WM0401268_Monitoring Well Permit Application_20201221

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:
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: Huffman Oil Company Telephone: [phone]
Applicant's Mailing Address: P.O. Box 730 Burlington. NC 27216-0730
Applicant's Email Address (if available):
5. Contact Person (if different than Applicant): Wayne Watterson (S&ME) Telephone: [phone]
Contact Person's Mailing Address: 8646 West Market Street, Suite 105 Greensboro. INC 27409
Contact Person's Email Address (if available): wwatterson gnsmeinc.com
6. Property Owner (if different than Applicant): Stephen Lee Seamster Telephone: [phone]
Property Owner's Mailing Address: 2475 Winding Trail, Burlington, INC 27217
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 2111 North INC 49 (8896894367)
City Green Level County Burlington Zip Code 27217
8. Reason for Well(s): groundwater contamination/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).
LUST Incident No. 44930
11. Type of contaminants being monitored or recovered: petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Six (on a different property)
Existing Monitoring or Recovery Well Construction Permit No(s).: Not applicable
13. Distance from proposed wells) to nearest known waste or pollution source (in feet): Approximately 200 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s): Approximately 430 feet
15. Well Contractor: S&ME Inc. Certification No.: 2907 A
Well Contractor Address: 3201 Spring 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: 3
5. How will the well(s) be secured? Locked
expandable cap within flush -mount cover
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: January 2021
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: March 2021
(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. 143-215.11013(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 Conston Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
ry�j
/ , Subchapter 2C) and accepts full responsibility for compliance with these rules
Environmental ScientistlAoent for Huffman Oil Co.
Signs re of A plicant or `Agent Title of Applicant or -Agent
Lvndal Butler If signing as Agent, attach authorization agreement stating
Printed name of 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 SIGNED SITE ACCESS AGREEMENT Stephen Lee Seamster
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: [phone]
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
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: [phone]
Phone: [phone]
Phone: [phone]
Fax: [phone]
Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
AR Rev. 3-1-2016
Raleigh Regional Office
Wilmington Regional Office
127 Cardinal Drive Extension
GW-22M (Rev. 5/11)

RE: Site Access Agreement for a Groundwater Assessment at the Incident Known As
MK's Grocery, Incident # 44930, 2073 North N.C. 49, Green Level, North
Carolina
I am the owner of a parcel of property, located at 2111 North NC 49 Highway (Parcel ID
No.: 174109; GPIN: 8896894367) in Green Level, North Carolina and hereby permit
Huffman Oil Company and its contractor, SBME, 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 groundwater monitoring wells, and periodic sampling of the
monitoring wells.
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.
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,
,Z�. ,
SignatLTre
Stephen Lee Seamster
ft N L �C 5eA,sSfe/�
hype Name
�3 G 5;-7k 979/
Phone Number
Date

Well ID
WELL
CONSTRUCTION DETAIL
Project Name
Project Number
4305-17-038A
i
s
Proposed MW-5 MK's Grocery
S&ME Staff
Installation Date
County
City
Well Permit Number
L. Butler
1/1/2020
Alamance
Burlington
Application
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Geologc Exploration
-
550X
Flush Monitor Well
Water Level at TOB (0.01 ft-
BTOC)
Date/Time
Latitude
Land Surface Elev. (0.01 ft)
Drilling Method
-
-
-
-
Hollow Stem Auger
Depth to Water (0.01 ft-
BTOC)
Date/Time
Longitude
Total Well Depth (0.1 ft-bgs)
Borehole Diameter (1 in)
-
-
-
12.2
8-inch
TOC Relative to Ground
0.3
ft
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
Depth Below Ground Surface (ft-bgs
2-in Sch 40 PVC
Top of Seal - 3.0 0.1 ft-bgs
Casing Interval (0.1 ft-bgs)
0.3
to
S.0
Screen Type
2-in Sch 40 PVC (0.010)
Screen Interval (0.1 ft-bgs)
5.0
to
15.0
Grout Type
Top of Filter Pack - 4.0 0.1 ft-bgs
Portland Cement T2
Grout Interval (0.1 ft-bgs)
Top of Screen - 5.0 0.1 ft-bgs
0.3
to
3.0
Seal Type
Screened Interval - 10.0 0.1 ft-bgs
Bottom of Screen - 15.0 0.1 ft-bgs
3/8 in. Holeplug®
Seal Interval (0.1 ft-bgs)
3.0
to
4.0
Filter Pack
#2 Silica Sand
Filter Pack Interval (0.1 ft-bgs)
4.0
to
15.0
Development
Bottom of Filter Pack -
Cave In -
Total Boring Depth -
15.0
15.0
0.1 ft-bgs
0.1 ft-bgs
0.1 ft-bgs
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

Well ID
WELL
CONSTRUCTION DETAIL
Project Name
Project Number
4305-17-038A
i
s
Proposed MW-6 MK's Grocery
S&ME Staff
Installation Date
County
City
Well Permit Number
L. Butler
1/1/2020
Alamance
Burlington
Application
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Geologc Exploration
-
550X
Flush Monitor Well
Water Level at TOB (0.01 ft-
BTOC)
Date/Time
Latitude
Land Surface Elev. (0.01 ft)
Drilling Method
-
-
-
-
Hollow Stem Auger
Depth to Water (0.01 ft-
BTOC)
Date/Time
Longitude
Total Well Depth (0.1 ft-bgs)
Borehole Diameter (1 in)
-
-
-
12.2
8-inch
TOC Relative to Ground
0.3
ft
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
Depth Below Ground Surface (ft-bgs
2-in Sch 40 PVC
Top of Seal - 3.0 0.1 ft-bgs
Casing Interval (0.1 ft-bgs)
0.3
to
S.0
Screen Type
2-in Sch 40 PVC (0.010)
Screen Interval (0.1 ft-bgs)
5.0
to
15.0
Grout Type
Top of Filter Pack - 4.0 0.1 ft-bgs
Portland Cement T2
Grout Interval (0.1 ft-bgs)
Top of Screen - 5.0 0.1 ft-bgs
0.3
to
3.0
Seal Type
Screened Interval - 10.0 0.1 ft-bgs
Bottom of Screen - 15.0 0.1 ft-bgs
3/8 in. Holeplug®
Seal Interval (0.1 ft-bgs)
3.0
to
4.0
Filter Pack
#2 Silica Sand
Filter Pack Interval (0.1 ft-bgs)
4.0
to
15.0
Development
Bottom of Filter Pack -
Cave In -
Total Boring Depth -
15.0
15.0
0.1 ft-bgs
0.1 ft-bgs
0.1 ft-bgs
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

Well ID
WELL
CONSTRUCTION DETAIL
Project Name
Project Number
4305-17-038A
i
s
Proposed MW-7 MK's Grocery
S&ME Staff
Installation Date
County
City
Well Permit Number
L. Butler
1/1/2020
Alamance
Burlington
Application
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Geologc Exploration
-
550X
Flush Monitor Well
Water Level at TOB (0.01 ft-
BTOC)
Date/Time
Latitude
Land Surface Elev. (0.01 ft)
Drilling Method
-
-
-
-
Hollow Stem Auger
Depth to Water (0.01 ft-
BTOC)
Date/Time
Longitude
Total Well Depth (0.1 ft-bgs)
Borehole Diameter (1 in)
-
-
-
12.2
8-inch
TOC Relative to Ground
0.3
ft
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
Depth Below Ground Surface (ft-bgs
2-in Sch 40 PVC
Top of Seal - 3.0 0.1 ft-bgs
Casing Interval (0.1 ft-bgs)
0.3
to
S.0
Screen Type
2-in Sch 40 PVC (0.010)
Screen Interval (0.1 ft-bgs)
5.0
to
15.0
Grout Type
Top of Filter Pack - 4.0 0.1 ft-bgs
Portland Cement T2
Grout Interval (0.1 ft-bgs)
Top of Screen - 5.0 0.1 ft-bgs
0.3
to
3.0
Seal Type
Screened Interval - 10.0 0.1 ft-bgs
Bottom of Screen - 15.0 0.1 ft-bgs
3/8 in. Holeplug®
Seal Interval (0.1 ft-bgs)
3.0
to
4.0
Filter Pack
#2 Silica Sand
Filter Pack Interval (0.1 ft-bgs)
4.0
to
15.0
Development
Bottom of Filter Pack -
Cave In -
Total Boring Depth -
15.0
15.0
0.1 ft-bgs
0.1 ft-bgs
0.1 ft-bgs
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

4
0
Fill
rp
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SOURCE: 2018 AERIAL PHOTOGRAPH AND 2016 ALAMANCE COUNTY NC PARCEL DATA OBTAINED FROM NC ONEMAP.
LEGEND
— MONITORING WELL LOCATION
— VERTICAL EXTENT MONITORING WELL
Q• — PROPOSED MONITOR WELL LOCATION
PROPOSED MONITOR WELL LOCATION MAP
MK'S GROCERY
III E 2073 NC HWY 49
BURLINGTON, NORTH CAROLINA
;I
I
0 120 240
GRAPHIC SCALE (IN FEET)
SCALE:
FIGURE NO.
AS SHOWN
1
DATE:
DEC. 2020
PROJECT NUMBER
4358-17-038