WM0401272_Monitoring Well Permit Speedway 7934_20210122 (2)

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: January 20, 2021
2. County: Guilford
3.
4. Applicant: Speedway LLC
FOR OFFICE USE ONLY
PERMIT NO. ISSUED DATE
What type of well are you applying for? (monitoring or recovery):
Monitoring
Telephone: [phone]
Applicant's Mailing Address: 500 Speedway Drive, Enon, OH 45323
Applicant's Email Address (if available): [e-mail]
5. Contact Person (if different than Applicant): Trey Marchant Telephone: [phone]
Contact Person's Mailing Address: 409 Rogers View Ct, Raleigh, NC 27610
Contact Person's Email Address (if available): [e-mail]
6. Property Owner (if different than Applicant): Randall Hinds Telephone: [phone]
Property Owner's Mailing Address: 2001 E. Wendover Ave, Greensboro, NC 27405
Property Owner's Email Address (if available): Not available
7. Property Physical Address (Including PIN Number) 2003 E. Wendover Ave, PIN: 7875516683
City Greensboro,
County Guilford
Zip Code 27405
8. Reason for Well(s): Environmental 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).
Speedway 7934, 2005 East Wendover Avenue, Greensboro, NC 27405, Incident No. 23436
11. Type of contaminants being monitored or recovered: Organics (gasoline)
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 20
Existing Monitoring or Recovery Well Construction Permit No(s).: DEQ number not available, Guilford County #057-01-MW18-
RWO
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): Approx. 15 ft to MUL STP spill
containment
14. Are there any water supply wells located less than 500 feet from the proposed well(s)? No
If yes, give distance(s):
15. Well Contractor: Geologic Exploration, Inc.
Well Contractor Address: 176 Commerce Blvd, Statesville, NC 28625
Certification No.: A-4163
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
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: 0
4. Total Number of wells to be constructed: 1
(add answers from 2 and 3)
5. How will the well(s) be secured? Flush mounted,
bolt -down lid manhole, locking cap and lock
6. Estimated beginning construction date: 3/4/2021
7. Estimated construction completion date: 3/4/2021
1.
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
Principal Geologist
Signature of Applicant or *Agent Title of Applicant or *Agent
Raymond S. Marchant, III "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).
See attached Access Agreement See attached Access Agreement
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: (252
L
In
GW-22MR Rev. 3-1-2016
Wilmington Regional Office
127 Cardinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston-Salem Regional Office
450 W. Hanes Mill Road
Wily ngton
C 27105
9800
7

GROUT
BENTONITE
GRANULAR BACKFLL
FLUSH MOUNT
WELL PROTECTOR
LOCKABLE CAP
DEPTH TO TOP OF •.
BENTONITE SEAL
DEPTH TO TOP OF
GRANULAR MATERIAL
RISER "-"1`�
•4
•
SCREEN
CAP
C
l
LENGTH OF
SOLID SECTION
THREADED C9UPL1NG
LENGTH OF
SLOTTED SECTION
T
LAND SURFACE
TOTAL DEPTH OF
WELL FROM TOC
1Uid Atlantic
Engineering & Environmental Soluticns
DRAWN
BY:
DATE:
DRAFT
CHECK:
JOB NO:
ENG
CHECK:
CAD NO:
REFERENCE:
APPROVAL:
DWG NO:

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