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
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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
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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