WM0401492_Application_20231127

AECOM AECOM Technical Services of North Carolina, Inc. [phone] tel
6000 Fairview Road,Suite 200
Charlotte,NC 28210
October 26, 2023
Mr. Jim Gonsiewski
Winston-Salem Regional Office
Division of Water Resources
Water Quality Regional Operations Section
Re: Monitoring Well Permit Applications
MW-17M,MW-17R,MW-19M,and MW-19D
Colonial Pipeline Company-Lexington Booster Station
667 Helmstetler Road,Lexington,Davidson County,NC
NCDEQ Incident Number: 95267
Dear Mr. Gonsiewski:
On behalf of Colonial Pipeline Company,AECOM Technical Services of North Carolina, Inc. (AECOM)
has prepared the attached permit application in accordance with 15A NCAC 2C .0105. This well permit
application is for the construction of 4 monitoring wells (MW-17M, MW-17R, MW-19M, and MW-19D)
in association with NCDEQ Incident Number 95267, the Colonial Pipeline Company Lexington Booster
Station(site)located at 667 Helmstetler Road,Lexington,Davidson County,North Carolina. The proposed
temporary and permanent groundwater monitoring well locations are to be located on the following
properties:
• MW-17M and MW-17R:
Colonial Pipeline Company, 685 Helmstetler Road,Lexington,NC 27295
PIN 6705-03-41-5191,Parcel ID 180250000095
• MW-19M and MW-19D:
Colonial Pipeline Company,Helmstetler Road, Lexington,NC 27295
PIN 6705-04-50-2422,Parcel ID 1802500000098
Included herein are the Applications for Permit to Construct a Monitoring or Recovery Well System packets
for each of the aforementioned properties. Each packet includes Form GW-22MR, a map of the proposed
well locations, and general well construction diagrams.
Upon approval, please forward the monitoring well construction permit(s) to me at
jeff.hvozdikkaecom.com. If you have any questions or require additional information, please do not
hesitate to call me at 412-977-4074.
Sincerely,
AECOM TECHNICAL SERVICES OF NORTH CAROLINA,INC.
Jeffrey T. Hvozdik,PG
Project Manager

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: 26 October 2023
2. County: Davidson PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: Colonial Pipeline Company Telephone: [phone]
Applicant's Mailing Address: 1000 Lake Street,Alpharetta, GA 30009
Applicant's Email Address(if available): dreedv(a)colpipe.com
5. Contact Person(if different than Applicant): Jeff Hvozdik(AECOM) Telephone: [phone]
Contact Person's Mailing Address: 6000 Fairview Road,Suite 200, Charlotte, NC 28210
Contact Person's Email Address(if available): ieff.hvozdik(a-)-aecom.com
6. Property Owner(if different than Applicant): Colonial Pipeline Company Telephone:
Property Owner's Mailing Address: 1185 Sanctuary Pkwy, P.O. Box 1624,Alpharetta,GA 30009-1624
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number) 685 Helmstetler Road(PIN 6705-03-41-5191)
City Lexington County Davidson Zip Code 27295
8. Reason for Well(s): Assessment,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: Pipeline booster 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).
NCDEQ Incident Number 95267
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? 52(total wells)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0400963,WM0400885,WM0401041,WM0401042,WM0401043
WM0401241,WM041242,WM0401243,WM0401244,WM0401245,WM0401250,WM0401251
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Approximately 400 ft
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? 2
If yes,give distance(s): One—200 feet SW(WSW-07),one—360 feet SE(WSW-06),WSW-21 (abandoned)
15. Well Contractor: Geologic Exploration Certification No.: Varies by individual driller
Well Contractor Address: 176 Commerce Boulevard,Statesville, NC 28625
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? Locking cap
material: 1
3. Number of wells to be constructed in bedrock: 1 6. Estimated beginning construction date: December 2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date:December 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
Signatur6 of Applicant or*Agent Title of Ap ca or Agent
*If signing as Agent, attach authorization agreement stating
Printed naPne of Appli ant 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
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s)conform to the Well Construction Standards(Title 15A of the North Carolina Administrative Code,Subchapter 2C).
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 Raleigh Regional Office
Swannanoa, NC 28778 3800 Barrett Drive Wilmington Regional Office
Phone: [phone] Raleigh, NC 27609 127 Cardinal Drive Extension
Fax: [phone] Phone: [phone] Wilmington, NC 28405
Fax: [phone] Phone: [phone]
Fayetteville Regional Office Fax: [phone]
225 Green Street,Suite 714 Washington Regional Office
Fayetteville, NC 28301-5094 943 Washington Square Mall Winston-Salem Regional Office
Phone: [phone] Washington, NC 27889 450 W.Hanes Mill Road
Fax: [phone] Phone: [phone] Suite 300
Fax: [phone] Winston-Salem_, NC 27105
Mooresville Regional Office - 6-9800
610 East Center Avenue W'" I° 797
Mooresville, NC 28115
ft al gh l�
Phone: [phone] A
Fax: [phone] t
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GW-22MR Rev.3-1-2016

I I I =�/ r I I _ I /� \ N
LEGEND
wsw-os ! II—
Release Point I I —i I — — — _ _ O i
0 Proposed Deep Monitoring Well Location
A Proposed Intermediate Monitoring Well Location
® Proposed Shallow Monitoring Well Location
0 Deep Monitoring Well Location _ _ _ L Wswoe
A Intermediate Monitoring Well Location I — _ —I �_• _�/ / \ \ \ \ /
• Shallow Monitoring Well Location
O Water Supply Well- In Use WSW-23
Q0 Water Supply Well-Not In Use I — _ — — — _
® Water Supply Well-Abandoned I — — — _ I I I I 1 L I J_
Approximate Location of Pipeline
-- Parcel Lines
Roadway Centerlines
Major Hydrography ' yWSW-4
Minor Hydrography CS
W o ewsw ' rF —
I
Approximate area of known NC 2L Standard ' SW �
—47--T
Exceedance(Dec. 2022) / _ o SW-02 ' 4 I W® 6
_ MW-20D7 / _
Notes:
Site features based on"Site Plan"from Apex CAD No. WSW-22
MW_3
CPC18000.003, 1/30/18 \ I / MZ • MW-29 I W30
Pipeline location based on images provided by Colonial > / o / _ MW-30"C-30M O
Pipeline Company on 8/1/19 / / WS®17 / • W®-01 \ /
Parcel lines and centerlines obtained from Davidson MW 4 25 /�� / r
MW-36D ��� MW 4 W-5D •
County Information Technology/GIS (http://www2.co.da- _ •� 7 M MW_21M /
vidson.nc.us/GIS/Web GISDownloads.aspx)on 2/7/19 — — _ MW:1
Aerial photography obtained from NC OneMap(http://da- e ` r T _ M;19 WSW-20® MW-26 I _
ta.nconemap.gov/geoportal/catalog/raster/down load.page) LMw\D`�I \ a)
on 2/18/19 I 1 _— MW-28• MW-,5 ` /
Major hydrography and other hydrography obtained from 1 w® 9 1 % ` / /\ \ MW-,SDI
City of Lexington (https://Iexington.connectgis.com/- !' WW-21 /-' e / \ MW-23D
Map.aspx)on 2/14/19 \ '0
•MW-18 WSW-06 L �_ / i+
e / \ MW-°MI
- M _
W-17 \ / r-
/ OMW-31M
MW-31.OMW-31D ` C
1 / / WS0-07 I ®w3w_1-6A
MW-35D[J �� / MW-17R ®wsw-1613 ` Q
I MW-35M/ <DAMW-17M I ~MW U)
` \ 1 1
I/ .�\iMW-16D 1 Q
I / W-33D Mw_ /\ �\ Q
MW-33M�
MW32W-32D 'Y ,
MW-32M ,
MW-34D
- e\ / /\ a \\ z
4.
57<
wsw.,, ~°0M
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WSW-,z� Z J
l
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�———
1 J--JOl1J
WSW-13® \ / / I APPROX.SCALE,ft. 0 W LU O Q
/ / / UJ2d�

Shallow Monitoring Well
2' X 2' CONCRETE PAD Diagram
GROUND SURFACE MAN HOLE COVER OR STICK UP
LOCKING WELL CAP
6" PVC OUTER CASING
Approximately 21'
2" DIAMETER SCH 40 PVC RISER
A.
a ,
NEAT CEMENT OR CONCRETE—GROUT
0
J
0 2t BENTONITE WELL SEAL
un
2'
J
W
Q _
X -
O
Q _
No. 2 SILICA SAND FILTER PACK
20'
_ 2" DIAMETER SCH 40 PVC
0.010" MACHINE SLOT SCREEN
NOTE: DRAWING NOT TO SCALE
Issue Status: PROPOSED
Colonial Pipeline Company
PROPOSED SHALLOW MONITORING WELL CONSTRUCTION DIAGRAM AMOM
667 HELMSTETLER ROAD
LEXINGTON, NORTH CAROLINA

Intermediate Monitoring Well
2' X 2' CONCRETE PAD Diagram
GROUND SURFACE MAN HOLE COVER OR STICK UP
LOCKING WELL CAP
Approximately 56' ~6" PVC OUTER CASING
2" DIAMETER SCH 40 PVC RISER
q
NEAT CEMENT OR CONCRETE—GROUT
0
J
0 2' BENTONITE WELL SEAL
0 2'
J
W
Q _
X -
O
d
Q _
No. 2 SILICA SAND FILTER PACK
10'
_ 2" DIAMETER SCH 40 PVC
0.010" MACHINE SLOT SCREEN
NOTE: DRAWING NOT TO SCALE
Issue Status: PROPOSED
Colonial Pipeline Company
PROPOSED INTERMEDIATE MONITORING WELL CONSTRUCTION DIAGRAM AMOM
667 HELMSTETLER ROAD
LEXINGTON, NORTH CAROLINA

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: 26 October 2023
2. County: Davidson PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: Colonial Pipeline Company Telephone: [phone]
Applicant's Mailing Address: 1000 Lake Street,Alpharetta,GA 30009
Applicant's Email Address(if available): dreedy(cDcolpipe.com
5. Contact Person(if different than Applicant): Jeff Hvozdik(AECOM) Telephone: [phone]
Contact Person's Mailing Address: 6000 Fairview Road,Suite 200, Charlotte, NC 28210
Contact Person's Email Address(if available): Ieff.hvozdikC�_)aecom.com
6. Property Owner(if different than Applicant): Colonial Pipeline Company Telephone:
Property Owner's Mailing Address: 1185 Sanctuary Pkwy, P.O. Box 1624,Alpharetta,GA 30009-1624
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number) Helmstetler Road(PIN 6705-04-50-2422)
City Lexington County Davidson Zip Code 27295
8. Reason for Well(s): Assessment,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: Pipeline booster station
(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 Incident Number 95267
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? 52(total wells)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0400963,WM0400885,WM0401041,WM0401042,WM0401043,
WM0401241,WM041242,WM0401243,WM0401244,WM0401245,WM0401250,WM0401251
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Approximately 400 ft
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? 1
If yes,give distance(s): One—380 feet SE(WSW-06),WSW-20 and WSW-21 abandoned
15. Well Contractor: Geologic Exploration Certification No.: Varies by individual driller
Well Contractor Address: 176 Commerce Boulevard,Statesville, NC 28625
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? Locking cap
material: 1
3. Number of wells to be constructed in bedrock: 1 6. Estimated beginning construction date: December 2023
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date:December 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 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
Signfatur of Applicant r*Agent Title of Ap lica t or Agent
I`A(e, If signing as Agent,attach authorization agreement stating
Printed hame of A plicant 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
wells as outlined in this Well Construction Permit application and that it shall be the responsibility of the applicant to ensure that the
well(s)conform to the Well Construction Standards(Title 15A of the North Carolina Administrative Code, Subchapter 2C).
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 Raleigh Regional Office
Swannanoa, NC 28778 3800 Barrett Drive Wilmington Regional Office
Phone: [phone] Raleigh, NC 27609 127 Cardinal Drive Extension
Fax: [phone] Phone: [phone] Wilmington, NC 28405
Fax: [phone] Phone: [phone]
Fayetteville Regional Office Fax: [phone]
225 Green Street,Suite 714 Washington Regional Office
Fayetteville, NC 28301-5094 943 Washington Square Mall Winston-Salem Regional Office
Phone: [phone] Washington, NC 27889 450 W. Hanes Mill Road
Fax: [phone] Phone: [phone] Suite 300
Fax: [phone] Winston-Salem_, NC 27105
Mooresville Regional Office Win Sale 6-9800
610 East Center Avenue 797
Mooresville, NC 28115 ✓L al
Phone: [phone]
Fax: [phone] ✓ p '
(e r le
F eM rMe t vJ
Will ngton
r
GW-22MR Rev.3-1-2016

LEGEND I I I WSW-o®
Release Point I --i
0 Proposed Deep Monitoring Well Location
A Proposed Intermediate Monitoring Well Location
® Proposed Shallow Monitoring Well Location
0 Deep Monitoring Well Location
0 Intermediate Monitoring Well LocationWSW-..
�A
Shallow Monitoring Well Location
O Water Supply Well- In Use I f—w.,W-23
I \ \
Q0 Water Supply Well-Not In Use
® Water Supply Well-Abandoned J_
Approximate Location of Pipeline r — r
-- Parcel Lines
Roadway Centerlines
Major Hydrography ' _ yWSW-4
Minor Hydrography o eWSW
Approximate area of known NC 2L Standard ' I LWSWW-4 — �—
Exceedance(Dec. 2022) / _ oSW-02 ' 14 �
I w® e 1 _,~
_
Notes:
Site features based on"Site Plan°from Apex CAD No. \\ / I / /, - MW_3 M / I WSW-22
CPC18000.003, 1/30/18 / MW- •
\ I / MW-29 - I W-30
Pipeline location based on images provided by Colonial > o MW-30"e.W-30M l /
Pipeline Company on 8/1/19 / / WS-17 / / • ® \ / /��. �/ O
Parcel lines and centerlines obtained from Davidson MW-36D.— _ o / MW 4 W MW 4 Mw25 i WSW-o1 I \ / \` t
7
County Information Technology/GIS (http://www2.co.da- _ _ _ 5D
MW_21M \/ / C�
vidson.nc.us/GIS/Web_GISDownloads.aspx)on 2/7/19 — _ ._ MW 11 MW iM ^ / / `\� I J
Aerial photography obtained from NC OneMap(http://da- e ` r M* MW-19D WSW-20ED MW-26
ta.nconemap.gov/geoportal/catalog/raster/down load.page) _ _ � y
MW-iSDD
on 2/18/19 _ _ I L MW-19M Mw-26* / g W-15
Major hydrography and other hydrography obtained from 1 W®SW 9 1 % /e \ MW-,5D — —y
City of Lexington (https://Iexington.connectgis.com/- !' WW-21 — / I L-23D
Map.aspx)on 2/14/19 MW 18
• WSW-06AW
® 17 / \ \W EMI fl\ / ! MW-17 OMW-31M \/MW-31.OMW-31D O
/ 1 W9OW-07 /\ ®WSW-,-6n )))�---
MW-35D[i a ®WSW-166 I w ` Q
/ MW-35M
CL
1 '_ /a MW-16D O
_MW-33DMW- \ ' A
MW-33M
M 32a � Y ,MW-32M {
MW-34D / �\ - 1 1 /1
�MW-34M / \ �.� I tJ
Lam\ / /4. \\ / �v / x
co
WSW.,, / / \ / I I N J o C)M
/ A o
WSW-12*- Z J \
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0 400 OZU)w�
1 `
\ / J-�0lil
WSW-130 A APPROX.SCALE,ft. O W w W Q
/ / UJ77n

Intermediate Monitoring Well
2' X 2' CONCRETE PAD Diagram
GROUND SURFACE MAN HOLE COVER OR STICK UP
LOCKING WELL CAP
Approximately 56' ~6" PVC OUTER CASING
2" DIAMETER SCH 40 PVC RISER
q
NEAT CEMENT OR CONCRETE—GROUT
0
J
0 2' BENTONITE WELL SEAL
0 2'
J
W
Q _
X -
O
d
Q _
No. 2 SILICA SAND FILTER PACK
10'
_ 2" DIAMETER SCH 40 PVC
0.010" MACHINE SLOT SCREEN
NOTE: DRAWING NOT TO SCALE
Issue Status: PROPOSED
Colonial Pipeline Company
PROPOSED INTERMEDIATE MONITORING WELL CONSTRUCTION DIAGRAM AMOM
667 HELMSTETLER ROAD
LEXINGTON, NORTH CAROLINA

Deep Monitoring Well
2' X 2' CONCRETE PAD Diagram
GROUND SURFACE MAN HOLE COVER OR STICK UP
LOCKING WELL CAP
Approximately 75' 6" PVC OUTER CASING
4 2" DIAMETER SCH 40 PVC RISER
CONCRETE-GROUT
NEAT CEMENT OR CONCRETE-GROUT
0
Q Approximately 16'
0 2' BENTONITE WELL SEAL
0
0 2,
w -
Q
X -
O
CL
d -
Q _
No. 2 SILICA SAND FILTER PACK
5'
_ 2" DIAMETER SCH 40 PVC
0.010" MACHINE SLOT SCREEN
NOTE: DRAWING NOT TO SCALE
Issue Status: PROPOSED
Colonial Pipeline Company
PROPOSED DEEP MONITORING WELL CONSTRUCTION DIAGRAM AMOM
667 HELMSTETLER ROAD
LEXINGTON, NORTH CAROLINA