WM0401272_Monitoring Well Permit Application Speedway 7934_20210122

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:

Speedway 7934
Write a description for your map.
Lb
© j020 r••
_i. WIS.`
32
r Ave E
Legend
1 2003 Wendove
•
• • 500 Ft radius
© Center
ug Feature 1
• Feature 2
a Greensboro Fire Station 07
W ilcoHess

LEGEND
ASPHALT
PARKING
MW-10
MONITORING WELL LOCATION
INTERMEDIATE MONITORING WELL LOCATION
LIGHT POLE
UTILITY POLE
WATER METER
® SANITARY SEWER MANHOLE COVER
xx— FENCE
PROPERTY BOUNDARY
SUBJECT SITE PROPERTY BOUNDARY
T
e MW-17
MW-13
Q5MW-12
ASPHALT
PARKING
e MW-16
DU MASTER
MW-14 e
JUNCTION
VAULT
MW-8
(ABANDONED)
IWATER VALVE
�x x�
x KEROSENEST
II U
_ J
wv
I DIESEL 1
MW-15e I UST
e MW-7 L----1
EXISTING
CANOPY
0
MW-1
■
MW-19 VE-1
sa MW-3
MW-3i MW-2 e
EAST IVENDOl�ER AVENUE (KVESTBOUND)
GRASS MEDIAN
EAST IVENDOVER AVENUE (EASTBOUNOf
eMW-11
POWER
OX
I
MW-4 e
MW-6
DISPENSERS
MW-5 •
6i
1
ADJACENT
BUILDING
0
40'
SCALE: 1 "= 40'
NOVEMBER 2017
w
0
z
0 CO
000R1 143.0A
0
0
0
Z
0
wz
Z J
Z
W
O Q Q
Q U
0 0 r,LLI
> i_
Z J O D_
w Q z 0
J
H w p
() UJ 0
w D'
ocLmo
z o < m
E wm
1- ow
z ow
O act
U
LP
r='.s
C
m
� E
0
w
no
•—�
Ew
Cif

peedway
OFF SITE ACCESS AGREEMENT
INITIAL REQUEST
December 28, 2020
Certified Mail
Return Receipt Requested
Mr. Randall Hinds
2001 E. Wendover Ave.
Greensboro, NC 27405
RE: Right of Entry Request
2003 E. Wendover Ave.
Greensboro, NC
Near Speedway Store #7934, Greensboro, NC
Dear Mr. Hinds:
Speedway LLC
Speedway Office
P.Q. Box 1500
Springfield, OH 45501
Telephone [phone]
Speedway LLC (Speedway) understands that you are the owner of the property referenced above, which is
Iocated in the vicinity of a certain Speedway property (Speedway #7934) located at 2005 E. Wendover Avenue
in Greensboro, North Carolina.
Speedway is conducting an investigation of subsurface environmental conditions in the vicinity of our property
(Speedway #7934) at the direction of the North Carolina Department of Environmental Quality. This
investigation requires us to move off our property to fully evaluate any petroleum -related impacts of the soil and
ground water.
As part of this investigation, Speedway is planning to drill one soil boring/monitoring well at the Location shown
on the enclosed map. As you are aware, three wells are currently existing on your property via an access
agreement with the previous property owner. We will be entering onto your property periodically thereafter to
take samples from any monitoring wells installed. We will be asking our consultant to do this work on our
behalf.
In performing this work, Speedway will take all reasonable measures to avoid damage to your property and/or
unreasonable interference with the present use of your property. Speedway will defend, indemnify and hold you
harmless from and against any loss, cost, damage or expense arising out of our work on your property. Upon
completion of its investigation, Speedway will close all wells in accordance with state regulations, remove all
equipment and restore your property to as near to its original condition (immediately prior to commencement of
the work) as reasonably possible.
An Equal Opportunity Employer

Whether you consent to or refuse Speedway's request, please check the appropriate box, sign at the space
provided below, return one original copy of this letter to me by January 11, 2021 and keep the second
copy for your records. A self-addressed envelope is provided for your convenience, If you check the
appropriate box and sign, your signature will serve to grant Speedway (including its employees and agents)
permission to enter unto your property for the purpose of performing the work described above. You may
revoke this permission at any time by giving Speedway at least sixty (60) days written notice of your intent to
revoke.
If you have any questions about the terms of this letter, or would like further information about Speedway's
proposed work, please do not hesitate to contact me at the above letterhead address or at [phone] or Trey
Marchant with Mid -Atlantic Associates, Inc. at 919-250-9918.
cc:
Sincerely,
SPEEDWAY LLC
Chuck Chiara
Environmental Representative
Trey Marchant - Mid -Atlantic Associates. Inc.
l have read the preceding letter and represent and warrant that I have full authority to enter into
this Access Agreement and to make it binding on any entity having a valid claim of an interest
in my property. I hereby grant Speedway LLC permission to enter onto my property under the
terms described above.
❑ I have read the preceding letter and hereby do not grant Speedway LLC permission to enter
Print Name:
Signature:
Date:
Email Address:
onto my property under the terms described above.
4-tJ Lt_ L. ( /74Jr :7- f
.. 7(j I A
frij
'4L) L
Attachments: Existing Monitoring Well Locations
Proposed Monitoring Well Location
An Equal Opportunity Employer

LEGEND
MW-1
®MW-3i
■ VE-1
_o-
ASPHALT
PARKING
0
MONITORING WELL LOCATION
INTERMEDIATE MONITORING WELL LOCATION
VACUUM WELL LOCATION
LIGHT POLE
U1UTY POLE
WATER METER
SANITARY SEWER MANHOLE COVER
FENCE
PROPERTY BOUNDARY
SUBJECT SITE PROPERTY BOUNDARY
ATER
VALVE
KEROSENE
UST
MW--1
OMW-3
3i MW-Ze
(ABANDONED)
EAST IrEAVOPE7P AYFNUE 0E372700HO)
EAST HfN00YFR AY£NUE (EAS727044V0)
VE-1
•MW-11
1
1
40'
SCALE
40'
APRIL 2016
F
JOB NO: 000R1143.27
CAD #01-114301-27
0
Z
4a>
O m
0
U
Z
00
S
U
W
W
2
z..
wm
O
rc
a..
REFERENCE: ROBERT E. WILSON, INC. SURVEY MAP DATED 2/23/04.

Speedway 7934
Proposed monitoring weft rocation
r
Flif
Legend
20D5 Wendover Ave E
3 WilcoHess
4