WM0401341_Montoring Well Permit Application_20220120

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: 1/18/2022
2. County: Ashe
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery):
4. Applicant: NCDEQ, DWM, UST Section (Herb Berger)
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Victoria Larson Telephone: [phone]
Contact Person's Mailing Address: 7606 Whitehall Executive Center Drive, Suite 200, Charlotte, NC 28273
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): David Sheets Telephone: [phone]
Property Owner's Mailing Address: 165 Foggy Ridge Road, West Jefferson, NC 28694
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number)107 Trading Post Road (12383016009) & 7385 Highway 16 South (12383016038)
City Jefferson/Glendale Springs County Ashe Zip Code 28629
8. Reason for Well(s): Groundwater assessment and remediation for State Lead
(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).
N/A
11. Type of contaminants being monitored or recovered: Volatile Organic Compounds
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 8 monitoring, 1 air sparse
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): -120 ft
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): Approximately 25 and 50 feet
15. Well Contractor: Carolina Soil Investigations Certification No.: 2579-A
Well Contractor Address: 132 Gurney Road Olin, NC 28660
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
material: 2
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
5. How will the well(s) be secured? Well vault and lock
6. Estimated beginning construction date: 1/26/2022
7. Estimated construction completion date: 1/27/2022
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
Signature of Applicant or *Agent Title of Applicant or *Agent
• 4
Victoria Larson
Printed name of Applicant or *Agent
Geologist
* 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 David Sheets
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]
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GW-22MR Rev. 3-1-2016

TYPICAL MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL CA
L1I
L
L2
v
L3
L1 = 0.3 FT.
L2 = 14.7 FT.
L3 = 15 FT.
L4 = 30 FT.
f
:/
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
CASING DIAMETER
CASING LENGTH
PAD DIMENSIONS
HEIGHT ABOVE GROUND
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
BACKFILL AROUND CASING
MATERIAL
THICKNESS
SEAL
TYPE OF SEAL
THICKNESS
FILTER PACK
TYPE OF FILTER
DISTANCE ABOVE SCREEN
WELL SCREEN
SCREEN MATERIAL
DIAMETER
LENGTH
SLOT SIZE
DEPTH TO BOTTOM OF
MONITORING WELL
DEPTH TO BOTTOM OF
BOREHOLE
DIAMETER OF BOREHOLE
Steel
8 inches
12 inches
2 feet x 2 feet
flush mounted
sch 40 PVC
2 inches
flush threaded
14.7 feet
cement grout
12 feet
bentonite
2'
#2 silica sand
2'
sch 40 PVC
2 inches
15 feet
0.010 inches
30.0 feet
30.0 feet
8.25 inches
TITLE Monitoring Well Diagram
(Example)
Moore's Exxon
7390 NC Highway 16
Glendale Springs, NC
ATC
7606 Whitehall Executive Center Drive
Charlotte, North Carolina 28273
FILE
PREP. BY
VL
REV. BY
AQ
DATE
1/18/2022
PROJECT NO.
SLC0614602

Honey Comb Lane
WSW-350
WSW-460
WS -165
WSW-248
WSW-275
WSW-11
0 150 300
WSW-120
WSW-195
WSW-7350
WSW-7385*
WSW-26*
WSW-7414
WSW-121.115
600
APPROXIMATE SCALE IN FEET
WSW-74
WSW-204
WSW-213
r—
°', WSW-285
WSW-171
WSW-193
d d�h9 A
ostR
°ad
WSW-216
WSW-156
NOTE:
= WSW-26 and WSW-7385 utilize
the same water supply well.
EXPLANATION
fa WATER SUPPLY WELL LOCATION
TITLE FIGURE 2
WATER SUPPLY WELL LOCATION MAP
MOORE'S EXXON - NCDEQ INCIDENT #6146
7390 NC HIGHWAY 16
GLENDALE SPRINGS, ASHE COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
Charlotte, North Carolina 28273 [phone] FAX [phone]
CAD FILE PREP. BY
6146 _SM LB
REV BY
CH
SCALE
"=300'
DATE
01/03/20
PROJECT NO.
SLP0614603

dry
Glendale
Springs
Inn
Restaurant
Commercial
Building
MW-11
ource: NC Geo.patial latabase
MW-13
Former
Glendale
Fire
Department
ommercial/
Building/
MW-3R
MW-10R
Residence
osed New Monitoring Wells
Residence
0
25
50
100
APPROXIMATE SCALE IN FEET
EXPLANATION
11 MONITORING WELL LOCATION
0 AIR SPARGE WELL LOCATION
TITLE FIGURE 3
SITE MAP
MOORE'S EXXON NCDEQ INCIDENT #6146
7390 NC HIGHWAY 16
GLENDALE SPRINGS, ASHE COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
CAD FILE
PREP. BY
LB
REV. BY
SS
SCALE
AS SHOWN
DATE
02/16/2021
PROJECT NO.
SLC0614601

Glendale
Springs
Inn
Restaurant
0
Commercial
Building
25
50
MW-13
NM
Fotrier
GI dale
ire
partm
100
APPROXIMATE SCALE IN FEET
MW-3R
78.97
Residence
Residence
Residence
EXPLANATION
MONITORING WELL LOCATION
AIR SPARGE WELL LOCATION
80.82 GROUNDWATER ELEVATION IN FEET
(MEASURED 01/22/2021)
NM NOT MEASURED
GROUNDWATER ELEVATION CONTOUR
(DASHED WHERE INFERRED)
-- — -IMP- GROUNDWATER FLOW DIRECTION
TITLE FIGURE 4
GROUNDWATER ELEVATION CONTOUR MAP
MOORE'S EXXON NCDEQ INCIDENT #6146
7390 NC HIGHWAY 16
GLENDALE SPRINGS, ASHE COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
CAD FILE
PREP. BY
LB
REV. BY
SS
SCALE
AS SHOWN
DATE
02/16/2021
PROJECT NO.
SLC0614601

Commercial
Building
1/22/2021
None Detected
AS-1
1/4/2021
1/22/2021
Benzene
171
0.61
Naphthalene
38.4
<0.66
Glendale
Springs
Inn
Restaurant
Former
Glendale
Fire
Department
MW-1
CO
MW-13
�V
MW-3R
Benzene
MW-10R
Residence
1/22/2021
11.4
MW-1
1/4/2021
1/22/2021
Benzene
3,080
1,840
Toluene
85,500
52,200
Ethyl benzene
5,290
3,860
Total Xylenes
30,100
24,100
Di isopropyl Ether
187 J
134 J
Naphthalene
615J
628J
Styrene
211 J
<102
1,2,4-Trimethylbenzene
3,560
3,150
0
25
50
100
APPROXIMATE SCALE IN FEET
EXPLANATION
MONITORING WELL LOCATION
AIR SPARGE WELL LOCATION
1. Only compounds exceeding 2L Standards shown (bold).
2. Concentrations in micrograms per liter (pg/L)
3. J = Estimated concentration.
TITLE FIGURE 5
GROUNDWATER QUALITY MAP
MOORE'S EXXON NCDEQ INCIDENT #6146
7390 NC HIGHWAY 16
GLENDALE SPRINGS, ASHE COUNTY, NORTH CAROLINA
ATC
ASSOCIATES OF NORTH CAROLINA, P.C.
CAD FILE
PREP. BY
LB
REV. BY
SS
SCALE
AS SHOWN
DATE
02/16/2021
PROJECT NO.
SLC0614601

Right of Entry Agreement
Moore's Exxon, Incident Number 6146
Stanly County PIN 12383016008
7390 NC Highway 16
Glendale Spring, Ashe County, 28694
December 7, 2021
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.
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Signature
Type/Print Name of Owner or Agent
331, NISI
Phone Number
air 5
Email Address
S K,Y 8&57 C© nA
165 Foggy Ridge Road
Mailing Address
West Jefferson, NC 28694
City/State/Zip Code
/2/ /7 /2° 2,1
Date