WM0401293_Monitoring Well Permit_20210429 (2)

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
1.
2.
3.
4.
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.
Date: 04/29/21
County: Surry
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: NCDEQ-DWM, UST Section, Federal & State Lead Program (TF#6538) Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699-1646 Attn: Linda Blalock
Applicant's Email Address (if available): Linda.Blalock©ncdenr.gov
5. Contact Person (if different than Applicant): Matthew James
Telephone: [phone]
Contact Person's Mailing Address: WithersRavenel, 115 MacKenan Drive, Cary, NC 27511
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Lois King Telephone:
Property Owner's Mailing Address: 125 Gillwalt Way, Mount Airy, NC
Property Owner's Email Address (if available):
Property Physical Address (Including PIN Number) 1714 Main St (Surry County Parcel # 593906295248)
7.
8.
9.
10.
336-786-2882
City Bannertown County Surry Zip Code 27030
Reason for Well(s): Groundwater Monitoring
(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: State Lead UST Cleanup Site (TF#6538)
(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).
Unknown
11. Type of contaminants being monitored or recovered: Petroleum Hydrocarbons
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes: 1 well
Existing Monitoring or Recovery Well Construction Permit No(s).: None
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): +/-25
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: Quantex, Inc.
Well Contractor Address: PO Box 1388, Wendell, NC 27591
Certification No.: 3106-A
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.
b.
c.
d.
Borehole and well diameter
Estimated well depth
Screen intervals
Sand/gravel pack intervals
e.
f.
9.
Type of casing material and thickness
Grout horizons
Well head completion details
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Locking well cap and a
material: 1 flush -mount manhole set in concrete
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 05/20/2021
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 05/20/2021
(add answers from 2 and 3)
1.
ADDITIONAL INFORMATION
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,
Subchapter 2C) and accepts full responsibility for compliance with these rules
NCDEQ-DWQ for TF Site #5608
Signature of Applicant or *Agent
On Behalf of
Matthew James, Project Manager, WithersRavenel, Inc.
Printed name of Applicant or *Agent
Title of Applicant or *Agent
* If signing as Agent, attach authorization 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 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 Access Agreement
Signature of Property Owner (if different than Applicant)
Lois King
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
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [phone]
Fax: [phone]
Fayetteville Regional Office
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: (252
Rev. 3-1-2016
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
$14:3411111
-",
9800
ram 17
AMMO 4171111 * "I
Aft

Environmental
Quality
North Carolina Department of Environmental Quality
Division of Waste Management
Roy Cooper
Governor
Ms. Linda Blalock, Incident Manager
NCDEQ-DWM, UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Ms. Blalock:
Re: NCDEQ Access Agreement
Surry County Parcel # 593906295248
1714 Main Street
Bannertown, Surry County, North Carolina
NCDEQ Incident: Hawk's Rental Property
NCDEQ Incident #: 5608
WR Project #: 02171214.91
Michael S. Reagan
Secretary
am/We are the owner(s) of the parcels of property listed above, located at or near the incident in
question, and hereby permit the NC Department of Environmental Quality (NCDEQ), or its contractor, to enter
upon said property for the purposes of conducting an investigation of the groundwaters under the authority of
G.S. 143-215.3(a)2.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.

Roy Cooper
Governor
Environmental
Quality
North Carolina Department of Environmental Quality
Division of Waste Management
Michael S. Reagan
Secretary
Site Access Agreement Page 2 of 2
NCDEQ Access Agreement
Surry County Parcel # 593906295248
1714 Main Street
Bannertown, Surry County, North Carolina
NCDEQ Incident: Hawk's Rental Property
NCDEQ Incident #: 5608
WR Project #: 02171214.91
6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental. The
Department or its contractor is not and shall not be construed to be an agent, employee, or contractor of
the landowner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its contractor's
well(s) and equipment during the investigation.
Attest:
f
Signatu
Type/Print Name(s) ofOwner/Agent
352v7f'-APR
Phone Number
125 Gillwalt Way
Owner(s) Mailing Address
Mount Airy, NC 27030-5460
City, State, Zip Code
Date

TYPE II WELL CONSTRUCTION
(TYPICAL)
LOCKING WELL CAP
FLUSH MOUNT
BOLT DOWN COVER
GRASS SURFACE
II II
4
8" DIA. STEEL SKIRT
I—
1 1
;IIII-IIIII��
_I -I -I I- 1',
1-I-I-.
1111 I}
TOP BENTONITE
TOP SAND 14'
TOP SCREEN 15'
III III III
I1 II 1-
NATIVE II
ILS =
II II IIOIII II
1 1 III 1 I III 1 I 11
NEAT CEMENT GROUT
I
2—INCH DIAMETER PVC CASING
PELLETIZED BENTONITE
(2' MIN.)
LEAN FILTER "TORPEDO" SAND
2—INCH DIAMETER PVC SCREEN
(0.01' SLOT)
PVC BOTTOM CAP
DIAMETER OF BORING VARIES
WithersRavenel
Engineers 1 Planners I Surveyors
Hawks Rental Property
1712 Main Street
Bannertown, Surry County, NC
DRAWN BY:
AP
SCALE:
NONE
FIGURE NO.:
2
APPROVED BY:
DATE:
PROJECT NO.:
15 MacKenan Drive 1 Cary, NC 275111 t: 919.469.33401 license N: C-0832 I
www.withersravenel.com
TYPICAL WELL SECTION
MJ
04/10/2021
02171214.91
K:\17\17-1210\171214.76—NCOEO — Brea %oak Shoe \EnNro\C0D\7Po638 MW Permit 02-2021.dro— F.bruanr 10. 2021 — POTE. AUSIN

WILL REQUIRE
ACCESS AGREEMENT
LEGEND
TYPE II MONITORING WELL LOCATION
NOTES:
1.) AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT.
•
GRAPHIC S
0 20 40
1 inch 40 ft.
WithersRavenel
I/ Engineers I Planners I Surveyors
HAWKS RENTAL PROPERTY
1710 S. MAIN STREET
BANNERTOWN, SURRY COUNTY, NC
PROPOSED MONITORING
WELL MAP
DRAWN BY:
MJ
SCALE:
1"=40 '
FIGURE NO.:
5
APPROVED BY:
DATE:
PROJECT NO.:
115 MacKenan Drivel Cary, NC 27511 I t: 919.469.33401 license #: C-0832 I
MJ
03/31/21
02171214.91
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