WM0401259_Monitoring Well Permit Application_20201028

MINERAL
SPRINGS
environmental, p.c. 4600 Mineral Springs lane Raleigh, NC 27616 919-261-8186
October 27, 2020
Mr. Jim Gonsiewski
Aquifer Protection Section
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105-7400
Reference: Monitoring Well Installation
Han Dee Hugo's 210 site
1020 High Point Street
Randleman, North Carolina
Dear Mr. Gonsiewski:
Please find enclosed a permit application to construct one monitoring well on the adjoining
property to the above mentioned site. Attached to the permit is a map showing the proposed well
location, well schematic, property map and an access agreement signed by the property owner.
Drinking water wells have been identified within a 1,500 foot radius, a map is provided. The well
will be installed to a depth of 45 to 50 feet and constructed of two-inch PVC screen and casing.
If you should have questions or require additional information please do not hesitate to call me at
[phone].
Sincerely,
Mineral Springs Environmental P.C.
4,�k,6. gdbA,01
Kirk B. Pollard L.G.
President

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER RESOURCES —AQUIFER PROTECTION SECTION
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: �/Z7 f 20ZO II
2. County: RAm dD / I?
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): 11.04Z /i "n a
4. Applicant:
Applicant's Mailing Address: _ 33D9 Z)Yt_Kp, 6AG/t°
Applicant's Email Address (if available):
Telephone:
'e cc(h AZ6 27(007
5. Contact Person (if different than Applicant): X&II�k YllaYd Telephone: 26/-8/9& /
Contact Person's Mailing Address: 7/OOD /r"(L1'J�a/�VL.!')GIS � -,. /LLL�,, N C
Contact Person's Email Address if available
6. Property Owner (if different than Applicant): TOCrlGislf✓/7S Of�f!! 6lshel�f o Telephone: A3& - 5Z3 - /ZD
Property Owner's Mailing Address: Pox 'Y031o. ltiSh�°bDYO� /t/� 27yb�
Property Owner's Email Address (if available):
7. Property Physical Address (including zip code) and PIN Number 048 f7� /Z P1 af, 9&IMW7 MF5_35&ZZq
8. Reason for W ell(s): �s sP 5�1 f t J
(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: L.n2d
(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).
11. Type of contaminants being monitored or recovered: 2
(ex: organics, nutrients, heavy metals, etc.) i-
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 121
Existing Monitoring or Recovery Well Construction Permit No(s).: A )D
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 5(%
14. Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s): T� !7
15. Well Contractor: f-b !- S /I Certification No.: Ale-
/3 e D I
Well Contractor Address: 17-63 g &1L9,, N /%L/� t1e , 78i ?i-7 8
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) 1
2. Number of wells to be constructed In unconsolidated 5. Flow will the well(s) be secured?cq/
material:
3. Number of wells to be constructed In bedrock: © 6, Estimated beginning construction date:
4. Total Number of wells to be constructed: �� 7. Estimated construction completion date:
(add answers from 2 and 3)
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 wall or well system.
c. The proposed well or well system,
d. Any test borings within 500 feet of proposed well or wail system,
a, 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. 143-216.10B(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) wail be constructed In accordance with approved specifications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards (Title 16A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility f1f rr compliance with these rules
5 nature of
�� � , " ea
g ^ r pliant or "Agent Tllle of Applicant r *Agent
"If signing as Agent, attach author/zaHon 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 shell be the responsibility of the applicant to ensure that the
well(s) conform to the Well Construction Standards (Title 15A of the North Carolina Acirinistratve Code, Subchapter 2C),
5lgnature of Property Owner (if differen ran App Icant't �� Printed Hama of Proporty Ownor (If different than Applicant) ._
DIRECTIONS
Please send the completed application to the appropriate Division of Water Rosources's Aquifer Protection Section Regional Office
Asheville Regional office
2090 U,S. Highway 70
Swannanoa,. NO 28770
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
226 Green Street, Suite 714
Fayetteville, NO 28301-6094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28116
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NO 27009
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NO 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 284,05
Phone: [phone]
Fax: [phone]
Winston-Salem Regional office
585 Waughtown Street
Winston-Salem, NO 27107
Phone: [phone]
Fax: (336)771A630
QW-221VIR (Rev. 8113)

ACCESS AGREEMENT
AUTOMASTERS OF ASHEBORO LLC SITE
RANDLEMAN, NORTH CAROLINA
As owner and/or authorized representative of the Automasters of Asheborol-LC site, hereby
permits Sampson Bladen Oil Company, Inc. (Sampson) or its contractors to enter upon said
property located at 1028 High Point Street, Randleman, North Carolina for the purpose of
performing groundwater investigation activities. I am granting permission with the understanding
that:
• All work will be conducted by Sampson or its contractors. Any monitoring well installed will
be flush to the ground to insure it does not interrupt the view of signs and landscape
maintenance.
Sampson agrees to indemnify and hold harmless Automastert of Asheboro LLC against
each and every claim, demand or cause of action that may be made against it by reason or
in any way arising out of the performance of soil and groundwater investigations, unless
such claim, demand or cause of action occurred by reason of Automasters of Asheboro
LLC negligence, recklessness or illegal activity.
• The costs of the assessment activities will be born by Sampson or its contractors. Sampson
or its contractors will protect and prevent damage to the work area during the course of
work. No cost will be borne by Automasters of Asheboro LLC.
• Sampson or its contractors may enter upon the subject property following notification of
owner.
• All test borings will be properly abandoned according to North Carolina regulations upon
completion of the soil sampling activities. Monitoring wells will be allowed to remain on the
site until a No- Further Action letter has been issued by the UST Section. At the conclusion
of work activities, the site will be brought back to the original condition.
I have read this entire agreement and fully understand and agree to all of the conditions and
limitations outlined.
Signature of property owner/authorized representative:
Print name of property owner/authorized representative: e
Address of property owner: �'® 1So x 9o'16
City/State/Zip Code: ✓,St1ai e�, s� C Z 20 �(
Home Phone Number: (—)
Work Phone Number: (36) S'2'3 1 Zd8
Date: t OA Z- /z O

MONITORING WELL
SITE: Uld L D
JOB N0:
CASING MATERIAi
DRILLING METHOD•
CAD DATE: OCTOBER 2004
PROJECT NO: ADMIN
CAD FILE: ADMINCAD TYPE II
DRAWN BY: LOT
APPROVAL: KR
REFERENCE:
PROTECTIVE MANHOLE CASING
WITH LOCKABLE CAP
PROTECTIVE CONCRETE DOME
CASING RISER'
GROUT, 0 A I I
Gcrncv� nor h�n�I
Garlwb, f�r�
BENTONITE SFAI. a( - A�
AND GRAVEI PACK, o�'✓
TOTAL DEPM-
STANDARD TYPE II BELOW GRADE
MONITORING WELL CONSTRUCTION SCHEMATIC
INERA
PRING
DRAWING NO:

9/21 /2020
Randolph County GIS
Wells
Disclaimer: This mvp was compiled f om recorded deeds, plats. and other public records Map Scale
and data. Users of this data are hereby notified that the aforementioned public it formation
(_ 1 inch = 42 feet
tis �! sources should be corsrdred for verification of the information, Randolph County, its 9/21/2020
,77s agents and employees make no warranty as to the accaracy of the information or this map.
https://gis.randolphcountync.gov/randolphis/ 111

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