WM0401503_WM0401503_Permit (Application)_Bunker Hill_20240110

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
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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: January 8, 2024
County: Forsyth
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery): Monitoring (MW-10, MW-11, & MW-12)
Applicant: NCDEQ, DWM, UST Section, Attn: Liz Price (Incident #44463) Telephone: [phone]
Applicant's Mailing Address: NCDEQ, DWM, UST Section, Attn: Liz Price,127 Cardinal Drive Ext., Wilmington, NC 28405
Applicant's Email Address (if available): Liz. Price(�deg.nc.gov
Contact Person (if different than Applicant): Al Quarles, ATC Associates of North Carolina, P.C. Telephone: [phone]
Contact Person's Mailing Address: 7606 Whitehall Executive Center Drive, Suite 800, Charlotte NC 28273
Contact Person's Email Address (if available): William. Quarles(acr�.oneatlas.com
Property Owner (if different than Applicant): Jennifer Rollosson Telephone: [phone]
Property Owner's Mailing Address: 1831 NC Highway 66 South, Kernersville, North Carolina 27284
Property Owner's Email Address (if available): Jrollossonaaol.com
Property Physical Address (Including PIN Number) 1831 NC Highway 66 South PIN: 6884-76-4869
City Kernersville County Forsyth Zip Code 27284
Reason for Well(s): Assessment of groundwater contamination from a petroleum UST release
(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
(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).
UST Incident #44463 (Bunker Hill Service Station)
Type of contaminants being monitored or recovered: Gasoline
(ex: organics, nutrients, heavy metals, etc.)
Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 9
Existing Monitoring or Recovery Well Construction Permit No(s).: Unknown
Distance from proposed well(s) to nearest known waste or pollution source (in feet): approximately 200 feet
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: TBD Certification No.: TBD
Well Contractor Address: TBD
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
material: 3
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? Bolt -down 8" manhole,
encased in a 2x2 concrete pad.
6. Estimated beginning construction date: 01/29/2024
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date: 01/30/2024
(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.
on behalf of NCDEQ, DWM, UST Section
Signature of Applicant or *Agent
Printed name of Applicant or *Agent
Senior Project 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
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 agreement Jennifer Rollosson, see attached 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 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
225 Green Street, Suite 714
Fayetteville, NC 28301-5094
Phone: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue
Mooresville, NC 281
Phone: [phone]t
Fax: [phone]C
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

Waste Management
ENVIRONMENTAL QUALITY
December 27, 2023
Ms. Liz Price
Hydrogeologist
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: Access Agreement
Bunker Hill Service Station
1813 Highway 66 South
Kernersville, Forsyth County, 27284
Incident Number 44463
Dear Ms. Price:
ROY COOPER
Governor
ELIZABETH BISER
Secretary
MICHAEL SCOTT
Director
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 Environmental Quality (Department) or its contractor to enter
upon said property for the purpose of conducting an assessment and/or remediation of the
groundwater and/or soils under the authority of G.S. 143-215.94G.
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 in accordance with the acceptance of the site into the State -Lead
Program. The Department or its contractor shall protect and prevent damage to the
surrounding lands. Any damages will be restored by the Department or its contractor to as
close to the pre -work condition as practicably possible.
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 will notify
the landowners 48 hours prior to entry and 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.
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.
Nothing Compares_
State of North Carolina I Environmental Quality � Waste Management
1646 Mail Service Center 1 217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T

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. No representations or warranties, either
expressed or implied, have been made to me/by the Department, the State of North
Carolina, or its/their contractor(s) regarding the results that may be obtained or the quality of
work to be performed
I/We agree not to interfere with, remove or any ways damage the Department's well(s) or its
contractor's well(s) and equipment during the investigation.
Sincerely,
Sign re
Jennifer lRollosson
Type/Print Name of Owner or Agent
Bernice I Smith Heirs
/ Owner f /
/ -_j
lk1s. 5ciaa�)
Phone Number / E-mail Address
—
1831 NC Highway 66 South
Address
Kernersville, NC 27284
City/State/Zip Code
Date
Associated with: Agreement for:
Bunker Hill Service Station 1831 NC Highway 66 South
1813 Highway 66 South Kernersville, NC 27284
Kernersville, Forsyth County 27284 PIN 6884-76-4869
Incident Number 44463
Nothing Compares_"_1k_111_
State of Nortli Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1 217 West Jones Street I Raleigh, NC 27699-1646
919 707 8200 T

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LOCKABLE WELL
L1
TYPICAL TYPE II MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
1
PROTECTIVE CASING AND CONCRETE PAD
CASING MATERIAL
steel
CASING DIAMETER
8 inches
CASING LENGTH
12 inches
PAD DIMENSIONS
2 feet x 2 feet
HEIGHT ABOVE GROUND
flush mounted
Nyl=1IS01eF1ILllr
MATERIAL
sch 40 PVC
DIAMETER
2 inches
JOINT TYPE
flush threaded
LENGTH
22 feet
BACKFILL AROUND CASING
MATERIAL cement -sand grout
THICKNESS 18 feet
SEAL
TYPE OF SEAL bentonite
THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 feet
Nyl=1I1&'%3C7=1 =1Ll
SCREEN MATERIAL Sch 40 PVC
DIAMETER 2 inches
LENGTH 15 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL 37.0 feet
DEPTH TO BOTTOM OF
BOREHOLE 37.0 feet
L1 = 0.25 FT.
L2 = 22 FT. DIAMETER OF BOREHOLE 8.25 inches
L3 = 15 FT.
L4 = 37 FT.
onrroring vveu uiagram
Bunker Hill Service Station 7606 Whitehall Executive Center Drive
1813 Highway 66 South Charlotte, North Carolina 28273
Kernersville, Forsyth County, NC 27284
FILE PREP. BY REV. BY DATE PROJECT NO.
KH I AQ 1 /8/2024 STL4446302

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TABLE 2
MONITORING WELL CONSTRUCTION AND WATER LEVEL ELEVATION DATA
Former Bunker Hill Service Station
1813 Highway 66 South
Kernersville, Forsyth County, North Carolina
NCDEQ Incident #44463
Well ID
ate
InsDtalled
Well Casing
Depth
(ft-TOC)
Screen
Interval
(ft-TOC)
TOC
Elevation
(ft)*
Dat
Measureed
Depth to
LNAPL
(ft)
Depth to
Water
(ft-TOC)
LNAPL
Thickness
(ft)
Groundwater
Elevation
(ft)**
MW-1
11/17/16
15
15-35
97.78
11/18/16
-
30.42
-
67.36
10/03/17
31.71
32.04
0.33
65.46
03/11/19
28.85
28.87
0.02
68.89
97.36
01/18/21
-
26.81
-
70.55
08/04/22
29.02
68.34
MW-2
10/02/17
20
20-35
99.66
10/03/17
33.73
65.93
03/11 /19
31.18
68.48
01 /18/21
29.09
70.57
08/04/22
31.30
68.36
MW-3
10/02/17
20
20-35
98.70
10/03/17
32.96
65.74
03/11 /19
30.41
68.29
01/18/21
28.32
70.38
08/04/22
30.49
68.21
MW-4
10/02/17
20
20-35
97.89
10/03/17
32.10
65.79
03/11 /19
29.48
68.41
01/18/21
27.38
70.51
08/04/22
29.61
68.28
MW-5
01/05/21
22
22-37
97.77
01/18/21
-
27.18
-
70.59
08/04/22
29.03
29.55
0.52
68.40
MW-6
01/05/21
22
22-37
97.51
01/18/21
-
26.94
-
70.57
08/04/22
21.95
75.56
MW-7
01/04/21
22
22-37
96.53
01/18/21
26.94
69.59
08/04/22
28.20
68.33
MW-8
01/05/21
22
22-37
97.65
01/18/21
27.14
70.51
08/04/22
29.32
68.33
DMW-8
01/07/21
48 / 52
52-57
97.69
01/18/21
27.18
70.51
08/04/22
29.36
68.33
Notes:
All monitoring \>57
ft = feet
TOC = top of casing
ft-TOC = feet below top of casing (TOC)
LNAPL = Light Non -Aqueous Phase Liquid
Reference point for Elevation Measurement prior to 2021, arbitrary Elevation: 100.00 ft.
*Elevations for monitoring wells MW-1, MW-5 through MW-8, and DMW-8 calculated in reference to MW-4
**Corrected depth to Groundwater using Free -Product Correction Factor for Specific Gravity of Automotive Gasoline (0.729) when present
ft. BGS: feet below ground surface
Page 1 of 1

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