WM0401421_Monitoring Well Permit Application_20221212

NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY - DIVISION OF WATER RESOURCES
7. Property Physical Address (Including PIN Number) 5434 University Parkway (6828-22-5867)
City Winston-Salem County Forsyth Zip Code 27105
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: 11/30/2022
2. County Forsyth
PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Speedway, LLC Telephone: [phone]
Applicant's Mailing Address: PO Box 1500, Springfield, OH 45501
Applicant's Email Address (if available): Samuel Kramer Slav-srne'r' 01•�
5. Contact Person (if different than Applicant): Nathan Pinsker Telephohe: 919-461-1559
Contact Person's Mailing Address: 5438 Wade Park Boulevard Suite 200. Raleigh, NC 2607
Contact Person's Email Address (if available): Nathan.Pinsker(a aecom.com
6. Property Owner (if different than Applicant): A.T. Williams Oil Company Telephone:[phone]
Property Owner's Mailing Address: 331 High Street, Winston-Saterp, NC 271Q1
Property Owner's Email Address (if available): 'er r` W �, 1 \ a`r�nS cAeV e\EVr (v\ }' 0-
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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: gasoline station
(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: Organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? No
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 50
14. Are there any water supply wells located Tess than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Resources Inc. Certification No.: 1270
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 5. How will the well(s) be secured? Na
material: 2
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 12/12/2022
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
7. Estimated construction completion date: 12/14/2022
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 welt 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. 143-215.1013(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
Signature of Applicant or *Agent
Nathan Pinsker
Printed name of Applicant or *Agent
Limited Field Accent for Speedway, LLC
Title of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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) c• f•rm to the Well Construuctiioa�/Stan�d�ti /%
Standards Tittle 15A of the Nort Carolina Ad`in relive Code, Subchapter 2C).
0 d%'�1 3 �frd t, �t �r ljl6atus it- C l `M
Siiat� joPertY O if .'fferent than Appiicant) l 40 Printed name f Prope Owner if d erent than Applicant)
IONS
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]
Va
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

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Client: Speedway 6927
Project Number:
WELL ID: Temporary Well
Site Location:
5434 University Parkway Winston-Salem NC
Date Installed: 12/12/2022
Well Location: Coords:
Inspector:
Method: Direct Push Technology (geoprobc)
Contractor: Geologic Resources, Inc.
Proposed Monitoring Well Construction Log
immiss
smmS
ISMS
Top of Riser Pipe
Ground Surface (G.S.)
Length 5'
Diameter (ID) 1"
Type of Material PVC
Thickness Sch 40
Top of Sand
Top of Screen
. Stabilized Water Level
Screen:
Length 15
Describe Measuring Point:
Diameter (ID) 1"
Slot Size 10 slot
Type of Material PVC
Thickness Sch 40
Type/Size of Sand #2
Sand Pack Thickness 12'
Bottom of Screen
Bottom of Tail Pipe:
Bottom of Borehole
Borehole Diameter
4"
Depth from G.S. (feet)
0.0
0.0
—15;
20
20
20
Signature Date
Elevation (feet)
Datum