WR0400428_Recovery Well Permit Application_20200828

In accordance with the' i pfovi
applil
1
Date: .._8/25/20
2.
Cicunty:�: 2: .:v--%x Aism;
1
What type of well are,youl
4.
Applicant: Speedway LL
Applicants Mailing Addrw
5. Contact Person (if:different than Applicar
Contact Person's Mailing Address: 176 Commerce Blvd. Statesvil
Contact Person's Email Address (if available): A mantak.6oxnaxo
6. Property Owner (if different than Applicant): E. Lawson Brown Jr.
Property Owner's Mailing Address: 522 South Lexington Ave. Bur
Property. Owner's Email Address (it available): [brown @vernonlaw.c
7. Property Physical Address (Including PIN Number) , 620 East D
ENVIRbNMENTAL.QUALITY. DIVISION OF WATER RESOURCES'
ISTRUCT M ONI_0RINQ ORAE6.0t' Mlir t WELL SYSTEM
EASE TYPE OR PRIM CLEARLY
iajote%87, General Statutes of North:Caroffna and regulations pursuant thereto,
Is fora permit toc nstruct monitoring of recovery wells ., .
FOR OFFICE USE QNL,Y. 0
PER,K4146.-%OW'01�qD ISSUED DATE?L
oring or. recovery) '. Recovery
)nsr 800-752-8853
)rive Enon, OH 45323
Is, NC 28626
Telephone: [phone]
linaton..NC27215,
om
tvis Street 1801M
unty Alamance Zip tode 27215
8. Reason for Well(s): Groundwater contamination
(ax: non -discharge permit reqUirements,sUspected contamination, assessment, groundwater contamination, remediation, etc.)
9. Type of facility or site for whic0he well(s) Islam) needed: apartment buildina near ass station
(ex: non -discharge facility, waste disp6sal site, landfill, LIST, 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).
11. Type of contaminants being monitored or recovered: croanles
(ex: organics, nutrients; heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? Ifyes„ jiowrmany? Yes,
Existing Monitoring oi:Recovery Well Construction Permit No(s).;' unknown'
131. Distance from proposed wells) to nearest known waste or pollution source (inleet): 180 to approximately 366.
14. Are there any water supply wells'located less than 500 feet from the proposed well(s)? no
If yes, give distance(s),,,
15. Well Contractor: Geologic Exoloratiorl Certification No.: A-2580
Well Contractor Address: 176 Commerce Blvd. Statesville, NC 28625
PROPOSED WELL CONSTRUCTION INFORMATION1. As required by 15A NCAC.012C,.0105(t)(7), attache well construction diagram of each well showing,the following:
a. Borehole and well diameter a. Type of casing material and thickness ...
b. Estimated well depth I. Grout horizons
C. Screen intervals 9. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL.CONSTRUCTION INFORIIAATION'(Continueti)
pDl.' OAL INFORMATION
,
1. As required by 15A NCAC 02C 0J05i.q(5)` #ftai scaled map of the site showing the locations of the followingo
a..:' All property boundaries; at least one bf which is iefergd o;a m nceinimum of twp landmarks such as identified roads,
intersections, streams, or lakes within 500 teat of the proposed well or well system;
b. All existing wells, identified by type of user.within 500 feet of the proposed well or well system.
d Any proposed s well or s within ell system.
y g within 00 fast oil proposed weli.or well system.
e. All sources,of known or potential groundwater contamination (such as septic iankisyste11 ms,.pesticide, chemical or fuel
storage areas, animal feedlots as defined in G.SI 143-215108(5), landfills,.or other waste disppsal:areas) within 500 feat
of the proposed well or well system. - - -
SIGNATUREV
The, Applicant hereby agrees that the proposed wells) will be constructed in accordance'with approved specifications and.c.,onditions of
this Well Construction Permit as:regulatad under the'WeII- onstructldn Standards (Titfa 15A pf the.North Carolina AdminlstYatwe Code,•.
Subchapter 2C) and.accepts:full responsibility for complianca:with these rules
i MA
Printed name of Applicant or *Age
If the property is owned by soma
wells as outlined in this WI Cc
wells) conform to the Well
Please send the completed application to the i
Asheville Regional Office
,2090 U.S. Highway 70
-.Swannanoa,,.NC 28778
Phone: '[phone]
Fax: [phone]
- Title of Appicant or `Agent V
If sighing,as Agent, attach authorization agreement stating,
that you have the authorfly tc act as the Agent
in the applicant, the property owner hereby consents to allow The applicant to construct
mit application and that t shall'be the responsibility of the applicant to ensure thatthe
Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C)•;
plicant) "Printed name of Property Owner (if different than'Applicant)
DIRECTIONS
spropriate Division of Water Resourceg"Regional Office:
i
Raleigh Regional Office Wilmington. Regional Office
3800 6arratt Drive 127:',CardinalDrive Extension
Raleigh, NC 27609,Wilmington, NC.28405
Phone:: (91 ,) 791-4200 Phone: [phone] '
Fax: [phone] Faxr [phone]
1p
Washingfgn, RegionaI Office 'Winston-Salem Regional office
B43 Washington 5quarelfvlall 450!W. Hanes Mill Road.
N%ashington; NC 27859 : Suite 306
Phone: (252)'946-6481' Winston-Salem,-NC-27105
Fax. [phone] Phone .(3,36) 776-9800
Faz; [phone]'

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1Z11,. SQUARE VAULT OR
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'. I,O' TRAPEIC.RATZH "kH "201 VAULT"'
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HASEU'ON LQOATION':'
ASPHALT/CONCRETE
11' SCH'; 8Q PVC TRUE UNION
BALL VALVE , TO- MATCH EXISTING DEPTH.
REMOVABLE THREADED
MIN: 2' LIFTS. 4"" THIOk
CONCRETE
- " WELL CAP
(6 MlN: WIDTH):.
"
QUICK 'CONNE,CT
'VALVE GAUGE
503 80 PVC TEE .:'
.. 4 ASPHUIT
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COMPACTED 4" OF.
AGGREGATE BASE
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ey
IGINAL SURFACE+.COVER
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r !
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1' x 2" SCH 80 PVC
SCH 80 PVC REDUCING BUSHING '.
REDUCING BUSHING
SCH 80 PVC REDUCING BUSHING
4' 80 PVG COUPLING;
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CONCRETE
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36'
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Es
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"` �QACKFILLY �J
EXISTING
EXISTING BENTONITE SEAL
2" SCH 40. PVC
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1"'`SCH 40 PVC, EXTRACTION PIPING
ONE FOOT OFF BOTTOM OF WELL
PETROLEUM RESISTANT
RUBBER HOOT WITH
METAL BANDS,.'
"
DRILL 1/4' HOLEI ABOVE GIV LEVELEXISTING
SAND PACK,
EXISTING 2" or 4j 0 0.010 SLOT', OR
0.020 SLOT SCH 40 PVC SCREEN
DEPTH OF WELL VARIE
DEPENDENT ON LOCATION
a, "
XISTING CAP
TYPICAL HIGH VACUUM EXTRACTION WELL SYSTEM
Speedway
NTU STANDARD
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05/78106`
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TYPICAL DPHVE WELL
BE
., PIPING & , :,
CONNECTION DETAILS
SPEEDWAY LLC,.
:'.ENON OH
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1-1 1. BUPLING TON. NC DIGITAL RASTER GRAPHIC FILE USES. SCANNED FROM ! SCALE: 1:12,000
1' 24 000.SCALE TOPOGRAPHIC MAP BURLINGTON NC 2013, USGS.
Z INSET MAP DIGITAL DATA FROM'2002 NATIONAL TRANSPORTATION ATLAS; .Fee{
BUREAU OF TRANSPORTATION STATISTICS WASHINGTON D.C. 0 1,000 2,000
DRAWN y;.�'" DATE.
TOPOGRAPHIC, SITE MAP BY " FEBRUARY 20
SPEEDWAY #6958 DRAFT JOB NO:
Mid Atlantic 653 EAST WEBS AVENUE CHECK' 097Ro5b9.e
Engineer E r.%m.�.a semem�9 ,ENG. GIS NO:
ngb
BURLINGTON, NORTH CAROLINA ,CHECK 02G-087055386-C
APPROVAL: WG NO: 11