WM0401493_Application_20231128

ENVIRONMENTAL • GEOTECHNICAL
BUILDING SCIENCES • MATERIALS TESTING
November 27, 2023
Ms. Shuying Wang
North Carolina Department of Environmental Quality
Winston-Salem Regional Office
Division of Water Resources
450 W. Hanes Mill Rd, Suite 300
Winston-Salem, North Carolina 27105
Re: Permit to Construct Temporary Monitoring Well
Wheeler's Grocery
9385-A US Highway 158
Reidsville, Rockingham County, North Carolina
NCDEQ Incident No. 14897
Dear Ms. Wang:
2725 E. Millbrook Road, Suite 121
Raleigh, North Carolina 27604
Telephone [phone]
Fax [phone]
www.atcgroupservices.com
Enclosed please find an application for a permit to construct six temporary 2-inch monitoring wells. The
temporary well will be installed in the NC DOT right-of-way in front of a property (PIN #098201353224)
located at 9385-A US Highway 158, Reidsville, Rockingham County, North Carolina. Following the
completion of the sampling activities, the well will be removed and the boring backfilled to the surface with
bentonite chips. 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 my office at [phone].
Sincerely,
ATC Associates of North Carolina, P.C.
Nick Kramer
Project Scientist
Direct Line: 919-820-7051
Email: Nicholas. Kramer(cD-oneatlas.com

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: 11 /27/2023
2. County: Rockingham I PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Temporary Monitoring
4. Applicant: Linda Blalock Telephone: [phone]
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Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address (if available): Ilnda.blaIock6a deg.nc.gov
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. Krameraoneatlas.com
Property Owner (if different than Applicant): Ronald Prater Telephone: [phone]
Property Owner's Mailing Address: 8892 US 158, Reidsville, NC 27320-7612
Property Owner's Email Address (if available):
Property Physical Address (Including PIN Number) 9385-A US Highway 158 (Parcel #0100577/PIN #3838-00-78-2314)
City Reidsville County Rockingham Zip Code 27823
Reason for Well(s): Groundwater assessment and remediation
(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: UST/petroleum
(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 UST Incident #14897
Type of contaminants being monitored or recovered: Petroleum
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 13
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
Distance from proposed well(s) to nearest known waste or pollution source (in feet): 200
Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): Attached is a potential receptor map — SW-17 is located 200 feet north of the site: SW-1, SW-2,
and SW-3 are located 300 feet, 380 feet, and 430 feet south of the site: SW-16 is located on the site and is inactive
15. Well Contractor: SAEDACCO Certification No.:
Well Contractor Address: 9088 Northfield Drive, Fort Mill, Scouth Carolina 29707
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 well cap,
material: 6 temporary construction
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 6
(add answers from 2 and 3)
6. Estimated beginning construction date: 12/12/2023
Estimated construction completion date: 12/13/2023
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
Signature of Applicant or *Agent
Agent for STL1489701
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 Raleigh Regional Office
Phone: [phone] Barrett Drive
Fax: [phone] Raleigh, NC 27609 Wilmington Regional Office
Phone: [phone] Cardinal Drive Extension
Fayetteville Regional Office Fax: [phone] Wilmington, NC 28405
225 Green Street, Suite 714 Phone: [phone]
Fayetteville, NC 28301-5094 Washington Regional Office Fax: [phone]
Phone: [phone] Washington Square Mall
Fax: [phone] Washington, NC 27889 Winston-Salem Regional Office
Phone: [phone] W. Hanes Mill Road
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
05

Ms. Linda Blalock
DWM UST Section
1637 Mail Service Ctr
Raleigh, NC 27699-1637
Dear Ms. Blalock:
RE: Site Access Agreement
Wheeler's Grocery
9385-A Hwy 158
Reidsville, Rockingham County
FTF #: 14897
I am/We are the owner(s) of a parcel of property, located at or near the incident in question, and hereby
permit the Department of Environment and Natural Resources (Department) or its contractor to enter upon said
property for the purpose of conducting an investigation of the groundwaters under the authority of G.S. 143-
215.3(a)2.
I am/We are granting permission with the understanding that:
The investigation shall be conducted by the UST Section of the Department's Division of Waste
Management .or its contractor.
2. The costs of construction and maintenance of the site and access shall be borne by the Department or its
contractor. The Department or its contractor shall protect and prevent damage to the surrounding lands.
3. Unless otherwise agreed, the Department or its contractor shall have access to the site by the shortest
feasible route to the nearest public road. The Department or its contractor may enter upon the land at
reasonable times and have full right of access during the period of the investigation.
4. Any claims which may arise against the Department or its contractor shall_ be governed by Article 31 of
Chapter 143 of the North Carolina General Statutes, Tort Claims Against State Departments and Agencies,
and as otherwise provided by law.
5. The information derived from the investigation shall be made available to the owner upon request and is
a public record, in accordance with G.S. 132-1.

6. The activities to be carried out by the Department or its contractor are for the primary benefit of the
Department and of the State of North Carolina. Any benefits accruing to the owner are incidental.
The Department or its contractor is not and shall not be construed to be an agent, employee, or
contractor of the landowner.
I/We agree not to interfere with, remove, or any way damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Signature
&n,f� J. 1�', r° gr4-x
Type/Print Name of Owner or Agent
Rex 14UV- 'lj-5
Address
ress
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Address
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City/State/Zip Code
Phone Number
Date

STATES',
-
STATE OF NORTH CAROLINA
DEPARTMENT OF TRANSPORTATION
Roy COOPER
GOVERNOR
November 21, 2023
ROCKINGHAM COUNTY
Linda Blalock, Environmental Engineer.
North Carolina Department of Environmental Quality
1646 Mail Service Center
Raleigh, NC 27699
J.R. "JOEY" HOPKINS
SECRETARY
SUBJECT: Encroachment Agreement E0730792300336-NCDEQ. Approval to erect
eight (8) vertical soil borings advanced to thirty (30) feet below ground
surface and up to six (6) temporary monitoring wells installed to a depth
of approximately twenty (20) feet below ground surface at address
9385 A US 158 in Reidsville.
Dear Ms. Blalock:
Attached is a Right of Way Encroachment Agreement which has been properly executed.
The Department of Transportation does not guarantee right-of-way on this road, nor will
it be responsible for any claim for damage(s) brought by any property owner by reason of
this installation.
Approval is contingent upon adhering to the attached special provisions.
If you need additional information, please advise.
Sincerely,
W. R. Archer, III, PE
Division Engineer
WA/ha
Cc: Bobby L. Norris, JR, PE, District Engineer.
Mailing Address: Telephone: [phone] Location:
NC DEPARTMENT OF TRANSPORTATION Fax: [phone] NORTH SCALES ST.
DISTRICT ENGINEER'S OFFICE Customer Service: 1.877-3684968 REIDSVILLE, NC 27320
PO BOX 1318
REIDSVILLE, NC27320 Website: www.ncdot.cov

713 0`7 q 2.30c733-6
STATE OF NORTH CAROLINA
ROUTE PROJECT COUNTY OF Rockingham County
DEPARTMENT OF TRANSPORTATION RIGHT OF WAY ENCROACHMENT AGREEMENT
FOR NON -UTILITY ENCROACHMENTS ON
-Al PRIMARY AND SECONDARY HIGHWAYS
North Carolina Department of Environmental Quality
THIS AGREEMENT, made and entered into this the 17 day of No ome= 20 23 by and between the Department
of Transportation, party of the first part; and the North Carolina Department of Environmental Quality
party of the second part,
W I T N E S S E T H
THAT WHEREAS, the party of the second part desires to encroach on the right of way of the public road designated as
Routes) US Highway 158 located immediately adjacent northwest of the intersection of
Monroeton Road and US Highway 158
with the construction and/or erection of: Eight vertical soil borings advanced to 30 feet below ground surface and up to six temporary
monitoring wells installed to a depth of approximately 20 feet below ground surface.
WHEREAS, it is to the material advantage of the party of the second part to effect this encroachment, and the
party of the first part in the exercise of authority conferred upon it by statute, is willing to permit the encroachment
within the limits of the right of way as indicated, subject to the conditions of this agreement;
NOW, THEREFORE, IT IS AGREED that the party of the first part hereby grants to the party of the second
part the right and privilege to make this encroachment as shown on attached plan sheet(s), specifications and
special provisions which are made a part hereof upon the following conditions, to wit:
That the said party of the second part binds and obligates himself to install and maintain the encroaching facility in such safe
and proper condition that it will not interfere with or endanger travel upon said highway, nor obstruct nor interfere with the proper
maintenance thereof, to reimburse the party of the first part for the cost incurred for any repairs or maintenance to its roadways
and structures necessary due to the installation and existence of the facilities of the party of the second part, and if at any time the
party of the first part shall require the removal of or changes in the location of the said facilities, that the said party of the second
part binds himself, his successors and assigns, to promptly remove or alter the said facilities, in order to conform to the said
requirement, without any cost to the party of the first part.
That the party of the second part agrees to provide during construction and any subsequent maintenance proper signs, signal
lights, flagmen and other warning devices for the protection of traffic in conformance with the latest Manual on Uniform Traffic
Control Devices for Streets and Hiohways and Amendments or Supplements thereto. Information as to the above rules and
regulations may be obtained from the Division Engineer of the party of the first part.
That the party of the second part hereby agrees to indemnify and save harmless the party of the first part from all damages
and claims for damage that may arise by reason of the instailation and maintenance of this encroachment.
It is clearly understood by the party of the second part that the party of the first part will assume no responsibility for any
damage that may be caused to such facilities, within the highway rights of way limits, in carrying out its construction and
maintenance operations.
That the party of the second part agrees to restore all areas disturbed during installation and maintenance to the satisfaction of
the Division Engineer of the party of the first part. The party of the second part agrees to exercise every reasonable precaution
during construction and maintenance to prevent eroding of soil; silting or pollution of rivers, streams, lakes, reservoirs, other water
impoundments, ground surfaces or other property; or pollution of the air. There shall be compliance with applicable rules and
regulations of the North Carolina Division of Environmental Management, North Carolina Sedimentation Control Commission, and
with ordinances and regulations of various counties, municipalities and other official agencies relating to pollution prevention and
control. When any installation or maintenance operation disturbs the ground surface and existing ground cover, the party of the
second part agrees to remove and replace the sod or otherwise reestablish the grass cover to meet the satisfaction of the Division
Engineer of the party of the first part.
That the party of the second part agrees to assume the actual cost of any inspection of the work considered to be necessary
by the Division Engineer of the party of the first part.
That the party of the second part agrees to have available at the encroaching site, at all times during construction, a copy of
this agreement showing evidence of approval by the party of the first part. The party of the first part reserves the right to stop all
work unless evidence of approval can be shown,
Provided the work contained in this agreement is being performed on a completed highway open to traffic; the party of the
second part agrees to give written notice to the Division Engineer of the party of the first part when all work contained herein has
been completed. Unless specifically requested by the party of the first part, written notice of completion of work on highway
projects under construction will not be required.
That in the case of noncompliance with the terms of this agreement by the party of the second part, the parry of the first part
reserves the right to stop all work until the facility has been brought into compliance or removed from the right of way at no cost to
the party of the first part.
That it is agreed by both parties that this agreement shall become void if actual construction of the work contemplated herein
is not begun within one (1) year from the date of authorization by the party of the first part unless written waiver is secured by the
party of the second part from the parry of the first part.
FORM 1 16.1A (Revised February 2021)

RIW (161A) : Party of the Second Part certifies that this agreement is true and accurate copy of the form
R1W (161A) incorporating all revisions to date.
IN WITNESS WHEREOF, each of the parties to this agreement has caused the same to be executed the day and
year first above written.
DEPARTMENT OF TRANSPORTA ON
DIVISION ENGINEER 01
ATTEST OR WITNESS:
`--'dcon)i Party
INSTRUCTIONS
When the applicant is a corporation or a municipality, this agreement must have the corporate seal and
be attested by the corporation secretary or by the empowered city official, unless a waiver of corporate
seat and attestation by the secretary or by the empowered City official is on file in the Raleigh office of the
State Utilities Manager. In the space provided in this agreement for execution, the name of the
corporation or municipality shall be typed above the name, and title of all persons signing the agreement
should be typed directly below their signature.
When the applicant is not a corporation, then his signature must be witnessed by one person. The
address should be included in this agreement and the names of all persons signing the agreement
should be typed directly below their signature.
This agreement must be accompanied, in the form of an attachment, by plans or drawings showing the
following applicable information:
1. All roadways and ramps.
2. Right of way lines and where applicable, the control of access lines.
3. Location of the proposed encroachment.
4. Length and typeDf encroachment.
5. Location by highway survey station number. If station number cannot be obtained, location
should be shown by distance from some identifiable point, such as a bridge, road,
intersection, etc. (To assist in preparation of the encroachment plan, the Department's
roadway plans may be seen at the various Highway Division Offices, or at the Raleigh
office.)
6. Drainage structures or bridges if affected by encroachment.
7. Typical section indicating the pavement design and width, and the slopes, widths and
details for either a curb and gutter or a shoulder and ditch section, whichever Is applicable.
8. Horizontal alignment indicating general curve data, where applicable.
9. Vertical alignment indicated by percent grade, P.t. station and vertical curve length, where
applicable.
10. Amount of material to be removed andlor placed on NCDOT right of way, if applicable.
11. Cross -sections of all grading operations, indicating slope ratio and reference by station
where applicable.
12. All pertinent drainage structures proposed. Include all hydraulic data, pipe sizes, structure
details and other related information,
13, Erosion and sediment control.
14. Any special provisions or specifications as to the performance of the work or the method of
construction that may be required by the Department must be shown on a separate sheet
attached to encroachment agreement provided that such information cannot be shown on
plans or drawings.
15. The Department's Division Engineer should be given notice by the applicant prior to actual
starling of installation included in this agreement.
16. Method of handling traffic during construction where applicable.
17. Scale of plans, north arrow, etc.

L41
TEMPORARY MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
L1'
L2
L3
L1 =
0
FT.
L2 =
10
FT.
L3 =
10
FT,
L4 =
20
FT,
TLE Soil Boring and Monitoring Well Details
Wheeler's Grocery
9835-A US Highway 158
Reidsville, Rockingham County
North Carolina
.E PREP. BY REV. BY
NK
— Ground Surface
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threac
LENGTH 10 fe
SEAL
TYPE OF SEAL
bentonite
THICKNESS
10 feet
FILTER PACK
TYPE OF FILTER
#2 silica sand
DISTANCE ABOVE SCREEN
2 feet
TOTAL LENGTH OF FILTER PACK
12 feet
WELL SCREEN
SCREEN MATERIAL
sch 40 PVC
DIAMETER
2 inches
LENGTH
10 feet
SLOT SIZE
0.010 inches
DEPTH TO BOTTOM OF
TEMPORARY MONITORING WELL
20 feet
DEPTH TO BOTTOM OF
BOREHOLE
10 feet
DIAMETER OF BOREHOLE 4 inches
IV
AwAkTc
iff
ASSOCIATES OF NORTN CAROLINA, P_C-
2725 East Millbrook Road, Suite 121
Raleigh, North Carolina 27604
TE PROJECT NO.
1111712023 STL1489701

L4
TEMPORARY MONITORING WELL CONSTRUCTION DETAILS
CROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP
L1
L2
♦� Ground Surface
WELL CASING
MATERIAL
DIAMETER
JOINT TYPE
LENGTH
SEAL
sch 40 PVC
2 inches
flush threaded
10 feet
TYPE OF SEAL bentonite
THICKNESS 10 feet
a 10 9 =1:»_Te3:/
`
TYPE OF FILTER
#2 silica sand
DISTANCE ABOVE SCREEN
2 feet
TOTAL LENGTH OF FILTER PACK
12 feet
WELL SCREEN
L3
SCREEN MATERIAL
sch 40 PVC
DIAMETER
2 inches
LENGTH
10 feet
SLOT SIZE
0.010 inches
L1 =
0
FT.
L2 =
10
FT.
L3 =
10
FT.
L4 =
20
FT.
DEPTH TO BOTTOM OF
TEMPORARY MONITORING WELL 20 feet
DEPTH TO BOTTOM OF
BOREHOLE 10 feet
DIAMETER OF BOREHOLE 4 inches
TITLE Soil Boring and Monitoring Well Details
NA
Wheeler's GroceryX C
9835-A US Highway 158 ASSOCIATES Or NONTN CAROLINA, P C.
Reidsville, Rockingham County 2725 East Millbrook Road, Suite 121
North Carolina Raleigh, North Carolina 27604
FILE PREP. BY REV. BY DATE PROJECT NO.
NK 1 11/17/2023 1 STL1489701