Dale W 409 Pine CTRural Hall NC 27045Yes 7616 Pine STBrown Rhonda J 7616 Pine SRural Hall NC 27045Yes 7620 Pine Street CONREX ML PORTFOLIO 2019 01 OPERATING CO1505 KING CHARLESTON SC 29405Yes 7624 Pine Street J & S Properties 577 FowlerWalnut Cove NC 27052
Connected to Municipal WaterProperty Address Owner Mailing Ad Mailing City, State, ZipYes 7628 Pine Street Roberts Roger Lee PO BOX 754Rural Hall NC 27045Yes 7631 Pine STAaron John W 7631 Pine SRural Hall NC 27045Yes 7632 PINE STVILLATORO JOSE LUIS 7632 PINE RURAL HALL NC 27045Yes 7635 Pine STSummers Jennifer J 7635 Pine SRural Hall NC 27045Yes 7636 Pine St PURYEAR SAM HENRY 7636 Pine SRural Hall NC 27045Yes 7638 Pine St BROWN JASON 7638 Pine SRural Hall NC 27045Yes 7642 Pine St WILKES KEITH K 2106 SALOCHARLOTTE NC 28262Yes 7650 Pine STSmith Earl J 7650 Pine SRural Hall NC 27045No 449 Bethania‐Rural Hall Road Nazareth Evangelical Lu Church PO BOX 51 Rural Hall NC 27045Yes 505 Bethania‐Rural Hall Road Clifton Leon EPO BOX 68 Walkertown NC 27051Yes 520 Bethania‐Rural Hall Road G L G Corporation PO BOX 40 Winston Salem NC 27115Yes 525 BETHANIA RURAL HALL RD WILLIAMS BERTHA N 525 BETHARURAL HALL NC 27045Yes 526 Bethania Rural Hall RD Brown Keith 526 BethanRural Hall NC 27045Yes 535 Bethania Rural Hall RD Bodenhamer Robin A535 BethanRural Hall NC 27045Yes 550 Bethania Rural Hall RD Butner Shirley V Koehn 455 CollegeRural Hall NC 27045Yes 551 Bethania Rural Hall RD Reid Jane Carol 551 BethanRural Hall NC 27045Yes 560 Bethania Rural Hall RD Groce Deborah A 560 BethanRural Hall NC 27045Yes 565 Bethania Rural Hall RD Rumley Kenneth L565 BethanRural Hall NC 27045Yes 570 BETHANIA RURAL HALL RD BODENHAMER LILLIAN T 360 LONG VFRANKLINTON NC 27525Yes 571 BETHANIA RURAL HALL RD SC DEACONS LLC 101 E WASGREENVILLE SC 29601Yes 575 Bethania Rural Hall Rd PERKINS ADAM L 575 BethanRural Hall NC 27045Yes 580 Bethania Rural Hall RD Simmons Violet M 580 BethanRural Hall NC 27045No 590 Bethania Rural Hall RD Simmons Violet M 580 BethanRural Hall NC 27045Yes 605 BETHANIA RURAL HALL RD Beheler Doris PO BOX 15 Rural Hall NC 27045Yes 615 BETHANIA RURAL HALL RD ROJAS ANGULO AMADO 615 BETHARURAL HALL NC 27045Yes 620 Bethania Rural Hall RD Fulk Clyde L620 BethanRural Hall NC 27045No(would need to be addressed) Unaddressed parcel along Bethania‐Rural Hall (Parcel 6910‐66‐0558)Groce Deborah A 560 BethanRural Hall NC 27045No(would need to be addressed) Unaddressed parcel along Bethania‐Rural Hall (Parcel 6910‐56‐8847)POLAKOFF KIMBERLEY DEAN DOUGHTEN 142 ROLLINSANTA ROSA BEACH FL 32459No 551 Bodenhamer Farm Rd GUYNN TYLER JOSEPH 551 BodenRural Hall NC 27045Yes 554 Bodenhamer Farm Rd PRIM DEBBIE STEPHENSON 875 Cook RRural Hall NC 27045No 557 Bodenhamer Farm Rd Gaither Gregory 557 BodenRural Hall NC 27045No 561 Bodenhamer Farm Rd Correa Adan Chavez 561 BodenRural Hall NC 27045No 562 Bodenhamer Farm Road PRIM MICHAEL W 875 COOK RURAL HALL NC 27045No 564 Bodenhamer Farm Road Wilson Jody APO BOX 13 Silver Springs FL 34489No 566 Bodenhamer Road PRIM MICHAEL W 875 COOK RURAL HALL NC 27045
Water Supply Well Information Survey
(This line to be completed by Responsible Party or their representative)
Incident Number: 12263 Incident Name: Former Bodenhamer's Store (Rural Hall, NC)
Please Provide the Following Information (to the best of your knowledge)
Name and telephone number of person completing the survey
Address of property receiving survey: Unaddressed Parcel along Bethania-Rural Hall Road -Polakoff
City: Rural Hall County: Forsyth
What is the source of your drinking water? &ublic Water/ Water Supply Well/ Stream Intake/ Other (please
exolain below) ~ Cn.-r 11 . .C.,. 1M41 'lA11,J .J..IAO f1'I ~ l/\b. h11>Cf AIA.. fw,_,, A , • .,: ,
' V I V
. ' . l
\l/\t\. +-~,-vv-
Is there a water suooly well on this propertv? Yeti No If"No" disregard remaining auestions and return survey
Name and address ofowner(s) ofpropertv with water sunnlv well
How many water suooly wells are on your propertv?
What is the well(s) used for? (check all that apply) Drinking___,, Irrigation___. Swimming Pool___.
Water Livestock Other (specify) . You do not use the Well
How many residences are connected to the well (list addresses below)?
How deep is the well(s)? Date well was installed?
What is the casing depth of the well(s)?
What is the screen interval of the well(s)?
Additional water sunnlv well information:
(This part to be completed by Responsible Party or their representative)
Please return completed survey to (WithersRavenel c/o Liz All)'.n } as soon as possible using one of the
following methods:
I. Fax to 919-467-6008
2. Mail to Withers Ravenel
ATTN: Liz Allyn
115 Mackenan Dr.
Cary NC 27511
3. Telephone [phone]
4. E-mail to lallyn@.withersravenel.com
5. Text a picture of the form to 919-418-0279
If you have any questions, please contact the consultant indicated above.
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