WM0501344_Application_20190320

Geological Resources, Inc.
March 14, 2019 C Dept Of Pnvi
'"Iftthl Quality
MAR 2 Q 2011
Mr. Rich Bolich
Ralcigh k�gion
NCDENR, Division of Water Quality
Raleigh Regional Office Office
3800 Barrett Drive
Raleigh, North Carolina 27609
Re: Monitoring Well Permit Application
Rich Square Tire Center
413 East Jackson Street
Rich Square, Northampton County
Incident No: 8975
Dear Mr. Bolich:
Please find enclosed a monitoring well permit application for the installation of one Type II monitoring
well at the Rich Square Tire Center facility located at 413 East Jackson Street in Rich Square,
Northampton County. GRI plans on installing the monitoring well immediately upon receipt of the
approved well permit.
Your prompt attention to this matter will be greatly appreciated. If you have any questions or require
additional information please do not hesitate to contact me at [phone].
Sincerely,
Z1404L
William Regenthal, P. G.
Project Manager
enclosures
cc: file
3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] [phone] • Fax [phone]

NORTH CAROLINA DEPARTMENT OF ENVIRONMENT & NATURAL RESOURCES
DIVISION OF WATER QUALITY — AQUIFER PROTECTION SECTION
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.
1. Date: March 14, 2019
2. County: Northampton
FOR OFFICE USE ONLY
PERMIT NO. I, MOS-D /35� ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Northeast Oil Co.
Applicant's Mailing Address: PO Box 1836, Ahoskie, NC 27910
Applicant's Email Address (if available):
NA
Telephone
252-862-0653
5. Contact Person (if different than Applicant): William Regenthal Telephone: [phone]
Contact Person's Mailing Address: 113 W. Firetower Road, Winterville NC 28590
Contact Person's Email Address (if available): wlr geologicalresourcesinc.com
6. Property Owner (if different than Applicant): James Thomas Boone
Telephone: [phone]
Property Owner's Mailing Address: 413 F Jackson Street, Rir Sgijare, NC 27869
Property Owner's Email Address (if available): NA
7. Property Physical Address (including zip code) and PIN Number PIN# 5902-82-7402; 413 E Jackson St, Rich Square, 27869
8. Reason for Well(s):
9.
10.
(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 8975
11.
Type of contaminants being monitored or recovered: Petroleum
x
(ex: organics, nutrients, heavy metals, etc.)
G
12.
Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes
CD
�°
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0 5 010 4 6tITj
13.
Distance from proposed well(s) to nearest known waste or pollution source (in feet): — 4 5 '
o 0
14.
Are there any water supply wells located less than 500 feet from the proposed well(s)? No
O
_
�
If yes, give distance(s): NA
15.
Well Contractor: Justin Radford Certification No.: 3270
r
C
c
Well Contractor Address: 3502 Haves Road, Monroe NC 28110
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? Locking cap
material: 1
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: April 2019
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: April 2019
(add answers from 2 and 3)
ADDITIONAL INFORMATION
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 s regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
/AT..apter 2C) and accepts full responsibility for compliance with these rules
aS,,, fr Yjlvi1,pr
a ure o pplic Title of Applicirit or *Agent
Al, � * If signing as Agent, attach authorization agreement stating
Printed name of Appli or *A6en_t1 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).
Please see attached right to enter 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 Quality's Aquifer Protection Section Regional Office:
Asheville Regional Office
2090 U.S. Highway 70
Swannanoa, NC 28778
Phone: [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 28115
Phone: [phone]
Fax: [phone]
Raleigh Regional Office
3800 Barrett Drive
Raleigh, NC 27609
Phone: [phone]
Fax: [phone]
Washington Regional Office
943 Washington Square Mall
Washington, NC 27889
Phone: [phone]
Fax: [phone]
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
585 Waughtown Street
Winston-Salem, NC 27107
Phone: [phone]
Fax: [phone]
GW-22MR (Rev. 7/11)

Type ff.-Monitoring Well
Typic t Construction Detalls
concrete pad ��•• macnhole cover
g'roundsurface ,.-�' •� .. .�.
locking wall CAP
grout cement +- v
r 2 Inch �ilarneler
is
tohedule 40 Qvo caging
1
j
benlonlle seal 6 —
(l - 0,01.0Inch siotled Ainoh diameter
r schedule 40 IWO roman
sand fJllar prick
.. and oxa

Geological Resources, Inc.
October 19, 2018
Mr. James Thomas Boone
413 East Jackson Street
Rich Square, North Carolina 27869
Re: Notification of Work to be Conducted/Access Agreement
Rich Square Tire Center
413 E. Jackson Street
Rich Square, North Carolina
Northampton County
Dear Mr. Boone:
Geological Resources, Inc. (GRI), on behalf of North East Oil Company, Inc., is conducting an
environmental assessment at the above referenced property located in Northampton County, North
Carolina. The assessment activities are being conducted at the direction of the North Carolina
Department of Environmental Quality (NCDEQ). It is our understanding that you are the owner of the
property identified as parcel number 5902-82-7402 in Northampton County. In order to complete the
assessment, GRI, in conjunction with NCDEQ, has determined that limited soil excavation is necessary at
your property. Please note, at the request of NCDEQ, a Right to Enter Agreement is needed in order to
complete this scope of work.
A Right to Enter Agreement for Conducting Subsurface Investigations has been enclosed for your review.
At your earliest possible convenience, please sign the agreement and return it in the envelope that has
been provided. GRI will attempt to minimize any inconvenience that the activities may cause. A map
showing the areas in which the soil will be excavated has been attached.
Please check either the right to enter denied or right to enter granted box on the attached agreement. Your
cooperation in this matter is greatly appreciated. Please do not hesitate to contact the undersigned at
[phone] if you have any questions or require additional information.
Sincerely,
Z1,0ALA
William Regenthal, P. G.
Project Manager
Enclosures
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF NORTHAMPTON
We, the undersigned, being all of the fee simple owners of certain tracts or parcel designated as 5902-82-
7402 of the County of NORTHAMPTON, recognizing the benefits to said properties by reason of
conducting subsurface investigations hereby grant to North East Oil Company, Incorporated and the
agents the right to enter said property in accordance with the requirements of the State of North Carolina.
North East's agents may include Geological Resources, Inc.
The undersigned hereby covenant and warrant that they are the sole owners of said property; that they
solely have the right to grant this right to enter for conducting subsurface investigations against the lawful
claims of all persons whomsoever.
It is agreed that North East Oil Company, Incorporated shall be responsible for restoring any damage
done to the ground of said property by its employees or its agents during the subsurface investigation and
monitoring period, and that North East Oil Company, Incorporated shall abandon monitoring wells on
said property in accordance with NCDEQ requirements at the conclusion of the monitoring period.
It is agreed that North East Oil Company, Incorporated shall hold harmless the owner of the
aforementioned property for any personal injury that might be sustained during the course of conducting
or proximately resulting from the conduct of subsurface investigations.
Right to Enter denied.
_Right to Enter granted.
�i
Jigriature
phone : A: & — 3 ct (—tfw('o
it g1if,
Date
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] 9 Fax [phone]

LEGEND
5902-82-7402 PARCEL NUMBER
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- -6742 5902-73--4838
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5902-82-5445
5902-82-16
5902- 7490
902
402
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5902-82-419
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1, 000-R radius
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SITE VICINITY MAP
0 200 400 800 Rich Square Are Center 413 East Jackson Street
( /W fE£T ) Rlch Square, Northampton County, NC UST Incident ,f 8975
Geo%g/co/ Resources, Inc. 1 inch = 400 R Date: 041041741 Drown 6y. £CH I Rgure.• 2

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Byers, Brion N
From: William Regenthal<[e-mail]>
Sent: Friday, March 15, 2019 2:19 PM
To: Byers, Brion N
Subject: [External] Rich Square Tire Center Well Permit Supplemental Info
Attachments: SKMBT_36319031514190.pdf
• External email. Do not click links or open attachments unless you verify. Send all suspicious email as an attachment to
redo i@ uov� -
Brion,
Attached is a notated vicinity map showing information regarding the only other known pollution site (Cotton Gin Plant;
UST Incident #11161) that I am aware of. There are 6 existing monitoring wells associated with that site (MW-1, MW-2,
MW-4, MW-5, MW-6 and TW-1). I also included a site map for Cotton Gin Plant.
William Regenthal, P. G.
Branch Operations Manager - Winterville
Geological Resources, Inc.
113 W. Firetower Road, Suite G., Winterville, NC 28590
Main [phone] Office [phone] Fax [phone]
[e-mail]
www.geologicalresourcesinc.com
NCPCM 2015 Vendor of the Year Recipient
Business North Carolina Magazine 2015 Small Business of the Year Runner-up Recipient
From: [e-mail] [mailto:[e-mail]]
Sent: Friday, March 15, 2019 3:20 PM
To: William Regenthal<[e-mail]>
Subject: Message from KMBT_363