WM0100450_Application_20190328

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: 3/8/19 1
FOR OFFICE USE ONLY
2. County: Mitchell
IPERMIT NO. ry O1 O So
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: United Oil of the Carolinas Telephone:
704-824-3561 ext. 119
Applicant's Mailing Address: PO Box 68, Gastonia, NC 28054-0068
Applicant's Email Address (if available): [e-mail]
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): wsbageologicalresourcesinc
com
6. Property Owner (if different than Applicant): My Wife / Anwar Gillum
Telephone: [phone]
Property Owner's Mailing Address: PO Box, 1272, Old Fort, NC 28762
Property Owner's Email Address (if available): iamieb3(clfronUer.com
7. Property Physical Address (Including PIN Number) 441 Crimson Laurel Way PIN 0863-11-77-4343
City Bakersvitle County Mitchell Zip Code 28705
8. 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 (Gateway Market)
(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)
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, one existing monitoring well
Existing Monitoring or Recovery Well Construction Permit Nola).: No existing permit no.
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): 30 to 120 feet
14. Are there any water supply wells located less than 500 feet from the proposed wells)? No
If yes, give distance(s): -.
suollm oD, w a a
15. Well Contractor: REDI Certification No.: 580-A O 3 M
Well Contractor Address: 111 Vest Lane West End NC 27376
W
1. As required by 15A NCAC 02C .0105(f)(7), attach a well construction diagram of each well showing the foll lvo�iy ( I.
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)
2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? Locking
material: expansion cap and bolt down manhole cover
3. Number of wells to be constructed in bedrock: 6
4. Total Number of wells to be constructed: 6
(add answers from 2 and 3)
6. Estimated beginning construction date: 3/25/19
Estimated construction completion date: 3127/19
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 feel 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. 143-215.108(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,
I Subchapter 2C) and accepts full responsibility for compliance with these rules
I,f� bill � 1� �s &OL-m-,ye UMnmeacor"nu: c*11r ns 10A6JL-c— MIMGtV
Signature of Applicant or `Agent Title of Applicant or -Agent
W. Scott Ball as Agent for United Oil of the Carolinas ' ffsigning 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 t/Q� thee W/�(I Constr ction Standards (Title 15A of the North Carolina Administrative Code, Subchapter 2C).
/Tl / �/y �'11LJ�r 1ri llFFni
Signature of Pro tarty if different than Applicant) Printed name of Property Owner (if different than Applicant)
11
DIRECTIONS
Please send the minpleted 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]
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
05
GW-22MR Rev. 3-1-2016

TYPE II MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
GROUND
To-"V, 0¢O,A -ZO'
VER
LL CAP
VE7FR
10 PVC CASING
V
SLOTTED
9ME7ER
40 PVC SCREEN

GROUND
TYPE /// MONITORING WELL
TYPICAL CONSTRUCTION DETAILS
CONCRETE
GROUT
SENTON/TE
COVER
WELL CAP
(, 5 -3 6 i 2 /NCH DIAMETER
�.�
SCHEDULE 40 PVC CASING
-yo`
3& 3 p
SAND F/L TER
3 0-c-r s-,
c INCH DIAMETER
(9 - 3 G 1 SCHEDULE 40 PVC CASING
&?a"Tu-n 0 -30/
0.010 INCH SLOTTED
2 INCH DIAMETER
SCHEDULE 40 PVC SCREEN
EEO. L/s- I
—END CAP
NOTE- NOT TO SCALE

Dedination
'�+"` �_.f `}�^''1 '* \yxpjj} t�
//� It4I F,F
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Figure I
Site Location Map
SCALE 1:24000
Gateway Market
441 Crimson Laurel Way, Bakersville, Mitchell County, NC
Incident No. 41648
a 1000 2000 3000 4000 5000
FEET
GRI Project No, 4186
MN 6.89°
W
Date: 12/09/18 Location: 036.0101310' N 082.1533240' W
Scale: 1 inch = 2,000 it

• • • •
LEGENQ
SUBxCT PROPERTY BOUNDARY LINE
-------
AD✓ALSNT PROPERTY BOUNDARY LINE
F.-MIF.-MI
FUEL DISPENSER
- - - - - -
S7REAM OR CREEK UAW
TWE // MON/TOR/NG WELL
--
----------
FORMER
FORMER UNDERGROUND STORAGE TANK
FILL PORT
^-
PRODUCT LINE
NO.
1. TMs Mt. Mop k Eased on data firm the M/tMal
Lbunty GS of NC
2 Ihk ette was not prokasiona//y su rea =/fe
Poot,. and af#& s ore oppioxB M.
TYPL�n WLzt
® PRoksc-o 7YPc—urmo1,o'M2 wr-ram
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MAR 2 R 2019
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/KEROSENE
�1 `UST
Dollar
General
Gateway
Market
550-GAL
HEA 77NG
OIL AST
/'pow
Residential
Res
0 15 30 60 SITE MAP
Gident Man Pet 441 Crimson Loure/ Wont
MENSIR Incident Na. 4164E BakersH//e, Mitchel/ County,
IN FEET) GRI Project No. 4186 NO
Geo/og/ca/ Resources, Inc. 1 inch - 30 ft I Dote: 0071191 Drawn by OTN Figure: 3

'1-1l140
RECEIVED MAR 2 9 2019
RIGHT TO ENTER AGREEMENT
FOR
CONDUCTING SUBSURFACE INVESTIGATIONS
STATE OF NORTH CAROLINA
COUNTY OF MITCHELL
We, the undersigned, being all of the fee simple owners of certain tract or parcel designated as 0863-11-
77-4343 of the County of Mitchell, recognizing the benefits to said properties by reason of conducting
monitoring well installations 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, hie.
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 monitoring well installations against the
lawful claims of all persons whomsoever.
It is agreed that United Oil shall be responsible for restoring any damage done to the ground of said
property by its employees or its agents during the monitoring well installations and monitoring period,
and that United Oil shall abandon the monitoring wells on said property in accordance with NCDEQ
requirements after the incident has been closed.
It is agreed that United Oil shall hold hamiless 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.
Right to Enter granted.
ue: ,
Signs e
Phone.
3 �ls�i9
Date
I
MAR 2 8 2019
N Prr nurr'• "��0�"'
3502 Hayes Road Monroe, North Carolina 28110
Phone [phone] • [phone] • Fax[phone]

Moore, Andrew W
From: Moore, Andrew W
Sent: Friday, March 29, 2019 10:55 AM
To:'[e-mail]'
Subject: Monitoring Well Construction Application, Gateway Market, Mitchell County
Scott,
On March 28, 2019, the Division of Water Resources (Division) received the subject application. The Division has
determined the application is incomplete and cannot be processed. The application is on hold until the following item is
addressed:
1. As you have signed the application as the Agent,. you must provide an authorization agreement stating that you
have the authority to act as the agent. The authorization must be signed by the applicant. Alternatively, the
applicant could sign the application.
Feel free to contact me if you have any questionis
Andrew W. Moore, P.G.
Environmental Specialist —Asheville Regional Office
Water Quality Regional Operations Section
NCDEQ — Division of Water Resources
828 296 4684 office
email: [e-mail]
2090 U.S. Hwy. 70
Swannanoa, N.C. 28778
Email correspondence to and from this address is subject to the
North Carolina Public Records Law and may be disclosed to third parties.