WM0501414_Permit (Issuance)_20201019

ROY COOPER
Governor
MICHAEL S. REGAN
Secretory
S. DANIEL SMITH
Director
NORTH CAROLINA
Environmental Quality
October 19, 2020
Circle K Stores, Inc.
1100 Situs Court, Suite 100
Raleigh, N.C. 27606
Subject: Monitoring Well Construction
Permit # WM0501414
Circle K #2708620
4100 Western Boulevard
Raleigh, NC -Wake County
To Whom It May Concern:
In accordance with the application received on October 5, 2020, and the additional requested -
information received on October 15, 2020, we are forwarding herewith Monitoring Well Construction
Permit No. WM0501414 dated October 19, 2020, issued for the construction of a monitor well system
(installation of two wells) at the subject property (4109 Western Boulevard). Please be aware that some
This Permit will be effective from the date of its issuance and shall be subject to the conditions and
limitations as specified therein. Please note the addition of stipulation #3 to the permit enclosed. If you have
any questions about this permit, please contact Eric Rice at [phone].
Sincerely,
DocuSignod by:
Sett Oi n44*a
BCDA9D82504A46D...
Scott Vinson, Regional Supervisor
Water Quality Regional Operations Section
Raleigh Regional Office
Division of Water Resources, NCDEQ
Enclosure
cc: RRO Files
Wake County Health Department
Email- maureen jackson(a,atc s.com Maureen Jackson, ATC, 609A Piner Road, Suite 115,
Wilmington, NC 28409
D E Q North Carolina Department of Environmental Quality I Division of Water Resources
Raleigh Regional Office 13800 Barrett Drive I Raleigh. North Carolina 27609
OepiN -161 '� �"" �� \ 919.791.4200

NORTH CAROLINA
DEPARTMENT OF ENVIRONMENTAL QUALITY
DIVISION OF WATER RESOURCES
PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL
In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable
Laws, Rules and Regulations.
PERMISSION IS HEREBY GRANTED TO
Circle K Stores, Inc.
FOR THE CONSTRUCTION OF A MONITOR WELL SYSTEM (Circle K #2708620) consisting of two wells
owned by Circle K Stores, Inc at mailing address 1100 Situs Court, Suite 100 in Raleigh, NC. The wells will be located
on the property owned by David J. Martin located at 4109 Western Boulevard in Raleigh, NC -Wake Co. This Permit
is issued in accordance with the application received on October 5, 2020 and the additional requested information
received on October 15, 2020 in conformity with specifications and supporting data, all of which are filed with the
Department of Environment and Natural Resources and are considered integral parts of this Permit.
This Permit is for well construction only, and does not waive any provision or requirement of any other applicable
law or regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina
Well Construction Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and
regulations pertaining to well construction.
If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing
upon written request within 30 days of receipt of this Permit. The request must be in the form of a written petition
conforming to Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative
Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit
is final and binding.
This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions,
limitations, or exceptions as follows:
1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are
being installed as part of an investigation for contamination from an underground storage tank or
dry cleaner incident.
2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by
another agency.
3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the
Permit application.
4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C
.0108(o).
5. Well construction records (GW-1) for each well shall be submitted to the Division of Water
Resource's Information Processing Unit within 30 days of the well completion.
6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC
02C .0113 and a well abandonment record (GW-30) shall be submitted to the Division of Water
Resource's Information Processing Unit within 30 days of the well abandonment.
7. If the well penetrates any water -bearing zone that contains contaminated waters, the upper three feet
of the well shall be grouted within one day after the casing is set or the well abandoned.
Permit issued the 19a' of October 2020
FOR THE NORTH CAROLINA FtNW&ROPOUNTAL MANAGEMENT COMMISSION
Scott inson, egional Supervisor
Divis1*B?MQ6sources
By Authority of the Environmental Management Commission
Permit No. WM0501414

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.
FOR OFFICE USE ONLY
1. Date: October 1, 2020
PERMIT NO. i� ISSUED DATE
2. County: Wake
3. What type of well are you applying for? (monitoring or recovery): Monitoring
Circle K Stores, Inc. Telephone: [phone]
4. Applicant: C'
Applicant's Mailing Address: 1100 Situs Court, Suite 100 Raleigh, North Carolina 27606
v N
Applicant's Email Address (if available): bpuzak(&circlek.com
5. Contact Person (if different than Applicant): Maureen Jackson Telephone: [phone]
Contact Person's Mailing Address: 609A Piner Road, Suite 115 Wilmington, North Carolina 28409 �-
o �
Contact Person's Email Address (if available): maureen jackson(a atcgs com �
6. Property Owner (if different than Applicant): David J. Martin Telephone: [phone] A
1201 Buck Jones Road RaleighNorth Carolina 27606
Property Owner's Mailing Address: g
Property Owner's Email Address (if available): N/A
7. Property Physical Address (Including PIN Number) 4109 Western Boulvard (PIN #0794006383)
City Raleigh County Wake Zip Code 27606
8. Reason for Well(s): petroleum release assessment for Circle K Store #2708620 (UST incident #46510)
(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 #46510
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? Yes - 13
Existing Monitoring or Recovery Well Construction Permit No(s).: WM0501396
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 212-265 feet
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s): N/A
15. Well Contractor: Geologic Exploration Certification No.: 1176
Well Contractor Address: 176 Commerce Blvd. Statesville, North Carolina 28625
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
�4�

PROPOSED WELL CONSTRUCTION INFORMATION (Continued)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured?
material: 2 Steel traffic bearing covers, sealine and locking caps
3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: Nov 2020
4. Total Number of wells to be constructed: 2 7. Estimated construction completion date: Nov 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. 143-215.106(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
c ,� Senior Project Manager ATC Associates of NC
Signature of Applicant or *Agent Title of Applicant or *Agent
Maureen A Jackson PG on behalf of Circle K Stores, Inc. * 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).
Executed ROE Attached Executed ROE Attached
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]
VIR Rev. 3-1-2016

RIGUT OF ENTRY AND PERMISSION FOR MONITORING WELL INSTALLATION
("the License')
The property owner(s) (referred to in this Agreement as the "Owne•(s)") have the sole right to possession
of the property for which a right of entry is granted by this document. The property located at:
4109 Western Boulevard Raleigh, Wake County, North Carolina
(PIN 0794006383)
The Owner(s)AGREE
❑ DO NOT AGREE
to give Circle K Stores. Inc.) (the "Licensee"), its agents, employees, and assigns, the right to enter upon
the property to install two (2) groundwater monitoring wells, and to do all activities required to complete
their work at no cost to the Owner(s). The Owner(s) acknowledge ATC Associates of North Carolina, P.C.
("ATC') is an agent of the Licensee.
This License is effective immediately upon signing. Licensee agrees to repair or cause to be repaired any
damage to the property resulting from entry onto the property by Licensee, its agents, employees, or
assigns, by restoring the property, as much as reasonably possible, to its condition immediately prior to the
entry.
Dated this 2O0 day of )�V( 2020.
"Owner(s)"
Signature
MAA-5 pAA,6 I A(ar.1 Md MC--ez
Printed Name
Signature
Printed Name
Telephone Number
"Licensee"
Circle K Stores, Inc.
ATC Associates of North Carolina, P.C.
Agen or Licensee,
Its Senior Project Mat =
Project #Circle K Store 92708620

0
r.
200k
4109 Western Blvd Raleigh, NC 500-foot Radius Map
• Proposed Monitoring Well Location
Scale (noted in bottom left comer) - V = 200 feet

PROPOSE© MONITORING WELL CONSTRUCTION DETAILS
FLUSH GRADE MANHOLE
GROSS SECTIONAL VIEW
(NOT TO SCALE)
LOCKABLE WELL CAP PROTECTIVE CASING AND CONCRETE PAD
("ASiNG MATERIAL
CASING DIAMETER 8 inches
CA --
SING LENGTH _12 inches
PAD DINIIENSIONS 2 feet
;-jEIC-HT ABOVE GRIOUNO Flush
'-4
j,
IT!.E FIGURE 1
NELL CASING
LIAT ERIAL
[)IAMETER
,jC)IN'f TYPE
LENGTH
BACKFILL AROUND CASING
MATEq!AL
HICKNESS
SEAL
TypF- OFF SEAL
1H1CKNIESS
FILTER PACK
TYPE OF FIL !'ER
DISTANCE ABOVE SCREEN
WELL SCREEN
SCREEN MATERIP,L
r, 1 A -,m, E T E R
F-JGTH
SLO", -SIEZE
DEPTH TO BOTTOM OF
MONITORING WELL
DEPTH TO BOTTOM OF
BOREHOLE
Proposed Monitoring Well
Circle K Store
KAA 11
DIAMETER OF BOREHOLE
sch 40
_9 inches
flush threarI2r' --­r
cement -sand grOLIt
#2 silica sand
sch 40 PVC
2 inches
0.010 inches
6 inches
pw 1A x^
2725 E. Millbrook Road. SLJite',21,
Raleigh, North Carolina 2'604
DATE
9�2612019