WM0701239_Application_20201125

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 9, 2020
2. County: Bertle
��jj
FOR OFFICE USE ONLY
PERMIT NO.*A10701239 ISSUEDDATE
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 Reaenthal Telephone: [phone]
Contact Person's Mailing Address: 113 W. Firetower Road, Suite G, Winterville NC 28590
Contact Person's Email Address (if available): wlr �peologicalresourcesinc.com
6. Property Owner (if different than Applicant): Cheryl D. Levinson & Julia Godwin Telephone: [phone]
Property Owner's Mailing Address: Post Office Box 2, Powellsville, NC 27967
Property Owner's Email Address (if available):
PIN# 6900-97-8563; 6900-97-9532; 101 Bethlehem Church
7. Property Physical Address (including zip code) and PIN Number Road, Powellsville, Berne County
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 3377
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; 2
Existing Monitoring or Recovery Well Construction Permit No(s).: NA
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —100,
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: 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(0(7), attach a well construction diagram of each well showing the following. J J
a. Borehole and well diameter e. Type of casing material and thickness t q 3LUl�
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)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Locking cap
material: 2
3. Number of wells to be constructed in bedrock: 0
4. Total Number of wells to be constructed: 2
(add answers from 2 and 3)
Estimated beginning construction date: Nov 2020
Estimated construction completion date: Nov 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 II Constructio emit 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
Project Manager
nature of Appl t 6r *Agent Title of Applicant or *Agent
William Regenthal, P. G. * 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).
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.
October 9, 2020
Cheryl D. Levinson
Post Office Box 2
Powellsville, North Carolina 27967
Re: Right to Enter Agreement
Bertie County Parcel #s 6900-97-8563 & 6900-97-9532
101 Bethlaham Church Road
Powellsville, North Carolina
Bertie County
To Whom It May Concern:
Geological Resources, Inc. (GRI), on behalf of North East Oil Company, Inc., is conducting an
environmental assessment at the above referenced property located in Bertie 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 properties
identified as parcel numbers 6900-97-8563 & 6900-97-9532 in Bertie County. In order to complete the
assessment, GRI, in conjunction with NCDEQ, has determined that it is necessary to install two
monitoring wells and collect water samples at your properties. Please note, at the request of NCDEQ, a
Right to Enter Agreement is needed in order to complete this scope of work.
A Right to Enter Agreement for Conducting Subsurface Investigations has been enclosed for your review.
At your earliest possible convenience, please sign the agreement and return it in the envelope that has
been provided. GRI will attempt to minimize any inconvenience that the activities may cause. A map
showing the area in which the monitoring well will be installed has been attached. This scope of work is
being performed for the former CB Jones Texaco which had been located across Bethlehem Church Road
from your properties.
Please check either the right to enter denied or right to enter granted box on the attached agreement.
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, elk
Z4
William Regenthal, P. G.
Project Manager
Enclosures
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] 9 Fax [phone]

RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF BERTIE
We, the undersigned, being all of the fee simple owners of certain tracts or parcels designated as 6900-
97-8563 & 6900-97-9532 of the County of BERTIE, recognizing the benefits to said properties by reason
of conducting subsurface investigations hereby grant to North East Oil Company, Inc. and the agents the
right to enter said property in accordance with the requirements of the State of North Carolina. North
East Oil Company, 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
iawful ciaims of ail persons whorr;soever.
It is agreed that North East Oil Company, 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 North East Oil Company, Inc. shall abandon monitoring wells on said
property in accordance with NCDEQ requirements at the conclusion of the monitoring period.
It is agreed that North East Oil Company, 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.
IV --.*,,'Right to Enter granted.
r
nature
phone a� 28`)
Date
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] [phone] • Fax [phone]

Type If'.. Monitoring Well
Typlc�f Construction Detalls
concrete pad - manhole cover
ground surface
looking well cap
grout cement
2 inch diameter
schedule 40 PVC caning
• I I
I- 1.5 - •
benlonlie opal
— 0,01-0 Inch slotted 21nch diameter
schedule 40 PVC Korean
f
sand filler ppok +.•
i
and cuts

pF
G
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w
1,500-FT RADIUS
1,000-FT RADIL
250-FT RI
SNO1V
GgRRF�
Legend
Water Supply Well
"C 0 Active
00' Inactive
�G`j` Destroyed
Parcel ID Number
Subject Parcel
Other Parcel
Road Centerline
0 150 300 600
� Feet
SCALE: 1 INCH = 300 FEET
FIGURE 2
SITE VICINITY MAC'
CB JONES TEXACO
N.C. HIGHWAY 42 & BETy1LEHEM
CHURCH ROAD
POWELLSVILLE, BERTIE %-"OUNTY,
NORTH CAROLIN;A
Cw
l�
3�G of INCIDENT NO. 3377
Mq/
d9� GRI PROJECT NO. 2607
PREPARED BY:
GEOLOGICAL RESOURCES, INC.
AN�UARY 26, 2017
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Geological Resources, Inc.
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NOTE:
THIS MAP IS BASED ON DATA FROM THE
BERTIE COUNTY GIS OF NC.

Spigot 1
LEGEND
TYPE l/ MONITORING WELL
DESTROYED TYPE /l MONITORING WELL
TYPE /// MONITORING WELL
POWER POLE
oe
OVERHEAD POWER LINE
WA TER LINE
QS
SPIGOT SAMPLE LOCH 7ION
- - ................. EXCA VA TION AREA (2009)
Note:
This Site Map is based on a Site Plan dated
October 7 200J that was prepared by CES
Engineering, Inc.
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SITE MAP
0 20 40 80 CB ✓ones Texaco N.C. Highway 42 & Bethlehem
Incident No. JJ77 Church Road
( IN FEET ) GRI Project No. 2507 Powellsville, Bertie County, NC
Geological Resources, Inc. 1 inch = 40 ft Date: 0410212020 Drawn b.. OTH Figure: 3

*0
Geological Resources, Inc.
November 9, 2020 N�0-
%j
Mr. David May
NCDEQ, Division of Water Quality
Washington Regional Office
946 Washington Square Mall
Washington, North Carolina 27889
Re: Monitoring Well Permit Application
CB Jones Texaco
NC Highway 42 and Bethlehem Church Road
Powellsville, Hertford County
Incident No: 3377
GRI Project No: 2507
Dear Mr. May:
Please find enclosed a monitoring well permit application for the installation of two Type II monitoring
wells at a property adjacent to the former CB Jones Texaco facility located at the intersection of NC
Highway 42 and Bethlehem Church Road in Powellsville, Bertie County. GRI plans on installing the
monitoring wells immediately upon receipt of the approved well permit.
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,
Z1� , *'
0,4
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] • [phone] • Fax [phone]