WM0701237_Permit (Issuance)_20201119

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.
Date: November 5, 2020
2. County: Bertie
FOR OFFICE USE ONLY p
PERMIT NO. WM 1 2-34 ISSUED DATE t
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: North East Oil Company, Inc. Telephone: [phone]
Applicant's Mailing Address: Post Office Box 1386, Ahoskie, NC 27910
Applicant's Email Address (if available): NA
5. Contact Person (if different than Applicant): William Re9enthal Telephone: [phone]
Contact Person's Mailing Address: 113 W. Firetower Road, Suite G, Winterville NC 28590
Contact Person's Email Address (if available): WIr _geologicalresourcesinc.Com
6. Property Owner (if different than Applicant): James Hoggard Telephone: NA
Property Owner's Mailing Address: _1235 Bull Hill Road, Windsor, NC 27983
Property Owner's Email Address (if available):
7. Property Physical Address (including zip code) and PIN Number 6825-77-1 145; 1235 Bull Hill Road, Windsor 27983
8. Reason for Well(s)
(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 11891
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;
Existing Monitoring or Recovery Well Construction Permit No(s).:
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 10,
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes
If yes, give distance(s): —65'
15. Well Contractor: Justin Radford Certification No.: 3270
Well Contractor Address: 3502 Haves 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. 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
Number of wells to be constructed in bedrock: 6.
Total Number of wells to be constructed: 9
(add answers from 2 and 3)
Estimated beginning construction date: November 202C
Estimated construction completion date: November 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. 143-215.1013(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,
Suhchapter 2C) anq accepts full responsibility for compliance with these rules
I ofPt{'
ure o plic t or'Age ,41 Title of Applicant or `Agent
Sn
�rs'/��` 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
I well(s) conform to the Well Con ruction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
—JAIn Ls /-2 46&,4,e0
Si nature of Prirly OvWe4,6ffWent 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)

concrete pad
ground surface
Type IF -Monitoring Well
Typic t Construction Details
- mimhole cover
plooking Well cap
gruul cement C� 1
�--- 2 Inott dlamater
schedule 40 PVC casing
bentonite seal
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LEGEND
Q TYPE // MONITORING WELL
TYPE ll/ MONITORING WELL
DESTROYED TYPE // MONITORING WELL
® WATER SUPPLY WELL
— - — - — - — DRA/NA GE DITCH
Note:
This Site Map is based on Site Plan created by CES, Inc
dated 09y08y2003.
MW-14
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(Abandoned in place)
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-- MW10 .,_i Former
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MBA=-1,-,
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S/TE MAP
0 20 40 ao
Haggard s Grocery 1235 Bull Hill Road
Incident No. 11891 Windsor Bertie County,
( IN FEET) GRl Project No. 2741 NC
Geological Resources, Inc. 1 inch = 40 It Dote: 71/09/19 Drawn by. DTH I Figure: 2

500-FOOT RADIUS
SITE WSW-1
6825771145 •
6825763989
'5'&L WO-
6825761829 ❑
WSW-2
6825668880
0
WSW-3
6825763343
6825779229
0
WOODEDSWAMP
Legend
6825771145 PIN Number
El Water Supply Wells
E j Parcel —Polygon
PINE RIDGE
0 150 300
Feet
1 inch equals 300 feet
1,500-FOOT RADIUS � FIGMAP
HOGGARD'S GROCER
A 1235 BULL HILL ROAD
WINDSOR, BERTIE COUNTY
NORTH CAROLINA
INCIDENT NO. 11891
1,000-FOOT RADIUS
PREPARED BY:
GEOLOGICAL RESOURCES, INC.
AUGUST 25, 2008

Geological Resources, Inc.
November 6, 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
Hoggard's Grocery
1235 Bull Hill Road
Windsor, Bertie County
Incident Nos: 11891
GRI Project No: 2741
Dear Mr. May:
RECEIVED/NCDENR/DWR
NOV 0 9 2020
Water Quality
Regional Operations Section
Washington Regional Office
Please find enclosed a monitoring well permit application for the replacement of one Type II monitoring
well at Hoggard's Grocery located at 1235 Bull Hill Road in Windsor, Bertie County. GRI plans on installing
the monitoring well in November 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,
Ethan Rogerson, 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] • [phone] • Fax [phone]