WM0501575_Final Permit_20230817

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
ROY COOPER Governor
ELIZABETH S. BISER
Secretary
RICHARD E. ROGERS, JR. NORTH CAROLINA
Director Environmental Quality
August 17, 2023
Ms. Linda Blalock
North Carolina Department of Environmental Quality
State Lead Program
1646 Mail Service Center
Raleigh, NC 27699-1646
Sent Via Email
Subject: Monitoring Well Construction
Permit # WM0501575
White Oak Convenience Mart (Incident #7036)
2932 Fishing Creek Road
Enfield, NC 27823 — Halifax County
Ms. Blalock:
In accordance with the application received on July 25, 2023, we are forwarding herewith
Monitoring Well Construction Permit No. WM0501575 dated August 17, 2023, issued for the construction
of a monitoring well. Please be aware that some counties have well construction programs, and you
may be required to obtain a well construction permit before installation.
This Permit will be effective from the date of its issuance and shall be subject to the conditions
and limitations as specified therein. Please note the addition of stipulation #3 to the permit enclosed. If
you have any questions about this permit, please contact Michael Hall at [phone] or via email at
[e-mail].
Sincerely,
ocuSigned by:
1�D
& f.
2916E6AB32144F...
Vanessa E. Manuel, Assistant Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Enclosure
-Permit
cc: RRO Files/Laserfiche
D E Q ,fJ North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1611 Mail Service Center I Raleigh, North Carolina 27699-1611
NORTH CAROLINA (J1(�.'�O'�.(�OQO
Department of Emlmnmenfal Duali�

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable Laws,
Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
North Carolina Department of Environmental Quality —State Lead Program
FOR THE CONSTRUCTION OF A MONITORING WELL owned by North Carolina Department of
Environmental Quality State Lead Program, at mailing address 1646 Mail Service Center, Raleigh, NC
27699-1646. The wells will be located on the property owned by Bernard and Gladys Brinkley at 1792
White Oak Road (Parcel #0100577), Enfield, NC 27823. This Permit is issued in accordance with the
application received on July 25, 2023, in conformity with specifications and supporting data, all of which
are filed with the Department of Environmental Quality and are considered integral parts of this Permit.
This Permit is for well construction only and does not waive any provision or requirement of any other applicable law or
regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina Well
Construction Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and regulations pertaining
to well construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing
upon written request within 30 days of receipt of this Permit. The request must be in the form of a written petition
conforming to Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative Hearings,
6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit is final and
binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions,
limitations, or exceptions as follows:
1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are being
installed as part of an investigation for contamination from an underground storage tank or dry cleaner
incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by
another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the Permit
application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C .0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC 02C
.0113 and a well abandonment record (GW-30) shall be submitted to the Division of Water Quality's
Information Processing Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet of
the well shall be grouted within one day after the casing is set or the well abandoned.
ocuSigned by:
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& f, �l.atn.ttit,(,2916E6AB32144F...
Scott Vinson, Regional Supervisor
Division of Water Resources
By Authority of the Environmental Management Commission
Permit Number: WM0501575
Permit Issued: August 17, 2023
D E Q �J North Carolina Department of Environmental Quality I Division of Water Resources
512 North Salisbury Street 1 1611 Mail Service Center I Raleigh, North Carolina 27699-1611
NORrH CAROLINA �/ 919.707.9000
oepanmem or environmental auaii

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
Aff
AkT
—AN ATLAS COMPANY-
July 25, 2023
Mr. Tyler Clark
Raleigh Regional Office
North Carolina Department of Environmental Quality
Water Quality Regional Operations Section
1628 Mail Service Center
Raleigh, North Carolina 27699-1628
Re: Permit to Construct Monitoring Wells
White Oak Convenience Mart
2932 Fishing Creek Road
Enfield, Halifax County, North Carolina
NCDEQ Incident No. 7036
Dear Mr. Clark:
2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina 27604
Telephone [phone]
Fax [phone]
www.atcgroupservices.com
Enclosed please find one application for a permit to construct one monitoring well. The monitoring
well will be installed at a property located at 1792 White Oak Road (Parcel No. 0100577/Parcel ID
No. 3838-00-78-2314) in Enfield, Halifax County, North Carolina. The permit application, site map
with the proposed location of the monitoring well, well construction details, and other relevant
information are enclosed as attachments. Please review this package and return the approved
permit to this office.
If you have any questions or require additional information, please contact our office at (919) 871-
0999.
Sincerely,
ATC Associates of North Carolina, P.C.
Nick Kramer
Project Scientist
Direct Line: 919-820-7051
Email: Nicholas. Krameraoneatlas.com

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
IYVRI rl VriRVLIIY/1 Uu_r/1RI Iflu-m 1 yr Crvvir% jAMENTAL 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:
2. County:
PERMIT NO.
FOR OFFICE USE ONLY
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Linda Blalock Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699-1646
ISSUED DATE
Applicant's Email Address (if available): linda.blalock(c�deg.nc.gov
5. Contact Person (if different than Applicant): Nick Kramer Telephone: [phone]
Contact Person's Mailing Address: 2725 E. Millbrook, Suite 121, Raleigh, NC 27604
Contact Person's Email Address (if available): Nick.Kramer(a).oneatlas.com
6. Property Owner (if different than Applicant): Bernard and Gladys Brinkley Telephone: [phone]
Property Owner's Mailing Address: 870 Lake Front Drive, Sacramento, CA 95831
Property Owner's Email Address (if available): gladysbrinkley(a)comcast.net
7. Property Physical Address (Including PIN Number) 1792 White Oak Road (Parcel #0100577/PIN #3838-00-78-2314)
City Enfield County Halifax Zip Code 27823
8. Reason for Well(s): Suspected Groundwater Contamination
(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).
NCDEQ UST Incident #7036
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? Yes, 7
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
3. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 175
4. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): Three inactive wells exist: WSW-7 on the property the proposed well is being installed
(approximately 100-feet away); WSW-3 approximately 200-feet away: WSW-15 approximately 300 feet away: and one potable
well, WSW-12, approximately 350-feet away
15. Well Contractor: Geologic Exploration, Inc. Certification No.: 4459-A
Well Contractor Address: 176 Commerce Boulevard, Statesville, NC 28625
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

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
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 well cap, 8"
material: 1 flush mount manhole cover.
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 08/22/2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 08/22/2023
(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. 143-215.10B(5), landfills, or other waste disposal areas) within 500 feet
of the proposed well or well system.
SIGNATURES
The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
this Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
Subchapter 2C) and accepts full responsibility for compliance with these rules
Signature of Applicant or *Agent Title of Applicant or *Agent
Nicholas Kramer (Agent for NCDEQ State Lead) * 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 See attached access 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
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
ial Office
I
05

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
'AIT
Wk C
ASSOCIATES OF NORTH CAROLINA, P.C.
June 30, 2023
Bernard C, and Gladys B. Brinkley
870 take Front Drive
Sacramento, California 95831
Subject: Access Agreement for Environmental Assessment
White Oak Convenience Mart
2932 Fishing Creels Road
Enfield, Halifax County, North Carolina
NCDEQ Incident No. 7036
Dear Mr, and Mrs, Brinkley:
2725 E. Millbrook Road, Suite 121
Raleigh, NC 27604
Telephone [phone]
www.atcgroupsewises, oom
ATC Associates of North Carolina, P.C. (ATC), on behalf of the North Carolina Department of Environmental
Quality (NCDEQ), is conducting an environmental assessment at the White Oak Convenience Mart site located
at 2932 Fishing Creek Road in Enfield, Halifax County, North Carolina. As part of the assessment activities,
ATC is requesting permission to access your property located at 1792 White Oak Road (Parcel # 0100577/
PIN #3838-00-78-2314) in Enfield, North Carolina for the purpose of conducting an assessment and/or
remediation of the groundwater and/or soils. A map showing the location of your property in reference to
the site property and the location of the proposed monitoring well is included following this fetter,
You, as the property owner, will not be held responsible or held liable for any damages or expenses for
injury to persons or property while ATC is on the premises.
Please provide your authorization and approval by signing the attached signature page in the enclosed
envelope by July 31, 2023. Acknowledgement of this form is required by NCDEQ. Denial of site access will
be forward to NCDEQ for their pursuit of site access.
If you have any questions regarding these activities, please do not hesitate to contact Nick Kramer with ATC
at nicholas.kramerna.oneatlas.com or [phone] or Linda Blaylock with NCDEQ at
linda.bla lock ncdenr. ov.
Sincerely,
ATC Associates of North Carolina, P.C.
Nick Kramer
Project Scientist
Enclosures:
1. Signature Page
2. Map of Proposed Monitoring Well Locations

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
19
fAFy1VTC White Oak Convenience Mart— Incident #7036
ASSOCIATES OF NORTH CAROLINA, P.C.
Response to access request for 1792 White Oak Road, Enfield, North Carolina for Incident #7036:
❑ " Access approved.
❑ Access denied.
Name 1,4
Signature '
Email �c� G'� ( f'77yt 1V'
Telephone Number / GC

DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
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DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
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DocuSign Envelope ID: EDAD74DC-7760-410E-B15F-728E28EC68D1
■CI
MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
sch 40 PVC
CASING DIAMETER
8 inches
X.
CASING LENGTH
12 inches
PAD DIMENSIONS
2 feet x 2 feet
HEIGHT ABOVE GROUND
flush mounted
L2
L3
L1 =
0
FT.
L2 =
10
FT.
L3 =
10
FT.
L4 =
20
FT.
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 15 feet
BACKFILL AROUND CASING
MATERIAL cement grout
THICKNESS 10 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 3 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 feet
WELL SCREEN
SCREEN MATERIAL sch 40 PVC
DIAMETER 2 inches
LENGTH 10 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL 25 feet
DEPTH TO BOTTOM OF
BOREHOLE 25 feet
DIAMETER OF BOREHOLE 6 inches
TITLE Monitoring Well
White Oak Convenience Mart AA 2725 East Millbrook Road
2932 Fishing Creek Road ■ Suite 121
WIRRIIMENTAL • BEOTECNBICAL
Enfield, Halifax County IIIIILOINCSCIENCES- NAFERIALSTESTINS Raleigh, North Carolina 27604
North Carolina
FILE PREP. BY REV. BY DATE PROJECT NO.
N K GA 7/21 /2023 STL0703601