WM0401457_Monitoring Well Permit Application_20230627

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,
aoDlication is herebv made for a permit to construct monitoring or recovery wells.
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Date: 6/2612023
County:. Stokes
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitorinf:
Applicant: Huffman Oil Company: James Barnwell Telephone: [phone]
Applicant's Mailing Address: P.O. Box 730 Burlington, NC 27216
Applicant's Email Address (if available): bamwell3 huffmanoil.net
Contact Person (if different than Applicant): _ Wayne Watterson Telephone: [phone]
Contact Person's Mailing Address: 8646 W. Market Street Suite 105 Greensboro NC 27409
Contact Person's Email Address (if available): wwatterson(&smeinc.com
Property Owner (if different than Applicant): N.C. Department of Transportation Telephone: [phone]
Property Owner's Mailing Address: NCDOT/DOH Division Nine 1605 Westbrook Plaza Dr Ste. 201, Winston-Salem, NC 27103
Property Owner's Email Address (if available): [e-mail] (Daneea Russell- Real Property Agent II)
Property Physical Address (Including PIN Number) 6066 NC 705 Hi hwa East Parcel No. 2117�
City_ Sandv_Ridge _County Stokes Zip Code 27046
Reason for Well(s): Groundwater Contamination
(ex: non -discharge permit requirements, suspected contamination, assessment, groundwater contamination, remediation, etc.)
Type of facility or site for which the well(s) is(are) needed: _ UST _
(ex: non -discharge facility, waste disposal site, landfill, UST, etc.)
Are there any current water quality permits or incidents associated with this facility or site? If so, list permit and/or incident no(s).
6080 NC 704 Hiahwav East: LUST Incident No. 29296. D&M,Grocery
Type of contaminants being monitored or recovered: _ volatile organic comaounds
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401451 6080 NC 704 Highway East
Distance from proposed well(s) to nearest known waste or pollution source (in feet):
Are there any water supply wells located less than 500 feet from the proposed well(s)?
If yes, give distance(s): . _ 200, 300, 350 feet
Yes
15. Well Contractor: Innovative Environmental Technologies, Inc. Certification No.: 3287-A
Well Contractor Address: 232 Highway 49 South, 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 5. How will the well(s) be secured? 2'x2' concrete
material: One MW-10i Bolt -down cover, locked expandable cap
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: July 2023
4. Total Number of wells to be constructed: One 7. Estimated construction completion date: 7/31/23
(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. 143-215.1013(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Ap icant ass u total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
/, ; Q l� Acient for Owner
Signature o pplicant or *Agent Title of Applicant or *Agent
Lyndal Butler S&ME. Inc. _ * 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 sinned Encroachment Agreement NC Dep artment of Transportation _
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
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 28405
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]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Mooresville Regional Office tt '�1'yy;n Ponsalery,
610 East Center Avenue 1 '�
Mooresville, NC 28115
Phone: [phone] ; ,,
Fax: [phone] - ` n
Ai9 yiia 1 r 41 le
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
W1I4ngton
GW-22M/R (Rev. 5-26-2022)

ROUTE NC-704
STATE OF NORTH CAROLINA
PROJECT D&M Grocery COUNTY OF Stokes
DEPARTMENT OF TRANSPORTATION RIGHT OF WAY ENCROACHMENT AGREEMENT
N
Huffman oil Company
-AND- REVIEWED
P.O. Box 730, Burlington, NC 2216-0730 By Carolina Carbajal at 10.28 am, Jun 23, 2023
THIS AGREEMENT, made and entered into this the 23 day of June, 20 __23_ , by and between the Department
of Transportation, party of the first part; and Huffman Oil Company
party of the second part,
WITNESSETH
THAT WHEREAS, the party of the second part desires to encroach on the right of way of the public road designated as
Route(s) NC 704
, located on the southwest side of NG-704
with the construction andlor erection of: One monitoring well as shown on the attached plans, for the purpose of environmental ental assessment.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the
party of the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment
within the limits of the right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the second
part the right and privilege to make this encroachment as shown on attached plan sheet(s), specifications and
special provisions which are made a part hereof upon the following conditions, to wit:
That the said party of the second part binds and obligates himseffto install and maintain the encroaching facility in such safe
and proper condition that it wilt not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper
maintenance thereof, to reirnburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways
and structures necessary due to the Installation and existence of the facilities of the party of the second part, and if at arty time the
party of the first part shall require the removal of or changes in the krcation of the said facilities, that the said party of the second
part binds himseff. his successors and assigns, to promptly remove or alter the said facilities, in order to conform to the said
requirement, without any cost to the party of the first part
That the party of the second pert agrees to provide during constnutiort and any subsequent maintenance proper signs, signal
lights, flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Un prM Traffic
Control Devices for Streets and Hi s and Amendments or Supplements thereto. Information as to the above rules and
regulations may be obtained from the Division Engineer of the party of the first Part.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages
and claims for damage that may arise by reason of the installation and maintenance of this encroachment.
It is dearly understood by the party of the second part that the party of the first part will assume no, rehsponsibility for any
damage that may be caused to such facilities. within the highway rights of way limits, in carrying out its construction and
maintenance operations.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of
the Division Engineer of the party of the first part The party of the second part agrees to exercise every reasonable Precaution
during construction and maintenance to prevent eroding of sod; silting or pollution of rivers. streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property: or pollution of the air. There shall be compliance with applicable ndes and
regulations of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and
with ordinances and regulations of various counties, municipalities and other official agencies relating to pollution prevention and
control. When any installation or msintenance operation disturbs the ground surface and existing ground cover, the party of the
second part agrees to remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division
Engineer of the party of the first part
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary
by the Division Engineer of the party of the first part
That the party of the second Part agrees to have available at the encroaching site. al first times art reserves construction,
s the M to stop all
this agreement showing evidence of approval by the party of the first part. The party telP
work unless evidence of approval can be shown.
Provided the work contained in this agreement is being performed on a completed highway open to traffic: the party of the
second part agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has
been completed. Unless specifically requested by the party of the first Part, written notice of completion of work on highway
projects under construction will not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part the party of the first part
reserves the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to
the party of the first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein
is not begun within one (1) year from the dale of authorization by the party of the first part unless written waiver is secured by the
party of the second part from the party of the first part.
FORM RAN 16.1A (Revised February 2021)

R/W (161A) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
R/W (161A) incorporating all revisions to date.
IN WITNESS WHEREOF, each of the parties to this agreement has caused the same to be executed the day and
year first above written. ar d
DEPART ENT ooruRU9PORTATIOr�+ A D88
BY:41
TDRMMIl...
ATTEST OR WITNESS:
_ .tiG3rrAA wGl� ��
v �
S .cond Party
INSTRUCTIONS
When the applicant is a corporation or a municipality, this agreement must have the corporate seal and
be attested by the corporation secretary or by the empowered city official, unless a waiver of corporate
seal and attestation by the secretary or by the empowered City official is on file in the Raleigh office of the
State Utilities Manager. In the space provided in this agreement for execution, the name of the
corporation or municipality shall be typed above the name, and title of all persons signing the agreement
should be typed directly below their signature.
When the applicant is not a corporation, then his signature must be witnessed by one person. The
address should be included in this agreement and the names of all persons signing the agreement
should be typed directly below their signature.
This agreement must be accompanied, in the form of an attachment, by plans or drawings showing the
following applicable information:
1. All roadways and ramps.
2. Right of way lines and where applicable, the control of access lines.
3. Location of the proposed encroachment.
4. Length and type of encroachment.
5. Location by highway survey station number. If station number cannot be obtained, location
should be shown by distance from some identifiable point, such as a bridge, road,
intersection, etc. (To assist in preparation of the encroachment plan, the Department's
roadway plans may be seen at the various Highway Division Offices, or at the Raleigh
office.)
6. Drainage structures or bridges if affected by encroachment.
7. Typical section indicating the pavement design and width, and the slopes, widths and
details for either a curb and gutter or a shoulder and ditch section, whichever is applicable.
8. Horizontal alignment indicating general curve data, where applicable.
9. Vertical alignment indicated by percent grade, P.I. station and vertical curve length, where
applicable.
10. Amount of material to be removed and/or placed on NCDOT right of way, if applicable.
11. Cross -sections of all grading operations, indicating slope ratio and reference by station
where applicable.
12. All pertinent drainage structures proposed. Include all hydraulic data, pipe sizes, structure
details and other related information.
13. Erosion and sediment control.
14. Any special provisions or specifications as to the performance of the work or the method of
construction that may be required by the Department must be shown on a separate sheet
attached to encroachment agreement provided that such information cannot be shown on
plans or drawings.
15. The Department's Division Engineer should be given notice by the applicant prior to actual
starting of installation included in this agreement.
16. Method of handling traffic during construction where applicable.
17. Scale of plans, north arrow, etc.

WELL CONSTRUCTION DETAIL
Well ID Project Name
Project Number
FI=
22580285D A I
Proposed MW-10 48461_D&M Grocery
S&ME Staff Installation Date
County
City
Well Permit Number
- To be installed
Stokes
Sandy Ridge
Application
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Innovative Environmental Technologies, Inc.
-
-
Flush Monitor Well
Water Level at TOB (0.01 ft- BTOC)
Date/Time
Latitude
Land Surface Elev. (0.01 ft)
Drilling Method
-
-
-
-
Hollow Stem Auger
Depth to Water (0.01 ft- BTOC)
Date/Time
Longitude
Total Well Depth (0.1 ft-bgs)
Borehole Diameter (1 in)
-
-
-
42.0
8-inch
TOC Relative to Ground 0.0 ft
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
Depth Below Ground Surface (ft-bgs
2-in Sch 40 PVC
Top of Seal - 3.0 0.1 ft-bgs
Casing Interval (0.1 ft-bgs)
0.0
to
27.0
Screen Type
2-in Sch 40 PVC (0.010)
Screen Interval (0.1 ft-bgs)
27.0
1 to
1 42.0
Grout Type
Top of Filter Pack - 25.0 0.1 ft-bgs
Portland Cement T2
Grout Interval (0.1 ft-bgs)
Top of Screen - 27.0 0.1 ft-bgs
0.0
to
F 3.0
Seal Type
Screened Interval - 15.0 0.1 ft-bgs
Bottom of Screen - 42.0 0.1 ft-bgs
3/8 in. Holeplug®
Seal Interval (0.1 ft-bgs)
3.0
to
25.0
Filter Pack
#2 Silica Sand
Filter Pack Interval (0.1 ft-bgs)
25.0
1 to
1 42.0
Development
Bottom of Filter Pack - 42.0 0.1 ft-bgs
Cave In - 0.1 ft-bgs
Total Boring Depth - 42.0 0.1 ft-bgs
Development Volume (gal)
Notes: Monitoring well permit application for MW-10; NCDOT Right -of -Way; 6066 NC 704 Highway East.
BTOC - Below Top of Casing
TBD - To Be Determined
For lithologic information
see attached boring log
Form Revision Date: 9/1/17 2:10 PM

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SOURCE: 2022 STOKES COUNTY, NC PARCEL DATA DOWNLOADED FROM NC ONEMAP
LEGEND
® LOCATION OF OBSERVED APPARENT WELL STRUCTURE
® APPROXIMATE WELL LOCATION (NOT OBSERVED)
0 400 800
GRAPHIC SCALE (IN FEET)
her
W L
L
0 C
c
Lu " [
0
r7 Z
Lu F
0
W U u
Z
e
3
SCALE:
AS SHOWN
DATE:
MARCH 2O23
PROJECT NUMBER
22580285
FIGURE N0.
i'