WM0401476_Groundwater monitoring well construction application_20230814

DocuSign Envelope ID: F209CFD3-A978-4863-8AB4-7B1712A8EBOO IJMENTAL QUALITY - DIVISION OF WATER RESOURCES
YVR 1 fl VFIRV LIIYPI L/CrF1R I IYI CIY 1 Vr CIY V IRVI
APPLICATION FOR PERMIT TO CONSTRUCT A MONITORING OR RECOVERY WELL SYSTEM
PLEASE TYPE OR PRINT CLEARLY
1.
2.
3.
4.
5.
6.
7.
8.
9.
10
11
12
13
14
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: 04/04/2023
County: Surry
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring
Applicant: Speedway, LLC Telephone: [phone]
Applicant's Mailing Address: PO Box 1500, Springfield, OH 45501
Applicant's Email Address (if available): Samuel Kramer
Contact Person (if different than Applicant): Nathan Pinsker Telephone: [phone]
Contact Person's Mailing Address: 5438 Wade Park Boulevard, Suite 200, Raleigh, NC 27607
Contact Person's Email Address (if available): Nathan. Pinskeraaecom.com
Property Owner (if different than Applicant): Williams Properties II LLC Telephone: Unknown
Property Owner's Mailing Address: 331 High Street, Winston-Salem, NC 27103
Property Owner's Email Address (if available):
Property Physical Address (Including PIN Number) 1012 Rockford Street (592907599739)
City Mount Airy County Surry Zip Code 27030
Reason for Well(s): Assessment
(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: Gasoline station
(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).
No
Type of contaminants being monitored or recovered: Organics
(ex: organics, nutrients, heavy metals, etc.)
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).:
Distance from proposed well(s) to nearest known waste or pollution source (in feet): 50
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: Geologic Resources, Inc. Certification No.: 1270
Well Contractor Address: 3502 Hayes 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

DocuSign Envelope ID: F209CFD3-A978-4863-8AB4-7B1712A8EBOO
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? NA
material: 6
3. Number of wells to be constructed in bedrock:
6. Estimated beginning construction date: 4/10/23
4. Total Number of wells to be constructed: 6 7. Estimated construction completion date: 4/10/23
(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. 143-215.10B(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.
Signature of Applicant or *Agent
Samuel Kramer
Printed name of Applicant or *Agent
Manager, Environmental Services
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
Es
UocuSigQ10jWre that the well(s) will be located, constructed, maintained, and abandoned in accordance with 15A NCAC 02C.
ftp" I— �� 5� �� Stephen T. Williams, Sr.
i�MUIV&Uperty 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 Avenue
Mooresville, NC 28115
Phone: [phone]
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)

,.F -. IA i

Ali * c AA a.,,a., 6949
DocuSign Envelope ID: F209CFD3-A978-4863-8AB4-7B1712A8EBOO WELL ID: Temporary Well
_ Project Number:
A.
Site Location: 1012 Rockford Street Mount Airy, NC Date Installed:
Well Location: Coords: Inspector:
Method: Direct Push Technology (geoprobe) Contractor: Geologic Resou
Proposed Monitoring Well Construction Log
Top of Riser Pipe
Ground Surface (G.S.)
Length
Diameter (ID)
Type of Material PVC
Thickness Sch 40
Top of Sand
Top of Screen
. Stabilized Water Level
Screen:
Length
Diameter (ID)
Slot Size
Type of Material
Thickness
Type/Size of Sand
Sand Pack Thickness
Bottom of Screen
Bottom of Tail Pipe:
Bottom of Borehole
Borehole Diameter
Describe Measuring Point:
5'
15
V
Sch 40
2.5"
Depth from G.S. (feet)
Signature Date
HE
0.0
TBD
25 ft bgs
25 ft bgs
25 ft bas
Inc.
Elevation (feet)
Datum