WM0401539_Monitoring well permit application_Moody's G WM0401539_20240710

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.
FOR OFFICE USE ONLY
1. Date: 7/3/2024
2. County: Wilkes PERMIT NO. ISSUED DATE
3. What type of well are you applying for?(monitoring or recovery): Monitoring
4. Applicant: NCDEQ, DWM, UST Section (Liz Price) Telephone: [phone]
Applicant's Mailing Address: 1646 Mail Service Center, Raleigh, NC 27699-1646
Applicant's Email Address (if available): Iiz.priceCcDdeg.nc.gov
5. Contact Person (if different than Applicant): Steven Aldis Telephone: [phone]
Contact Person's Mailing Address: 7606 Whitehall Executive Center Drive, Suite 200, Charlotte, NC 28273
Contact Person's Email Address(if available): [e-mail]
6. Property Owner(if different than Applicant): Dwight Moody Telephone: [phone]
Property Owner's Mailing Address: 934 Old Highway 21, State Road, NC 28676
Property Owner's Email Address(if available):
7. Property Physical Address(Including PIN Number)934 Old Highway 21 (PIN 4944-37-1605, Parcel 0604032)
City State Road County Wilkes Zip Code 28676
8. Reason for Well(s): Groundwater assessment for State Lead UST Site
(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: petroleum 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).
Moody's Grocery(Inc.#11910), existing monitoring wells on the UST site property
11. Type of contaminants being monitored or recovered: Volatile Organic Compounds
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? 5 monitoring wells
Existing Monitoring or Recovery Well Construction Permit No(s): N/A all 5 existing wells on UST site
13. Distance from proposed well(s)to nearest known waste or pollution source(in feet): --90 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes(8 within 500')
If yes, give distance(s): Approximately on site 934 Old Highway 21, State Road, NC 28676; 200'west 912 Old Highway 21,
State Road, NC 28676,200' north 937 Old Highway 21, State Road, NC 28676; 250' northeast 955 Old Highway 21, State Road, NC
28676; 350' northeast 893 Old Highway 21, State Road, NC 28676; 425' northwest 857 Old Highway 21, State Road, NC 28676; 500'
west northwest 835 Old Highway 21, State Road, NC 28676; 500'south 265 Hidden Chambers Drive, State Road, NC 28676
15. Well Contractor: EDPS Certification No.: 3307
Well Contractor Address: 17538 Greenhill Road, Charlotte, NC 28278
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? Well vault and lock
material: 2
6. Estimated beginning construction date: 7/15/2024
3. Number of wells to be constructed in bedrock: 0
7. Estimated construction completion date: 7/15/2024
4. Total Number of wells to be constructed: 2
(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. 143-215.10B(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 Project Manager
Signature of Applicant or*Agent Title of Applicant or*Agent
Steven Aldis *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
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 Access Agreement Dwight Moody
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 3800 Barrett Drive Wilmington, NC 28405
2090 U.S. Highway 70 Raleigh, NC 27609 Phone: [phone]
Swannanoa, NC 28778 Phone: [phone] Fax: [phone]
Phone: [phone] Fax: [phone]
Fax: [phone] Winston-Salem Regional Office
Washington Regional Office 450 W. Hanes Mill Road
Fayetteville Regional Office 943 Washington Square Mall Suite 300
225 Green Street, Suite 714 Washington, NC 27889 Winston-Salem, NC 27105
Fayetteville, NC 28301-5094 Phone: [phone] Phone: [phone]
Phone: [phone] Fax: [phone] Fax: [phone]
Fax: [phone]
Mooresville Regional Office
610 East Center Avenue Win
Mooresville, NC 28115 ^ 1[�
Phone: [phone] r 01
Fax: [phone]
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GW-22MR Rev.3-1-2016
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Wilmington Region`a(I e GW-22M(Rev.5/11)
Raleigh Regional Office 127 Cardinal Drive Extension

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EXPLANATION
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FORMER MOODY'S GROCERY/ NCDEQ INCIDENT #22446 Aff kT
912 OLD HIGHWAY 21 ASSOCIATES OF NORTH CAROLINA, P.C.
STATE ROAD, NORTH C A R O L I N A 28676 Charlotte„North Caroi na 28273 [phone] FAX [phone]
CAD FILE PREP BY REV.BY SCALE DATE PROJECT NO.
MOODYSSM AD FL AS SHOWN 6.22.18 SLP2244602

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ROY COOPER
Governor
ELIZABETH BISER
Secretary
Waste Management MICHAEL SCOTT
ENVIRONMENTAL QUALITY Director
July 2, 2024
Ms. Liz Price
Hydrogeologist
DWM UST Section
1637 Mail Service Center
Raleigh, NC 27699-1637
RE: State-Lead Acceptance
Moody's Grocery
912 Old Highway 21
State Road, Wilkes County, NC 28676
Incident Number 11910
Dear Mr. Ryals
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 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-
1. 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.
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.
Nothing Compares!:-_,-
State of North Carolina I Environmental Quality I Waste Management
1646 Mail Service Center 1217 West Jones Street I Raleigh,NC 27699-1646
919 707 8200 T

I
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.
7. 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,
7f, oil
Signature
Type rint Name of Owner or Agent
_ (336) G9c) q
Phone Number
934 Old Highway 21
Address
State Road, North Carolina 28676
City/State/Zip Code
17Lz 2�
Date
RE: Moody's Grocery
912 Old Highway 21
State Road, North Carolina 28676
Incident Number 22446
MQy pIQr-Q- wgi�s I,„ woods
Nothing Compares!�-� bof-�� l h
State of North 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

TYPICAL MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
MW-6
LOCKABLE WELL CAP
PROTECTIVE CASING AND CONCRETE PAD
Li CASING MATERIAL Steel
CASING DIAMETER 8 inches
..........
......... ....................
........... CASING LENGTH 12 inches
......................
r...... PAD DIMENSIONS 2 feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 35 feet
L2 BACKFILL AROUND CASING
MATERIAL cement grout
THICKNESS 35 feet
SEAL
TYPE OF SEAL bentonite
L4 THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 feet
WELL SCREEN
L3 . . .
SCREEN MATERIAL sch 40 PVC
DIAMETER 2 inches
LENGTH 15 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL 50.0 feet
. . . . . . . . DEPTH TO BOTTOM OF
BOREHOLE 50.0 feet
Ll = 0.3 FT.
L2= 35 FT. DIAMETER OF BOREHOLE 8.25 inches
L3= 15 FT.
L4=— 50 FT.
TITLE Monitoring Well Diagram Iff
(Example) IffAkT(.XF
Moody's Grocery 7606 Whitehall Executive Center Drive
934 Old Highway 21 Charlotte, North Carolina 28273
State Road, NC 28676
FILE PREP. BY REV. BY DATE PROJECT NO.
I SMA 1 7/3/2024 STL2244601

TYPICAL MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
CROSS SECTIONAL VIEW
NOT TO SCALE
MW-7
LOCKABLE WELL CAP
PROTECTIVE CASING AND CONCRETE PAD
Li CASING MATERIAL Steel
CASING DIAMETER 8 inches
..........
......... ....................
........... CASING LENGTH 12 inches
......................
r...... PAD DIMENSIONS 2 feet x 2 feet
HEIGHT ABOVE GROUND flush mounted
WELL CASING
MATERIAL sch 40 PVC
DIAMETER 2 inches
JOINT TYPE flush threaded
LENGTH 26 feet
L2 BACKFILL AROUND CASING
MATERIAL cement grout
THICKNESS 26 feet
SEAL
TYPE OF SEAL bentonite
L4 THICKNESS 2 feet
FILTER PACK
TYPE OF FILTER #2 silica sand
DISTANCE ABOVE SCREEN 2 feet
WELL SCREEN
L3 . . .
SCREEN MATERIAL sch 40 PVC
DIAMETER 2 inches
LENGTH 15 feet
SLOT SIZE 0.010 inches
DEPTH TO BOTTOM OF
MONITORING WELL 41.0 feet
. . . . . . . . DEPTH TO BOTTOM OF
BOREHOLE 41.0 feet
Ll = 0.3 FT.
L2= 26 FT. DIAMETER OF BOREHOLE 8.25 inches
L3= 15 FT.
L4= 41 FT.
TITLE Monitoring Well Diagram Iff
(Example) IffAkT(.XF
Moody's Grocery 7606 Whitehall Executive Center Drive
934 Old Highway 21 Charlotte, North Carolina 28273
State Road, NC 28676
FILE PREP. BY REV. BY DATE PROJECT NO.
I SMA 1 7/3/2024 STL2244601