WM0501453_Application_20210930

FOR OFFICE USE ONLY

PERMIT NO. ISSUED DATE
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: 9/30/21

2. County: Wake

3. What type of well are you applying for? (monitoring or recovery): Monitoring

4. Applicant: Miller Oil Company . Telephone:

Applicant’s Mailing Address: PO Box 1858 Norfolk, VA 23501

Applicant’s Email Address (if available):

5. Contact Person (if different than Applicant): Ryan Kerins Telephone: [phone]

Contact Person’s Mailing Address: 100 E Ruffin St, Mebane, NC 27302

Contact Person’s Email Address (if available): [e-mail]

6. Property Owner (if different than Applicant): Living Light Properties Telephone:

Property Owner’s Mailing Address: 3035 Banks Rd. Raleigh, NC 27603-9684

Property Owner’s Email Address (if available):

7. Property Physical Address (Including PIN Number) 3300 Ten Ten Rd. PIN 0761006956
City Cary County Wake Zip Code 27518

8. Reason for Well(s): petroleum UST release 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).

no

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? 23

Existing Monitoring or Recovery Well Construction Permit No(s).:

13. Distance from proposed well(s) to nearest known waste or pollution source (in feet): <50’

14. Are there any water supply wells located less than 500 feet from the proposed well(s)? Yes

If yes, give distance(s): <150’

15. Well Contractor: Terraquest Environmental – Jonathan Grubbs Certification No.: 3001

Well Contractor Address: 100 E Ruffin St, Mebane, NC 27302

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? Manhole
and locking wellcap

6. Estimated beginning construction date: 10/2021

7. Estimated construction completion date: 10/2021

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 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

Project Manager
Signature of Applicant or *Agent Title of Applicant or *Agent

Ryan D. Kerins, Terraquest Environmental Consultants, P.C. * 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 Parkview Shopping Center Condominium Association

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: [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
Winston-Salem, NC 27105
Phone: [phone]
Fax: [phone]
GW-22MR Rev. 3-1-2016

 ACCESS AGREEMENT FORM 

Access is hereby granted to Miller Oil Company, Inc., Terraquest Environmental Consultants, P.C., 
and their agents and assigns for the purpose of installing, sampling, and maintaining, one 
groundwater monitoring well at 3300 Ten Ten Rd, in Cary, NC 27518 with the tax PIN number 
0761006956.   

The proposed well location is the northeast corner of the property as shown on the enclosed 
Figure 1.  Note that the monitoring well location may be adjusted at the time of drilling, should 
unanticipated utilities or other obstacles be encountered at the location.  The well will be 
constructed in accordance with regulations under Title 15A NCAC 2C.  Miller Oil will be 
responsible for all costs associated with the installation, maintenance, and subsequent 
abandonment of the well.  Access is hereby granted for personnel to access the well for sampling 
and maintenance purposes on a regular basis.   

Once the NC Division of Waste Management’s Underground Storage Tank Section has issued a 
Notice of No Further Action the well will be abandoned by filling with cement or bentonite in 
accordance with the rules contained within Title 15A NCAC 2C.   

______________________________________________ __________ 
Living Light Properties, LLC Date 

_______________________________________________      9/30/21 __ 
TERRAQUEST ENVIRONMENTAL CONSULTANTS, P.C. Date 
Ryan D. Kerins, Project Manager 

09/30/21
0'
FIGURE 1 - TYPICAL TYPE II MONITORING WELL DETAIL
MANHOLE COVER
3'
4'
LOCKING CAP
1 1
5'
25'
6"
CEMENT GROUT
BENTONITE SEAL
TOP OF SCREEN
GRAVEL PACK
BOTTOM OF SCREEN
BOTTOM OF BORING
GENERAL INFORMATION
Groundwater monitoring wells are simple 2"
diameter wells used to monitor groundwater
quality. They are constructed using Schedule 40
PVC piping and screen as shown in the diagram
to the left. Upon completion, an 8" round
manhole cover is installed over the well for
protection. In the event that the well is
installed in an area where there exists the
possibility that it could be damaged such as an
agricultural field, an aboveground or stickup
manhole will be used. After the manhole is set,
a small concrete pad is poured around the
manhole. Both the manhole and pad are flush
with the ground surface, except as noted, and
will not interfere with driving, mowing, foot
traffic, etc. Type II monitoring wets are used
for sampling groundwater from shallow,
unconfined aquifers. They are used to
determine the horizontal extent of contamination.
Well Driller:
Terraquest Environmental Consultants,
Jonathan R. Grubbs #3001
TERRAciue st
. WM in
ENVIRONMENTAL CONSULTANTS, P.C.
P.C. —

ENVIRONMENTAL CONSULTANTS, P.C.Terraquest knows of no know sources of groundwater contamination as listed under NCAC 02C .0105(f)(5)within a 500 foot radius