WM0401368_Monitoring Well Permit Application_20220524

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: Guilford
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
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
Applicant's Email Address (if available): rtb©geologicalresourcesinc.com
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): Safina and Kahlid Rashid Telephone: [phone]
Property Owner's Mailing Address: 1605 East Fairfield Road, High Point, NC 27263
Property Owner's Email Address (if available): [e-mail]
7. Property Physical Address (Including PIN Number) PIN 7719925598; 1605 East Fairfield Road
City High Point County Guilford Zip Code 27263
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 — Twin Roads Rex
(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).
NPDES #0162
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? 21
Existing Monitoring or Recovery Well Construction Permit No(s).: Guilford County Well Permit 116923(attached)
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): approx. 60'
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): 150'
15. Well Contractor: Geological Resources, Inc. Certification No.: 3270A
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
material: 0
3. Number of wells to be constructed in bedrock: 1
4. Total Number of wells to be constructed: 1
(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: May 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. 143-215.10B(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 Manager, P.G.
Signature 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 RTE Saphina Rashid
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

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF GUILFORD
We, the undersigned, being all of the fee simple owners of certain tracts or parcels designated as 7719-
92-5598 of the County of GUILFORD, recognizing the benefits to said property by reason of conducting
subsurface investigations hereby grant to Rex Oil Company and the agents the right to enter said
property in accordance with the requirements of the State of North Carolina. Rex Oil Company agents
may include Geological Resources, Inc.
The undersigned hereby covenant and warrant that they are the sole owners of said property; that they
solely have the right to grant this right to enter for conducting subsurface investigations against the
lawful claims of all persons whomsoever.
It is agreed that Rex Oil Company shall be responsible for restoring any damage done to the ground of
s,,id I,loperty by its employee er its ag,::rits the ,ubsurface in.cstit,ation and n1Jnito;ing peric:'d,
and that Rex Oil Company shall abandon monitoring wells on said property in accordance with NCDEQ
requirements at the conclusion of the monitoring period.
It is agreed that Rex Oil Company shall hold harmless the owner of the aforementioned property for any
personal injury that might be sustained during the course of conducting or proximately resulting from
the conduct of subsurface investigations.
Right to Enter denied.
Right to Enter granted.
Signature
phone: 4 �!- ..)�}_
Date
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

PROFESSIONAL SERVICES AGREEMENT
In Reference to Proposal # 21-760
I. SERVICES. Geological Resources, Inc. ("GRI") proposes to perform the services for
the undersigned client ("CLIENT") at the fees and costs set forth in the scope of services and cost
proposal attached hereto and incorporated herein by reference (the "Services"). GRI represents
and warrants that the Services will be performed in a manner consistent with customary
industry standards. No other representation, warranty, or guaranty, expressed or implied, is
intended.
II. FEES. GRI reserves the right to revise its fee schedule subject to thirty (30) days written
notice. In the event GRI revises its fee schedule, CLIENT shall have fifteen (15) days from receipt
of notice of the revision to determine whether to terminate this Agreement. Any revision to the
Services shall be pursuant to a written change order agreed to in advance by CLIENT and made a
part of this Agreement.
III. CONFIDENTIALITY. The Services are solely for the benefit of CLIENT. This Agreement
shall not be construed as creating any contractual relationship of any kind between GRI and any
third party. The information and materials provided by GRI to CLIENT in connection with the
Services shall be utilized by CLIENT only for the purposes contemplated by this Agreement, and
shall not be provided by CLIENT to third parties without the prior written consent of GRI, except
that GRI agrees that information and materials provided by GRI to CLIENT may, if required, be
provided to and used by governmental regulatory agencies, CLIENT's attorneys, and pursuant to
any valid court order. GRI agrees that all reports and other documents prepared for CLIENT
pursuant to this Agreement are the property of CLIENT. GRI also agrees that it will not disclose
to any third party any documents, reports, laboratory data or other information generated,
created or produced for CLIENT pursuant to this Agreement unless required by law, pursuant to
a valid court order, or upon written instruction of CLIENT.
IV. CLIENT DISCLOSURES. CLIENT shall notify GRI of any known or suspected hazardous
substances or conditions on the property upon which the Services are to be performed which in
anyway relate to or affect the Services and GRI shall have the right to rely on the accuracy of
such CLIENT -furnished information. Thereafter, GRI shall take all reasonably necessary and
appropriate measures to protect its employees, agents and subcontractors against such possible
hazards and to prevent adverse impacts to the environment. The cost of such measures shall
constitute a revision to the Services and shall be managed in accordance with Section II of this
Agreement.
V. RIGHT OF ENTRY. GRI is to have free access to the applicable properties at the times
and on the dates Services are scheduled. Delays to GRI are subject to waiting time charges to
the extent such delays are caused by CLIENT or its employees, contractors or agents. GRI shall
take reasonable and customary precautions to prevent damage to CLIENT's property. CLIENT
understands that the discovery of certain hazardous substances and conditions and/or the
taking of preventive measures relative to these substances and conditions may result in a
reduction of the value of the property upon which the substance or condition is found to exist or
on which the preventative measures are taken. Accordingly, CLIENT waives any claim against
GRI and its subcontractors and agrees to defend, indemnify and hold GRI and its subcontractors
harmless from any claim based upon the diminished value of real property allegedly arising from
1 o12

the discovery of a hazardous substance or condition or the taking of a preventive measure,
unless such claim is based upon GRI's gross negligence.
VI. INDEMNIFICATION. GRI will defend, indemnify and hold harmless CLIENT and its
representatives, agents, employees and successors and assigns from and against any and all
claims, suits, actions, losses, penalties, fines and damages of any nature whatsoever, including
reasonable attorney's fees, expert witness fees, consultant fees and court costs (collectively
"Legal Claims and Costs") arising or resulting from (1) GRI's breach of this Agreement; and/or (2)
GRI's negligence or intentional misconduct. In addition to the specific provisions set forth
above, CLIENT will defend, indemnify and hold harmless GRI and its representatives, agents,
employees and successors and assigns from and against any and all Legal Claims and Costs
arising or resulting from (1) CLIENT's breach of this Agreement; and/or (2) CLIENT's negligence
or intentional misconduct, and (3) the existence of any hazardous substance or condition at any
site(s) where Services are performed, unless the negligent conduct of GRI exacerbates and
causes the spread of such hazardous substance(s) or the development of such hazardous
condition.
VII. PAYMENT TERMS CLIENT agrees to pay all charges as set forth in the GRI Proposal # 21-
760. Payment is due upon receipt of invoice. Additionally, all subcontractor invoices will be
forwarded directly to client for payment. Payments not received within 30 days are subject to a
finance charge of 1.5% per month (18% annually).
VIII. COMPLETE AGREEMENT. This Agreement, along with its attachments, including the GRI
Proposal # 21-760 incorporates all of the provisions and contemporaneous discussions,
representations, understandings, and agreements between the parties with respect to the
subject matter of this Agreement. The terms and conditions expressed in this Agreement shall
not be altered except in writing, signed by both parties.
IX. APPLICABLE LAW. This Agreement is governed by, and will be construed in accordance
with the laws of the state where such property is located.
Executed as of the latest date set forth below.
GRI:
GEOLOGICAL RESOURCES, INC.
JOUIZ2dA0---,
By:
Date: December 16, 2021
CLIENT:
MR. HAROLD KENNEDY
REX OIL COMPANY
By:
Date:
1Z`J(o 21
2of2

11780230-4-1-2
Guilford County Finance Department
PO Box 3427
Greensboro, NC 27402-3427
Return Service Requested
General Statement
Customer Copy
CUSTOMER
CUSTOMER NUMBER
STATEMENT DATE
STATEMENT TOTAL DUE
REX OIL COMPANY
Bill Description: 21001 ENVIRONMENTAL HEALTH
112621
Date: 04/30/2022
05/01/2022
1,740.00
Bill Number: 142417
DETAIL DESCRIPTION
DATE
BILLED ADJUSTED PAID AMOUNT DUE
REX OIL COMPANY
04 30 2022 1,740.00
0.00
0.00
1,740.00
This statement reflects the balance due as of today for services rendered by Guilford County Environmental Health Division. If you have
questions regarding this statement, please call the Environmental Health Office at 336-641-6798.
A fee of $25.00 will be charged for any Returned Checks. Hearing Impaired: TDD [phone]
General Statement REMIT PORTION
Guilford County Finance Department
PO Box 3427
Greensboro, NC 27402-3427
Return Service Requested
Please return original coupon and write account number on check.
11780230-4-2 1 2
IIlill111111IIlili'IIIIuli11.111lIIIIl'Il'IIIIuuilillir illli'I
REX OIL COMPANY
"":. 1000 LEXINGTON AVE
THOMASVILLE NC 27360-3541
1-30DAYS 31-60DAYS
61- 90 DAYS OVER 90 DAYS
1,740.00
0.00
0.00
0.00
INTEREST
OTHER FEES
TOTAL DUE
0.00
1,740.00
Statement Date 05/01/2022
Customer Number 112621
Statement Total Due 1,740.00
Make check payable and remit to:
I'iIIIIII'iIIIiiiIIIIIIuII9lIuiIIuIhIIIIIIIIIIiuIIIIII"IIIIIuu
GUILFORD COUNTY AR DEPARTMENT
PO BOX 71072
CHARLOTTE NC 28272-1072
01090182022200142417500001740000

TYPE II CVO\ITORI\G WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PA
GROUND SURFACE
0'
GROUT CEMENT
BENTONITE SEAL
SAND FILTER PACK
a
PROPOSED WELL DEPTH 12' BGS
MANHOLE COVER
LOCKING WELL CAP
a ad
11
4 a
a
2 /NCH DIAMETER
SCHEDULE 40 PVC CAS/NG
(PROPOSED CAS/NG LENGTH
OF 2 FEET)
TOP OF BENTONITE 0.5' BGS
TOP OF SAND PACK 1 ' BGS
0.010 /NCH SLOTTED
2 /NCH DIAMETER
SCHEDULE 40 PVC SCREEN
(PROPOSED SCREEN LENGTH
OF 10 FEET)
END CAP
Geological Resources, Inc.
C & P Mini Mart
Corner of US 74 and US 710
Pembroke, Robeson County, NC
Inc/dent No. 29552
GR/ Project No. 3501
Note:
1. This diagram is not to scale.

Guilford County, NC
Base Layers
GC Centerline
Parcels
Disclaimer: While every effort is made to keep information provided over the Internet accurate and
up-to-date, Guilford County does not certify the authenticity or accuracy of such information. No
warranties, express or implied, are provided for the records and/or mapping data herein, or for their
use or interpretation by the User.
Map Scale
1 inch = 63 feet
5/3/2022

250-FOOT_ RADIUS
1,500-FOOT RADIUS
LEGEND
0161850 REID Number
0
Pond
Water Supply Well
AII_Streams_polyline
Guilford Streets
Parcels_April_2011
150 300
Feet
1 inch = 300 feet
NOTE:
Based on Guilford County, NC GIS Website.
FIGURE 2: SITE VICINITY MAP
TWIN ROADS MOBIL
1011 LIBERTY ROAD
HIGH POINT, GUILFORD COUNTY
NORTH CAROLINA
INCIDENT NO. 37896
GRI PROJECT NO. 3035
PREPARED BY:
GEOLOGICAL RESOURCES, INC.
AUGUST 30, 2013

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