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HomeMy WebLinkAboutWM0401270_Monitoring Well Permit Application_20201221NORTH 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: December 18, 2020 2. County: Guilford FOR OFFICE USE ONLY PERMIT NO. ISSUED DATE 3. What type of well are you applying for? (monitoring or recovery): Monitoring 4. Applicant: Huffman Oil Company Telephone: 336-227-8881 5 6 7. 8. 9. 10 11 12 13 Applicant's Mailing Address: P.O. Box 730 Burlington, NC 27216-0730 Applicant's Email Address (if available): net Contact Person (if different than Applicant): Wayne Watterson (S&ME) Telephone: 336-288-7180 Contact Person's Mailing Address: 8646 West Market Street, Suite 105 Greensboro, NC 27409 Contact Person's Email Address (if available): wwatterson(@smeinc.com Property Owner (if different than Applicant): Otis T. and Joanne P. Green Telephone: 336-342-6039 Property Owner's Mailing Address: 132 Green Fee Drive, Reidsville, NC 27320 Property Owner's Email Address (if available): NA - Property Physical Address (Including PIN Number) 8015 Old Reidsville Road (0114396) City Browns Summit County Guilford Zip Code 27214 Reason for Well(s): groundwater contamination/assessment (ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.) Type of facility or site for which the well(s) is(are) needed: UST (ex: non -discharge facility, waste disposal site, landfill, UST, etc.) Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s). Incident No. 44936 Type of contaminants being monitored or recovered: petroleum (ex: organics, nutrients, heavy metals, etc.) Are there any existing wells associated with the proposed well(s)? If yes, how many? Two (on same parcel) Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401160 Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 250 feet 14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes If yes, give distance(s): Approximately 180, 260, 300, 440, 500 feet 15. Well Contractor: S&ME, Inc. Certification No.: 2907 A Well Contractor Address: 3201 Sprinq Forest Road, Raleigh, NC 27616 PROPOSED WELL CONSTRUCTION INFORMATION 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: 0 5. How will the well(s) be secured? Locked expandable cap within bold -down cover 6. Estimated beginning construction date: January 2020 4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: January 2020 (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 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, jn p Subchapter 2C) and accepts full responsibility for compliance with these rules A Gi y C flaPrA Environmental ScientistlAgent for Huffman Oil Co. Signature Pf Applicant or *Agent Title of Applicant or *Agent �y hd4� SN t�r 5 ' if signing as Agent, attach authorization agreement stating Printed name 6f Applicant or *Agent 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 SITE ACCESS AGREEMENT Otis Green 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 3800 Barrett Drive Wilmington, NC 28405 2090 U.S. Highway 70 Raleigh, NC 27609 Phone: (910) 796-7215 Swannanoa, NC 28778 Phone: (919) 791-4200 Fax: (910) 350-2004 Phone: (828) 296-4500 Fax: (919) 571-4718 Fax: (828) 299-7043 Winston-Salem Regional Office Washington Regional Office 450 W. Hanes Mill Road Fayetteville Regional Office 943 Washington Square Mall Suite 300 225 Green Street, Suite 714 Washington, NC 27889 Winston-Salem, NC 27105 Fayetteville, NC 28301-5094 Phone: (252) 946-6481 Phone: (336) 776-9800 Phone: (910) 433-3300 Fax: (252) 975-3716 Fax: (336) 776-9797 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue Mooresville, NC 28115 Phone: (704)663-1699 Fax: (704) 663-6040 AR Rev. 3-1-2016 Raleigh Regional Office Wilmington Regional Office 127 Cardinal Drive Extension GW-22M (Rev. 5111) RE: Site Access Agreement for a Groundwater Assessment at the Incident Known As Monticello Oil Company, Incident # 44936, 8007 Benaja Road, Browns Summit, North Carolina I am the owner of a parcel of property, located at 8015 Old Reidsville Road in Browns Summit, North Carolina and hereby permit Huffman Oil Company and its contractor, S&ME, Inc., to enter upon said property for the purpose of conducting an assessment of the soil and groundwater. Assessment services will include the installation of a groundwater monitoring well, and periodic sampling of the monitoring well. I am granting permission with the understanding that: 1. The assessment shall be conducted as required by the North Carolina Department of Environmental Quality Underground Storage Tank (UST) Section. 2. The costs of construction and maintenance of the site and access shall be borne by the Huffman Oil Company or its contractor. Huffman Oil Company or its contractor shall protect and prevent damage to the surrounding lands. 3. Unless otherwise agreed, Huffman Oil Company or its contractor shall have access to the site by the shortest feasible route to the nearest public road. Huffman Oil Company or its contractor may enter upon the land at reasonable times and have full right of access during the period of the assessment. 4. The information derived from the assessment shall be made available to the owner upon request. I agree not to interfere with, remove, or any way damage Huffman Oil Company's well(s) or its contractor's well(s) or equipment during the assessment. Sincerely,, Q Signature Otis Green Type/Print Name 336-342-6039 Phone Number Date 1/3/2019 Property Report Guilford County, NC It Property Report Convert to PDF 1/3/2019 Parcel ID Property Address Legal Description 114396 8015 Old Reidsville Rd I 25.48 AC LAMBETH SR 2514 r Owner Information Owner Name Mailing Address FGREEN, OTIS T, GREEN, JOANNE P 132 GREEN FEE DR Parcel Information "00 Zoning RS-30 Residential, Single -Family, 1.3 units per acre Parcel Size Appraisal Nlorhood 25.48 890OB03 Mobile Maps City, State Zip REIDSVILLE, NC 27320 Use Tax District RESIDENTIAL 0 Plat/Condo Bk & Pg N/A Recent Sales Book & Page I—SaleDate j Sale Price Qualified? Improved? 00194400351 1 $0 Yes Yes Appraisal Values Land I Buildings Extra Features Total Value $136,100 $0 $0 $136,100 Disclaimer. Map and parcel data are believed to be accurate, but accuracy is not guaranteed. This is not a legal document and should not be substituted for a title search, appraisal, survey, or for zoning verification. Disclaimer: Map and parcel data are believed to be accurate, but accuracy is not guaranteed. This is not a legal document and should not be substituted for a title search, appraisal, survey, or for zoning verification. http://gis.guifordeountyne.gov/PropertyCardjs_TesVDefault.aspx?pin=l14396&maplmage=_ags_Oab4aac93b034bb2a533cb69a25490a3.jpg&isTinySc... 1 /1 WELL Well ID CONSTRUCTION DETAIL Project Name Project Number 4358-17-031A i s Proposed MW-11 44936-Monticello Oil Company S&ME Staff Installation Date County City Well Permit Number L. Butler 1/1/2020 Guilford Browns Summit Application Drilling Contractor License Number Drill Rig Well Type / Use Proposed Geologic Exploration - Stickup Temporary 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) - - - 35.1 8.25-inch Stickup Height - 3.0 ft Pad Type 2' x 2' Concrete Ground Surface 0.0 ft Depth Below Ground Surface (ft-bgs Top of Seal - 3.0 0.1 ft-bgs Top of Filter Pack - 5.0 0.1 ft-bgs Top of Screen - 6.0 0.1 ft-bgs Screened Interval - 10.0 0.1 ft-bgs Bottom of Screen - 16.0 0.1 ft-bgs Bottom of Filter Pack - 16.0 0.1 ft-bgs Cave In - 0.1 ft-bgs Total Boring Depth - 16.0 0.1 ft-bgs Protective Casing Flush Vault (8" diam) Casing Material 2-in Sch 40 PVC Casing Interval (0.1 ft-bgs) 0.0 to 6.0 Screen Type 2-in Sch 40 PVC (0.010) Screen Interval (0.1 ft-bgs) 6.0 to 16.0 Grout Type Portland Cement T2 Grout Interval (0.1 ft-bgs) 0.0 to 3.0 Seal Type 3/8 in. Holeplug® Seal Interval (0.1 ft-bgs) 3.0 to 5.0 Filter Pack #2 Silica Sand Filter Pack Interval (0.1 ft-bgs) 5.0 to 1 16.0 Development Development Volume (gal) Notes: 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 x - X\V\1 1p �X, A I ZZI - X V MW-8 IX MW-7 "N N MW-9 pq TW-1 In MW-3 I , d LL dew" DW-2, MW-6 MW-11 P-1 0 o .0 A-1 -0� MW-1 0 MW-5 S P -2 mw-1 DW-1 VW-4 � A 9 SOURCE: 2014 AERIAL PHOTOGRAPH AND 2016 PARCEL DATA OBTAINED FROM NC ONEMAP. LEGEND MONITORING WELL WATER SUPPLY WELL 0 100 200 I a TEMPORARY MONITORING WELL PROPOSED MONITORING WELL LOCATION GRAPHIC SCALE (IN FEET) SCALE: FIGURE NO. o SITE MAP AS SHOWN DATE: MONITCELLO OIL SITE OCT. 2019 Ill S BENAJA ROAD PROJECT NUMBER BROWNS SUMMIT, NORTH CAROLINA 4358-17-031