WM0701234_Permit (Issuance)_20200929

Geological Resources, Inc.
September 25, 2020
Mr. David May
NCDEQ, Division of Water Quality
Washington Regional Office
943 Washington Square Mall
Washington, North Carolina 27889
Re: Monitoring Well Permit Application
Handy Mart #15
2495 US Highway 13 N
Goldsboro, Wayne County
Incident Nos: 38811
GRI Project No: 5415
Dear Mr. May:
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Please find enclosed a monitoring well permit application for the installation of four Type II monitoring
wells at Handy Mart #15 located at 2495 US Highway 13 N in Goldsboro, Wayne County. GRI plans on
installing the monitoring wells in October 2020.
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,
p4k
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] - 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: September 25, 2020 FOR OFFICE USE ONLY
2. County: Wayne PERMIT NO. ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: EJ Pope & Sons, Inc. Telephone: [phone]
Applicant's Mailing Address: Post Office Box 649 Mount Olive, NC 28365
Applicant's Email Address (if available): NA
5. Contact Person (if different than Applicant): William Regenthal Telephone: [phone]
Contact Person's Mailing Address: 113 W. Firetower Road, Suite G, Winterville NC 28590
Contact Person's Email Address (if available): wlr p[�geologicalresourcesinC com
6. Property Owner (if different than Applicant): Marie Peele Telephone: NA
Property Owner's Mailing Address: 2521 US Highway 13 N, Goldsboro, NC 27534-7319
Property Owner's Email Address (if available):
7. Property Physical Address (including zip code) and PIN Number 3620831877; 2495 US Highway 13 N, Goldsboro 27534
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
(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).
UST Incident 38811
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).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 0 '
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): 600' N; 750' E
15. Well Contractor: Justin Radford Certification No.: 3270
Well Contractor Address: 3502 Hayes Road, Monroe NC 28110
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)
Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Locking cap
material: 0
4
Number of wells to be constructed in bedrock: 6.
Total Number of wells to be constructed: 4
(add answers from 2 and 3)
Estimated beginning construction date: October 2020
Estimated construction completion date: October 2020
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. 143-215.10B(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
t - Project Manager
Signature of cant or *Agent Title of Applicant or *Agent
William Regenthal, P. G.
Printed name of Applicant or *Agent
* If signing as Agent, attach authorization agreement stating
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 RTE
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)

Geological Resources, Inc.
September 11, 2020
Marie Peele
2521 US Highway 13 N
Goldsboro, North Carolina 27534-7319
Re: Right to Enter Agreement
Handy Mart #15
2495 US Highway 13 North
Goldsboro, North Carolina
Wayne County
GRI Project No. 5415
Dear Ms. Peele:
Geological Resources, Inc. (GRI), on behalf of EJ Pope & Sons, Inc., is conducting an environmental
assessment at the above referenced property located in Wayne 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 3620831877 in Wayne County. In order to complete the assessment, GRI, requires permission
to enter your property to conduct ground water sampling.
At your earliest possible convenience, please sign the right -to -enter agreement and return it via email,
fax or US Mail. GRI will attempt to minimize any inconvenience that the activities may cause.
The ground water assessment activities will be conducted at NO COST TO YOU, as EJ Pope & Sons, Inc. is
responsible for the activities.
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,
Z144 'A
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 WAYNE
We, the undersigned, being all of the fee simple owners of certain tracts or parcel designated as
3620831877 of the County of WAYNE, recognizing the benefits to said properties by reason of
conducting subsurface investigations hereby grant to EJ Pope & Sons, Incorporated and the agents the
right to enter said property in accordance with the requirements of the State of North Carolina. EJ Pope
& Sons, Inc.'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 EJ Pope & Sons, Inc. 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 Red Apple Markets, Incorporated shall abandon monitoring wells on said property in
accordance with NCDEQ requirements at the conclusion of the monitoring period.
It is agreed that EJ Pope & Sons, Inc. 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.
Signature
phone :
---------------
Date
(RTE Handy Mart #15)

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