WM0401418_Minitoring Well Permit_20221212

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.
FOR OFFICE USE ONLY
1. Date: 12/02/2022
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2. County: Davidson I PERMIT NO. t3' ISSUED DATE a a ao a
3. What type of well are you applying for? (monitoring or recovery): Monitorin
4. Applicant: NCDEQ, DWM. UST Section (Scott Rvals) Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC2766-1646
Applicant's Email Address (if available): scott.rvalsOncdenr.gov
5. Contact Person (if different than Applicant): Al Quarles Telephone: [phone]
Contact Person's Mailing Address: 7606 Whitehall Executive Center Drive, Suite 200, Charlotte, NC 28273
Contact Person's Email Address (if available): wi(Iiam.guarlesCa2oneatlas.com
6. Property Owner (if different than Applicant): Mr. Michael S Lane Telephone: [phone]
Property Owner's Mailing Address: PO Box 2106, Welcome, NC 27374
Property Owner's Email Address (if available): mlane160thad.rr.com
7. Property Physical Address (Including PIN Number) 158 Arnold Rd PIN 1132100000039
City Lexington County Davidson Zip Code 27295
8. Reason for Well(s): Groundwater 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).
UST Incident #449197 Crossroads Center-C, 134 Arnold Rd Lexington NC 27295
11. Type of contaminants being monitored or recovered: Volatile Organic Compounds
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many?
Existing Monitoring or Recovery Well Construction Permit No(s).: All on UST site Property
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): approximately 50 feet
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:
Well Contractor Address:
Certification No.:
PROPOSED WELL CONSTRUCTION INFORMATION
As required by 15A NCAC 02C .0105(0(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? Well Vault and lock
material: 1
6. Estimated beginning construction date: TBD. Depending
3. Number of wells to be constructed in bedrock: 0 on driller availability
7. Estimated construction completion date: TBD
4. Total Number of wells to be constructed: 1 Depending on driller availability
(add answers from 2 and 3)
ADDITIONAL INFORMATION
1. 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.
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QiGLf.�—,�,_/A ""d•'^"••Y•�-��•%rt�� ProfessionalGeolooist
Signature pplicant or *Agent we n ctr us Ts o.rr• Title of Applicant or *Agent
AI Quarles `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
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.
See attached access agreement Mr. Michael S. Lane
Signature of Property Owner (if different than Applicant) Printed name of Property Owner (If different than Applicant)
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Please send the completed application to the appropriate Division of Water Resources' Regional Office:
Asheville Regional Office Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 2a405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
00
GW-22M/R (Rev. 5-26-2022)

SITE VICINITY MAP
CROSSROADS CENTER-C
134 ARNOLD ROAD
LEXINGTON, DAVIDSON COUNTY, NORTH CAROLINA
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PROPOSED MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
LOCKABLE WELL C /
L1 /
L2
L3
Ll =
.0.25
FT.
L2 =
5
FT.
L3 =
I
15
FT.
L4 =
20
FT.
(Example of typical MW Installation displayed above)
134 Arnold Rd
Lexington, NC 27295
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
sch 40 PVC
CASING DIAMETER
2 inch
CASING LENGTH
0-35 feet
PAD DIMENSIONS
2 ft x 2 ft
HEIGHT ABOVE GROUND
flush mount
WELL CASING
MATERIAL
sch 40 PVC
DIAMETER
2 inches
JOINT TYPE
flush threaded
LENGTH
5 feet
BACKFILL AROUND CASING
MATERIAL
Grout
THICKNESS
3 feet
SEAL
TYPE OF SEAL
Bentonite
THICKNESS
1 feet
FILTER PACK
TYPE OF FILTER
#2 silica sand
DISTANCE ABOVE SCREEN
1 feet
WELLSCREEN
SCREEN MATERIAL
sch 40 PVC
DIAMETER
2 inches
LENGTH
15 feet
SLOT SIZE
0.01 inch
DEPTH TO BOTTOM OF
MONITORING WELL
20.0 feet
DEPTH TO BOTTOM OF
BOREHOLE
20.0 feet
DIAMETER OF BOREHOLE 8.5 inches
7606 Whitehall Executive Center Drive
Charlotte, North Carolina 28273
(FILE IPREP.AT REV.AO 11/D182022 SLC0449C19020

;ETC
7606 Whitehall Executive Center Drive
Suite 800
Charlotte, North Carolina 28273
www.atgroupservices.com
Phone: [phone]
ENVIRONMENTAL • GEOTECHNICAL Fax: [phone]
BUILDING SCIENCES • MATERIALS TESTING
October 4, 2022
Place of Praise, Inc
1655 Payne Road 158 Arnold Road
Lexington, NC 27295 Lexington, NC 27295
Re: Right of Entry Agreement
158 Arnold Road, Lexington, NC 27295
Davidson County PIN 6727-04-92-3937
Adjacent to:
Crossroad Center-C, Incident Number 44919
134 Arnold Road, Lexington, NC 27295
Dear Place of Praise, Inc:
An environmental soil and groundwater investigation has historically been conducted at the
Crossroad Center-C underground storage tank incident (UST) located at 134 Arnold Road, in
Lexington, Davidson County, North Carolina. According to the Davidson County GIS website, you
are current owner of the property located at 158 Arnold Road (PIN# 6727-04-92-3937). The North
Carolina Department of Environmental Quality (NCDEQ), Division of Waste Management, UST
Section is requesting access to your property to continue assessment and remediation activities
under the State -Lead Program. ATC Associates of North Carolina, P.C. (ATC), is NCDEQ's
current contractor for this site, and will conduct environmental investigation and remediation
activities at your property under contract to the NCDEQ. Please review and sign the enclosed
agreement to either grant or deny permission to access to your property. You may return the
agreement to Mr. Al Quarles at ATC using the enclosed envelope, or Mr. Scott Ryals at the
NCDEQ at the address referenced in the enclosed agreement, or email to
[e-mail].
Thank you in advance for your assistance with this project. If you have any questions or need
additional information, please contact me at 704-529-3200 or William.Quarles(cDoneatlas.com.
Sincerely,
ATC Associates of North Carolina, P.C.
Al Quarles, PG
Senior Project Manager
Attachment: Property Access Request

Right of Entry Agreement
Davidson County PIN 6727-04-92-3937
158 Arnold Road
Lexington, NC 27295
Scott Ryals, P.E.
Environmental Engineer
DWM UST Section
1646 Mail Service Center
Raleigh, NC 27699-1646
RE: Right of Entry Agreement
Crossroads Center-C, Incident No. 44919
134 Arnold Road
Lexington, NC 27295
Dear Mr. Ryals,
October 4, 2022
I am/We are the owner(s) of a parcel of property, located at or nearthe incident in question,
and hereby permit the Department of Environment Quality (Department) or Its contractor to enter
upon said property for the purpose of 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 Department's Division of
Waste Management or its contractor.
2. The costs of the investigation and/or remediation of the site and access shall be borne by
the Department or its contractor in accordance with the acceptance of the site into the
State -Lead Program. The Department or its contractor shall protect and prevent damage
to the property and 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 agreed, 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 land owners 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 otherwise provided by law.
5. 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.

Right of Entry Agreement
Davidson County PIN 6727-04-92-3937
158 Arnold Road
Lexington, NC 27295
October 4, 2022
The information derived from the investigation shall be made available to the owner upon
request and is a public record, in accordance with G.S. 132-1.
IMe 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,
Signature � � V V
s / ! l,r1 q61 S-
Type/Print Name of Owner or Agent
33( �ZD� FO-c
Phone Number
Email Address
o, ady V6
Mailing Address
W4-LCME ti. c. all*
City/State/Zip Code
Date

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