WM0401300_Monitoring Well Permit Application_20210614

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: 05/10/2021
2. County: Davidson
PERMIT NO.
FOR OFFICE USE ONLY
ISSUED DATE
3. What type of well are you applying for? (monitoring or recovery): Monitoring
4. Applicant: Hill Oil Company
Applicant's Mailing Address: P.O. Box 367, Lexington NC 27293
Applicant's Email Address (if available): mayne(aThilloil.com
Telephone: [phone]
5. Contact Person (if different than Applicant): Kevin Stachura Telephone: [phone]
Contact Person's Mailing Address: 4301 Taggart Creek Rd, Charlotte NC 28208
Contact Person's Email Address (if available): kstachuraashieldengineering.com
6. Property Owner (if different than Applicant): RAC, LLC Telephone:
Property Owner's Mailing Address: 1513 E. Center Street Extension. Suite C, Lexington. NC 27292
Property Owner's Email Address (if available):
7. Property Physical Address (Including PIN Number) 808 North Main Street (PIN /16735-01-09-8777)
City Lexington County Davidson Zip Code 27292
8. Reason for Well(s): Groundwater 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: Petroleum 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).
Groundwater incident #19692
11. Type of contaminants being monitored or recovered: Organics
(ex: organics, nutrients, heavy metals, etc.)
12. Are there any existing wells associated with the proposed well(s)? If yes, how many? Yes, 10
Existing Monitoring or Recovery Well Construction Permit No(s):
13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —40 feet & —60 feet
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: Certification No.:
Well Contractor Address:
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 t. Grout horizons
c. Screen intervals g. Well head completion details
d. Sand/gravel pack intervals
Continued on Reverse

PROPOSED WELL CONSTRUCTION INFORMATION (Contlnuod)
2. Number of wells to be coniltnicted M unconeolldsted
material:
i Nurnber of wells to be constructed In bedrock: 0
4. Total Number of welts to be constructed: 1
Odd answers from 2 and 3)
9, How will the well(s) be secured? hocking cep8 wilt] steel nvetencryme
6 Estimated beginning construction date: Mav 2021
7. Estimated construction completion deli): Mav 2021
ADDITIONAL INFORMATION
1. As required by 15A NCAC 02C .0105(0(5), attach a scaled map of the site showing the locations of the following:
a.
b.
c.
d.
e.
All property boundaries, at lead one of which Is referenced to a minimum of two landmarks such as identified roads,
Inlersedions, streams, or lakes within 500 feet of the proposed well or well system.
All existing wens, Identified by type of use, within 500 feet of the proposed well or well system.
The proposed weU or well system.
Any test borings within 500 feel of proposed well or well system.
All eourc s 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
4. The Applicant hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of
r this Well Construction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code,
j Subchapter 2C) an. acc-•■t • f . + • i • ity for compliance with these rules
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Signature of pelic ►t or 'Agent Title off„ din Or 'Agent
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that you have the authority to act as the Agent.
o her than the applicant, the property owner hereby consents to allow the applicant 10 construct
ion Permit application and that it shall be th re onsibility of the applicant to ensure that the
ruction Standards (Title 15A of the ar i a Adminislrativ Cale, Subchapter 2C). A
t than Applicant)
i
Printed name of
DIRECTIONS
A
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
Korn: [phone]
Fax: [phone]
Mooresvttie Regional Office
810 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 Marl
Washington, NC 27889
Phone: [phone]
Fax: [phone]
(if di erent tha'ri Apptican
Wilmington Regional Office
127 Canlinal Drive Extension
Wilmington, NC 28405
Phone: [phone]
Fax: [phone]
Winston -Salim Regional office
450 W. Hanes MiU Road
Suite 300
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]

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DATE : 05/03/12 - DRAWN BY : RBS
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