WM0401398_Monitoring Well Permit Application_20221011

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: 10/7/2022
County: Davidson
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: NCDEQ Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Greg Hans Telephone: [phone]
Contact Person's Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte, NC 28273
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Harold & Betty Ruth Myers Telephone: [phone]
Property Owner's Mailing Address: PO Box 1205, Lexington, NC 27293
Property Owner's Email Address (if available): attn: [e-mail]
7. Property Physical Address (Including PIN Number) 823 West Center Street PIN 6725-02-59-0980
City Lexington County Davidson Zip Code 27292
8. Reason for Well(s): 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).
No known water quality permits. NCDEQ Incident No.: 14039
11. Type of contaminants being monitored or recovered: organics / metals
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? None
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): Approximately 15-20 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give clistance(s):
15. Well Contractor: Carolina Soil Investigation Certification No.: Corey Speece 42904 /
Daniel Summers 42579
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 5. How will the well(s) be secured? 2 x 2 pad, well
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)
covers, locking i-plug
6. Estimated beginning construction date: 10/13/2022
7. Estimated construction completion date: 10/13/2022
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 assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Signature of Applicant or *Agent
Greg Hans
stating Printed name of Applicant or *Agent
CES Group Engineers, LLP / Environmental Division Manager
Title of Applicant or *Agent
If signing as Agent, attach authorization agreement
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
well(s) as g#Tined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ure ttyz¢ the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Signature of Proper'ry Owner (if different than Applicant)
Printed name of Property wner (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: (252
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
C 27105
9800
7

ENVIRONMENTAL PROTECTION
HAZARDOUS SITES RESPONSE PROGRAM
TYPICAL
FLUSH -MOUNT GROUNDWATER MONITORING WELL
CONSTRUCTION DIAGRAM
(TOP OF MANHOLE
(SPACING DEPENDS
ON WELL DEPTH)
2 FEET
2 FEET
BOLTED MANHOLE COVER
CONCRETE PAD
MANHOLE SLEEVE
LOCKING WELL CAP
2" SCHEDULE 40 PVC PIPE
BENTONITE GROUT
BENTONITE SEAL
TYPE
SAND PACK
GRAIN SIZE
2" SLOTTED SCHEDULE
40 PVC SCREEN
BOTTOM CAP
BOTTOM OF BORING
ANNULUS

9/14/22, 2:32 PM
823 W Center St - Google Maps
Go gle Maps 823 W Center St
Proposed Monitoring Wells
Divine Hair Designs
The Outlet Warehouse
r r� Outlet store
Smart Start
Davidson Coun
MIS Liquidation
Discount store
Map data ©2022 , Map data ©2022 20 ft
https://www.google.com/maps/place/823+W+Center+St,+Lexington,+NC+27292/@35.8314288,-80.2648367,91 m/data=!3m1!1e3!4m5!3m4!1s0x88539831c33e11 bd:0xb327d7cf8effa80a!8m2!3d35.831... 1/1

ROY COOPER
Governor
ELIZABETH BISER
Secretary
MICHAEL SCOTT
Director
CERTIFIED MAIL
RETURN RECEIPT REQUESTED
7019 1120 0001 4896 202
Mr. Monroe Snyder
1301 Bringle Ferry Roa
Denton, NC 27239
RE: State -Lead Acceptance
Snyder's Phillips 6
828 W Center Stre t
Lexington, Davidson County, NC
Incident Number 14039 & 20707
Dear Mr. Snyder:
NORTH CAROLINA
Environmental Quality
April 26, 2022
The Winston-Salem Regional Office (WSRO) has referred the subject release incident to the State
Underground Storage TanC (UST) Trust Fund Branch, State -Lead Program for inclusion on the list of
releases awaiting state -led cleanup. In November 1991 & August 1999, during tank removal, soil
and groundwater contamination was detected. To date, the required assessment and cleanup of the
release have not been co pleted due to the dissolution of the company that formerly owned the UST
system, recalcitrance of th former UST system owner, or death of the former UST system owner.
Due to the potential prese ce of groundwater users within 1500 feet of the release and based on the
confirmation of contaminat on remaining at the release location, the subject release incident is being
accepted by the State -Lea', program for inclusion on the list of releases awaiting further assessment
and cleanup and/or UST removal pursuant to G.S. 143-215.94G. -- - -
Currently, the risk of this !-elease is "Low". An assessment and, if necessary, a cleanup, will be
conducted as soon as funds are available to determine and alleviate impacts to the environment and
human health. The State - lead Program contractor must access the property to conduct assessment
and cleanup activities, whach may include the installation and sampling of monitoring wells, and
cleanup activities, Pursuan to G.S. 143-215.94A, based on the information currently available in our
files you are not considere to the responsible for the release.
North carolina Department of Environmental Quality 1 Division of Waste Management
217 W(lst Jones Street 1 1646 Mail Service Center 1 Raleigh, North Carolina 27699-1646
919.707.8200

The UST Section would appreciate your approval for access to your property to conduct necessary
assessment and cleanup activities. Please note that pursuant to 15A NCAC .0106(b), failure to allow
the UST Section and/or their contractor to access your property to conduct the necessary assessment
and cleanup activities may result in a determination that you are controlling an activity which results
in the discharge of waste, and you may potentially be held responsible for assessment and cleanup
of the contamination.
Please review and sign the access agreement that is included. You will be notified before assessment
and/or cleanup activities begin.
Should there be any questions concerning this action, please contact Scott Ryals at [phone]
or via e-mail at [e-mail]
Sincerely,
Z Vance Jackson Jr
UST Section Chief
CC: Mindy Lepard, WSRO (e-mail)
Davidson County Manager, Casey Smith, [e-mail]
Davidson County Health Director, Lillian Koontz, [e-mail]
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mail Service Center I Raleigh, North Carolina 27699-1646
919.707.8200

wi
Waste Management
ENVIRONMENTAL QUALITY
April 26, 2022
Mr. Scott Ryals
Environmental Engineer
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: :,State -Lead Acceptance
Snyder's Phillips, 66
828 W Center Street
Lexington, Davidson County, NC
Incident Number 14039 & 20707
Dear Mr. Ryals
- ROY COOPER
Governor
ELIZABETH BISER
Secretafy
MICHAEL SCOTT
Director
I am./We are the wner(s) of a parcel of property, located at or near the incident in question, and
hereby permit the Depart ent of Environmental Quality (Department) or its contractor to enter upon said
property for the purpose f conducting an assessment and/or remediation of the groundwater and/or soils
under the authority of G.S. 143-215.94G.
I am/We are granting permission with the understanding that:
1. The investigation shall be conducted by the UST Section of the Departments Division of Waste
Management or its contractor.
2. The costs of constructon and maintenance of the site and access shall be borne by the Department or
its contractor in acc rdance with the acceptance of the site into the State -Lead Program. The
Department or its con actor shall protect and prevent damage to the surrounding lands. Any damages
will be restored by the Department or its contractor to as close to the pre -work condition as -practicably -
possible.
3. Unless otherwise agred, 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 will notify the landowners
48 hours prior to entry and 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 othe ise provided by law.
5. The information deriv�d from the investigation shall be made available to the owner upon request and
is a public record, in a cordance with G.S. 132-1.
Nothing Compares
State of North Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T

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. No representations or warranties, either expressed or implied, have been
made to me/by the Department, the State of North Carolina, or its/their contractor(s) regarding the
results that may be obtained or the quality of work to be performed
UWe 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,
R11/41;913 M0r c� � 5,N c� d�`T�+,� rint Name of Owner or Agent
(Db(um_ are- r Lel eid GA-rwa /4—
`'Phone Number / E-mail Address
/30/ 8,(--,,,1/e_ FeTrr g,
Address
,✓—fog . me2)-3/
City/State/Zip Code
Date
RE: State -Lead Acceptance
Snyder's Phillips 66
828 W Center Street
Lexington, Davidson County, NC
Incident Number 14039 & 20707
/Nothing Compares
State of North Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T