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WM0601163_Monitoring Wells_20201021
ROY COOPER Governor MICHAEL S. REGAN Secretary S. DANIEL SMITH Director Mr. Howell Clark Sampson Bladen Oil Company, Inc. P.O. Box 469 Clinton, North Carolina 28328 NORTH CAROLINA Environmental Quality October 21, 2020 SUBJECT: Well Construction Permit No. WM0601163 (MW-15 & 16) Two (2) monitoring wells: Sampson County Complex - Salemburg Salemburg, Sampson County Mr. Clark: In accordance with the application prepared by Geological Resources, Incorporated dated 15 October 2020 and received in the Fayetteville Regional Office on 19 October 2020; we are forwarding herewith Well Construction Permit No. WM0601163 dated 21 October 2020 issued to Sampson Bladen Oil Company, Incorporated for the construction of two (2) monitoring wells located on property owned by Sampson County at 600 N. Main Street (PIN #: 06011723101) located across NC Hwy 242 from the former site of Hill's Grocery in Salemburg, North Carolina. This Permit will be effective from the date of its issuance for one year and shall be subject to the conditions and limitations as specified therein. Please note that according to North Carolina Administrative Code, Title 15A, Subchapter 2C, Section .0105 (g), "it is the responsibility of the well owner or his agent to see that a permit is secured prior to the commencement of construction of any well for which a permit is required." Issuance of this permit does not constitute approval of the subject wells for reimbursement from Trust Funds. If any parts, requirements, or limitations contained in this Permit are unacceptable to you, you have the right to an adjudicatory hearing before a hearing officer upon written demand to the Director within 30 days following receipt of this Permit, identifying the specific issues to be contended. Unless such demand is made, this Permit shall be final and binding. Sincerely, DocuSignedd by: .J�R.0 Tr Atggb, .egional Supervisor Division of Water Resources — Water Quality Programs Enclosure cc: FRO Files Sampson County Health Department Geological Resources Inc. Sampson County — Edwin Causey, Manager North Carolina Department of Environmental Quality ' Division of Water Resources Fayetteville Regional Office i 225 Green Street, Suite 714 I Fayetteville, North Carolina 28301 910.433.3300 NORTH CAROLINA DEPARTMENT OF ENVIRONMENTAL QUALITY DIVISION OF WATER RESOURCES — WATER QUALITY PROGRAMS PERMIT FOR THE CONSTRUCTION OF A MONITORING WELL In accordance with the provisions of Article 7, Chapter 87, North Carolina General Statutes, and other applicable Laws, Rules and Regulations. PERMISSION IS HEREBY GRANTED TO SAMPSON BLADEN OIL COMPANY, INCORPORATED FOR THE CONSTRUCTION OF A MONITORING WELL SYSTEM consisting of two (2) monitoring wells owned by Sampson Bladen Oil Company, Incorporated located at 510 Commerce Street, Clinton, North Carolina. The monitoring wells will be located on property owned by Sampson County at 600 N. Main Street (PIN #: 06011723101) across NC Hwy 242 from the former Hill's Grocery site, Sampson County, North Carolina. This Permit is issued in accordance with the application received on 19 October 2020, in conformity with specifications and supporting data, all of which are filed with the Department of Environmental Quality and are considered integral parts of this Permit. This Permit is for well construction only, and does not waive any provision or requirement of any other applicable law or regulation. Construction of any well under this Permit shall be in strict compliance with the North Carolina Well Construction Regulations and Standards (15A NCAC 02C .0100), and other State and Local Laws and regulations pertaining to well construction. If any requirements or limitations specified in this Permit are unacceptable, you have a right to an adjudicatory hearing upon written request within 30 days of receipt of this Permit. The request must be in the form of a written petition conforming to Chapter 150B of the North Carolina General Statutes and filed with the Office of Administrative Hearings, 6714 Mail Service Center, Raleigh, North Carolina 27699-6714. Unless such a demand is made, this Permit is final and binding. This Permit will be effective for one year from the date of its issuance and shall be subject to other specified conditions, limitations, or exceptions as follows: 1. Issuance of this Permit does not obligate reimbursement from State trust funds, if these wells are being installed as part of an investigation for contamination from an underground storage tank or dry cleaner incident. 2. Issuance of this Permit does not supersede any other agreement, permit, or requirement issued by another agency. 3. The well(s) shall be located and constructed as shown on the attachments submitted as part of the Permit application. 4. Each well shall have a Well Contractor Identification Plate in accordance with 15A NCAC 02C .0108(o). 5. Well construction records (GW-1) for each well shall be submitted to the Division of Water Resources Information Processing Unit within 30 days of the well completion. 6. When the well is discontinued or abandoned, it shall be abandoned in accordance with 15A NCAC 02C .0113 and a well abandonment record (GW-30) shall be submitted to the Division of Water Resources Information Processing Unit within 30 days of the well abandonment. Permit issued the 21st day of October 2020 FOR THE NORTH CAROLINA ENVIRONMENTAL MANAGEMENT COMMISSION ,,—DocuSigneddby: / V Trent Alicn,5Rclpervisor Division of Water Resources — Water Quality Programs By Authority of the Environmental Management Commission Permit No. # WM0601163 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: October 15, 2020 2. County: Sampson FOR OFFICE USE ONLY PERMIT NO. IAlmo r'o D// % 3 ISSUED DATE /D/2' / D / 3. What type of well are you applying for? (monitoring or recovery): 4. Applicant: Sampson Bladen Oil Company Applicant's Mailing Address: PO Box 469, Clinton NC 28328 Applicant's Email Address (if available): Howell.Clark(c�sampsonbladen.com 5. Contact Person (if different than Applicant): Rae Troiano Brown _ Telephone: 704-845-4010 Contact Person's Mailing Address: 3502 Hayes Road, Monroe, NC 28110 Contact Person's Email Address (if available): rtb(cr�geologicalresourcesinc.com 6. Property Owner (if different than Applicant): Sampson County Telephone: 910-542-6308 Property Owner's Mailing Address: 406 County Complex Road, Building C, Clinton NC 28328 Monitoring Telephone: 910-862-3297 Property Owner's Email Address (if available): jstarling@sampsonnc.com 6or J. P2A,A2 a(oo 1 17Z3/o 6 7. Property Physical Address (Including PIN Number) 13t-Rir Feet PIN #: 060 City Salemburq County Sampson Zip Code 28385 8. Reason for Well(s): Ground water contamination 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 Retail Facility (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). NCDEQ Incident Number 5861 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, 15 wells Existing Monitoring or Recovery Well Construction Permit No(s).: WM0600853, WM0600854, WM0600855, WM0600856, WM0600857 13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): —35 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: Geological Resources, Inc. Certification No.: 3270-A Well Contractor Address: 3502 Hayes Road, Monroe, NC 28110 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 PROPOSED WELL CONSTRUCTION INFORMATION (Continued) 4. Total Number of wells to be constructed: 2 (add answers from 2 and 3) 2. Number of wets to be constructed in unconsolidated 5. How will the well(s) be secured? material: 2 Locking well cap K.)Ql% • 3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: lvt-d '2020 NtAt'' 7 Estimated construction completion date: .AL4a} 2020 pee- 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. The this SIGNATURES lic. t hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of I nstruction Permit as regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code, chapter 2C) and accepts full responsibility for compliance with these rules f �...�. ` P '4(k nature of Applicant or "Agent Title of Applicant or *Agent r-4,,,,(/ere-Kt a � Printed name of Applicant or Agent * If signing as Agent, attach authorization agreement stating 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). i2-11173 SCo Signature of Property Owner (if different than Applicant) Printed name of Property Owner (if dill rnt 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: (828) 296-4500 Fax: (828) 299-7043 Fayetteville Regional Office 225 Green Street, Suite 714 Fayetteville, NC 28301-5094 Phone: (910) 433-3300 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue Mooresville, NC 28115 Phone: (704) 663-1699 Fax: (704) 663-6040 Raleigh Regional Office 3800 Barrett Drive Raleigh, NC 27609 Phone: (919) 791-4200 Fax: (919) 571-4718 Washington Regional Office 943 Washington Square Mall Washington, NC 27889 Phone: (252) 946-6481 Fax: (252) 975-3716 Moorctsv lle. `t Fdyctt piilc`\ Wilmington Regional Office 127 Cardinal Drive Extension Wilmington, NC 28405 Phone: (910) 796-7215 Fax: (910) 350-2004 Winston-Salem Regional Office 450 W. Hanes Mill Road Suite 300 Winston-Salem, NC 27105 Phone: (336) 776-9800 Fax: (336) 776-9797 fngk n GW-22MR Rev. 3-1-2016 RIGHT TO ENTER AGREEMENT FOR CONDUCTING SUBSURFACE INVESTIGATIONS STATE OF NORTH CAROLINA COUNTY OF SAMPSON We, the undersigned, being all of the fee simple owners of certain tracts or parcel designated as 06011723101 of the County of Sampson, recognizing the benefits to said property by reason of conducting subsurface investigations hereby grant to Sampson Bladed Oil Company (SBOC) and its agents the right to enter said property in accordance with the requirements of the State of North Carolina. SBOC's agents may include Geological Resources, Inc. The undersigned hereby covenant and warrant that they are the owners of said property; that they have the right to grant this right to enter for conducting subsurface investigations, It is agreed that SBOC and their agents shall have the right of future entry for the purpose of maintaining any permanent monitoring points for the duration of the monitoring period, as required by the North Carolina Department of Environmental Quality (NCDEQ). It is further agreed that SBOC 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 SI3OC shall abandon sampling points on said property in accordance with the NCDEQ requirements at the conclusion of the monitoring period. It is agreed that SBOC shall hold harmless occupants of Sampson County parcel 06011723101 and Sampson County for claims arising out of its activities on the property that might be sustained during the course of conducting or proximately resulting from the conduct of subsurface investigations. It is also agreed that the occupants of Sampson County parcel 06011723101 and Sampson County will not be held responsible for any soil or ground water remediation activities for petroleum contamination originating at the former Hill's Grocery prope ty. Right to Enter denied, e C(s-(Signature Phone : i D ' / 0 9 Date Right to Enter granted. laden Oil Company Signature J (ok512.o Date 1 Ft oCS PINE STREET O N M N 4 1118ON cfrL .(M,/ / 13_78I S N/V/'Y TYPE II VIO\ITORI\G WELL TYPICAL CONSTRUCTION DETAILS CONCRETE PAD GROUND SURFACE GROUT CEMENT BENTON/TE SEAL SAND FILTER PACK MANHOLE COVER LOCKING WELL CAP 6 ad d'b 2 /NCH DIAMETER SCHEDULE 40 PVC CASING • 0.010 /NCH SLOTTED 2 /NCH DIAMETER SCHEDULE 40 PVC SCREEN END CAP Geological Resources, Inc. October 15, 2020 Mrs. Stephanie Barnhardt NCDEQ—Aquifer Protection Section 225 Green Street, Suite 714 Fayetteville, NC 28301 Re: Monitoring Well Permit Application Hill's Grocery Pine Street and Main Street Salemburg, Sampson County Incident No. 5861 GRI Project No. 3011 Dear Mrs. Barnhardt: R EUL(VhL) DEQ/DWR ►Q OS -AYE TTF\llt OF :(CE ' . 01,1119:Hi2 01/2F Y T?�F ��a ROS — _ F PPR(INALOFFiCE Geological Resources, Inc. (GRI) presents this monitoring well permit application for the installation of two Type II monitoring wells for the above referenced site. An access agreement approved by Sampson County has been attached in lieu of a signature for the property owner. If you have questions or comments, please contact me at (704) 845-4010 or rtb@geologicalresourcesinc.com. Sincerely, Geological Resources, Inc. Rae Troiano Brown, P.G. Project Manager attachment 3502 Hayes Road • Monroe, North Carolina 28110 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 P agc "ICON NEzqg Overview Map Quick Search Advanced Search Search Builder Cnordinate Search Google Maps or Bing Maps Clear Lat/Lon Lat 35.021241 Lon -78.501242 Local Coordinates X 2,149,326.753 Y 463,031.84 r PS Natice5;l Grid 17S CCU 27963 78253 Comparable Search Excel 2000/2003 1:254 Results ©2009-2020 Dude Solutions. All Rights Reserved. 1 Software Notices Welcome Guest Users Oniine: 1358 Help Mobile View 0L. 6,0 Feet OWNER CITY: OWNER STATE: OWNER ZIP: ACREAGE: APN: BK PG: DATE RECORDED: LAND TAX DEFERRED: ASSESSED VALUE: TOTAL TAX VALUE: TWP CODE: TAX CODE: SEG TYPE: Legend Display 50 Layers information Parcels (Yellow) Tax Bill Deed PIN: xy 06011723101 SAIViFSON LUUN i OWNER ADDRESS: 406 COUNTY COMPLEX RD, SUITE 120 CLINTON NC 28328 9.25 1446.16-92-2795 1395/762 6/5/2001 0 1429064 0 600 N IVIAH 6 Null LOT Result https://sampsort.connectgis.com/Map.aspx 10/21 /2020 2021 0315 BK:02021 PG:0315 Sampson County 12-31-2018 NORTH CAROLINA I-Ixcise Fax $350.00 FILED SAMPSON COUNTY ELEANOR N. BRADSHAW REGISTER OF DEEDS FILED Dec 31, 2018 AT 10:41:36 am BOOK 02021 START PAGE 0315 END PAGE 0317 INSTRUMENT # 06538 PREPARED BY AND MAIL TO: H. W. Sanderson, Jr., HOLLAND, POOLE, HOLLAND & SANDERSON, P.A., P. O. Box 1046, Clinton, N. C. 28329 THE DRAFTSMAN OF THIS INSTRUMENT HAS NOT EXAMINED OR CERTIFIED THE TITLE TO THIS PROPERTY. THE DESCRIPTION WAS FURNISHED TO THE DRAFTSMAN BY THE GRANTOR. Sampson County PIN: 06003570701 Revenue Stamps: $350.00 NORTH CAROLINA WARRANTY DEED SAMPSON COUNTY THIS DEED, made this the 31'1-day of December, 2018, by and between AHMED ALKHANSHALI, 3900 Roseboro Hwy, Clinton, NC 28328, party of the first part; to ALI TAWFIQ KHANSHALI, 4670 Roseboro Hwy, Clinton, NC 28328, party of the second part; WITNESSETH: WHEREAS, the said party of the first part, for and in consideration of the sum of TEN DOLLARS ($10.00), and other good and valuable consideration to him paid by the said party of the second part, the receipt of which is hereby acknowledged, has bargained and sold and by these presents does grant, bargain, sell and convey unto the said party of the second part, his heirs and assigns, all that certain lot or parcel of land lying and being in Honeycutts Township, Sampson County, State of North Carolina and more particularly described as follows: BEING all of Lot No. 3, containing .51 acres, more or less, as shown on that CONVEYANCE OF THIS PROPERTY HAS BEEN DULY NOTED ON THE TAX,CORDS. f) TAX ADMINISTRATOR 2021 0316 BK:02021 PG:0316 survey entitled "Survey for Sampson-Bladen Oil Company" prepared by Owen Surveying, Inc., dated April 2004, and recorded in Map Book 50 at Page 37 of the Sampson County Registry, reference to which is hereby made for a more complete description. Being a portion of that parcel conveyed to Sampson Bladen Oil Co., by deed recorded in Deed Book 1038 at page 141 of the Sampson County Registry. Being also that same property conveyed to Salemburg Food Mart, LLC, by deed recorded in Deed Book 1561 at Page 521 of the Sampson County Registry and also see Deed recorded in Deed Book 1815 at Page 9 of the Sampson County Registry. This also being the same property conveyed in Deed recorded in Deed Book 1821 at Page 908 of the Sampson County Registry. Being the same land described in a Deed dated February 7, 2013 from Salemburg Food Mart, LLC to Ahmed Alkhanshali which is recorded in Book 1850, Page 896 of the Sampson County Registry. THE PROPERTY CONVEYED HEREIN DOES DOES NOT / INCLUDE THE PRIMARY RESIDENCE OF THE GRANTOR. TO HAVE AND TO HOLD the aforesaid land, together with all privileges and appurtenances thereunto belonging to the said party of the second part, his heirs and assigns, to his only proper use and behoof forever. And the party of the first part for himself and his heirs and assigns, does covenant that he is seized of said premises in fee and has the right to convey the same in fee simple; that the same are free and clear from encumbrances; and that he will warrant and defend the said title to the same against the lawful claims of ail persons whomsoever. IN TESTIMONY WHEREOF, the said party of the first part has hereunto set his hand and seal, the day and year first above written. .�� `� (SEAL) AHD ALKHANSHALI 2021 0317 BK:02021 PG:0317 NORTH CAROLINA, COUNTY OF SAMPSON 1, 17 el)oro G--oc.kSon , Notary Public, do hereby certify that AHMED ALKHANSHALI personally appeared before me this day, and acknowledged the due execution of the foregoing and annexed instrument. WITNESS my hand and notarial seal, this the •3I St day of Dtc2 ►m b€ r , 2018. MY COMMISSION EXPIRES: 1 I --)q-1o;.)b NOTARY UBLIC Administration Office Page 1 of 2 Administration Government Calendar Horne » Depatrnents» Administration Administration Office HOME DEPARTMENTS TOPICS GOVERNMENT Search Search_. The Administration Office consists of the County Manager, Assistant County Manager/Clerk to the Board, the Deputy Clerk to the Board and the Projects and Communications Specialist. The staff of the Sampson County Administration Office is dedicated to the fulfillment of the County's mission statement: Working with integrity and fiscal prudence, Sampson County Local Government will partner with its citizens to create and sustain a safe, healthy and prosperous community which affords all of its citizens the opportunities. resources and services they need to protect or to enhance their lives. The County Manager Since 1972, Sampson County has operated under the Board of Commissioners/County Manager form of government. The County Manager serves as the local government's chief administrator, providing administration and supervision of all departments over which the Board of Commissioners has authority to control. The Manager advises the Board on the development of policy and strategic planning initiatives and ensures that the regulations, policies, orders and ordinance adopted by the Board are faithfully executed. In Sampson County, the County Manager also serves as the Personnel Officer, overseeing the recruitment of subordinate offices and employees as deemed necessary by the Board (except those officers elected by the people or whose appointment is otherwise provided for by law) and as the Budget Officer, overseeing the receipt, disbursement, accounting and investment of County funding and preparation of the annual budget. Edwin W. Causey has served as the Sampson County Manager since May. 2010. Prior to his appointment as County Manager, Mr. Causey worked for almost forty years for USDA Rural Development specializing in financing and administering community programs (such as water and sewer infrastructure). Mr. Causey holds a Master's degree in Economics from North Carolina State University, where he also completed undergraduate degrees in Animal Science Technology and Poultry Science Technology. The Assistant County Manager/Clerk to the Board The Assistant County Manager assists the County Manager in the administrative and management functions of the County's government. In Sampson County, the Assistant County Manager also serves as the Clerk to the Board, responsible for overseeing the preparation and dissemination of Board of Commissioners agendas and minutes and acting as the official custodian of the local government's public records. The Assistant County Manager also serves as the County's official Public Information Officer. Deputy Clerk to the Board The Deputy Clerk performs administrative support work for the County Manager, Assistant County Manager and for the Board of Commissioners and functions as the Clerk to the Board in the Clerk's absence. The Deputy Clerk manages the front desk operations for the Administration Office, serving as the initial contact for citizen inquiries. Projects and Communications Specialist The Projects and Communications Specialist provides administrative support for the County Manager and Assistant Sampson County Administration Office Phone: (910) 592-6308 Fax: (910) 592-1945 Physical Location 406 County Complex Rd. Clinton. NC 28328 Mailing Address: 406 County Complex Rd., Bldg C, Suite 110 Clinton, NC 28328 Hours of Operation Monday - Friday 8 a.m. - 5 p.m. Edwin W. Causey County Manager ecausey@sampsonnc.com Susan J. Holder Assistant County Manager susanh(a?sampsonnc.com http://www.sampsonnc.com/departments/administration/index.php 10/21/2020 North Carolina Secretary of State Search Results Page 1 of 2 • File an Annual Report/Amend an Annual Report • Upload a PDF Filing • Order a Document Online • Add Entity to My Email Notification List • View Filings • Print a Pre -Populated Annual Report form • Print an Amended a Annual Report form Business Corporation Legal Name Sampson-Bladen Oil Company, Incorporated Information Sosld: 0128585 Status: Current -Active 0 Date Formed: 3/3/1939 Citizenship: Domestic Fiscal Month: October Annual Report Due Date: February 15th Registered Agent: Clark, Haddon M, III Addresses Principal Office 510 Commerce Street Clinton, NC 28328 Officers Secretary David K. Clark P 0 Box 469 Clinton NC 28328 Stock Reg Office 510 Commerce Street Clinton, NC 28328 Treasurer David K. Clark P 0 Box 469 Clinton NC 28328 Reg Mailing 510 Commerce Street Clinton, NC 28328 President Haddon M. Clark , III PO Box 469 Clinton NC 28329-0469 Mailing PO Box 469 Clinton, NC 28329-0469 Vice President John Litton Clark 510 Commerce St Clinton NC 28328 https://www.sosnc.gov/online_services/search/Business_Registration_Results 10/21/2020 Geological Resources, Inc. October 20, 2020 Mr. Jim Barber NCDEQ— Division of Water Resources 225 Green Street, Suite 714 Fayetteville, NC 28301 Re: Monitoring Well Permit Application Hill's Grocery Pine Street and Main Street Salemburg, Sampson County Incident No. 5861 GRI Project No. 3011 Dear Mr. Barber: .. n\\PE-,, Tr DE/''R OCT 2 3 2 ,` 6rCaym(uS UE R?"GiO iA OFFICE: Geological Resources, Inc. (GRI) presents this monitoring well permit application for the installation of two Type II monitoring wells for the above referenced site. An access agreement approved by Sampson County has been attached in lieu of a signature for the property owner. If you have questions or comments, please contact me at (704) 845-4010 or rtb@geologicalresourcesinc.com. Sincerely, Geological Resources, Inc. Rae Troiano Brown, P.G. Project Manager attachment 3502 Hayes Road • Monroe, North Carolina 28110 Phone (704) 845-4010 • (888) 870-4133 • Fax (704) 845-4012 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: October 15, 2020 2. County: Sampson FOR OFFICE USE ONLY PERMIT NO. ISSUED DATE 3. What type of well are you applying for? (monitoring or recovery): 4. Applicant: Sampson Bladen Oil Company Applicant's Mailing Address: PO Box 469, Clinton NC 28328 Applicant's Email Address (if available): Howell.Clark@sampsonbladen.com 5. Contact Person (if different than Applicant): Rae Troiano Brown Telephone: 704-845-4010 Contact Person's Mailing Address: 3502 Hayes Road, Monroe, NC 28110 Contact Person's Email Address (if available): rtb@geologicalresourcesinc.com 6. Property Owner (if different than Applicant): Sampson County Telephone: 910-542-6308 Property Owner's Mailing Address: 406 County Complex Road, Building C, Clinton NC 28328 Property Owner's Email Address (if available): jstarling(a�sampsonnc.com 7. Property Physical Address (Including PIN Number) City Salemburg Monitoring Telephone: 910-862-3297 130 West Pine Street PIN #: 06015921403 County Sampson Zip Code 28385 8. Reason for Well(s): Ground water contamination 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 Retail Facility (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). NCDEQ Incident Number 5861 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, 15 wells Existing Monitoring or Recovery Well Construction Permit No(s).: WM0600853, WM0600854, WM0600855, WM0600856, WM0600857 13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): -35 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: Geological Resources, Inc. Certification No.: 3270-A Well Contractor Address: 3502 Hayes Road, Monroe, NC 28110 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 PROPOSED WELL CONSTRUCTION INFORMATION (Continued) 2. Number of wells to be constructed in unconsolidated 5. How will the well(s) be secured? material: 2 Locking well cap Ki0U• 3. Number of wells to be constructed in bedrock: 0 6. Estimated beginning construction date: 1087'2020 4. Total Number of wells to be constructed: 2 7 Estimated construction completion date: 2020 (add answers from 2 and 3) 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 wet 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 • • lic. t hereby agrees that the proposed well(s) will be constructed in accordance with approved specifications and conditions of thi : 1 f/snstruction Permit a s regulated under the Well Construction Standards (Title 15A of the North Carolina Administrative Code, cha ter 2C) and accepts full responsibility for compliance with these rules k(r? i'4(era k nature of Applicant or *Agent Title of Applicant or *Agent Printed name of Applicant or *Agent * If signing as Agent, attach authorization agreement stating 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), 5SWAY sue. Co Signature of Property Owner (if different than Applicant) Printed name of PropertyOwner(if Jiff, nt than Applicant) 9 PP ) 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: (828) 296-4500 Fax: (828) 299-r 043 Fayetteville Regional Office 225 Green Street, Suite 714 Fayetteville, NC 28301-5094 Phone: (910) 433-3300 Fax: (910) 486-0707 Mooresville Regional Office 610 East Center Avenue Mooresville, NC 28115 Phone: (704) 663-1699 Fax: (704) 663-6040 Raleigh Regional Office 3800 Barrett Drive Raleigh, NC 27609 Phone: (919) 791-4200 Fax: (919) 571-4718 Washington Regional Office 943 Washington Square Mali Washington, NC 27889 Phone: (252) 946-6481 Fax; (252) 975-3716 • `As , Vn .:client re- Moorq vWc F yettertie, Wilmington Regional Office 127 Cardinal Drive Extension Wilmington, NC 28405 Phone: (910) 796-7215 Fax: (910) 350-2004 Winston-Salem Regional Office 450 W. Hanes Mill Road Suite 300 Winston-Salem, NC 27105 Phone: (336) 776-9800 Fax: (336) 776-9797 GW-22MR Rev. 3-1-2016 RIGHT TO ENTER AGREEMENT FOR CONDUCTING SUBSURFACE INVESTIGATIONS STATE OF NORTH CAROLINA COUNTY OF SAMPSON We, the undersigned, being all of the fee simple owners of' certain tracts or parcel designated as 06011723101 of the County of Sampson, recognizing the benefits to said property by reason of conducting subsurface investigations hereby grant to Sampson Bladen Oil Company (SBOC) and its agents the right to enter said property in accordance with the requirements of the State of North Carolina, SBOC's agents may include Geological Resources, Inc. "I'he undersigned hereby covenant and warrant that they are the owners of' said property; that they have the right to grant this right to enter for conducting subsurface investigations. It is agreed that SBOC and their agents shall have the right of future entry for the purpose of maintaining any permanent monitoring points for the duration of the monitoring period, as required by the North Carolina Department of Environmental Quality (NCDEQ). It is further agreed that SBOC 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 SBOC shall abandon sampling points on said property in accordance with the NCDEQ requirements at the conclusion of the monitoring period. It is agreed that SBOC shall hold harmless occupants of Sampson County parcel 06011723101 and Sampson County for claims arising out of its activities on the property that might be sustained during the course of conducting or proximately resulting from the conduct of subsurface investigations. It is also agreed that the occupants of Sampson County parcel 06011723101 and Sampson County will not be held responsible for any soil or ground water remediation activities for petroleum contamination originating at the former Hill's Grocery prope Right to Enter denied, j.. e Cc) Signature , Phone . Cr I I)' / �.. —e 0 jo- j~, oz-D- Date Right to Enter granted. laden Oil Company Signature v- I , I,Uhi 4-3 (0 k S1 z4 Date Lfs2/2 1YPf 11 dta'.orfh?lNG .H:'£L 19 TYPE" ,1 14cbw1106YNC $fu DES7Z0YEO MCW110.6W0 HELL WAS L(E 1IW Nola: Ari sbvrturxa (haVev, cohopy, dapa+ars .4 ;ISO how Deal GanolaIoA 461,-6 Coalopcal Rcrnurca Inc uY. -B uiV-9 PIAIE STREET Dispcnsars Canopy- r ``sr ASAWhir oRt tf7YA r MAIN STREET / HWY 24'2 NORTH Al 10 kW a113 .tIW-12 Ci WV-16 1 SY1t MAP 0 15 30 60 ( av trt e ) T mch R Data 03/17/16 J Dram? by: }lw7's Carry tGgbsay 24? Neat!) Ine:Mont Na Seal Solomon¢ Sampson Comity, GRI Project Na 30i1 NC EC11 Fguro: J YPE II MONITORING WELL TYPICAL CONSTRUCTION DETAILS CONCRETE P'AD . GROUND SURFACE GRour CEMEN BENTOMTE SEAL— -- SAND Fit TER PACK 15' bgs • 6' bgs 8' bgs 10' bgs • MANHOLE COVER LOCKING WELL CAP 2 /NCH D/AMETER SCHEDULE 40 PVC CAS/NG 0070 INCH SLOTTED 2 INCH DIAME7E1? SCHEDULE 40 PVC SCREEN END CAP