WM0100477_Application_20200919

3502 Hayes Road • Monroe, North Carolina 28110
113 West Firetower Road, Suite G • Winterville, North Carolina 28590
Phone [phone] • [phone] • Fax [phone]
September 19, 2020
Mr. Brett Laverty
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. 47150
GRI Project No. 5258
Dear Mr. Laverty:
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 wells
are 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
WM0100477 09/21/2020
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

NO
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UNDERGROUND STORAGE TANK
— EXCAVATION BOUNDARY AREA
PRODUCT PIPING
the Rutherford
SITE MAP
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3
0
0
O
N
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Geological Resources, Inc.

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]

YPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE PAD
GROUND SURFACE
GROUT CEMENT
BENTON/TE SEAL
SAND FILTER PACK
e
•
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