WM0401494_Application_20231129

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: November 27, 2023
2. County: Guilford
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Huffman Oil Company Telephone: [phone]
Applicant's Mailing Address: P.O. Box 730 Burlington, NC 27216-0730
Applicant's Email Address (if available): sbarnwell(o)huffmanoil.net
5. Contact Person (if different than Applicant): Wayne Watterson (S&ME) Telephone: [phone]
Contact Person's Mailing Address: 8646 West Market Street, Suite 105 Greensboro, NC 27409
Contact Person's Email Address (if available): wwatterson(a�smeinc.com
6. Property Owner (if different than Applicant): Nancy F. Hudson Telephone: [phone]
Property Owner's Mailing Address: 8005 Benaia Road, Browns Summit, NC 27214
Property Owner's Email Address (if available): NA-
7. Property Physical Address (Including PIN Number) 8005 Benaia Road
City Browns Summit County Guilford Zip Code 27214
8. Reason for Well(s): groundwater contamination/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: 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)
Incident No. 44936
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? 13 (on other parcels)
Existing Monitoring or Recovery Well Construction Permit No(s).: On other parcels: WM0401255, WM0401256, WM0401270
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approximately 300 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): Approximately 50, 220, 260, 440, 570 feet
15. Well Contractor: Innovative Environmental Technologies, Inc. Certification No.: 3287-A
Well Contractor Address: 232 Highway 49 South, Concord, NC 28025
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? Locked
material: 1 expandable cap within bold -down cover
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: December
2023
4. Total Number of wells to be constructed: _ 1
(add answers from 2 and 3) 7. Estimated construction completion date: January 2024
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
_ Senior Engineer/Agent for Huffman_ _Oil Co
Signature of pplicant or *Agent Title of Applicant or *Agent
Wayne Watterson
Printed name of Applicant or *Agent
* tf 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
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).
SEE ATTACHED SITE ACCESS AGREEMENT Nancy F. Hudson
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
Phone: [phone]
Winston-Salem Regional Office
2090 U.S. Highway 70
Fax: [phone]
450 W. Hanes Mill Road
Swannanoa, NC 28778
Phone: [phone]
Washington Regional Office
Suite 300
Winston-Salem, NC 27105
Fax: [phone]
943 Washington Square Mall
Phone: [phone]
Washington, NC 27889
Fax: [phone]
Fayetteville Regional Office
Phone: [phone]
225 Green Street, Suite 714
Fax: [phone]
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
0
L i r'�F ygeM�rill e ;
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016
GW-22M (Rev. 5/11)
GW-22MR (6111)

Reference: Site Access Agreement for a groundwater assessment at the incident
known as Monticello Oil Company, Incident No. 44966, 8007 Benaja Road, Brown
Summit, North Carolina.
am the owner of a parcel of property, Parcel No. 114085, located at 8005 Benaja Road, Brown
Summit, N.C., and hereby permit Huffman Oil Company and its contractor, S&ME, Inc., to enter
upon said property for the purpose of conducting a groundwater assessment. Assessment
services will include the installation of groundwater monitoring wells, and periodic sampling of
the monitoring wells.
am granting permission with the understanding that:
1. The assessment shall be conducted as required by the North Carolina Department of
Environmental Quality, Division of Waste Management, Underground Storage Tank
Section.
2. The costs of construction of the monitoring wells, and maintenance of the area
immediately adjacent to the monitoring wells and access, shall be borne by Huffman Oil
Company or its contractor. Huffman Oil Company or its contractor shall protect and
prevent damage to the surrounding lands during installation and sampling of the
monitoring well.
3. Unless otherwise agreed, Huffman Oil Company or its contractor shall have access to
the site by the shortest feasible route to the nearest public road. Huffman Oil Company
or its contractor may enter upon the land at reasonable times and have full right of
access during the period of the assessment.
4. The information derived from the assessment shall be made available to the owner
upon request.
I agree not to interfere with, remove, or damage Huffman Oil Company's well(s) or its
contractor's equipment during the assessment.
�Je
y
.f
Sign%ature
Type/Print Name
-4 70
Phone Dumber
Date

Well ID
Proposed MW-12
Project Name
44936-Monticello Oil Company
Project Number
4358-17-031
•
s
S&ME Staff
Installation Date
County
City
Well Permit Number
L. Butler
Guilford
Browns Summit
Application
Drilling Contractor
License Number
Drill Rig
Well Type / Use
Flush Monitor Well
Water Level at TOB (0.01 ft-
BTOC)
Date/Time
Northing (0.1 ft)
Land Surface Elev. (0.01 ft)
Drilling Method
Hollow Stem Auger
Depth to Water (0.01 ft-
BTOC)
Date/Time
Easting (0.1 ft)
Total Well Depth (0.1 ft-bgs)
Borehole Diameter (1 in)
35.1
8.25-inch
TOC Relative to Ground 0.0 ft
Depth Below Ground Surface (ft-bgs)
Top of Seal - 3.0 0.1 ft-bgs
Top of Filter Pack - 18.0 0.1 ft-bgs
Top of Screen - 20.0 0.1 ft-bgs
Screened Interval - 15.0 0.1 ft-bgs
Bottom of Screen - 35.0 0.1 ft-bgs
Bottom of Filter Pack - 35.0 0.1 ft-bgs
Cave In - 0.1 ft-bgsEWE
Total Boring Depth - 35.0 0.1 ft-bgs
Pad Type
2' x 2' Concrete
Protective Casing
Flush Vault (8" diam)
Casing Material
2-in Sch 40 PVC
Casing Interval (0.1 ft-bgs)
0.0
to
20.0
Screen Type
2-in Sch 40 PVC (0.010)
Screen Interval (0.1 ft-bgs)
20.0
to
35.0
Grout Type
Portland Cement T2
Grout Interval (0.1 ft-bgs)
0.0
to
3.0
Seal Type
3/8 in. Holeplugg)
Seal Interval (0.1 ft-bgs)
3.0
to
18.0
Filter Pack
#2 Silica Sand
Filter Pack Interval (0.1 ft-bgs)
18.0
1 to
1 35.0
Development
Development Volume (gal)
Notes:
BTOC - Below Top of Casing
TBD - To Be Determined
For lithologic information
see attached boring log
Form Revision Date: 9/1/17 2:10 PM

..........................................................................................
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LEGEND SOURCE: 2014 AERIAL PHOTOGRAPH AND 2016 PARCEL DATA OBTAINED FROM NC ONEMAP.
MONITORING WELL
PROPOSED MONITORING WELL LOCATION 0 100 200
WATER SUPPLY WELL
TEMPORARY MONITORING WELL
HAND AUGER LOCATION GRAPHIC SCALE (IN FEET)
MONITORING WELL LOCATIONS SCALE: FIGURE NO.
® Incident No. 44936 AS DHAOWN
MONTICELLO OIL SITE SEPT. 2023 3
I I I 8007 BENAJA ROAD PROJECT NUMBER
BROWNS SUMMIT, NORTH CAROLINA 4358-17-031

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8021 Benaja' Rd
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8• 5 Be?aja Rd 00,15 .
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�8007 Old Reidsville Rd
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:. enaja Rd
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8009 Benaja Rd
(Inactive)
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(5900001580) 7929 Old Reidsville Rd
'�,• . 3
7921 Old Reidsville Former Monticello Oil Bulk Facility
(7924 Old Reidsville Rd)
4 '
' 7919 Old Reidsville
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�7�920 Old Reidsville Rd
�9 Former McGee s Grocery
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SOURCE: 2014 AERIAL PHOTOGRAPH AND 2016 PARCEL DATA OBTAINED FROM NC ONEMAP.
LEGEND
WATER SUPPLY WELL LOCATION WITH WELL IDENTIFICATION 0 300 600
A SENSITIVE LAND USE FEATURES
(8900005935)- CONTIGUOUS PROPERTY GRAPHIC SCALE (IN FEET)
WATER SUPPLY WELL LOCATIONS SCALE: FIGURE NO.
® Incident No. 44936 AS DAAOWN
III = MONTICELLO OIL SITE SEPT. 2023 4
8007 BENAJA ROAD PROJECT NUMBER
BROWNS SUMMIT, NORTH CAROLINA 4358-17-031