WM0701261_Application_20211103

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION:OF WATER QUALITY — AQUIFER PROTECTION SECTION. RECEIVED/NCDENR/DWR
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY OCT 2 O 2021
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. Water 01 Wky
FOR OFFICE USE ONLY.,: Regional Operations Sectio
1. Date: October 15, 2021 Washington Regional Offic
2. County: Gates PERMIT IVO. ' " r ( ( ISSUED;DATE_if
3. What type of well are you applying for? (monitoring or recovery):
i
4. Applicant: Jiyan, LLC
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 2025 Indian Point Road, Suffolk, VA 23434
Applicant's Email Address (if available): NA
5. Contact Person (if different than Applicant): William Regenthal Telephone: [phone]
Contact Person's Mailing Address: 113 West Firetower Road, Suite G, Winterville, NC 28590
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): DEVANSH, LLC Telephone:
3 US Highway 158 W, Gatesville, NC 27938-9438
Property Owner's Mailing Addrese:
Property Owner's Email Address (if available): NA
7. Property Physical Address (including zip code) and PIN Number3 US Highway 158 W; 10-03467
8. Reason for Well(s): 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).
UST Incident 38790
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? Yes; 6
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0701240; WM0701556
r
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0�
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes, 3
If yes, give distance(s): WSW-2 - 150': WSW-3 - 350': WSW-4 - 370'
15. Well Contractor: Justin Radford Certification No.: 3270
Well Contractor Address: 3502 Hayes Road, Monroe, NC 28110
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
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Oct 2021
4 Total Number of wells to be constructed: 1 7. Estimated construction completion date: Oct 2021
(add answers from 2 and 3)
Locking cap
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 Per it as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
ubchapter 2C) and accepts full responsibility for compliance with these rules
Project Manager
nature of AppFrfor *Agent Title of Applicant or *Agent
William Regenthal, P. G.
* 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 RTE
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 Quality's Aquifer Protection Section 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
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
Fax: [phone]
GW-22MR (Rev. 7/11)

.,"
° RIGHT TO ENTER'AGREEmENT
FOR
CIDNDOCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA -
COUNTY OF GATES
r 4
We, thitindersigried,, being all"Orttle:fee sirrPle'ownersof certain traits,eirrcfiti -designatedas 10-
01467 of the County of qAT:Esi,,,i4ogniiing the benefits to said ' proper* by", reason of...conducting
subsurfaceinvestigations'herebygrant to,J1Van, LIC, Incorporated and the agents the right to enter said
property in accordance with,the requirements of -the State of North 'Caroline, liyan,Ild's agents may
Include Geological Resourcesitnc.
The undeisigned hereby covenant and warrant that they are the sole owners'of. said property; that they
sole* ,have the right to gratitthis 'right to ,enter for conducting subsurface investigations against the
laWrful claims of all persons whornsedver.
„ .
it is agreed that Jiyan,, LIC,shaille responsible for' restoring any damageidoneto the ground of said
,,
property by its employeeS'Or hi'agents during the subsurface Investigatiand Monitoring period, and
thetliyin,,,t1C, IncorporpOil,iii0 abandon monitoring wells on said property Maccordance With NCOEQ
requirements at the concliiit'Oti of the monitoring,perlod:
W:' It is agreed that Jiyan,'1.1C, Incorporated shall hold.harmless the oWner4f;the aforementioned property
for any personal injury ttMt"rhight be sustained during the course Of conducting or proxiinatetiresultIng
from ttie Conduct of subSurfaei inveStigatIons. , .
Right to Enter denied.
Right to Eriter granted:
..........
SigriatUre
phone
Date
(RTEGateS Food Mart)
°

RECEIVED/NCDENR/DWR
OCT 2 0 2021
Water Quality
Regional Operations Section
Washington Regional Office
Geological Resources, Inc.
October 14, 2021
Mr. David May
NCDEQ, Division of Water Quality
Washington Regional Office
943 Washington Square Mall
Washington, North Carolina 27889
Re: Monitoring Well Permit Application
Gates Food Mart
3 US Highway 158
Gatesville, Gates County
Incident No: 38790
Dear Mr. May:
Please find enclosed a monitoring well permit application for the installation of f one Type II monitoring
well at the Gates Food Mart facility located at 3 US Highway 158 in Gatesville, Gates County. GRI plans
on installing the monitoring wells immediately upon receipt of the approved well permit.
Your prompt attention to this matter will be greatly appreciated. If you have any questions or require
additional information please do not hesitate to contact me at [phone].
Sincerely,
William Regenthal, P. G.
Project Manager
enclosures
cc: file
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G• Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]

concrete pad
ground surface
0-3
grout cement
bentonite seal
sand Inter peek
3-4
4-15
.11 •
Type 1ll Monitoring Well
Typic 1 Construction Details .
•
�.- manhole cover
.5-15
r.
• 5-15
�•
• 15
looking well cap
2 Inoh diameter
schedule d0 PVC caning
•
0.01.0 Inch slotted 2$noh diameter
schedule 40 PVC rorean
•
• !
end Gap

250-FOOT RADIUS
t
1,500-FOOT RADIUS
LEGEND
O Water Supply Well
•• ncrivers
Roads
Well Owners and Adjacent Properties
. .411k
Gates County NC Parcels
ss,as1003000
s^a:osws000 / M A -
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,�• � I �nst - -
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SITE
6978601533sw3
6970603
41111,
500-FOOT RADIUS
)161
,000-FOOT RADIUS
150 300
® Feet
1 inch = 300 feet
FIGURE 2: SITE VICINITY MAP
GATES FOOD MART
3 US HIGHWAY 158 WEST
GATESVILLE, GATES COUNTY
NORTH CAROLINA
INCIDENT NO. 38790
GRI PROJECT NO. 5325
PREPARED BY:
GEOLOGICAL RESOURCES, INC.
JUNE 25, 2020
GO
Geolaskal Ratouna,, lno.

LEGEND
FUEL DISPENSER
TREES
- — SUBJECT PROPERTY BOUNDARY LINE
FIBER OPTIC LINE
---�—UNDERGROUND ELECTRIC LINE
— • UNDERGROUND WATER LINE
UNDERGROUND STORAGE TANK
--•••••--••••••••••-•• • PRODUCT PIPING
TYPE II MONITORING WELL
SIGN
VACUUM
Note:
1. This Site Mop is based on data from the
Gates County, NC GIS office.
2. This Site was not professionally surveyed; all
utilities, locations, and distances are
approximate.
GR
Geological Resources, /nc.
0 20 40 80
( IN FEET )
1 inch = 40 ft
500- Gallon
• Kero AST
MW-5
SITE MAP
Gates Food Mart
Incident No. 38790
GRI Project No. 5325 •
3 US Highway 158 West
Gatesville, North Carolina
Gates County
Date: 02/10/2021 I Drawn by.
DTH I Figure: 3