WM0401364_Monitoring Well Permit Application_20220505

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: 5/3/22
2. County: Davidson
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Geological Resources, Inc. Telephone: [phone]
Applicant's Mailing Address: 3502 Hayes Road, Monroe NC 28110
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Rae Troiano Brown Telephone: [phone]
Contact Person's Mailing Address: 3502 Hayes Road, Monroe NC 28110
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): NC DOT Telephone: [phone]
Property Owner's Mailing Address: 1555 Mail Service Center, Raleigh, NC
Property Owner's Email Address (if available): NA
7. Property Physical Address (Including PIN Number) 1-85 Bus and SR 1797
City Thomasville
County Davidson
Zip Code NA
8. Reason for Well(s): assessment ground water 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: petroleum retail facility
(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).
No
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? 23
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401081 and WM0401292 (attached)
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 20'
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: Geological Resources, Inc. Certification No.: 3270A
Well Contractor Address: 3502 Haves 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
material: 3
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 3
(add answers from 2 and 3)
5. How will the well(s) be secured?
Bolted manhole cover with locking well cap
6. Estimated beginning construction date: Mav 2022
7. Estimated construction completion date: May 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. 143-215.106(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
So ;tots cl v'k d
Project Manager, P.G.
i nature of Applicant or *Agent Title of Applicant or *Agent
Rae Troiano Brown * 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 DOT NCDOT ROW
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]
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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

STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
ROY COOPER
GOVERNOR
J. ERIC BOYETTE
SECRETARY
April 18, 2022
COUNTY: Davidson
SUBJECT: Encroachment Contract E091-029-22-00037 — Geological Resources, Inc.
Carrie Kennedy
Secretary/Treasurer
Geological Resources, Inc.
3502 Hayes Road
Monroe, NC 28110
Dear Carrie Kennedy:
Attached for your files is a copy of the above -referenced Right of Way Encroachment Contract,
properly executed. This contract covers the following:
Installation of three (3) Type II monitoring wells along I-85 Bus and SR 1797 (Evans Rd) in/near
Thomasville.
APPROVED SUBJECT TO: Attached Special Provisions and subject to the attached memo and
any additional special provisions dated February 17, 2022, from Kelly Seitz, PE, District
Engineer.
Sincerely,
Byron Sanders, Jr., PE, CPM
State Utilities Manager
Docusipned by:
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Larry D. Sanders, MGIST, PE, CPM
State Encroachments Engineer
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Attachment
Mailing Address: TELEPHONE: [phone] Location:
NC DEPARTMENT OF TRANSPORTATION FAX: [phone] CENTURY CENTER COMPLEX
UTILITIES UNIT CUSTOMER SERVICE: 1-877-368-4968 ENTRANCE A-1
1555 MAIL SERVICE CENTER 1000 BIRCH RIDGE DRIVE
RALEIGH NC 27699-1555 WEBSITE: NCDOT.GOV RALEIGH NC 27610

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TYPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PAD
Gf'OUND SURFACE
GROUT CEM£Nr
BENTONITE SEAL
SAND FIL T "R PACK
45' bgs
a 4
26' bgs
28' bgs
30' bgs
MANHOLE COI2
L OCK/NG MIL CAP
2 /NCH DIAMETER
SCHEDULE 40 PVC CASING
0 010 INCH SLOTTED
2 /NCH DIAMETER
SCHEDULE .40 PVC SCREEN
END CAP

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