WM0100475_Application_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: Rutherford
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: United Oil of the Carolinas
Applicant's Mailing Address: PO Box 68, Gastonia, NC 28054-0068
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
Telephone: [phone] ext. 119
Applicant's Email Address (if available): lewisPunitedoilofthecarolinas.com
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): wsbc geoloaicalresourcesinc.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
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).
No
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 Hayes 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:
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Locking
expansion cap and bolt down manhole cover
6. Estimated beginning construction date: 8/7/2020
7. Estimated construction completion date: 8/7/2020
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
Signature of Applicant or `Agent
D. Lewis C. Efird
Printed name of Applicant or *Agent
President
Title 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).
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
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
450 W. Hanes Mill Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR 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, i -clasp
(2o,
Date
3502 Hayes Road • Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax [phone]

6/15/2020
ConnectGlS Feature Report
W HOSTING
RutherfordCounty
Printed June 15, 2020
See Below for Disclaimer
Major Highways
Roads
Lake Lure
Limits
Bostic
Chimney Rock Villa
Ellenboro
Forest City
Lake Lure
Ruth
R I,therfo rdto n
Spindale
Parcels
County Lines
0
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6/15/2020
ConnectGlS Feature Report
Geo-pin City
1631285589
ParcellD Township
34562 Logan Store
Acreage Zoning
3 NONE
Deed Page Map Book
4191
Index Type Map Block Lot
CRP 732 1 2 B
Property Address
2924 HUDLOW RD
Special Tax Districts
Owner Mailing City
GASTON IA
Neighborhood
C90J
Owner Name
KHODAL MAAVDI LLC
Deed Date
12/20/2019 12:00:00 AM
Land Class
COMMERCIAL
Deed Book
2028
Map Page
Parcel Number
1620644
Fire District
F08 HUDLOW
Owner Mailing Address
3400 YARMOUTH LN
Owner Mailing State Owner Mailing Zip
NC 28056
Land Tax Value Building Tax Value
35800 38600
Revenue Stamp Structure Size
390 0
Subdivision Sale Price
195000
Total Assessed Value
74400
Under Assmt Flag
N
OBJECTID 1
14962
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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
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SOIL SAMPLE LOCATION MAP— OVER EXCAVATION SAMPLES
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YPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PAD
GROUND SURFACE
GROUT CEMENT
BENTON/TE SEAL
SAND FILTER PACK
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•
MANHOLE COVER
LOCKING WELL CAP
2 INCH DIAMETER
SCHEDULE 40 PVC CASING
0.070 /NCH SLOTTED
2 /NCH DIAMETER
SCHEDULE 40 PVC SCREEN
END CAP