WM0401335_Monitoring Well Permit Application_20211217

peedway
December 16, 2021
Certified Mail
Return Receipt Requested
Mr. Jim Gonsiewski
North Carolina Department of Environmental Quality
Division of Water Resources
Water Quality Regional Operations Section
Via Email @ [e-mail]
Subject: Monitoring Well Permit Application
Speedway 6952
2201 N. Main Street
High Point, Guilford County, North Carolina
Incident No. 47271
Mid -Atlantic Job No. R1200.C4
Dear Mr. Gonsiewski:
Speedway LLC
Speedway Office
P.O. Box 1500
Springfield, OH 45501
Telephone [phone]
Speedway LLC is pleased to submit this Monitoring Well Construction Permit application
associated with groundwater assessment associated with the Speedway 6952 facility located at
2201 N. Main Street in High Point, North Carolina. We propose to install one monitoring well at
2206 N. Main St., which is the property across N. Main St. and owned by Sharon W. Bullard and
Terry Workman. If you have any questions, please feel free to contact me at [phone] or
Trey Marchant with Mid -Atlantic Associates, Inc. at [phone].
Sincerely,
SPEEDWAY LLC
/vii".#(.6-
Charles A. Chiara
Environmental Representative
Attachment: Application for Permit to Construct a Monitoring or Recovery Well System
An Equal Opportunity Employer

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: December 16, 2021
2. County: Guilford
3.
4. Applicant: Speedway LLC
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 500 Speedway Drive, Enon, OH 45323
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Trey Marchant Telephone: [phone]
Contact Person's Mailing Address: 409 Rogers View Ct, Raleigh, NC 27610
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Sharon W. Bullard Telephone: [phone] or 910-619-2307
Property Owner's Mailing Address: 7801 Baltusrol Lane, Charlotte, NC 28210-4900
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number)
City High Point
2206 N. Main Street (PIN: 6891-74-2740)
County Guilford
Zip Code 27262
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).
Speedway 6952, 2201 N. Main Street, High Point, NC 27262, Incident No. 47271
11. Type of contaminants being monitored or recovered: Organics (gasoline)
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 4 current
Existing Monitoring or Recovery Well Construction Permit No(s).: Guilford Count only, # 2021-04-29-MW4-RWO
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 130 ft to Speedway release
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: Parratt-Wolff, Inc. Certification No.: NC 3371-A
Well Contractor Address: 501 Millstone Drive, Hillsborough, NC 27278
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 O. 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
5. How will the well(s) be secured? Flush mounted,
bolt -down lid manhole, locking cap and lock
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 2/15/21
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 2/15/21
(add answers from 2 and 3)
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
Environmental Representative
Signature of Applicant or *Agent Title of Applicant or *Agent
Charles A. Chiara, Speedway LLC "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 Access and License Agreement See attached Access and License Agreement
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
6-9800
797
41SZC, .4e4
ngton
GW-22MR Rev. 3-1-2016

GROUT
BENTONITE
GRANULAR BACKFLL
FLUSH MOUNT
WELL PROTECTOR
LOCKABLE CAP
DEPTH TO TOP OF •.
BENTONITE SEAL
DEPTH TO TOP OF
GRANULAR MATERIAL
RISER "-"1`�
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SCREEN
CAP
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LENGTH OF
SOLID SECTION
THREADED C9UPL1NG
LENGTH OF
SLOTTED SECTION
T
LAND SURFACE
TOTAL DEPTH OF
WELL FROM TOC
1Uid Atlantic
Engineering & Environmental Soluticns
DRAWN
BY:
DATE:
DRAFT
CHECK:
JOB NO:
ENG
CHECK:
CAD NO:
REFERENCE:
APPROVAL:
DWG NO:

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REFERENCES:
1. HIGH POINT WEST, NC DIGITAL RASTER GRAPHIC FILE, USGS. SCANNED FROM
1:24,000-SCALE TOPOGRAPHIC MAP: HIGH POINT WEST, NC, 2013, USGS.
2. INSET MAP DIGITAL DATA FROM 2002 NATIONAL TRANSPORTATION ATLAS,
BUREAU OF TRANSPORTATION STATISTICS, WASHINGTON, D.C.
SCALE: 1:12,000
0
Feet
1,000 2,000
Mid Atlantic
Engineering & Environmental Solutions
TOPOGRAPHIC SITE MAP
SPEEDWAY #6952
2201 NORTH MAIN STREET
HIGH POINT, NORTH CAROLINA
DRAWN
BY:
DATE:
JUNE 2021
DRAFT
CHECK:
JOB NO:
000R1200.C3
ENG.
CHECK:
GIS NO:
04G-R1200.11-1
APPROVAL: RSM
DWG NO: 1

W Parris,Ave
110
.11
Legend
SUBJECT SITE
PARCEL BOUNDARIES
NOTE: UST SYSTEM AND CANOPY
HAVE BEEN REMOVED
SPEEDWAY 6952
(2201 N MAIN ST)
Scott Ave
Mk
111
E Parris Ave
11.44
I -
NCCGIA, NO911 Board
REFERENCES:
1. AERIAL IMAGERY FROM NC ONEMAPS
2. GUILFORD COUNTY GIS
3. MID -ATLANTIC FIELD NOTES
SCALE:1:1,200
0 50 100 200
Feet
SEngineering & Environmental Solutions
Mid Atlantic
SITE LOCATION MAP
SPEEDWAY #6952
2201 NORTH MAIN STREET
HIGH POINT, NORTH CAROLINA
DRAWN
BY: KRC
DATE:
JUNE 2021
DRAFT
CHECK: RSM
JOB NO:
000R1 200.C3
ENG.
CHECK:
GIS NO:
03G-R1200.C3-2
APPROVAL RSM
DWG NO: 2

4
(2, ,200)
5;000
(42.4) , WO
SPEEDWAY 6952
tql
4
Legend
9 MONITORING WELL
BENZENE ISOCONCENTRATION
LINE (DASHED WHERE INFERRED)
SUBJECT SITE
(42.4) BENZENE CONCENTRATION (ug/L)
Scott Ave
(26;400
(7.30)
NIA
Board
REFERENCES:
1. AERIAL IMAGERY FROM NC ONEMAPS
2. GUILFORD COUNTY GIS
3. MID -ATLANTIC FIELD NOTES
SCALE:1:360
0 15 30 60
Feet
SEngineering & Environmental Solutions
Mid Atlantic
ESTIMATED BENZENE
ISOCONCENTRATION MAP
(MAY 11, 2021)
SPEEDWAY #6952
2201 NORTH MAIN STREET
HIGH POINT, NORTH CAROLINA
DRAWN
BY: KRC
DATE:
JUNE 2021
DRAFT
CHECK: RSM
JOB NO:
000R1200.C3
ENG.
CHECK:
GIS NO:
03G-R1200.C3-5
APPROVAL: RSM
DWG NO: 4

W Parris,Ave
110
.11
Legend
SUBJECT SITE
PARCEL BOUNDARIES
NOTE: UST SYSTEM AND CANOPY
HAVE BEEN REMOVED
SPEEDWAY 6952
(2201 N MAIN ST)
Scott Ave
Mk
111
E Parris Ave
11.44
I -
NCCGIA, NO911 Board
REFERENCES:
1. AERIAL IMAGERY FROM NC ONEMAPS
2. GUILFORD COUNTY GIS
3. MID -ATLANTIC FIELD NOTES
SCALE:1:1,200
0 50 100 200
Feet
SEngineering & Environmental Solutions
Mid Atlantic
SITE LOCATION MAP
SPEEDWAY #6952
2201 NORTH MAIN STREET
HIGH POINT, NORTH CAROLINA
DRAWN
BY: KRC
DATE:
JUNE 2021
DRAFT
CHECK: RSM
JOB NO:
000R1 200.C3
ENG.
CHECK:
GIS NO:
03G-R1200.C3-2
APPROVAL RSM
DWG NO: 2

500 ft radius map
Write a description for your map.
Parris Aye
hipot e
tStarbue s
ript
21 ritAA"'"I
Legend
2201 N Main St
Claddagh Restaurant & Pub E
Feature 1
Feature 2
Starbucks
The Home Depot
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//
,�� A/ I ,',
/ = Cla da9 h„Re_ staurant
s

Speedway
OFF SITE ACCESS AGREEMENT
INITIAL REQUEST
November 24, 2021
Certified Mail
Return Receipt Requested
Ms. Sharon W. Bullard
Mr. Terry Workman
7801 Baltusrol Lane
Charlotte, NC 28210-4900
RE: Right of Entry Request
2206 N. Main St.
High Point, NC
Parcel Tax ID No.
Near Speedway Store #6952, High Point, NC
Dear Mr. Workman:
Speedway LLC
Speedway Office
P.O. Box 1500
Springfield, OH 45501
Telephone [phone]
Speedway LLC (Speedway) understands that you are the owner of the property referenced above, which is
located in the vicinity of a certain Speedway property (Speedway #6952) located at 2201 N. Main Street in High
Point, North Carolina.
Speedway is conducting an investigation of subsurface environmental conditions in the vicinity of our property
(Speedway #6952) at the direction of the North Carolina Department of Environmental Quality. This
investigation requires us to move off our property to fully evaluate any petroleum -related impacts of the soil and
ground water.
As part of this investigation, Speedway requests your permission to install one (1) monitoring well on your
property near the location shown on the enclosed map. We will be entering onto your property periodically
thereafter to take samples from this monitoring well. We will be asking our consultant to do this work on our
behalf.
In performing this work, Speedway will take all reasonable measures to avoid damage to your property and/or
unreasonable interference with the present use of your property. Speedway will defend, indemnify and hold you
harmless from and against any loss, cost, damage or expense arising out of our work on your property. Upon
completion of its investigation, Speedway will close all wells in accordance with state regulations, remove all
equipment and restore your property to as near to its original condition (immediately prior to commencement of
the work) as reasonably possible.
An Equal Opportunity Employer

Whether you consent to or refuse this request for access, please check the appropriate box, sign at the
space provided below, return one original copy of this letter to me by December 10, 2021 and keep the
second copy for your records. A self-addressed envelope is provided for your convenience. If you check the
appropriate box and sign, your signature will serve to grant Speedway (including its employees and agents)
permission to enter unto your property for the purpose of performing the work described above. You may
revoke this permission at any time by giving Speedway at least sixty (60) days written notice of your intent to
revoke.
If you have any questions about the terms of this letter, or would like further information about Speedway's
proposed work, please do not hesitate to contact me at the above letterhead address or at [phone] or Trey
Marchant with Mid -Atlantic Associates, Inc. at 919-250-9918.
cc:
Sincerely,
SPEEDWAY LLC
Chuck Chiara
Environmental Representative
Trey Marchant - Mid -Atlantic Associates, Inc.
I-7 I have read the preceding letter and represent and warrant that I have full authority to enter into
this Access Agreement and to make it binding on any entity having a valid claim of an interest
in my property. I hereby grant Speedway LLC permission to enter onto my property under the
terms described above.
Print Name:
Signature:
Date:
Email Address
I have read the preceding letter and hereby do not grant Speedway LLC permission to enter
onto my property
under the terms described above.
C.51hadron VV . i3tiJkrgi
ArA4)1-kde,e,f,tiaite,
/ ( 30, 02e
Attachment: Proposed Monitoring Well Location
An Equal Opportunity Employer