WM0100504_Monitoring Well Construction Application_20220218

FOR OFFICE USE ONLY 
PERMIT NO.    ISSUED DATE  
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: 2-18-22
2.County: Jackson
3.What type of well are you applying for? (monitoring or recovery): Monitoring
4.Applicant: NCDEQ – DWM – UST Section Telephone: [phone]
Applicant’s Mailing Address: 217 West Jones St, Raleigh, NC 27603
Applicant’s Email Address (if available): [e-mail]
5.Contact Person (if different than Applicant): Matthew James Telephone: [phone]
Contact Person’s Mailing Address: 115 MacKenan Dr., Cary, NC 27511
Contact Person’s Email Address (if available): [e-mail]
6.Property Owner (if different than Applicant): DT Ventures III, LLC Telephone: [phone]
Property Owner’s Mailing Address: 334A E. Main St #14 Sylva, NC 28779
Property Owner’s Email Address (if available): [e-mail]
7.Property Physical Address (Including PIN Number)29 Toad Road – 7559-46-1864
City: Cullowhee County Jackson Zip Code28723
8.Reason for Well(s): assessment, groundwater contamination
(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: Mobile Home Park
(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).
Yes Incident # 7280
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? Three
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 to 50 ft
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: M&W Drilling Certification No.: 02173214
Well Contractor Address: PO Box 7024 Knoxville, TN
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
WM0100504 02/23/2022

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? Locking well cap
and bolt down cover

6. Estimated beginning construction date: March 3

7. Estimated construction completion date: March 4

ADDITIONAL INFORMATION

1. 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
Project Manger
Signature of Applicant or *Agent Title of Applicant or *Agent

Matthew James * 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 Access Agreement See Access 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
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016
GW-22M (Rev. 5/11)
■ WithersRavenet
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VIA CERTIFIED MAIL - RETURN RECIEPT REQUESTED
December 2, 2021
DT Ventures III, LLC
PO Box 2406
Cullowhee, Jackson County, North Carolina
Re: NCDEQ Access Agreement for Jackson County Parcel # 7559-46-1864
29 Toad Road
Cullowhee, Jackson County, NC
Former Roadrunner Market
3000 Old Cullowhee Rd
Cullowhee, Jackson County, NC
NCDEQ Incident # 7280
WR Project # 02172214.37
To whom it may concern,
WithersRavenel [WR] is under contract with the North Carolina Department of Environmental Quality
(NCDEQ), Underground Storage Tank (UST) Section, Federal Trust Fund (FTF) Branch for the assessment of
leaking underground storage tanks (LUSTs). NCDEQ has tasked WR with completing assessment and
monitoring activities at the Former Roadrunner Market site, located at 3000 Old Cullowhee Road in
Cullowhee, Jackson County, NC. The assessment process for this site will include assessing properties
adjacent to the site. According to Jackson County GIS data, you are the owner of the subject property as
well as two adjacent parcels.
As the current property owners, we are seeking your permission to access your property at 29 Toad Road,
Cullowhee, Jackson County, NC to install additional groundwater monitoring wells to better understand the
current groundwater quality. Any and all fees for this monitoring and assessment are the responsibility of
NCDEQ and you will incur no charges of any kind for this work. 1 have included an access agreement for
your consideration, and I request that you complete and return the agreement in the enclosed, pre -
addressed, and stamped envelope. I have also included a copy of the agreement for your records.
We appreciate your consideration in this matter. Should you have questions, comments, or require additional
information, please feel free to contact me at your earliest opportunity. I can be reached at 919-469-3340
(direct), or via email: [e-mail]. Alternatively, the NCDEQ Incident Manager for the site
(Mrs. Sharon Ghiold) can be reached via phone at 919-707-8166 or email: [e-mail].
Cordially,
WithersRavenei
„4Ji941444„,,2____
Matthew James, PG
Project Manager
/ attachments
115 MacKenan Drive I Cary, NC 27511
t, 919 469.334G ! f: 919.467.6008 I www.withersravenel.corn I License No. C-08.32
Asheville 1 Cary1 Greensboro Pittsboro } Raleigh I Wilmington

Environmental
Quality
North Carolina Department of Environmental Quality
Division of Waste Management
Roy Cooper
Governor
Ms. Sharon Ghiold, Incident Manager
NCDEQ-DWM, UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
Dear Ms. Ghiold:
Re: NCDEQ Access Agreement for Jackson County Parcel # 7559-46-1864
29 Toad Road
Cullowhee, Jackson County, NC
Former Roadrunner Market
3000 Old Cullowhee Rd
Cullowhee, Jackson County, NC
NCDEQ Incident # 7280
WR Project # 02172214.37
Michael S. Reagan
Secretary
I am/We are the owner(s) of the parcel 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
NC;
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 for Jackson County Parcel # 7559-46-1864
29 Toad Road
Cullowhee, Jackson County, NC
Former Roadrunner Market
3000 Old Cullowhee Rd
Cullowhee, Jackson County, NC
NCDEQ Incident # 7280
WR Project # 02172214.37
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:
UFA\MIREIS
Signature
PT Ve s 111 b
Type/Print Name(s) 4f Owner/Agent
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Phone Number
33 H t.14,47.. S-'- 0,4
Owner(s) Mailing Address
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City, State, Zip Code
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LUST BASINUST'S # 2, 3, 4UST BASINUST #1FREE PRODUCTAUGUST 1996MW-4MW-5MW-6ESTIMATED EXTENTSOF LNAPLESTIMATED EXTENTSOF NC 2L EXCEEDANCESPROPOSED MWPROPOSED MWPROPOSED MW1"=40 '402080LEGENDTYPE II MONITORING WELL LOCATIONCONTAMINANT ISOCONCENTRATION CONTOURNOTES: 1.) AERIAL OBTAINED FROM THE LOCAL COUNTY GIS DEPARTMENT.MJMJDRAWN BY:05/28/2102172214.377SCALE:FIGURE NO.:PROJECT NO.:DATE:APPROVED BY:PROPOSED MONITORING WELLMAPAPRIL 2021WithersRavenelEngineers | Planners | Surveyors115 MacKenan Drive | Cary, NC 27511 | t: 919.469.3340 | license #: C-0832 |www.withersravenel.comROADRUNNER MARKET3000 CULLOWHEE ROADCULLOWHEE, JACKSON COUNTY, NC
,di
TYPE II WELL CONSTRUCTION
(TYPICAL OF THREE)
LOCKING WELL CAP
ASPHALT SURFACE
" DIA. STEEL SKIRT
-11 I I1
TOP BENTONITE
TOP SAND
TOP SCREEN
BOTTOM SCREEN
FLUSH MOUNT
BOLT DOWN COVER
111 IIII III I Ir
1—I 1I
-1 - 1 1 1I NATIVE 11
SOILS
1 I—III-
11 � 1—11 I-
1 1 11 —11 1
11 —III 1' 1
- 111� �
111
.I=%NEAT CEMENT GROUT
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
a• W i t h e rs Rave n e l
/CULLOWHEE,
Our People. Your Success.
FORMER ROADRUNNER MARKET — INCIDENT # 7280
3000 CULLOWHEE RD
JACKSON COUNTY, NC
DRAWN BY:
MJ
SCALE:
NTS
FIGURE NO.
1
APPROVED BY:
MJ
DATE:
02/18/22
JOB NO:
02172214.37
PROPOSED MONITORING WELL DIAGRAM