WM0401481_Application_20230928

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.
FOR OFFICE USE ONLY
1. Date: 09/25/2023
2. County: Alamance PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: NCDEQ Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699
Applicant's Email Address (if available): scott.ryalsc@.ncdenr.gov
5. Contact Person (if different than Applicant): Greg Hans Telephone: [phone]
Contact Person's Mailing Address: 3525 Whitehall Park Drive, Suite 150, Charlotte, NC 28273
Contact Person's Email Address (if available): ghans(a1ces-group.net
6. Property Owner (if different than Applicant): Bank of America Corporate Real Estate Telephone: N/A
Property Owner's Mailing Address: 101 N Tryon Street, Charlotte, NC 28255
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number:) 141 S Main Street PIN: 8884145010
City Graham County Alamance Zip Code: 27253
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: USTs
(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).
No known water quality permits. UST Incident No. 6853
11. Type of contaminants being monitored or recovered: organics / metals
(ex: organics, nutrients, heavy metals, etc.)
12. 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).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): To be installed within presumed Source
Area
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No known
If yes, give distance(s):
15. Well Contractor: Carolina Soil Investigation Certification No.: Corey Speece #2904 / Daniel
Summers #2579
Well Contractor Address: 132 Gurney Road, Olin, NC 28660
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? 2 x 2 pad, well
material: 1 covers, locking i-plua
3. Number of wells to be constructed in bedrock: 0
6. Estimated beginning construction date: 10/9/2023
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3) 7. Estimated construction completion date: Same Day
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
Greg Hans
Printed name of Applicant or *Agent
Environmental Division Manager
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 Access Agreement with NCDEQ State Trust Fund)
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
—' -----3-9800
797
GW-22M/R (Rev. 5-26-2022)

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ANNULUS

ROY COOPER NORTH CAROLINA
Uovernor Environmental Quality
ELIZABETH BISER
Secretary
MICHAEL SCOTT
Director
October 6, 2022
Bank of America
Corporate Real Estate Assessments
101 N Tryon Street
Charlotte, NC 28255
RE: State -Lead Acceptance
McClure Funeral Home
141 S Main Street
Graham, Alamance County, NC
Incident Number 6853
Dear Bank of America:
The Winston-Salem Regional Office (WSRO) has referred the subject release incident to the State
Underground Storage Tank (UST) Trust Fund Branch, State -Lead Program for inclusion on the list of
releases awaiting state -lead cleanup. In July 1991 during tank removal, soil and groundwater
contamination was detected at the former Wick's Mini Mart (see figure below). The lighter areas
represent the concrete coverings of the dispenser and tank areas. To date, the required assessment
and cleanup of the release have not been completed due to the dissolution of the company that
formerly owned the UST system, recalcitrance of the former UST system owner, or death of the former
UST system owner. Due to the potential presence of groundwater users within 1500 feet of the
release and based on the confirmation of contamination remaining at the release location, the subject
release incident is being accepted by the State -Lead program for inclusion on the list of releases
awaiting further assessment and cleanup and/or UST removal pursuant to G.S. 143-215.94G.
Currently, the risk of this release is "low". An assessment and, if necessary, a cleanup, will be
conducted as soon as funds are available to determine and alleviate impacts to the environment and
human health. The State -Lead Program contractor must access the property to conduct assessment
and cleanup activities, which may include the installation and sampling of monitoring wells, and
cleanup activities, Pursuant to G.S. 143-215.94A, based on the information currently available in our
files you are not considered to the responsible for the release.
„ter.; . �D_ End
North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 11646 Mail Service Center I Raleigh, North Carolina 27699-1646
919.707.8200

The UST Section would appreciate your approval for access to your property to conduct necessary
assessment and cleanup activities. Please note that pursuant to 15A NCAC .0106(b), failure to allow
the UST Section and/or their contractor to access your property to conduct the necessary assessment
and cleanup activities may result in a determination that you are controlling an activity which results
in the discharge of waste, and you may potentially be held responsible for assessment and cleanup
of the contamination.
Please review and sign the access agreement that is included. You will be notified before assessment
and/or cleanup activities begin.
Should there be any questions concerning this action, please contact Scott Ryals at [phone]
or via e-mail at scott.ryalsAncdenr. oovv .
Sincerely,
/l
\ Z�yne ndolph, CPM
Trust Fund Branch Head
CC: James Brown, WSRO (e-mail)
Alamance County Manager, Bryan Hagood, 124 W Elm St, Graham, NC 27253
Alamance County Health Director, Tony Lo Giudice, 319 N Graham -Hopedale Rd,
Burlington, NC 27217
WS-2820 6853 G ACCLTR 20221006
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North Carolina Department of Environmental Quality I Division of Waste Management
217 West Jones Street 1 1646 Mail Service Center I Raleigh, North Carolina 27699-1646
919.707.8200