WM0100475_Monitoring Well Construction Permit_20200803

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
August 3, 2020

Mr. Andrew Moore
NCDEQ – Aquifer Protection Section
Asheville Regional Office
2090 US Highway 70
Swannanoa, North Carolina 28778

Re: Application for Permit to Install Monitoring Well
Mt. Vernon Cubbard
2930 Hudlow Road
Forest City, Rutherford County, NC
Incident No. Pending
GRI Project No. 5258

Dear Mr. Moore:

Geological Resources, Inc. (GRI) is pleased to submit the attached monitoring well permit
application for the above-referenced site (Figure 1). Location of the proposed monitoring well is
shown on the attached site map (Figure 2).

If you have questions or comments, please do not hesitate to contact me at [phone].

Sincerely,

W. Scott Ball
Senior Project Manager

cc: file
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.
1. Date: 7/30/2020
2. County:
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: United Oil of the Carolinas Telephone: [phone] ext. 119
Applicant's Mailing Address: PO Box 68, Gastonia, NC 28054-0068
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Scott Ball Telephone: [phone]
Contact Person's Mailing Address: Geological Resources, Inc., 3502 Haves Road, Monroe, NC 28110
Contact Person's Email Address (if available): wsb(ageologicalresourcesinc.com
6. Property Owner (if different than Applicant): Khodal Maavdi, LLC Telephone: [phone]
Property Owner's Mailing Address: 3400 Yarmouth Lane, Gastonia, NC 28056
Property Owner's Email Address (if available): NA
7. Property Physical Address (Including PIN Number) 2930 Hudlow Road PIN 1620644
City Forest City County Rutherford Zip Code 28752-5285
8. Reason for Well(s): Ground Water Assessment
(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: Former UST facility (Mt. Vernon Cubbard)
(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).
11. Type 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? No
Existing Monitoring or Recovery Well Construction Permit No(s): No existing permit no.
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 1.0'
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): NA
15. Well Contractor: GRI Certification No.: 3220-A
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. Sandlgravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated
material: 1
3. Number of wells to be constructed in bedrock:
5. How will the well(s) be secured? Lockinq
expansion cap and bolt down manhole cover
6. Estimated beginning construction date: 8/7/2020
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: 8/7/2020
(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
(�fri�r�G���/.•.aZ, 0�Lw• President
Signature of Applicant or `Agent L7 Title of Applicant or *Agent
D. Lewis C. Efird * 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).
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 28115
Phone: [phone]
Fax: [phone]
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]
AR Rev. 3-1-2016

RECEIVED JUN 2 6 2020 RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF RUTHERFORD
GRI JOB NO. 5258
MT. VERNON CUBBARD
We, the undersigned, being all of the fee simple owners of certain tract or parcel designated as 1620644
of the County of Rutherford, recognizing the benefits to said properties by reason of conducting
underground storage tank (UST) removal activities hereby grant to United Oil of the Carolinas (United
Oil) and their agents the right to enter said property in accordance with the requirements of the State of
North Carolina. United Oil'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 the UST closure activities against the
lawful claims of all persons whomsoever.
It is agreed that United Oil 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 UST closure activities.
Right to Enter denied.
Right to Enter granted.
Signature
Phone: 0 G, 4,u
Date
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

6/15/2020 ConnectGIS Feature Report
RutherfordCounty
NNECTGISPrinted June 15, 2020
'':M HOSTING i� See Below for Disclaimer
4,
iY�3�Qr Hlgh'�va;,�s
Roads
F" ' a
3F4
1:115Feet
Lake Lure
C
Limns
0
Bostic
0
Chimney Rack Villa
0
EllenbarD
FormtCity
0
Lake Lure
0
Ruth
0
Rutherfordtan
0
Spindale
Parcels
County Lines
13
https://rutherfordcounty.connectgis.com/DownloadFile.ashx?i=_ags_map682adcecO6874fO8a6Ob5f23fce74b93x.htm&t=printid 1/2

6/15/2020 ConnectGIS Feature Report
Geo-pin City Deed Date
1631285589 12/20/2019 12:00:00 AM
ParcellD Township Land Class
34562 Logan Store COMMERCIAL
Acreage Zoning Deed Book
3 NONE 2028
Deed Page Map Book Map Page
4191
Index Type Map Block Lot Parcel Number
CRP 732 1 2 B 1620644
Property Address Neighborhood Fire District
2924 HUDLOW RD C90J F08 HUDLOW
Special Tax Districts Owner Name Owner Mailing Address
KHODAL MAAVDI LLC 3400 YARMOUTH LN
Owner Mailing City Owner Mailing State Owner Mailing Zip
GASTONIA NC 28056
Land Tax Value Building Tax Value Total Assessed Value
35800 38600 74400
Revenue Stamp Structure Size Under Assmt Flag
390 0 N
Subdivision Sale Price OBJECTID 1
195000 14962
Rutherford County Geographic Information Systems (GIS) Data Distribution Disclaimer The County of Rutherford acquires, develops, maintains and uses GIS data in
support of its internal business functions and for the public services it provides. The GIS data which Rutherford County distributes and to which it provides access, may
not be suitable for other purposes or uses. It is the useraE' s responsibility to verify any information derived from the GIS data before making any decisions or taking
any actions based on the information. Rutherford County shall not be held liable for any errors in the GIS data. This includes errors of omission, commission, errors
concerning the content of the data, and relative and positional accuracy of the data. Source information used for this data may have been collected at different scales,
times or definitions, resulting in inconsistencies among features represented together on this map. In no event shall Rutherford County become liable to users of these
data, or any other party, for any loss or direct, indirect, special, incidental or consequential damages, including but not limited to time, money or goodwill, arising from
he use or modification of the data. The Geographic Information System (GIS) Data made available on the GIS website does not represent legally recorded maps or
surveys and is not intended to be used as such. The information contained in GIS data is dynamic and constantly changes over time. This data is not better than the
original sources from which they were derived. GIS data should not be used for navigational, tracking or any other purpose requiring exact measurement of distance or
direction or precision in the depiction of geographic features. Nor should it be used for making financial or any other commitments. The maps/data provided herein are
for illustration purposes only and are not suitable for site -specific decision making. Parcel data was prepared for the visual representation of real property found within
Rutherford County, and is not necessarily accurate by surveying standards. If absolute accuracy and detail is required, the deeds, plats and other related records on file
should be consulted. Parcel ownership lines are for taxing purposes only and are not intended for conveyance. This data has been developed using public funds. It is
therefore in the public domain. Users agree that they will not sell this data; neither will they sell or share their access to this data. As a condition of providing access to
electronic GIS data, Rutherford County reserves the right to require that the user agree in writing that the data will not be resold or otherwise used for trade or
commercial purposes pursuant to N.C. Gen. Stat. A§132.10.
https://rutherfordcounty.connectgis.com/DownloadFile.ashx?i=_ags_map682adcec06874f08a60b5f23fce74b93x.htm&t=printid 2/2

SITE LOCATIONFigure 1 Site LocationMt. Vernon Cubbard2930 Hudlow Road Forest City, Rutherford County, NC Incident No. N/AGRI Project No. 5258500 M2000 FTDate: 07/19/2020Location: 36.449988° N -76.699906 W Dad
T
0
-o U
O
O �
O
O U
Z
� � N
S
� U
N
in S
N �
O
Q �
W
� 3
O Q N 6
\L 0
� Z
O
U O Z
Z _ O
n O U O
N
O \
U
C _ \
U o
w
� ao
�
U�
oCD(J�
o
Q J
0
D
Ii i Q
0
^o
p � N
L W
0CN
Q � Z U
� � C
C�
O
c
L
'J O
J'
I'
C N
O O ~
U
w N
U
v
b �
m
0
Z Q
Q o 6
W
U
Q Q O X \
O o
�-
C/-) O O T
O
z n O
=) z FLC O O
O O O m
CC F7 I-- -o N
U Q U u0i O O
Z 0- >
LJ W Q c)
U W z X O O '6
U U7 O
W O
' a F- U F- O
Z � N

LO
Z
W
U
W
J
W
W
W
r
I
Z
O
Q I--
Q
Z U
D U O
O Z J
m
n W
Z d J
O n
Q U Q
> (n
U O J
X cl� O
J a_ (n
I -
i
C/-) T
W I
J 73
n O
> o U
Q O
O
O
Z � �
O O
U
Q
> _
Q O > o
O r)
X O-) U
W N
p S
N H
�O
O)d
W
U _
0
c
J -
0 _
N -
c -
7 _
7
mmkl _
U
L_—INN----m--j
N■ _ N
LLJ w -
m ■
U�: r_ -.w-- ---
C�^
O �Cf) ommmmmm
cn o U)
0 =
CD z
■
E
(IHVMOHHV(I 'Wd 00:LO: L L OZOZ/6Z/L 'lapow `(5mp-deWaseq 8SZS\8SZS\(Z) aaplo; MGN\doiNsaQ\(]HVMOHHv(i\siesN\:O

TYPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
cc
GROUND SURFA Cl
GROG
BEN
SAND Fl,
L L CAP
METER
40 PVC CASING
V SL 0TTED
AMETER
40 PVC SCREEN