WM0401499_Monitoring well permit application_20231220

DocuSign Envelope ID:C24A454E-AE38-4E4D-B082-E093A4C7DADC
IVVICI rl %1Mr%VLII14N ur-r- MI Ivir-N i Vr r-mvi t iNMENTAL 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: 10/27/2023
2. County: Forsyth PERMIT NO. ISSUED DATE
3. Whattype of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: Speedway, LLC Telephone: [phone]
Applicant's Mailing Address: PO Box 1500, Springfield, OH 45501
Applicant's Email Address (if available): Samuel Kramer
5. Contact Person (if different than Applicant): Nathan Pinsker Telephone: [phone]
Contact Person's Mailing Address: 5438 Wade Park Boulevard, Suite 200, Raleigh, NC 27607
Contact Person's Email Address (if available): Nathan.Pinsker(@aecom.com
6. Property Owner(if different than Applicant): Arthur T.Williams Telephone: Unknown
Property Owner's Mailing Address: 19 East 72"d Street, Apt.5D, New York, NY 10021
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 605 Akron Drive(6837-52-0234)
City Winston-Salem County Forsyth Zip Code 27105
8. Reason for WelI(s): Assessment
(ex: non-dis charge p ermit req ui remen ts,s us p ected co ntami n ati on,assess men t,g ro u n d water co n tami n ati o n, remed i ati o n, etc.)
9. Type of facility or site for which the well(s) is(are) needed: Gasoline station
(ex: non-discharge facility,waste disposal site, landfill, UST,etc.)
10. Are thereany currentwater quality permits or incidents associated with thisfacility orsite? If so,listpermit and/or incidentno(s).
Yes —Incident Number 44453
11. Type of contaminants being monitored or recovered: Organics
(ex: organics, nutrients, heavy metals,etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes —12 wells onsite
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): 10
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes,give distance(s):
15. Well Contractor: Geologic Resources, Inc. Certification No.: 1270
Well Contractor Address: 3502 Haves Road, Monroe, NC 28110
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

DocuSign Envelope ID:C24A454E-AE38-4E4D-B082-E093A4C7DADC
PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? 5
material: 4
3. Number of wells to be constructed in bedrock: 1 6. Estimated beginning construction date: 12/10/23
4. Total Number of wells to be constructed: 5 7. Estimated construction completion date: 12/10/23
(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
storageareas,animal feedlots as defined in G.S.143-215.10B(5), landfills,orother 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.
-7, -
Manager, Environmental Services
Signature of Applicant or*Agent Title of Applicant or*Agent
Samuel Kramer *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 app I icatio n 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.
CI�w'��/`'�''/-// Arthur T. Williams, III
�g}gRE6R6E
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 Raleigh Regional Office Wilmington Regional Office
2090 U.S. Highway 70 3800 Barrett Drive 127 Cardinal Drive Extension
Swannanoa, NC 28778 Raleigh, NC 27609 Wilmington, NC 28405
Phone: [phone] Phone: [phone] Phone: [phone]
Fax: [phone] Fax: [phone] Fax: [phone]
Fayetteville Regional Office Washington Regional Office Winston-Salem Regional Office
225 Green Street, Suite 714 943 Washington Square Mall 450 W. Hanes Mill Road
Fayetteville, NC 28301-5094 Washington, NC 27889 Suite 300
Phone: [phone] Phone: [phone] Winston-Salem, NC 27105
Fax: [phone] Fax: [phone] Phone: [phone]
Fax: [phone]
Mooresville Regional Office
Wia r s
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
1 i1y
GW-22M/R(Rev. 5-26-2022)

DocuSign Envelope ID:C24A454E-AE38-4E4D-B082-E093A4C7DADC
LEGEND
N Residential Approximate Site Property Boundary
I
Approximate Property Boundary
- - Approximate Building Footprint
o to Product Dispenser
Proposed Underground Storage Tank
Underground Storage Tank
MW-8R 9 8,000-Gal. Kerosene
Residential `, I oNl�"�
_ _ 10 8,000-Gal. Diesel
i I I Al 12,000-Gal. Gasoline
o� I MW-12
) SB-
E I ` Az 10,000-Gal. Gasoline
— A3 8,000-Gal. Gasoline
N -
'oN� o `n i�o
g
I P_ J — T� --P-- Product Piping
Residential I
� Vent Line
�� --CG/T--
Buried Telephone Line
_
/ Speedway
' Store #6928 -°GA-- Buried Electric Line
- I T �/
J I --OH --
Tank Overhead Electric
h I Field � � MW-2 and MW-5 still --W-- Water Line
�VWI
--�-- Storm Drain
Residential y� -j iL1 active
I � �-� � I ewer
MW-14 MW-11 -- -- S
m E 1P an tary S
— _
--ST-- Storm Sewer
sB-�I f / \? - �o Utility Pole/ Power Pole
MW-7 5P� 'i _P "-� '� i MW_5 / ;o; Light Post/Traffic Light
3/Q 0 Catch Basin /Stormwater Inlet
-'k►, I P� ` -w_, v, MW 2,� - Tank Field
;i XSB-2 / Deep Monitoring Well
��I��,I —�AN �_� / MW-13R Shallow Monitoring Well
'sAN---SAN- �,° 'eww_ 1j m Vents Soil Boring Location
1 MW-10 /
- MW-3 ,'\E �� I Proposed
�� , A3 %IVi'v"v-,i� Tank Field,
CD
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SB-6 �� T,A/ B-3
r _ MW-4R
CD CD Canopy �„���- '1 ``�SB-4
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TW-9
3- o
000, 30 0 30 SCALE IN FEET: Speedway LLC. FIGURE 2
1.
o Speedway Store#6928
'
I 653 Akron Drive SITE PLAN
N / IN NOTE: ALL MAP FEATURES ARE APPROXIMATE Winston-Salem, NC ��M
IN SCALE AND LOCATION.
3 OAT.: SEPTEMBER 2023 DRAWN BY: I.DUMITRU REVIEWED BY' N.PINSKER PROJECT NO.: 60690074
ti

ter, .,.. c,.00a......6928
DocuSign Envelope ID:C24A454E-AE38-4E4D-B082-E093A4C7DADC
_ Project Number. WELL ID:MW-1R,MW-4R,MW-8R,MW-13R
J COM Site Location: 653 Akron Dr Winston-Salem,NC Date Installed:
Well Location. Coords: Inspector:
Method: Hollow Stem Auger Contractor: Geologic Resources,Inc.
WELL CONSTRUCTION DETAIL
Depth from G.S. (feet) Elevation(feet)
Datum
Ground Surface(G.S.) 0.0
Top of Riser Pipe -0.25
Riser Pipe:
Length 5'
Diameter(ID) 2"
Type of Material PVC
Thickness Sch 40
Grout:
Type Neat Cement
Thickness
Top of Bentonite -2'
............... ................
G G%Bentonite Seal Thickness 2'
............... ................
............... ................
!!!Top of Sand 4
Top of Screen -5'
. Stabilized Water Level -11,
Screen:
Length 15,
Diameter(ID) 2"
Slot Size 10 slot
Type of Material PVC
Thickness Sch 40
Type/Size of Sand #2
Sand Pack Thickness 17
Bottom of Screen -20'
Bottom of Borehole -20'
Borehole Diameter 2.25"ID Geoprobe
Describe Measuring Point:
Signature Date

011;A^f. 6928 WELL ID: TW-3
DocuSign Envelope ID:C24A454E-AE38-4E4D-B082-E093A4C7DADC
jd�=C0M Project Number:
Site Location: 653 Akron Dr Winston-Salem,NC Date Installed:
Well Location: Coords: Inspector:
Method: HSA/Air Rotary Contractor:
MONITORING WELL CONSTRUCTION DETAIL
NOT TO SCALE Depth from G.S.(feet) Elevation(feet)
Datum
Ground Surface(G.S.) 0.0
Measuring Point
for Surveying&
Water Levels Top of Riser Pipe -0.25
Cement,Bentonite,
Bentonite Slurry
Grout,or Native
Materials Riser Pipe:
Length 130
Inside Diameter(ID) 2 inches
95 %Cement Type of Material PVC
5 %Bentonite
Bottom of Outer Steel Casing -50
0 %Native
Materials
Top of Bentonite -60
GG GG
G G Bentonite Seal Thickness 3-feet
Top of Sand -63
Top of Screen -65.0
Screen:
Length 5-feet
Inside Diameter(ID) 2-inch
Slot Size 0.01
Type of Material PVC
Type/Size of Sand #2
Sand Pack Thickness
Bottom of Screen -70
Bottom of Tail Pipe: -70
Bottom of Borehole -70
Borehole Diameter: 4 Approved:
Describe Measuring Point:
Signature Date