WM0401416_Monitoring Well Permit Application_20221202

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: 11/22/2022
2. County: Randolph
FOR OFFICE USE ONLY j f
PERMIT NO. W NV 14 0 1.VgUED DATE I/ 9C t o
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Angels Inc DBA Trindale Mini Mart
JO ctv\ (finge
Applicant's Mailing Address: 7619 NC Highway 62, Trinity NC 27370
Applicant's Email Address (if available): beachhouse402enorthstate.net
5. Contact Person (if different than Applicant): Joanna Alley
Telephone: [phone]
Telephone: [phone]
Contact Person's Mailing Address: Geological Resources. Inc., 3502 Haves Rd., Monroe NC 28110
Contact Person's Email Address (if available): ira gngeologicalresourcesinc.com
6. Property Owner (if different than Applicant): Doug Woodaeard Telephone: [phone]
Property Owner's Mailing Address: 7613 NC Highway 62, Trinity, NC 27370
Property Owner's Email Address (if available): dwhighoointnc(5 vahoo.com
(,l 3
7. Property Physical Address (Including PIN Number) 7649 NC Highway 62
City Trinity County Randolph Zip Code 27370
8. Reason for Well(s): ground water 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: petroleum retail 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 #44719
11. Type of contaminants being monitored or recovered: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 11
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401311
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 40
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: Geological Resources. Inc. Certification No.:
Well Contractor Address: 3502 Haves Road, Monroe NC 28110
3270A
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: 1
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Locking
expansion cap and bolt down manhole cover
6. Estimated beginning construction date: Dec. 2022
7. Estimated construction completion date: Dec. 2022
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.
b.
c.
d.
e.
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.
All existing wells, identified by type of use, within 500 feet of the proposed well or well system.
The proposed well or well system.
Any test borings within 500 feet of proposed well or well system.
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.
nature of Applicant or *Agent
Joanna Allev, P.E.
Printed name of Applicant or *Agent
Project Manager (GRI)
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
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 Right to Enter Agreement)
Signature of Property Owner (if different. than Applicant)
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)
GW-22M (Rev. 5/11)

Joanna Alley
From: D W <[e-mail]>
Sent: Thursday, November 3, 2022 6:30 PM
To: Stephanie Gainey
Subject: Re: Right To Enter follow up
Attachments: Screenshot_20221103-182843.png
Hope this works for you
On Wednesday, November 2, 2022, 09:57:47 AM EDT, Stephanie Gainey <[e-mail]> wrote:
Hi Doug,
Just following up on the attached document. I do not see a signed copy in our file. Please sign and return as soon as you
can. If you have any questions, please let me know.
Best Regards,
Stephanie Gainey
Operations Coordinator
Geological Resources, Inc.
2021 Winner of the Union County Chamber Excellence In Business Award
3502 Hayes Road I Monroe, NC 28110 1 website I facebook
704-845-4010-office 1704-845-4012-fax
From: Stephanie Gainey
Sent: Friday, October 7, 2022 10:38 AM
To: [e-mail]
Cc: Joanna Alley<[e-mail]>
Subject: Right To Enter
Doug,
t

Per our conversation, please sign the attached and return to me at your earliest convenience. Thank you and please let
me know if you have any questions.
Stephanie Gainey
Operations Coordinator
Geological Resources, Inc.
2021 Winner of the Union County Chamber Excellence In Business Award
3502 Hayes Road I Monroe, NC 28110 I website I facebook
704-845-4010-office I 704-845-4012-fax
2

marrow
Geological Resources, Inc,
RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF RANDOLPH
•
•
•
We, the undersigned, being all of the fee simple owners of certain tracts or parcel designated 7
5108 of the County of Randolph, recognizing the benefits to said properties by reason of cor
monitoring well installation hereby grant to Angels, Inc. DBA Trindale Mini Mart and the agents t
to enter said property in accordance with the requirements of the State of North Carolina. Anc
DBA Trindale Mini Mart agents may include Geological Resources, Inc.
The undersigned hereby covenant and warrant that they are the sole owners of said property; tl
solely have the right to grant this right to enter for conducting the monitoring well installation
the lawful claims of all persons whomsoever.
It is agreed that Angels, Inc. DBA Trindale Mini Mart shall be responsible for restoring any dama
to the ground of said property by its employees or its agents during the monitoring well installal
monitoring period, and that Angels, Inc. DBA Trindale Mini Mart shall abandon the monitoring
said property in accordance with NCDEQ requirements after the incident has been closed.
It is agreed that Angels, Inc. DBA Trindale Mini Mart shall hold harmless the owner
aforementioned property for any personal injury that might be sustained during the cc
conducting or proximately resulting from the conduct of subsurface investigations.
___Right to Enter denied.
_ X__ Right to Enter granted.
Doug woodgeard
Print--��-�---
doug woodgeard
Signature
3363827319______________
Phone
11,3,22_______
Date
3502 Hayes Road Monroe, North Carolina 28110
113 West Firetower Road, Suite G o Winterville,. North Carolina 28590
Phone [phone] ^ [phone] • Fax [phone]

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TYPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PA
GROUND SURFACE
GROUT CEMENT
BENTONITE SEAL
SAND FILTER PACK
PROPOSED WELL DEPTH 35__ BGS
6• 4
a
MANHOLE COINER
LOCK/NG WELL CAP
2 /NCH DIAMETER
SCHEDULE 40 PVC CAS/NG
(PROPOSED CAS/NG LENGTH
OF 2 FEET)
TOP OF BENTON/TE _ 11 _ BGS
TOP OF SAND PACK _13 _BGS
0.010 /NCH SLOTTED
2 /NCH DIAMETER
SCHEDULE 40 PVC SCREEN
(PRO,POSED SCREEN LENGTH
OF _ 5__ FEET)
END CAP
ER
Geological Resources, Inc.
Note:
1. This diagram is not to scale.