WM0401517_Application_20240306

AA AECOM Technical Services of North Carolina,Inc. [phone] tel
S_ 6000 Fairview Road,Suite 200
Charlotte,NC 28210
March 4,2024
Ms. Shuying Wang
Winston-Salem Regional Office
Division of Water Resources
Water Quality Regional Operations Section
Re: Monitoring Well Permit Applications
MW-37,MW-37M,and MW-37D
Colonial Pipeline Company-Lexington Booster Station
Multiple Addresses,Lexington,Davidson County,NC
NCDEQ Incident Number: 95267
Dear Ms.Wang:
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 3 monitoring wells(MW-37,MW-37M,and MW-37D)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-37,MW-37M,and MW371):
Rob and Wende Rummage,738 Helmstetler Road,Lexington,NC 27295
PIN 6705-04-51-7663,Parcel ID 18025000000348
Included herein are the Applications for Permit to Construct a Monitoring or Recovery Well System
applications for each of the aforementioned properties,a map of the proposed monitoring wells,and general
well construction diagrams.
Upon approval, please forward the monitoring well construction permit(s) to me at
[e-mail]. If you have any questions or require additional information, please do not
hesitate to call me at 412-9774074.
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 reeovery-welis-
FOR OFFICE USE ONLY
1. Date: February 19,2024
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(acolpipe.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(cDaecom.com
6. Property Owner(if different than Applicant): Robby and Wende Rummage Telephone: [phone]
Property Owner's Mailing Address: 738 Helmstetler Road, Lexington, NC 27295
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number)738 Helmstetler Road(PIN 6705-04-51-7663)
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. i ype 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? 56(total wells)
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0400963,WM0400885,WM0401041,WM0401042,WM0401043.
WM0401241 WM041242,WM0401243,WM0401244,WM0401245,WM0401250,WM0401251.WM0401492
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): Approximately 850 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--220 feet East(WSW-18)
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: 2
3. Number of wells to be constructed in bedrock: 1 6. Estimated beginning construction date: Mid-March 2024
4. Total Number of wells to be constructed: 3 7. Estimated construction completion date:Aoril 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,
f Subchapter 2C)and accepts full responsibility for compliance with these rules
Signat a of Applica or*Agent Title of App canan—tlor* ent
6 LPG 4,0 *If signing as Agent, attach authorization agreement stating
Printed tame of ApplIlbant 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).
See attached signed access agreement Robby and Wende Rummage
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 Offic3
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 ~j Wm 797
Mooresville, NC 28115 _
Phone: [phone] r�
Fax: [phone] -
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GW-22MR Rev.3-1-2016

LAND ACCESS AND WELL INSTALLATION AGREEMENT
THIS LAND ACCESS AND WELL INSTALLATION AGREEMENT("Agreement")dated February
_, 2024, is by and between ROBBY D RUMMAGE and WENDE PICKETT RUMMAGE
('landowner"),whose mailing address is 738 Helmstetler Road, Lexington,NC 27295,and COLONIAL
PIPELINE COMPANY ("Colonial"), a Delaware and Virginia corporation with its principal office at
1000 Lake Street,Alpharetta,Georgia 30009.
Landowner warrants and acknowledges that he, she, or it, as the case may be,has the lawful authority to
undertake the activities described herein,including the granting and conveying of such rights and privileges
so designated.Landowner is either a full or partial owner of the following real estate parcel("Property"):
• Tax Parcel No.1802500000034B or physical address Same as Above located in Davidson County,
North Carolina,being approximately 3.43 acres.
For and in consideration of the one-time payment of$ 4 b0• , and for other good and valuable
consideration,the receipt and sufficiency of which is hereby acknowledged,Landowner hereby GRANTS
AND CONVEYS to Colonial the right for Colonial and its employees, agents, contractors, and
subcontractors to access and use the Property for the purpose of(i)installing and maintaining groundwater
monitoring wells on the Property; and (ii) obtaining subsurface soil samples during an initial well
installation;(iii)periodically obtaining surface water samples, and/or groundwater samples from installed
equipment or from streams,seeps,wells,and other water sources on the Property,so long as such use does
not interfere with or damage Landowner's personal or real property beyond an unrepairable condition.
This Agreement is subject to the following covenants and conditions:
1. In coordination with Landowner, Colonial and its employees, agents, contractors, and subcontractors
shall have the right of ingress and egress across, upon and over the Property to periodically installing
and maintaining groundwater monitoring wells on the Property, obtaining subsurface soil samples
during an initial well installation,and periodically obtaining surface water samples,and/or groundwater
samples from installed equipment or from streams, seeps, wells, and other water sources on the
Property.
2. This Agreement and all of the rights and privileges herein granted and conveyed shall continue so long
as Colonial believes them to be reasonably necessary to comply with the laws, regulations, rules or
other requirements of the North Carolina Department of Environmental Quality. All rights, duties,
and/or obligations arising by or under this Agreement shall only apply while this Agreement is in effect.
3. Any damage to the Property caused by Colonial's employees, agents, contractors, or subcontractors
shall either be promptly restored or repaired by Colonial or Colonial shall compensate Landowner for
such damages.
4. This Agreement embodies the entire understanding and agreement of the parties and there are no further
agreements or understandings,written or oral,in effect between the parties relating to the subject matter
hereof. Any amendment of this Agreement shall not be effective unless in writing and fully executed
by the authorized representatives of Landowner and Colonial.
EXECUTED and made effective by the authorized representatives of the Parties on the last date written
below.
FOR LANDOW FOR COLONIAL PIPELINE COMPANY
Signature Signature: sit,
Print:�; uw�r,No. _ Print: �! �1p"1 C`
Date: � '� D yY Title: d21
iF -�t�+� rZ,�V l fit?tl t�l 6�VT►��-
Date: 7"12- -t-Lq

LAND ACCESS AND WELL INSTALLATION AGREEMENT
THIS LAND ACCESS AND WELL INSTALLATION AGREEMENT("Agreement")dated February
_,, 2024, is- by-and between- RONNIE DEAN RUMMAGE-and WANDA RUMMAGE
("Landowner"),whose mailing address is 708 Hehnsteder Road,Lexington,NC 27295,and COLONIAL
PIPELINE COMPANY ("Colonial"), a Delaware and Virginia corporation with its principal office at
1000 Lake Street,Alpharetta,Georgia 30009.
Landowner warrants and acknowledges that he,she, or it, as the case may be,has the lawful authority to
undertake the activities described herein,including the granting and conveying of such rights and privileges
so designated.Landowner is either a full or partial owner of the following real estate parcel("Property"):
Tax Parcel No.1802500000034 or physical address Same as Above located in Davidson County,North
Carolina,being approximately 9.36 acres.
For and in consideration of the one-time payment of S 5 0 t," , and for other good and valuable
consideration,the receipt and sufficiency of which is hereby acknowledged,Landowner hereby GRANTS
AND CONVEYS to Colonial the right for Colonial and its employees, agents, contractors, and
subcontractors to access and use the Property for the purpose of(i jinstalling and maintaining groundwater
monitoring wells on the Property; and (ii) obtaining subsurface soil samples during an initial well
installation;(iii)periodically obtaining surface water samples,and/or groundwater samples from installed
equipment or from streams,seeps,wells,and other water sources on the Property,so long as such use does
not interfere with or damage Landowner's personal or real property beyond an unrepairable condition.
'� Ei'1V►�D �lea-- v�>�t�--4
This Agreement is subject to the following covenants and conditions:
1. In coordination with Landowner, Colonial and its employees,agents,contractors, and subcontractors
shall have the right of ingress and egress across, upon and over the Property to periodicall}'Ainstalling
and maintaining groundwater monitoring wells on the Property, obtaining subsurface soil samples
during an initial well installation,and periodically obtaining surface water samples,and/or groundwater
samples from installed equipment or from streams, seeps, wells, and other water sources on the
Property.
2. This Agreement and all of the rights and privileges herein granted and conveyed shall continue so long
as Colonial believes them to be reasonably necessary to comply with the laws, regulations, rules or
other requirements of the North Carolina Department of Environmental Quality. All rights, duties,
and/or obligations arising by or under this Agreement shall only apply while this Agreement is in effect.
3. Any damage to the Property caused by Colonial's employees, agents, contractors, or subcontractors
shall either be promptly restored or repaired by Colonial or Colonial shall compensate Landowner for
such damages.
4. This Agreement embodies the entire understanding and agreement of the parties and there are no further
agreements or understandings,written or oral,in effect between the parties relating to the subject matter
hereof. Any amendment of this Agreement shall not be effective unless in writing and fully executed
by the authorized representatives of Landowner and Colonial.
EXECUTED and made effective by the authorized representatives of the Parties on the last date written
below.
FOR LANDOWNER FOR COLONI
AL,PIPELINE COMPANY
Signature: � � J�,c, ,,.. --- Signature:
Print: 0M1ItC R t,{,wt t t�,�t�, Print: i5 Ao CAVyk1f1)-r -P1
Date: " L 7— Z Title: tt' �i F-NJJk01JJ CAC- L-
Date:

Shallow Monitoring Well
2' X 2' CONCRETE PAD Diagram
GROUND SURFACE MAN HOLE COVER OR STICK UP
-T I LOCKING WELL CAP
Approximately 21' 6" PVC OUTER CASING
2" DIAMETER SCH 40 PVC RISER
NEAT CEMENT OR CONCRETE—GROUT
2' BENTONITE WELL SEAL
LO
21
Uj
CD
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 P"Nom
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 561
6" PVC OUTER CASING
2" DIAMETER SCH 40 PVC RISER
dja NEAT CEMENT OR CONCRETE—GROUT
Uj
2' BENTONITE WELL SEAL
c)
2'
LLJ
0
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 ASS OM
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' f i 6" PVC OUTER CASING
DIAMETER SCH 40 PVC RISER
CONCRETE-GROUT
w NEAT CEMENT OR CONCRETE-GROUT
Approximately 16'
2' BENTONITE WELL SEAL
0
0 2'
J ..Y'
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 443coM
667 HELMSTETLER ROAD
LEXINGTON, NORTH CAROLINA

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