WM0801162_Application_20200817

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:
2. County: Duplin PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Speedway LLC Telephone: [phone]
Applicant's Mailing Address: 500 Speedway Drive Enon, Ohio 45323
Applicant's Email Address (if available): cachiaraCcDspeedway.com
5. Contact Person (if different than Applicant): D.T. Hurdle Telephone: [phone]
Contact Person's Mailing Address: 211 Expressway Court, Virginia Beach, Virginia 23462
Contact Person's Email Address (if available): donald.hurdle aa)atcgs.com
6. Property Owner (if different than Applicant): Sue Bowden Telephone: [phone]
Property Owner's Mailing Address: 404 East Ridge Street Rose Hill, NC 28458
Property Owner's Email Address (if available): stbowden(aa-)gmail.com
7. Property Physical Address (Including PIN Number) 209 North Sycamore Street PIN 239914331605
City Rose Hill County Duplin Zip Code 28458
8. Reason for Well(s): 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: UST facility across street
(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).
None
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? 3 wells on adjacent property
Existing Monitoring or Recovery Well Construction Permit No(s).: N/A
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 80 feet
14. 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: Geological Exploration Inc Certification No.: A-3098
Well Contractor Address: 176 Commerce Boulevard Statesville, NC 28625
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: 1
3. Number of wells to be constructed in bedrock: 0
5. How will the well(s) be secured? Locking Cap
6. Estimated beginning construction date: Aug 19, 2020
4. Total Number of wells to be constructed: 1 7. Estimated construction completion date: Aug 19, 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. 143-215.10B(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
D..41 / ;"
Project Manager
Signature of Applicant or *Agent Title of Applicant or *Agent
Donald T. Hurdle * 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).
Access Agreement attached Sue Bowden
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 Office
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
610 East Center Avenue
Mooresville, NC 28115
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

8
Speedway LLC
500 Speedway Drive
Enon, Ohio 45323
Telephone [phone]
OFF -SITE ACCESS AGREEMENT
SECOND REQUEST
April 16, 2020
Ms. Mary Jones Teachey
Post Office Box 520
Rose Hill, North Carolina 28458
RE: Right of Entry Request
209 North Sycamore Street
Rose Hill, North Carolina 28458
Parcel Tax ID No. 239914331605
Near Speedway LLC Store No. 8290
Dear Ms. Teachey:
Speedway LLC (Speedway) understands that you are the owner of the property referenced
aboveI which is located in the vicinity of a certain Speedway property located at 206 North
Sycamore Street Rose Hill, North Carolina.
Speedway is conducting an investigation of subsurface environmental conditions in the vicinity of
our property at Speedway No. 8290 at the direction of the North Carolina Department of
Environmental Quality (NCDEQ). This investigation requires us to move off our property to fully
evaluate possible petroleum -related impacts to the soil and groundwater.
As part of this investigation, Speedway requests your permission to install one (1) monitoring well
on your property near the location depicted on the enclosed map. We will be entering onto your
property periodically to take samples from the monitoring well.
In performing this work, Speedway will take all reasonable measures to avoid damage to your
property and/or unreasonable interterence with the present use of your property. Speedway will
defend, indemnify and hold you harmless from and against any loss, cost, damage or expense
arising out of our work on your property. Upon completion of its investigation, Speedway will
close all wells in accordance with state regulations, remove all equipment and restore your
property to as near to its original condition (immediately prior to commencement of the work) as
reasonably possible.

Speedway No. 8290 PJ2
SECOND REQUEST
W1•qy JoFle beach
April 16, 2020
Page 2
Whether you consent to or refuse this request for access, please check the appropriate
box below, sign at the space provided below, and return one original copy of this letter by
May 16, 2020. A second copy has been provided for you to keep for your records. A self-
addressed, postage paid envelope is provided for your convenience. If you check the appropriate
box and sign, your signature will serve to grant Speedway (including its employees and agents)
permission to enter unto your property for the purpose of well installation and continued well
monitoring. You may revoke this permission at any time by giving Speedway at least sixty (60)
days written notice of your intent to revoke
If you have any questions or require additional information, please contact me at 919-516-8069
or by email at cachiara(u)speedway.com.
Sincerely,t
Speedway LLC
Charles A. Chiara
Environmental Representative
Enclosures
cc: Mr. Donald Hurdle, ATC Group Services LLC (Phone: [phone])
�j Yes, I have read the preceding letter and represent and warrant that I have full authority
to enter into this Access Agreement and to make it binding on any entity having a valid
claim of an interest in my property. I hereby grant Speedway permission to enter onto my
property under the terms described above.
[ ] No, I have read the preceding letter and hereby do not grant Speedway permission to
enter onto my property under the terms described above.
Signatu
Date:
{00008767.DOCx }

SPILL BUCKET
(TYP.)
PROPOSED
MONITORING WELL
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Proposed Well: MW-04
ENVIRONMENTAL - GEOTECHNICAL
(Page 1 of 1)
BUILDING SCIENCES - MATERIALS TESTING
Speedway No. 8290
Date(s) Drilled : 08/19/20 (Proposed) Boring Diameter : 6.25
206 North Sycamore Street
Drilling Contractor : Geological Exploration Inc Sampling Method : Split Spoon
Rose Hill, North Carolina
Driller : TBD Sampling Interval : 2 Feet
ATC Project No. SWDP829003
Drilling Method : Hollow Stem Auger Logged By : TBD
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DESCRIPTION
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SM Topsoil
Concrete
Brown silty SAND (Anticipated)
Grout
Casing
2
Bent onite
4
Groundwater anticipated between 5 and 7 feet
6
Sand Pack
SM
Screen
7.
8
10
12
End of boring
14
Boring terminated at 13' bgs.
Soils wet at 7 feet below ground surface
Proposed Well is located approxamatly 80 feet west of Speedway No. 8290