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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: 919-707-8168 Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699 Applicant's Email Address (if available): scott.ryals@ncdenr.gov 5. Contact Person (if different than Applicant): Greg Hans Telephone: 704-325-5408 / 617-828-9948 Contact Person's Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte, NC 28273 Contact Person's Email Address (if available): ghans@ces-group.net 6. Property Owner (if different than Applicant): Harold & Betty Ruth Myers Telephone: 336-250-4831 Property Owner's Mailing Address: PO Box 1205, Lexington, NC 27293 Property Owner's Email Address (if available): attn: thm2516@gmail.com 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: (828) 296-4500 Fax: (828) 299-7043 Fayetteville Regional Office 225 Green Street, Suite 714 Fayetteville, NC 28301-5094 Phone: (910) 433-3300 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue Mooresville, NC 28115 Phone: (704) 663-1699 Fax: (704) 663-6040 Raleigh Regional Office 3800 Barrett Drive Raleigh, NC 27609 Phone: (919) 791-4200 Fax: (919) 571-4718 Washington Regional Office 943 Washington Square Mall Washington, NC 27889 Phone: (252) 946-6481 Fax: (252 Wilmington Regional Office 127 Cardinal Drive Extension Wilmington, NC 28405 Phone: (910) 796-7215 Fax: (910) 350-2004 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 (919) 707-8168 or via e-mail at scott.ryals@ncdenr.gov Sincerely, Z Vance Jackson Jr UST Section Chief CC: Mindy Lepard, WSRO (e-mail) Davidson County Manager, Casey Smith, casey.smith@davidsoncounty.nc.gov Davidson County Health Director, Lillian Koontz, lillian.knootz@davidsoncounty.nc.gov 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