WM0401225_Permit (Issuance)_20200317

......... .................
March 17, 2020
Mr. Herbert Berger
NCDEQ - DWM
1646 Mail Service Center
Raleigh, North Carolina 27699
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0401225
COUNTY: Surry
FILE NAME: Former Yokum Grocery — LUST Incident # 10402
Dear Mr. Berger:
In accordance with your application received on March 11, 2020, we are forwarding herewith:
Monitoring Well Construction Permit No. WM0401225 for the construction of one (1)
monitoring well at 950 Jenkintown Road in Dobson in Surry County.
Henceforth, correspondence and data relating to this well shall be designated as specified in the
subject heading above. This Permit will be effective from the date of issuance and shall be
subject to the conditions and limitations as specified therein. If you have any questions regarding
this permit, please contact me or Jim Gonsiewski at [phone].
Sincerely,
CDocuSigned by:
t-0ti T SMd�
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Lon T. Snider
Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
cc: Rosemery Ruiz Palacios — Iglesia Evangelica Pentecostes, Lirio De Los Valles, Inc.
Lyndal Butler — S&ME (Electronic Copy)
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NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOURCES
DIVISION OF WATER RESOURCES - WATER QUALITY REGIONAL OPERATIONS
SECTION
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
NCDEQ - DWM
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of one monitoring
wells owned by the NCDEQ - DWM. The well will be located at 950 Jenkintown Road in
Dobson, North Carolina, in Surry County. This Permit is issued in accordance with the
application received on March 11, 2020 in conformity with specifications and supporting data,
all of which are filed with the Department of Environment and Natural Resources 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 Resources' 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 Resources' Information Processing Unit within 30 days of the well
abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 17th day of March, 2020
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION
o u9TgnealEy:
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Lon T. Snider, Regional Supervisor
Water Quality Regional Operations Section
Division of Water Resources, NCDEQ - WSRO
By Authority of the Environmental Management Commission
Permit No. WM0401225

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 ft
1. Date: March 11, 2020
2. County:
it a permit to construct monitoring or recovery wells.
FOR OFFICE USE ONLY
PERMIT NO.vVANAc,' j 'S- ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
336-288-7180
4. Applicant: S&ME Inc. Telephone:
Applicant's Mailing Address: 8646 West Market Street Suite 105 Greensboro NC 27409
Applicant's Email Address (if available): IbutlerAsmeinc corn
5. Contact Person (if different than Applicant): Herbert Berger (NCDEQ) Telephone: [phone]
Contact Person's Mailing Address: 1646 Mail Service Center Raleigh NC 27699-1646
Contact Person's Email Address (if available): HerbertBergerAncdenr gov
6. Property Owner (if different than Applicant): Iglesia Evangelica Pentecostes Lirio De Los Valles, Inc. Telephone: [phone]
Property Owner's Mailing Address: 950 Jenkinstown Road Elkin NC 27017
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) Parcel has no address (former 962 Jenkinstown Road( (PIN. 499300432809
City Dobson, NC County Surry Zip Code 27017
8. Reason for Well(s): Assessmenttgroundwater contamination
(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).
LUST Incident No 10402 (adjacent property; Yokum Grocery (9127 US 601 Dobson NC
11. Type of contaminants being monitored or recovered: petroleum products
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes: 3 (MW-5. MW-6 MW-7)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0400879
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 220 feet to former UST basin.
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): Two inactive wells on -site to be abandoned; Other properties (feet): 60 240 290 310 340 400, 410
15. Well Contractor: Geologic Exploration, Inc. Certification No.: A-3098
Well Contractor Address: 176 Commerce Boulevard Statesville NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION f iC Department u
Environmental Quality
1. As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the following: Received
a. Borehole and well diameter e. Type of casing material and thi$(f 16 2020
b. Estimated well depth f. Grout horizons
C. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals Winston-Salem
Continued on Reverse Regional Office

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2.
9
4.
Number of wells to be constructed in unconsolidated
material: 1
Number of wells to be constructed in bedrock: 0
Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Flush -mount cover
6. Estimated beginning construction date: 3/23/2020
Estimated construction completion date: 3/27/2020
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. 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. 143-215.1013(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,
��,, nn Subchapter 2C) and accepts full responsibility for compliance with these rules
i""
Lynda[ Butler Environmental Scientist (NCDEQ Contractor)
Signature of Applicant or *Agent Title of Applicant or *Agent
Printed name 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) confoan to the Well Construction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
Seeattachedsigned Off -Site Property Access Consent
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
Raleigh Regional Office
Swannanoa, NC 28778
3800 Barrett Drive
Wilmington Regional Office
Phone: [phone]
Raleigh, NC 27609
127 Cardinal Drive Extension
.Fax: [phone]
Phone: [phone]
Wilmington, NC 28405
Fax: [phone]
Phone: [phone]
Fayetteville Regional Office
Fax: [phone]
225 Green Street, Suite 714
Washington Regional Office
Fayetteville, NC 28301-5094
943 Washington Square Mall
Winston-Salem Regional Office
Phone: [phone]
Washington, NC 27889
450 W. Hanes Mill Road
Fax: [phone]
Phone: [phone]
Suite 300
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
05
GW-22MR Rev. 3-1-2016

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Site Access Agreement, cont. 7019 FFR 2 5 Pill 1 a 4 0
Yokum Grocery, FTF Incident # 10402
Page 2
February 12, 2019
I agree not to interfere with, remove, or any way damage the Department's well(s) or Its
contractors well(s) or equipment during the Investigation.
Sincerely,
Signature
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Type/Print Name
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Address
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13
Well ID Project Name AMW
Project Number�j
Proposed MW-8 10402- Yokum Grocer 4305-17-231B
S&ME Staff Installation Date
County
City
Well Permit Number
L.Butler Scheduled March 2020
Surry
Dobson
Application
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Geologic Exploration, Inc.
A-3098
TBD
Flush Monitor Well
Water Level at TOB (0.01 ft- BTOC)
Date/Time
Northing (0.1 ft)
Land Surface Elev. (0.01 ft)
Drilling Method
Hollow Stem Auger
Depth to Water (0.01 ft- BTOC)
Date/Time
Easting (0.1 ft)
Total Well Depth (0.1 ft-bgs
Borehole Diameter (1 in)
35.0
8
TOC Relative to Ground 0.3 ft
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
Depth Below Ground Surface (ft-logs)
2-in Sch 40 PVC
Top of Seal - 16.0 0.1 ft-bgs
Casing Interval (0.1 ft-bgs)
0.3
to
20.0
Screen Type
Screen Interval (0.1 ft-bgs)
20.0
1 to
1 35.0
Grout Type
Top of Filter Pack - 18.0 0.1 ft-bgs
Grout Interval (0.1 ft-bgs)
Top of Screen - 20.0 0.1 ft-bgs
0.3
1 to
1 16.0
Seal Type
Screened Interval - 15.0 0.1 ft-bgs
Bottom of Screen - 35.0 0.1 ft-bgs
Seal Interval (0.1 ft-bgs)
16.0
to
18.0
Filter Pack
Filter Pack Interval (0.1 ft-bgs)
18.0
to
35.0
Development
Bottom of Filter Pack -35.0 0.1 ft-bgs
Cave In - 0.1 ft-bgs
Total Boring Depth - 35.0 0.1 ft-bgs
Development Volume (gal)
Notes: Proposed MW-8 construction details for Jenkinstown Road, Surry Co., NC
BTOC - Below Top of Casing
TBD - To Be Determined
For lithologic information
see attached boring log
Form Revision Date: 9/1/17 2:10 PM

PROPOSED MW-8
SUSPECT FORMER ®LL
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Not Bampietl
MW-)
FORMER
ISLAND
1OSILE FORMER
rt—= —HOME FUEL OILAST
all ' =Il
II
� INFORMER 11 _-
MWa C/JRISTIAN OUTREACH ASSEMBLY
FORMER UST MWl
LOCATIONS Nol Bempletl
FORMER UST LOCATIONS
�FNK�A/STOW/VRD
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p
MW-. I^I
I
II FORMER II PBS
IIf
( Pi
YOKUM • FORMER WELL
II GROCERY )CAVED IN�
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II II (CAS NGIN
FORMER II II
DISPENSER II II
W
ryp gMW-2
empleU Z
ISLAND
j
LL _JJ a I
F
INACTIVE (CASED) WELL UDIL
Benzene 0.191
Ethylbenzene 0.17 J
ToW Xylenea 0.75J
Toluene 1.5
NOTES:
CONCENTRATIONS GREATER THAN 21.
STANDARD ARE SHOWN. VALUES
GREATER THAN GROSS
CONTAMINANT LEVEL ARE SHOWN IN
I I ' I I
BOLD.
I
SOURCES: BASE MAP DEVELOPED FROM 2014 AERIAL PHOTOGRAPH INC ONEMAP)
PARCEL DATA FROM SURRY COUNTY GIS
ug/L - MICROGRAMS PER LITER
J - ESTIMATED CONCENTRATION
KEY
- MONITORING WELL LOCATION
OO - SOIL PROBE LOCATION (11/8/17)
0 40
80
• - FORMER/INACTIVE WELL LOCATION
® - SUSPECTED WELL LOCATION
LNAPL -LIGHT NON -AQUEOUS PHASE LIQUID
GRAPHIC SCALE
(IN FEET)
®
GROUNDWATER CONSTITUENT MAP
Site ID:10402
SCALE:
FIGURE NO.
WN
AS SDA
E
IEq{
YOKUM GROCERY
MARCH 2O19
3
PROJECT NUMBER
M®
141 O
9127 US HIGHWAY 601
4305-17-231A
DOBSON. CURRY COUNTY. NORTH CAROLINA

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North Carolina Department of Environment and Natural Resources
Pat McCrory
Governor
July 23, 2014
Lyndall Butler
S&ME, Inc.
3718 Old Battleground Road
Greensboro NC 27410
SUBJECT: MONITORING WELL CONSTRUCTION
PERMIT NO. WM0400879
COUNTY: Surry
FILE NAME: Yokum Grocery (UST# 10402)
Dear Mr. Butler:
John E. Skvarla, III
Secretary
In accordance with your application submitted July 22, 2014, we are forwarding herewith:
1. Monitoring Well Construction Permit No. WM0400879 for the construction of three
monitoring wells at 962 Jenkinstown Road, Dobson, North Carolina, 27017 (PIN
499300432809).
Henceforth, correspondence and data relating to these wells shall be designated as specified in
the subject heading above. This Permit will be effective from the date of issuance and shall be
subject -to -the -conditions and limitations as specified therein. - ---
Sincerely,
r
Sherri V. Knight, PE
Assistant Supervisor
Water Quality Regional Operations
Division of Water Resources, NCDENR
cc: Groundwater Protection Unit - Central Office
Surry County Health Department
Herbert Berger NCDENR-UST, 1637 Mail Service Center, Raleigh, INC 27699-1637
WSRO Files
585 Waughtown Street, Winston-Salem, North Carolina 27107
Phone: [phone] Internet: www.ncdenr.gov
An Equal opportunity Affirmative Action Empioyei - Waoa in part by recycled paper

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENT AND NATURAL RESOUF
DIVISION OF WATER RESOURCES
WATER QUALITY REGIONAL OPERATIONS SECTION
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
SBME, Inc.
Agent for NCDENR, Division of Waste Management, UST Section - Trust Fund Branch
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM consisting of three (3) wells, owned
by NCDENR - Trust Fund Branch, 1636 Mail Service Center, Raleigh, NC 27699-1636. The
well(s) will be on the property owned by Jimmy Dave Jenkins, located at 962 Jenkintown Road,
Dobson, North Carolina, 27017 in Surry County (PIN 499300432809). This Permit is issued in
accordance with the application received on July 22, 2014, in conformity with specifications and
supporting data, all of which are filed with the Department of Environment and Natural Resources
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 150E 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 Resources' 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 Resources' Information Processing Unit within 30
days of the well abandonment.
7. The County Health Department may require a county monitoring well construction
permit. Please contact the health department for their requirements.
Permit issued the 23rd day of July, 2014
FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT
Division of Water Resources
Water Quality Regional Operations Section
By Authority of the Environmental Management Commission
Permit No. # WM0400879