WM0801158_Application_20200813

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: 7/23/2020
2. County: New Hanover
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4.
5.
H
Applicant: GPM Southeast, LLC Telephone: [phone]
Applicant's Mailing Address: 8565 Magellan Parkway, Suite 400, Richmond, VA 23227
Applicant's Email Address (if available):
Contact Person (if different than Applicant): Aaron Williamson, CES of NC, PLLC Telephone:
Contact Person's Mailing Address: 5104 Reagan Drive, Suite 7, Charlotte, NC 28206
Contact Person's Email Address (if available): [e-mail]
Property Owner (if different than Applicant): Ralph S. Zimmerman Telephone: [phone]
Property Owner's Mailing Address: 217 Trails End Road, Wilmington, NC 28409
980.819.9333
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number) 609 Piner Road - Pin #R07610-005-002-000
City Wilmington County New Hanover Zip Code 28409
8. Reason for Well(s): Groundwater Assessment
(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 Number 43177
11. Type of contaminants being monitored or recovered: Organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 5
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): 100-feet to UST area
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): 350-400 feet
15. Well Contractor: Geologic Exploration, Inc. - David Hall Certification No.: 4459-A
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 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 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

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 1
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? steel vault, lockable
expanding plug
6. Estimated beginning construction date: 9/2/2020
Estimated construction completion date: 9/3/2020
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 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
Sign ure of Applicant or *Agent
Rolfe Lann
Printed name of Applicant or *Agent
VP Env
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).
See attached access agreement
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
R Rev. 3-1-2016

-I�
WELL CONSTRUCTION
LOCKABLE CAP
PROTECTIVE COVER
MATERIAL
DIAMETER
LENGTH
SETTING DIMENSIONS
HEIGHT ABOVE GROUNC
WELL CASING / RISER
MATERIAL
DIAMETER
LENGTH
JOINT TYPE
ANNULAR FILL
MATERIAL
THICKNESS
ANNULAR SEAL
TYPE
THICKNESS
FILTER PACK
TYPE
DISTANCE ABOVE SCREEI
WELL SCREEN
MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF WELL
DEPTH TO THE BOTTOM OF
FILTER SAND
BOREHOLE DIAMETER
NAW�NVIRONMENTAI
SERVICES
Steel Traffic -Bearing
8-inch
0.5-feet
2-foot x 2-foot x 0.5-foot
0
polyvinyl chloride (PVC)
2 inches
5 feet
locking thread
Cement grout slurry
1.0 feet
Sodium-bentonite pellets
2.0 feet
#2 filter sand
1.0 feet
PVC
2 inches
10 feet
0.01-inch horizontal slot
15.5 feet
15.5 feet
8 inches
WELL ID:
TBD
L1 =
0.5
feet
DRILLING METHOD: 4.25" Inner Diameter HSA
INSTALL DATE:
TBD
L2 =
5.0
feet
SURFACE COMPLETION: Concrete Pad At Grade
PROJECT:
GPM 3323
L3 =
10.0
feet
PROJECT NUMBER:
9.0668
L4 =
15.5
feet

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FIGURE I
Site Location Map
Scotchman #3323
5325 S College Road
Wilmington, North Carolina
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Wilmington, North Carolina Project: Risk Assessment Report
C E S@ N C a
Source: U.S.G.S Topographic Map of the Client: GPM Southeast LLC
Wilmington Quadrangle, North Carolina, 5°
301 McCullough Drive, Suite 400 7.5 Minute Series (2016)
Charlotte, NC 28262 Scale: 1:24,000 Contour Interval: 5 Feet CES NC Job #: 9.0619 Latitude:
Vertical Datum: National Geodetic Vertical 34°08'25.4"N
Datum 1988 Longitude:
540-343-6256 (office) 540-343-6259 (fax) Horizontal Datum:North American Datum 1983 Date: 6/l/2020 77°53'34.1 "W

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CLIENT: GPM Southeast, LLC
Figure 3
5325 S College Road
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LOCATION: Wilmington, North Carolina
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Scotchman #3323
Site Vicinity Map
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Risk Assessment Report
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Zimmerman
217 Trails End Road - Wilmington, NC 28409
RIGHT OF ENTRY LICENSE AGREEMENT RE VEST
(the "License")
"Owner(s)" Property:
Ralph S. & Nancy P. Zimmerman (217 Trails End Road, Wilmington, North Carolina 28409)
PIN #: R07610-005-002-000 — 609 Piner Road, Wilmington, North Carolina
Property "Owner(s)" Ralph S. Zimmerman & Nancy P. Zimmerman have sole right to possession of the above Property
and grants this right -of -entry request as indicated herein to allow environmental investigations associated with the
below Neighboring Property to be conducted under guidance of the North Carolina Department of Environmental
Quality (NCDEQ).
Neighboring Property:
GPM Southeast, LLC—Scotchman #3323
5325 S. College Road
Wilmington, North Carolina 28412
PIN #: R07610-005-001-000
NCDEQ LIST Incident Number: 43177
Planned activities to be conducted on the Owner's Property include:
• Installation of soil boring(s) and groundwater monitoring well(s) on the Property.
• Collection of environmental soil and groundwater samples from the Property.
• Periodic monitoring and sampling of monitoring well(s) installed on the Property.
■ Periodic sampling of water supply wells or surface water bodies on the Property (if any).
0 Actual sampling frequency will be determined by the state regulator. Generally, monitoring events
are conducted semi-annually or annually.
■ Periodic groundwater remediation activities utilizing monitoring wells installed on the Property.
• Future Property monitoring well abandonment.
0 Once the NCDEQ grant incident closure for the Neighboring Property or otherwise determine that
Property monitoring wells are no longer needed, the Property monitoring wells will be abandoned
in accordance with state and local regulations.
The current and any future Owner(s) of Owner's Property grant GPM Southeast, LLC and its environmental
consultants ("Licensee") the right to enter upon the Property.
All activities will be performed as required by the NCDEQ until incident closure is granted. All activities will be
conducted to eliminate or minimize disruption to the Property. Work will typically be performed Monday through
Friday, 8:00 AM to 5:00 PM excluding holidays. Work related to well installation, removal, and repair will be
conducted during hours as agreed to by the Owner(s).
Licensee will notify the Owner(s) a minimum of 24 hours prior to performing minimally disruptive and short -duration
work such as groundwater monitoring. Well installation and similar activities will be coordinated with the Owner(s)
for approval in advance of scheduling. Reasonable advance verbal or written notification will be made to Owner(s)
should the planned work or schedule change.
This License may be immediately terminated by the Owner(s) through written notice following any breach of this
License by Licensee.
This License is effective upon signing. Licensee agrees to repair any damage to the Property resulting from entry by
Licensee and affiliates by restoring, to the extent reasonably possible, the Property to its condition immediately prior
to entry.
Page 1 of 2

Zimmerman
217 Trails End Road - Wilmington, NC 28409
i', Grant
Month: v v�
Owner(s)
wo -
Telephone
Email
❑ Deny
Day: ��/ , 2020
A=
Licensee
GPM Southeast, LLC
8565 Magellan Parkway, Suite 400
Richmond, Virginia 23227
Signa re
Rolfe Lann, Vice President of Environmental
Printed Name
Maury Brlcks, General Counsel
Page 2 of 2