WM0401324_Monitoring Well Permit Application_20211028

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: 10/25/2021
2. County: Alamance
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: City of Mebane
Telephone: [phone]
Applicant's Mailing Address: 106 East Washington Street, Mebane NC 27302
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Kyle Smith
Telephone: [phone]
Contact Person's Mailing Address: 636 Corregidor Street, Mebane, NC 27302
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): City of Mebane
Telephone: [phone]
Property Owner's Mailing Address: 106 East Washington Street, Mebane NC 27302
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) Center Street (9825045285)
City Mebane
County Alamance
Zip Code 27302
8. Reason for Well(s): UST related 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).
30451
11. Type of contaminants being monitored or recovered: Petroleum -related
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Currently 10
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —100 ft.
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? NO
If yes, give distance(s): N/A
15. Well Contractor: 3D Environmental Investigations, LLC Certification No.: 3162A
Well Contractor Address: 2157 Mocksville Highway, Statesville, NC 28625
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)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured?
material: 1 (MW-11) Lockable Metal Cover
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
6. Estimated beginning construction date: 11/23/21
7. Estimated construction completion date: 11/23/21
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
Agent
Signature of Applicant or *Agent Title of Applicant or *Agent
Jason Ricks - Agent * 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).
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
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: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

1
i
LEGEND
Site Boundary
Proposed Monitoring Well Location
Drawing 1
Google Earth
Interactive Mapping Software
Scale : 1"= 30'
{: :JI .:
P11.01% .
• F I L ti 1 S L J 4 k 1 L h L
Proposed Monitoring Well Location
Map
120 West Center Street
Mebane, Alamance County, NC
Pilot Project G-6376.1

PROPOSED MONITORING WELL CONSTRUCTION DIAGRAM
Project
Owner
Well No.
Location
MD Coordinators
State Permit No.
Topography Setting
Ground Elevation
By
Drilling Started
Drilling Completed
Method of Drilling
Type of Rig
Former Crawford Service
Mebane, NC
Lockable steel cover
set in concrete
MW-10 and MW-11
120 W. Center St.
I I
II
Pending
II
/Drilled
II
%
II
I I
/ 1
I p
I I
4 inch diameter
drilled hole
Well casing,
2 inch diameter,
Grout to surface
1 ft Top of bentonite
3D
11/23/2021
11/23/2021
Augers
Augers
MONITORING
Well No.
Hole Diameter
Hole Depth
Casing Diameter
Casing Length
Screen Diameter
Screen Slot
Screen Type
Surface Elevation
Screen Top El.
Screen Bottom El.
Well Status
WELL DATA
Bentonite
3 ft Top of sand
MW-10 and MW-11
4 inches
15 ft.
5 ft
2 inch
5 ft.
2 inch
0.01
slot
Well Screen,
1 inch diamter
0.01 slot
Sand Pack
15 ft.
No Data
No Data
No Data
Active
REMARKS
15 ft.
All Measuring Points are from the Top of
Casing Unless Otherwise Noted.
Well log.xls

CITY OF MEBANE ROUTING FORM
Vendor/Contractor Name: Pilot Geological, PLLC 0
Vendor #
DocumentName/Title: Right of Access Agreement
Bid # (If applicable)
Department: Utilities
Return To: Kyle Smith
Contact Person: Kyle Smith
Department: Utilities
Phone Number: 919-563-3401
Date Received
Signature
Insurance & Risk Management (Required)
*Insurance Certificates must be attached
131 1
Department Head (Review & Approve)
4/30/2021 ..
Finance Officer (Per Budget Act)
S- ti _ 2 ‘
�+
Legal Review
�yl '' // -L
City Manager (If Required) 61)19
2
iCityClerk(Attest,Date and Notarize)/
y�M l ► ifZj
i0Y �
Deadline for Signing:
G/L Account Number(s):
N/A
Contract DollarAmount(s):
N/A
Special Distribution Instructions
Chris to sign Right -of -Access Agreement
Notes/Explanation
Provide access to Police Department property to
install monitoring well as required by the State.
Vendor MailingAddress/Telephone
Pilot Geological, PLLC
PO Box 128
Kernersville, NC 27285
336-310-4527
Form Revised 09/2014
Please do not remove form if revisions to document are necessary

(
PILOT G E O L O G I C A L, P L L C
April 29, 2021
City of Mebane
106 East Washington Street
Mebane, North Carolina 27302
Reference: Right -of -Access Agreement
Former Crawford Service Center - B
102 West Center Street
Mebane, Alamance County, North Carolina
Pilot Project G-6376.1
NCDEQ Incident No. 30451
To Whom it May Concern:
Pilot Geological, PLLC (Pilot) requests your permission to install monitoring well (MW-8, Drawing
1) on your property (Center Street, Adjacent and east of 102 West Center Street) in association
with the former underground storage tank (UST) systems that were located at 102 West Center
Street in Mebane, North Carolina (adjoining property to the west). The North Carolina
Department of Environmental Quality (NCDEQ), UST Section has required that the monitoring
well be installed due to a release of petroleum from the former underground storage tank (UST)
systems. The UST systems were previously removed by others. The two-inch diameter
monitoring well will be installed flush with the ground surface and covered with a secured steel
cover set in an approximate 2' by 2' concrete pad. A drill rig and associated equipment will be
utilized to install the monitoring well. Pilot and its subcontractor will repair damages as best as
feasibly possible. Periodic access for sampling and other activities will be required. Please
provide the requested information below to grant Pilot permission to install and sample the
monitoring well. In the future Pilot will attempt to contact you via phone or email prior to
accessing your property. We currently are planning on installing the monitoring wells in June of
2021.
Name: _CMC.:s 2.owinIS
Signature:
Phone #: (q let) S6,3-Slot
Date: .)l 1 `9 1(2
Email: cgo(L/JS C"e1-ni bir massui,Gook
PO Box 128, Kernersville, NC 27285
www.pilotenviro.com

Former Crawford Service Center - B
April 29, 2021
If you have questions regarding this agreement, please contact Pilot at [phone].
Sincerely,
Pilot Geological, PLLC
Jason T. Ricks
Principal Geologist
Attachment: Drawing 1

I
LEGEND
Site Boundary
Approximate Proposed Monitoring Well Location
Drawing 1
Google Earth
Interactive Mapping Software
Scale : 1"= 20'
Proposed Monitoring Well Location
Map
102 West Center Street
Mebane, Alamance County, NC
Pilot Project G-6376.1