WM0401409_Monitoring Well Permiot Application_20221104

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.
Date: 10/26/2022
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NOWtMqI9 QC1 ISSUED DATE \
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Products (SE) Pipe Line/Greg Dempsey
Telephone: [phone]
Applicant's Mailing Address: 1000 Windward Concourse, Suite 450, Alpharetta, GA 30005
Applicant's Email Address (if available): greg [e-mail]
5. Contact Person (if different than Applicant):
Contact Person's Mailing Address:
Contact Person's Email Address (if available):
6. Property Owner (if different than Applicant): Carolina Thomas Telephone: [phone]
Property Owner's Mailing Address: 6340 A Burnt Poplar Road
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 6327 Burnt Poplar Road
City Greensboro County Guilford Zip Code 27409
Telephone:
8. Reason for Well(s): Environmental 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: Bulk Petroleum Breakout 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).
Incident numbers 3367, 10558, 87185
11. Type of contaminants being monitored or recovered: Petroleum Hydrocarbons
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 54
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A — County Permit: 040-99-MW63-RWO
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 350'
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: Innovative Environmental Technologies, Inc. Certification No.: 2725-A
Well Contractor Address: 232 Hwv 49 S, Concord. NC 28025
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: 2
5. How will the well(s) be secured? Bolted flush -
mount manhole and locked watertight plug
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 11/14/2022
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: 11/18/2022
(add answers from 2 and 3)
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 o f Applicant or*rAgent /
J. Greg Dempsey
Printed name of Applicant or *Agent
Project Manager - Specialist II
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement staling
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 outlined in this Well Construction Permit application and acknowledges that it shall be the responsibility of the Applicant to
ensure that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
Signature of Property Owner (if different than Applicant)
Carolina Thomas
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-22M/R (Rev. 5-26-2022)

vacobs.
PROJECT NUMBER
KMGROM22
WELL NUMBER
PMW-33 SHEET 1 OF 1
PROPOSED WELL DIAGRAM
PROJECT : Greensboro Bulk Petroleum Breakout Faclk LOCATION : Greensboro, North Carolina DATE: TBD
DRILLING CONTRACTOR : Innovative Environmental Technologies
DRILLING METHOD AND EQUIPMENT USED : 4.25-Inch ID Hollow Stem Auger
WATERLEVEL:TBD START: TBD END:TBD LOGGER :TBD
g 1- Ground elevation at well TBD
' 2
2- Top of casing elevation TBD
• • 3 ,
as k
a Y.
3- Wellhead protection cover type 8-Inch diameter well vault
a) concrete pad dimensions 2-foot square, 4 Inches thick
8 Ji
;`s 4„y
1.. . 1
sift
- 5`+ 4<
4- Dia./type of well casing 2-inch ID Schedule 40 PVC
qa
as, y
5- Screen slot size 0.010-inch
60.5ft
6- Type filter pack Sand - Well -graded, fine to medium silica
7
2 ft a) Quantity used TBD
7- Type of seal 3/8 Inch sodium bentonite pellets
60 ft
a) Quantity used TBD
2ft
8- Grout
a) Grout mix used high -solids bentonite or cementitious
grout mixture,
b) Method of placement tremie pipe
0
5
Development method Surging and over -pumping
6
5 ft
Comments:
T 6 Inches
(Blank casing)
Threaded End Cap
7 inches

Jacobs.
PROJECT NUMBER
KMGROM22
WELL NUMBER
PMW-34 SHEET 1 OF
PROPOSED WELL DIAGRAM
PROJECT : Greensboro Bulk Petroleum Breakout Facility LOCATION : Greensboro, North Carolina DATE: TBD
DRILLING CONTRACTOR : Innovative Environmental Technologles
DRILLING METHOD AND EQUIPMENT USED : 4.25-Inch ID Hollow Stem Auger
WATERLEVEL:TBD START: TBD END:TBD LOGGER:TBD
g 1- Ground elevation at well TBD
2
2- Top of casing elevation TBD
9� S
Kr
}lei,.
-
3- Wellhead protection cover type 8-Inch diameter well vault
'�<41_,
a) concrete pad dimensions 2-foot square, 4 inches thick
6 21Y •5
-
,
ii
11
ft
4- Dia./type of well casing 2-Inch ID Schedule 40 PVC
uti
444,
(
a
5- Screen slot size 0.010-Inch
i
AO
25.5 ft
6- Type filter pack Sand - Welt -graded, fine to medium silica
7
2 ft a) Quantity used TBD
7- Type of seal 318 inch sodium bentonite pellets
25 ft
a) Quantity used TBD
2ft
8- Grout
a) Grout mix used high -solids bentonite or cementitious
grout mixture,
b) Method of placement tremle plpe
Development method Surging and over -pumping
6
10 ft
Comments:
:..
8 inches
(Blank casing)
-,-JThreaded End Cap
I,
7 Inches

L�
Property Boundary
Base Map Sources:
Earl World Imagery Layer, 2020 and
Esrl World Transportation Reference Layer
5.1)
I 1 I
r»i
Figure 1. Site Location Map
2021 Annual Monitoring Report
Products (SE) Pipe Line Corporation Breakout Facility
Greensboro, North Carolina
Jacobs
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LEGEND
• 2" Diameter Well
5) 4" Diameter Weil
Isoconcenlratlon Contour
(dashed where Inferred)
Property Boundary
Road
-•� Railroad
[`] Pond
i� Building
I_ _J Tanks
Tank Dikes
Release Site
Notes
1. All locations are approldmale
2. Groundwater samples collected Mardi 2017
3. MTBE concentrations In micrograms per Star tpulLl
4• Wells not sampled were not Included In creation of lsamap
5. Deep wells not Included In creation of lsamap
MTRF -methyl lad butyl ether!
BRL - below reporting limit
NS - not sampled
PMW-33
N
?BANS oN a ENE
4• "20,pg1L
r SMW-i6A
tr®A2.70
SMW-10
BRL
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(1941-42)
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rr C PMW-`26
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1 / 000` ILA._- .167
• gW
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e MW-8 ''))
s ▪ err 6770 • 2M6W-32 PMWZ5
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.,1 • J., a 200 pg1L ---. •PMW.11
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(1972)
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SMIW-13A' Rnl)roeu Spur
Kerosenefljelease
smw•1�', (1961) I SMw 2,
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Kerosene Release
(1975)
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• PAc111d ananx. eae H+f7 Yhr
Figure 2
Proposed Groundwater Sample and
Monitoring Woll Locations
Plantation Pipe Line Breakout Facility
Greensboro, North Carolina
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ACCESS AGREEMENT
THIS AGREEMENT is made by and between Carolina Thomas ("Owner") and
Plantation Pipe Line Company, ("Plantation"). The purpose of this Agreement is for the Owner
to give Plantation permission to access the Property to conduct an environmental assessment
and/or remediation of the property as more fully described below.
1. Description of Property:
6340 A Burnt Poplar Road, Greensboro, North Carolina
Parcel Number 0099372
2.73 Acre lot
2. Description of Work: Plantation will install a series of groundwater
monitoring wells for the purpose of collecting groundwater samples for laboratory analyses (the
"Work"). Such Work shall also include the abandonment of any groundwater monitoring wells.
3. Grant of Access: Owner has the right to grant and hereby grants
Plantation, its agents, employees, contractors, subcontractors and state and federal
representatives with oversight responsibility the right to enter the Property for the sole purpose of
carrying out the Work, without rent, fee or other form of charge.
a) Plantation's right of access to the Property pursuant to this
Agreement shall be exercised in a manner that does not unreasonably interfere with the
Owner's business conducted on the Property.
b) Plantation's activities on the Property shall be undertaken in
compliance with all applicable federal, state and local rules and regulations.
c) Owner shall cooperate with Plantation to facilitate access onto the
Property for purposes of completing the Work.

d) Plantation will restore the Property to the extent reasonably
possible to the condition which existed when the Work was commenced.
e) All borings not converted to groundwater monitoring wells will be
abandoned at the time the boring is completed. Plantation will abandon any groundwater
monitoring wells in accordance with the applicable regulatory requirements when the
North Carolina Department of Environmental Quality determines the wells are no longer
required.
fJ All Work will be conducted at Plantation's expense.
4. Duration of Agreement: Plantation shall have access to the Property at all
reasonable times, beginning on the Effective Date and continuing until the Work is complete, or
until December 31, 2018, whichever is later.
5. Indemnification: Plantation will defend, indemnify and hold harmless
Owner from and against any and all claims, damages, liabilities, costs and expenses, including
reasonable attomey's fees, ("Losses") arising out of any personal injury or property damage
caused by Plantation's negligent performance of the Work on the Property or caused by
environmental contamination of the Owner's Property, except that Plantation will not be
responsible for Losses caused by Owner's sole negligence, gross negligence or willful
misconduct.
For purposes of this Indemnification, "environmental contamination" means the
presence of any pollutant or contamination in or on the groundwater, surface water,
soil, or subsurface soil that exceeds any applicable state or federal cleanup standard
for industrial site cleanups that originated from Planation's operations.

6. Governing Law: This Agreement shall be governed by and construed in
accordance with the laws of the State of North Carolina.
7. Amendment: This Agreement may be amended only by a writing signed
by both Owner and Plantation.
8. Binding Effect: This Agreement shall bind Owner and Plantation, and
their respective successors and assigns.
9. Effective Date: This Agreement shall be effective when both parties have
executed this Agreement as evidenced by the signatures of the parties or their representatives
below.
For Plantation Pipe Line Company:
By
Ti
Date
?"/ Z.v, 11