WM0401463_Monitoring well construction permit application_20230725

Geological Resources, Inc.
July 20, 2023
Mr. Lon Snider
NCDEQ, Division of Water Resources
Winston Salem Regional Office
450 W. Hanes Mill Road, Suite 300
Winston-Salem, North Carolina 27105-7407
Re: Monitoring Well Permit Application
Rushco Food Store 8
1532 Yadkinville Road
Mocksville, Davie County
Incident No: 48104
GRI No: 5725
Dear Mr. Snider:
Please find enclosed a well permit application for the installation of one Type III telescoping well and three
Type II monitoring wells at the Rushco Food Store 8 located at 1532 Yadkinville Road in Mocksville, Davie
County.
Your prompt attention to this matter will be greatly appreciated. If you have any questions or require
additional information, please do not hesitate to contact me at [phone].
Sincerely,
Samuel L. McKay, III, P. G.
Project Manager
attachments
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]

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: 7/20/2023
2. County: Davie
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Rusher Oil Co., Inc. Telephone: [phone]
Applicant's Mailing Address: PO Box 1483, Salisbury NC 28145-1483
Applicant's Email Address (if available): 0rushera-bellsouth.net
5. Contact Person (if different than Applicant): Sam McKay Telephone: [phone]
Contact Person's Mailing Address: Geological Resources, Inc., 3502 Hayes Rd., Monroe NC 28110
Contact Person's Email Address (if available): smckayageologicalresourcesinc.com
6. Property Owner (if different than Applicant): Sampson Bladen Oil Company Inc. Telephone: [phone]
Property Owner's Mailing Address: PO Box 469, Clinton NC 28329-0469
Property Owner's Email Address (if available): howell.clarka-sampsonbladen.com
7. Property Physical Address (Including PIN Number) 1532 Yadkinville Road Parcel #H40000001301
City Mocksville County Davie Zip Code 27028
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: 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 # 48104
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? 1
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0401366
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): range from 20' to 100'
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: Justin Radford Certification No.: 3270A
Well Contractor Address: 3502 Hayes Road, Monroe NC 28110
PROPOSED WELL CONSTRUCTION INFORMATION
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? Locking
material: 4 expansion cap and bolt down manhole cover
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: June/July 2023
4. Total Number of wells to be constructed: 4 7. Estimated construction completion date: June/July 2023
(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 Applicant assumes total responsibility for ensuring that the well(s) will be located, constructed, maintained, and abandoned in
accordance with 15A NCAC 02C.
Protect Manager
Signature of Applicant or "Agent Title of Applicant or "Agent
Sam McKay. III / Geological Resources, 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 signed RTE Sampson-Bladen Oil Company Inc.
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]
Mooresville Regional Office
610 East Center A
Mooresville, NC 2£
Phone: (704) 663-
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
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)

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF DAVIE
RUSHCO FOOD STORE #8
GRI PROJECT NO. 5725
We, the undersigned, being all of the fee simple owners of certain tract or parcel designated as
H40000001301 of the County of Davie, recognizing the benefits to said property by reason of conducting
monitoring well installations hereby grant to the NCDEQI(Ruscho Food Store #8) and their agents the right
to enter said property in accordance with the requirements of the State of North Carolina. The
NCDEQ/(Ruscho Food Store #8) agents may include Geological Resources, Inc.
The undersigned hereby covenant and warrant that they are the sole owners of said property; that they solely
have the right to grant this right to enter for conducting the monitoring well installations against the lawful
claims of all persons whomsoever.
It is agreed that the NCDEQ/(Ruscho Food Store #8) shall be responsible for restoring any damage done to
the ground of said property by its employees or its agents during the monitoring well installations and
monitoring period, and that the NCDEQ/(Ruscho Food Store 48) shall abandon the monitoring wells on
said property in accordance with NCDEQ requirements after the incident has been closed_
It is agreed that the NCDEQ/(Ruscho Food Store #8) shall hold harmless the owner of the aforementioned
property for any personal injury that might be sustained during the course of conducting or proximately
resulting from the conduct of subsurface investigations.
Right to Enter denied.
✓ Right to Enter
Phone: ,F/6) 514 t1397
/Z VL
Date
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

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TYPE 11 MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PAD
GROUND SURFA CE
gQUT CEMENT —
ement from 0' - 22'
BENTONI TE SEAL
Seal from 22' - 24'
SAND FIL TER PACK
Filter pack from 24'
- 35'
MANHOLE COVER
(Borehole diameter
= 6"
LOCKING WELL CAP
M
a e4
2 INCH DIAMETER
SCHEDULE 40 PVC CASING
a
a,
Riser from 0' - 25'
Screen from 25' -
35'
0. 010 INCH SL 0TTED
2 INCH DIAMETER
SCHEDULE 40 PVC SCREEN
END CAP

TYPE /// MONITORING WE/ L
TYPICAL CONSTRUCTION DE T% IL S
MANHOLE COVER
CONCRETE PA
L OCKING WELL CAP
GROUND SURFACE
a
a
0' to 46' 44
GROUT CEMENT
a 0 2 INCH DIAMETER
° SCHEDULE 40 PVC CASING
a
a
46' to 48'
HEN TONITE SEAL
0' to 45'
INCH DIAMETER
SCHEDULE 40 PVC CASING
48' to 55'
SAND F/L TER PACK
50' to 55'
010 INCH SL 0 TIED
2 INCH DIAMETER
SCHEDULE 40 PVC SCREEN
otal Depth - 55' END CAP
NOTE.- NOT TO SCALE